Search Results (331)

Background: The identification and clinical implementation of robust biomarkers are essential for improving diagnosis, prognosis, and treatment across a wide range of diseases. Pancreatic stone protein (PSP) has recently emerged as a promising candidate biomarker. Objective: This narrative review aims to provide an updated and comprehensive overview of the clinical applications of PSP in infectious, oncological, metabolic, and surgical contexts. Methods: We conducted a structured literature search using PubMed^®, applying the SANRA framework for narrative reviews. Boolean operators were used to retrieve relevant studies on PSP in a wide range of clinical conditions, including sepsis, gastrointestinal cancers, diabetes, and ventilator-associated pneumonia. Results: PSP has shown strong diagnostic and prognostic potential in sepsis, where it may outperform traditional markers such as CRP and PCT. It has also demonstrated relevance in gastrointestinal cancers, type 1 and type 2 diabetes, and perioperative infections. PSP levels appear to rise earlier than other inflammatory markers and may be less affected by sterile inflammation. Conclusion: PSP represents a versatile and clinically valuable biomarker. Its integration into diagnostic protocols could enhance early detection and risk stratification in critical care and oncology settings. However, widespread adoption is currently limited by the availability of point-of-care assay platforms. Full article

This review explores the advantages of ivabradine in the management of cardiac surgery patients, particularly highlighting its heart rate (HR)-reducing properties, its role in minimizing the impact of atrial fibrillation, and its contributions to improving left ventricular diastolic function, as well as reducing pain, stress, and anxiety. In parallel, studies provide evidence that ivabradine influences endothelial inflammatory responses through mechanisms such as biomechanical modulation. Unlike traditional beta-blockers that may induce hypotension, ivabradine selectively inhibits hyperpolarization-activated cyclic nucleotide-gated (HCN) channels, allowing for effective HR reduction without compromising blood pressure stability. This characteristic is particularly beneficial for patients at risk of atrial fibrillation post-surgery, where HR control is crucial for cardiovascular stability. This is an area in which ivabradine appears to play a role prophylactically, possibly in combination with beta-blockers. Furthermore, ivabradine has been associated with enhanced diastolic parameters in left ventricular function, reflecting its potential to improve surgical outcomes in patients with compromised heart function. In addition to its cardiovascular benefits, it appears to alleviate psychological stress and anxiety, common in postoperative settings, by moderating the neuroendocrine response to stress, thereby reducing stress-induced hormone levels. Furthermore, it has notable analgesic properties, contributing to pain management through its action on HCN channels in both the peripheral and central nervous systems. Collectively, these findings indicate that ivabradine may serve as a valuable therapeutic agent in the perioperative care of cardiac surgery patients, addressing both physiological and psychological challenges during recovery. Full article

Background and Objectives: Despite significant advances in surgical techniques and perioperative care, major adverse cardiovascular events (MACE) remain a leading cause of postoperative morbidity and mortality in patients undergoing coronary artery bypass grafting and/or aortic valve replacement. Accurate preoperative risk stratification is essential yet often limited by models that overlook atrial mechanics and underutilized biomarkers. Materials and Methods: This study aimed to develop an interpretable machine learning model for predicting perioperative MACE by integrating clinical, biochemical, and echocardiographic features, with a particular focus on novel physiological markers. A retrospective cohort of 131 patients was analyzed. An Extreme Gradient Boosting (XGBoost) classifier was trained on a comprehensive feature set, and SHapley Additive exPlanations (SHAPs) were used to quantify each variable’s contribution to model predictions. Results: In a stratified 80:20 train–test split, the model initially achieved an AUC of 1.00. Acknowledging the potential for overfitting in small datasets, additional validation was performed using 10 independent random splits and 5-fold cross-validation. These analyses yielded an average AUC of 0.846 ± 0.092 and an F1-score of 0.807 ± 0.096, supporting the model’s stability and generalizability. The most influential predictors included total atrial conduction time, mitral and tricuspid annular orifice areas, and high-density lipoprotein (HDL) cholesterol. These variables, spanning electrophysiological, structural, and metabolic domains, significantly enhanced discriminative performance, even in patients with preserved left ventricular function. The model’s transparency provides clinically intuitive insights into individual risk profiles, emphasizing the significance of non-traditional parameters in perioperative assessments. Conclusions: This study demonstrates the feasibility and potential clinical value of combining advanced echocardiographic, biochemical, and machine learning tools for individualized cardiovascular risk prediction. While promising, these findings require prospective validation in larger, multicenter cohorts before being integrated into routine clinical decision-making. Full article

(1) Background: Wilms’ tumor (WT) is the most common pediatric renal malignancy. Although survival outcomes have improved with multimodal therapy, the optimal sequence of surgery and chemotherapy remains debated, particularly in resource-limited settings. This study evaluates the effect of treatment strategy on surgical complications and survival, utilizing two decades of data from Thai tertiary centers. (2) Methods: A retrospective cohort study was conducted on 83 children who underwent radical nephrectomy for WT between 2002 and 2022 at two university hospitals in Thailand. Patients were grouped by treatment protocol: primary nephrectomy (n = 59) or neoadjuvant chemotherapy (n = 24). Clinical, pathological, operative, and follow-up data were analyzed to identify predictors of surgical complications and survival. (3) Results: Short-term postoperative complications occurred in 16.9% of cases, more frequently in males and in patients with hypoalbuminemia, anemia, or large tumors. Estimated blood loss greater than 5 mL/kg, serum albumin less than 3.5 g/dL, and hemoglobin lower than 10 g/dL were independent predictors of complications. The five-year overall survival (OS) and progression-free survival (PFS) rates were 82.4% and 68.1%, respectively. Patients with unfavorable histology or short-term complications experienced significantly poorer OS. Neoadjuvant chemotherapy was associated with increased nutritional compromise and a trend toward higher complication rates, although it was not directly linked to inferior OS. (4) Conclusions: In pediatric WT, the perioperative nutritional and hematologic statuses significantly influence surgical outcomes. While neoadjuvant chemotherapy may assist in tumor downsizing, it might also compromise surgical fitness. Customized preoperative risk assessment and nutritional support can enhance outcomes, particularly in low- and middle-income countries. Full article

Background and Objectives: Regional and systemic analgesic techniques, such as erector spinae plane (ESP) block and opioid administration, implemented during cancer surgery, have been shown to influence immune responses and potentially affect cancer outcomes. Surgical stress and analgesic techniques used in cancer surgery—such as regional nerve blocks or systemic opioids—not only affect pain control but also influence immune and inflammatory pathways that may impact cancer progression. To understand the biological consequences of these interventions, metabolomic profiling has emerged as a powerful approach for capturing systemic metabolic and immunological changes, which are particularly relevant in the oncologic perioperative setting. In this study, we examined the impact of the ESP on the metabolomic profile, as well as levels of VEGF, cortisol, and CRP, in addition to its analgesic effects in breast cancer surgery. Materials and Methods: Ninety patients were placed into three different analgesia groups (morphine, ESP, and control groups). Demographic data, ASA classification, comorbidities, surgery types, and pain scores were documented. Blood samples were taken at preoperative hour 0, postoperative hour 1, and postoperative hour 24 (T0, T1, and T24). VEGF, cortisol, and CRP levels were measured, and metabolomic analysis was performed. Results: Study groups were comparable regarding demographic findings, comorbidities, and surgery types (p > 0.05). NRS scores of group ESP were lowest in the first 12 h period (p < 0.01) and ESP block reduced opioid consumption (p < 0.01). VEGF and cortisol levels of group morphine were similar to ESP at T24 (p > 0.05). Group ESP had lower VEGF and cortisol levels than the control at T24 (p = 0.025, p = 0.041, respectively.). The CRP level of group morphine was higher than both ESP and control at T24 (p = 0.022). Metabolites involved in primary bile acid, steroid hormone biosynthesis, amino acid, and glutathione metabolism were changed in group ESP. Conclusions: Metabolites in bile acid biosynthesis and steroid hormone pathways, which play a key role in immune responses, were notably lower in the ESP group. Accordingly, VEGF and cortisol peaks were more moderate in group ESP. In conclusion, we think that ESP block, which provides adequate analgesia, is an acceptable approach in terms of modulating immune responses in breast cancer surgery. Full article

Background: Hypotension following epidural labor analgesia (ELA) is its most common complication, affecting approximately 20% of patients and posing risks to both maternal and fetal health. As digital tools and predictive analytics increasingly shape perioperative and obstetric anesthesia practices, real-world implementation data are needed to guide their integration into clinical care. Current monitoring practices rely on intermittent non-invasive blood pressure (NIBP) measurements, which may delay recognition and treatment of hypotension. The Hypotension Prediction Index (HPI) algorithm uses continuous arterial waveform monitoring to predict hypotension for potentially earlier intervention. This clinical trial evaluated the feasibility, acceptability, and efficacy of continuous HPI-guided treatment in reducing time-to-treatment for ELA-associated hypotension and improving maternal hemodynamics. Methods: This was a prospective randomized controlled trial design involving healthy pregnant individuals receiving ELA. Participants were randomized into two groups: Group CM (conventional monitoring with NIBP) and Group HPI (continuous noninvasive blood pressure monitoring). In Group HPI, hypotension treatment was guided by HPI output; in Group CM, treatment was based on NIBP readings. Feasibility, appropriateness, and acceptability outcomes were assessed among subjects and their bedside nurse using the Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM), and Feasibility of Intervention Measure (FIM) instruments. The primary efficacy outcome was time-to-treatment of hypotension, defined as the duration between onset of hypotension and administration of a vasopressor or fluid therapy. This outcome was chosen to evaluate the clinical responsiveness enabled by HPI monitoring. Hypotension is defined as a mean arterial pressure (MAP) < 65 mmHg for more than 1 min in Group CM and an HPI threshold < 75 for more than 1 min in Group HPI. Secondary outcomes included total time in hypotension, vasopressor doses, and hemodynamic parameters. Results: There were 30 patients (Group HPI, n = 16; Group CM, n = 14) included in the final analysis. Subjects and clinicians alike rated the acceptability, appropriateness, and feasibility of the continuous monitoring device highly, with median scores ≥ 4 across all domains, indicating favorable perceptions of the intervention. The cumulative probability of time-to-treatment of hypotension was lower by 75 min after ELA initiation in Group HPI (65%) than Group CM (71%), although this difference was not statistically significant (log-rank p = 0.66). Mixed models indicated trends that Group HPI had higher cardiac output (β = 0.58, 95% confidence interval −0.18 to 1.34, p = 0.13) and lower systemic vascular resistance (β = −97.22, 95% confidence interval −200.84 to 6.40, p = 0.07) throughout the monitoring period. No differences were found in total vasopressor use or intravenous fluid administration. Conclusions: Continuous monitoring and precision hypotension treatment is feasible, appropriate, and acceptable to both patients and clinicians in a labor and delivery setting. These hypothesis-generating results support that HPI-guided treatment may be associated with hemodynamic trends that warrant further investigation to determine definitive efficacy in labor analgesia contexts. Full article

Background/Objectives: Ketorolac is commonly used for pain management after orthopedic surgery, but concerns regarding its effects on postoperative complications remain. This study evaluates the impact of ketorolac use on short- and long-term outcomes in adult patients undergoing uncemented primary total hip arthroplasty (THA), where implant stability relies on biological fixation through bone ingrowth into a porous-coated prosthesis rather than bone cement. Methods: A retrospective cohort study was conducted using the TriNetX Research Network. Patients aged 18 years or older who underwent uncemented primary THA between 1 January 2004 and 1 January 2024 were included. Two cohorts were compared: those who received ketorolac on the day of or within one week of surgery and those who did not. Cohorts were propensity score-matched. Outcomes were assessed at 30 days, 1 year, and 5 years postoperatively. Results: At 30 days, ketorolac use was associated with significantly lower risks of transfusion (RR: 0.6, p < 0.01). However, it was linked to higher rates of acute posthemorrhagic anemia (RR: 1.2, p < 0.01) and periprosthetic fracture (RR: 1.4, p < 0.01). At 1 year, ketorolac use was associated with reduced risks of death (RR: 0.8, p < 0.01) and transfusion (RR: 0.7, p < 0.01), but increased risks of acute posthemorrhagic anemia (RR: 1.2, p < 0.01), deep surgical site infection (SSI) (RR: 1.8, p = 0.01), superficial SSI (RR: 1.9, p < 0.01), periprosthetic joint infection (RR: 1.1, p < 0.01), wound dehiscence (RR: 1.2, p < 0.01), periprosthetic mechanical complication (RR: 1.2, p < 0.01), and periprosthetic fracture (RR: 1.5, p < 0.01). Conclusions: Our findings highlight the complex risk profile of ketorolac in uncemented THA patients and suggest that clinicians should carefully consider individual patient factors and engage in shared decision-making when counseling patients on the use of ketorolac in the perioperative setting. Full article

Background: Systemic inflammatory markers have emerged as accessible and reproducible tools for oncologic risk stratification, yet their prognostic value in rectal cancer remains incompletely defined, particularly in acute surgical settings. This study aimed to assess six inflammation-based indices—NLR, PLR, MLR, SII, SIRI, and AISI—in relation to tumor stage, recurrence, and outcomes among patients undergoing emergency versus elective resection for rectal cancer. Methods: We retrospectively evaluated 174 patients treated between 2018 and 2024. Pre-treatment blood counts were used to calculate inflammatory indices. Clinical and pathological parameters were correlated with biomarker levels using univariate and multivariate analyses. Results: Pre-treatment inflammation markers were significantly elevated in patients requiring emergency surgery (e.g., NLR: 3.34 vs. 2.4, p = 0.001; PLR: 204.1 vs. 137.8, p < 0.001; SII: 1008 vs. 693, p = 0.007), reflecting advanced tumor biology and immune activation. Notably, these patients also had higher rates of stage IV disease (p = 0.029) and permanent stoma (p = 0.002). Post-treatment, recurrence was paradoxically associated with significantly lower levels of SII (p = 0.021), AISI (p = 0.036), and PLR (p = 0.003), suggesting a potential role for immune exhaustion rather than hyperinflammation in early relapse. Conclusions: Inflammatory indices provide valuable insights into both tumor local invasion and host immune status in rectal cancer. Their integration into perioperative assessment could improve prognostication, particularly in emergency presentations. Post-treatment suppression of these markers may identify patients at high risk for recurrence despite initial curative intent. Full article

Background and Objectives. Umbilical hernia is particularly common among patients with liver cirrhosis, affecting about 20% of this group, compared to 3–8.5% in healthy individuals. This increased prevalence is mainly due to weakened abdominal fascia, elevated intra-abdominal pressure, and malnutrition. The rapid progression of umbilical hernias often leads to complications such as skin necrosis, perforation, and strangulation. Historically, patients with liver cirrhosis and complicated umbilical hernia have faced high morbidity and mortality rates. However, recent advancements in perioperative management, especially in controlling ascites, have improved outcomes in elective treatments. Despite these advancements, managing patients with decompensated liver cirrhosis and complicated umbilical hernia in emergency settings remain a significant surgical challenge. Materials and Methods: We conducted a retrospective review of patients treated for complicated umbilical hernia at the University Medical Centre Ljubljana from 2015 to 2024, using prospectively collected data. This analysis involved implementing hernioplasty combined with incisional negative pressure wound therapy (iNPWT) as part of the surgical protocol. The primary endpoint of our study was the rate of local complications, while the secondary endpoints included the rate of systemic complications and 90-day mortality. Results: We treated 28 consecutive patients with complicated umbilical hernia and liver cirrhosis. Local wound complications were observed in three (10.7%) patients. Systemic complications developed in 10 patients (35.7%). The median duration of hospitalization was 8 days (range: 5–29), and no readmissions were recorded within the 30-day period. Two (7.1%) patients died within 90 days. Conclusions: Our experience indicates that iNPWT, when combined with surgical repair, can be safely utilized, yielding outcomes comparable to elective hernia repairs, even in emergency contexts. Further randomized controlled trials are necessary to validate these findings and optimize treatment protocols. Full article

Resectable non-small cell lung cancer (NSCLC) continues to pose significant challenges with high recurrence and mortality rates, despite traditional platinum-based chemotherapy yielding only an approximate 5% improvement in 5-year overall survival when administered preoperatively or postoperatively. In recent years, the integration of immune checkpoint inhibitors (ICIs), such as nivolumab, durvalumab and pembrolizumab, with platinum-based regimens in the perioperative setting has emerged as a transformative strategy. Our comprehensive review, based on a systematic bibliographic search of PubMed, Google Scholar, EMBASE, Cochrane Library, and clinicaltrials.gov, targeting pivotal clinical trials from the past two decades, examines the impact of these neoadjuvant and adjuvant chemoimmunotherapy approaches on major pathological response rates and overall survival in early-stage NSCLC. Although these perioperative strategies represent a paradigm shift in treatment, promising durable responses are offset by persistent recurrence, emphasizing the necessity for optimized treatment sequencing, duration, and the identification of predictive biomarkers. Collectively, our findings underscore the critical role of the perioperative schema, particularly the neoadjuvant component, which enables the evaluation of novel biomarkers as surrogates for overall survival, in improving patient outcomes and delineating future research directions aimed at reducing mortality and enhancing the quality of life for patients with resectable NSCLC. Full article

Background: Obstructive Sleep Apnea (OSA) is a common occurrence in the perioperative patient population but is often undiagnosed. Point-of-Care Ultrasound (POCUS) has emerged as a promising tool for perioperative assessment; however, its effectiveness in detecting the presence or severity of OSA needs to be evaluated. Objective: We assessed the ability of airway POCUS as a screening and severity evaluation tool for OSA by examining its correlation with STOP-BANG scores and the Apnea–Hypopnea Index (AHI). Design: Cross-sectional observational study. Setting: A single-center study in a tertiary care hospital between June 2020 to May 2021. Patients: Adult patients aged 18–65 with prior Polysomnography (PSG) for OSA workup were screened. Interventions: The participants completed the STOP-BANG questionnaire and subsequently underwent POCUS examinations, either pre- or post-surgery. Ten different POCUS views previously used for evaluating OSA were acquired in a predefined sequence, with subsequent measurements of airway parameters. Outcome measures: Generalized linear modeling was used to explore and assess the relationships between the measured parameters, STOP-BANG, and AHI scores (modeled continuously and categorized into risk levels of STOP-BANG and AHI). Results: A total of 260 patients were screened, of which 142 were enrolled and 127 completed the scanning studies. The median AHI was 16.71, while the STOP-BANG scores were mostly between 5 and 6, indicating a moderate-to-high OSA risk in the study population. Notably, only neck circumference was significantly associated with AHI severity (p = 0.012), whereas none of the other POCUS measures were. Among the POCUS measures, significant associations with STOP-BANG scores were observed for the Tongue Cross-Sectional Area (T-CSA) (p = 0.002), Retro-Palatal Diameter (RPD) (p = 0.034), Distance Between Lingual Arteries (DLA) (p = 0.034), and Geniohyoid Muscle Thickness (GMT) (p = 0.040). Conclusions: Neck circumference is a more reliable predictor of OSA severity (AHI) compared to other POCUS measurements. Many of the POCUS measures had a good correlation with the STOP-BANG scores, highlighting the utility of POCUS as a screening tool for OSA rather than as a severity evaluation tool. Full article

Non-small cell lung cancer (NSCLC) is the leading cause of cancer-related mortality worldwide. Nonetheless, deeper molecular understanding of NSCLC has resulted in novel therapeutic approaches, including targeted therapy and immunotherapy, which have improved patient prognosis and outcomes in recent years. Immune checkpoint inhibitors (ICIs), with or without chemotherapy, are now considered valuable components of treatment for NSCLC cases that do not have specific actionable genetic mutations. Patients with actionable genetic mutations are candidates for targeted therapies. The primary focus of this review is the rationale for using ICIs in the perioperative setting for patients with resectable NSCLC and in advanced disease settings. Furthermore, we compare the benefits of using ICIs with the challenges associated with their clinical implementation in resectable and advanced NSCLC. Finally, we emphasize the development of novel treatment strategies that potentially provide an optimal treatment choice for patients with advanced NSCLC. Full article

Introduction: Airway management remains a high-risk intervention in a subset of patients, with traditional predictors like the Mallampati score demonstrating poor sensitivity and specificity. Point-of-care ultrasound (POCUS) has emerged as a transformative tool, offering real-time, objective assessment of airway anatomy to improve safety and outcomes. Methods: A narrative approach was conducted to evaluate the literature on airway ultrasound, incorporating clinical metrics and procedural applications. Results: Ultrasound has demonstrated utility in pre-intubation risk stratification using quantitative measures such as skin-to-epiglottis distance (>2.75 cm) and hyomental distance ratio (<1.2), which outperform traditional exams, especially in obese patients. Procedural uses include endotracheal tube confirmation with 98.9% sensitivity and enhanced success rates in emergent cricothyroidotomy—from 50% to nearly 100%—in patients with difficult anatomy. Dynamic applications like assessing laryngeal edema via parapharyngeal thickness offer advantages over traditional cuff leak tests. Technical considerations such as optimal probe selection, patient positioning, and interpretation of key anatomical landmarks are also discussed. Conclusions: Airway ultrasound is poised to become a standard tool in perioperative and critical care settings. The review concludes by emphasizing POCUS as an indispensable adjunct for modern airway management. Full article

Background/Objectives: To summarize the relevant trials relating to novel strategies and therapeutic advances in the treatment of bladder cancer. Methods: A comprehensive review of the literature and recent/ongoing clinical trials was conducted, focusing on novel treatments and strategies for bladder cancer. Trials started or published as of 2020 were included. Results: The standard of care for MIBC remains neoadjuvant chemotherapy with perioperative immunotherapy in the cisplatin-eligible population, while guidelines do not exist for cisplatin-ineligible patients. Strategies under investigation include combinations of chemotherapy, immunotherapy, radiation, and/or novel therapies, such as ADCs, targeted agents, intravesical treatments, and personalized vaccines. Bladder-sparing approaches using these novel therapies are also being studied. In the advanced/metastatic setting, enfortumab vedotin plus pembrolizumab has supplanted platinum-based chemotherapy as the first-line treatment option. For those with contraindications, or who progress, strategies under investigation include newer immunotherapies and ADCs, novel small molecule inhibitors, and cellular therapies. Conclusions: The treatment landscape for bladder cancer has changed drastically within the last few years. Ongoing trials hope to build on this success by investigating bladder-sparing strategies for MIBC and novel systemic therapies in advanced patients. Full article

Background: Hip fractures are a major cause of morbidity and mortality, particularly in the elderly, and the incidence is expected to rise significantly in the coming years. One of the key challenges in managing hip fracture patients is perioperative blood loss, which often necessitates allogeneic blood transfusion. Tranexamic acid (TXA), a synthetic antifibrinolytic agent, has been shown to reduce blood loss in various surgical settings, including elective orthopaedics. However, unlike elective surgery where bleeding begins intraoperatively, bleeding in hip fracture patients starts at the time of injury. This scoping review aimed to evaluate the existing literature on the use of early TXA administration, specifically at the point of admission, in patients with hip fractures. Methods: A comprehensive search of EMBASE and PubMed was conducted up to March 2025, and eight studies were identified that met the inclusion criteria, including three randomised controlled trials (RCTs). Six of these studies compared patients receiving TXA on admission to controls who received no TXA, involving a total of 840 patients. Most studies focused on extracapsular fractures in elderly, predominantly female patients. Results: Findings were mixed: four of the six studies found no statistically significant differences in haemoglobin levels or transfusion rates, while two RCTs demonstrated significantly reduced transfusion needs in the TXA group. Trends across studies suggested reduced blood loss and transfusion risk with TXA administered on admission. Importantly, no increase in complications, including venous thromboembolism, were observed. Conclusion: Early TXA administration in hip fracture patients appeared to be safe and may reduce transfusion requirements. Further high-quality research is warranted to determine the optimal timing and dosing strategy for TXA in this setting and to confirm the efficacy in reducing perioperative blood loss and transfusion risk. Full article