OBJECTIVE: Postoperative cognitive decline (POCD) is characterised by deficits in attention, memory, executive function, and information processing that persist beyond the early postoperative period. Its incidence ranges from 10%-25% after noncardiac surgery. Limited literature exists on POCD after gynecologic oncology surgery. Our primary objective was to identify the incidence of POCD among patients 55 years or older undergoing major gynecologic oncology surgery.
METHODS: This mixed-methods, prospective, observational cohort study followed patients 55 years or older who underwent surgery for gynecologic malignancies between February and July 2022. Semi-structured interviews and the Mini-Mental State Exam (MMSE) were administered before surgery as well as 1 and 3 months after. Assessments were delivered virtually and in-person in the context of the COVID-19 pandemic. POCD was defined as ≥2-point decline from baseline MMSE score.
RESULTS: Twenty-four patients participated; 19 completed the 1-month follow-up, and 15 completed the 3-month follow-up. The average age was 64 (range: 56-90). The mean preoperative MMSE score was 16.6 out of 17 (virtual) and 12.9 out of 13 (in-person). Two patients had a 1-point decline in their 1-month MMSE score; both recovered by 3 months. One patient had a 1-point decline in their 3-month MMSE score. Semi-structured interviews revealed common themes of \"brain fog\" at the 1-month follow-up and mild, persistent attention and word-finding deficits at 3 months postoperatively.
CONCLUSIONS: This study\'s qualitative component captured subtle subjective findings suggestive of potential POCD. Larger studies are required, and a more extensive neuropsychological test battery may be required to elicit subtle findings not clearly reflected by MMSE scores.

BACKGROUND: Women have classically been excluded from the development of normal data and reference ranges, with pregnant women experiencing further neglect. The incidence of Caesarean section in pregnant women, and of general operative management in young women (both pregnant and non-pregnant), necessitates the formal development of healthy baseline data in these cohorts to optimise their perioperative management. This systematic review assesses the representation of young women in existing reference ranges for several functional exercise tests in common use to facilitate functional assessment in this cohort.
METHODS: Existing reference range data for the exercise tests the Six Minute Walk Test (6MWT), the Incremental Shuttle Walk Test (ISWT) and Cardiopulmonary Exercise Testing (CPET) in young women of reproductive age were assessed using the MEDLINE (Ovid) database, last searched December 2023. Results were comparatively tabulated but not statistically analysed given underlying variances in data.
RESULTS: The role of exercise testing in the perioperative period as an assessment tool, as well as its safety during pregnancy, was evaluated using 65 studies which met inclusion criteria.
CONCLUSIONS: There is a significant lack of baseline data regarding these tests in this population, especially amongst the pregnant cohort, which limits the application of exercise testing clinically.

Matrix metalloproteinase 9 (MMP9) and microRNA-145 (miR-145) have emerged as essential biomarkers in thyroid cancer progression and metastasis. However, their combined evaluation and clinical utility as a unified prognostic marker across diverse thyroid cancer subgroups remain unexplored. We investigated the diagnostic and prognostic value of the MMP9/miR-145 ratio in thyroid cancer, hypothesizing it may overcome inter-patient heterogeneity and serve as a versatile biomarker regardless of genetic mutations or autoimmune status. MMP9 and miR-145 expressions were analyzed in 175 paired papillary thyroid cancer (PTC) and normal tissues. Plasma levels were assessed perioperatively and longitudinally over 12-18 months in 86 matched PTC patients. The associations with clinicopathological parameters and patient outcomes were evaluated. MMP9 was upregulated, and miR-145 downregulated in cancer tissues, with a median MMP9/miR-145 ratio 17.6-fold higher versus controls. The tissue ratio accurately diagnosed thyroid malignancy regardless of BRAF mutation or Hashimoto\'s thyroiditis status, overcoming genetic and autoimmune heterogeneity. A high preoperative circulating ratio predicted aggressive disease features, including lymph node metastasis, extrathyroidal extension, progression/relapse, and recurrence. Although the preoperative plasma ratio was elevated in patients with unfavorable outcomes, it had limited utility for post-surgical monitoring. In conclusion, the MMP9/miR-145 ratio is a promising biomarker in PTC that bridges genetic and immunological variabilities, enhancing preoperative diagnosis and prognostication across diverse patient subgroups. It accurately stratifies heterogenous cases by aggressiveness. The longitudinal trends indicate decreasing applicability for post-thyroidectomy surveillance. Further large-scale validation and protocol standardization can facilitate clinical translation of the MMP9/miR-145 ratio to guide personalized thyroid cancer management.

Anatomically correct patient-specific models made from medical imaging can be printed on a three-dimensional (3D) printer or turned into a virtual reality (VR) program. Until recently, use in anesthesia has been limited. In 2019, the anesthesia department at Tel Aviv Medical Center launched a 3D program with the aim of using 3D modelling to assist in preoperative anesthesia planning.
A retrospective review of all relevant patients between July 2019 and June 2021 referred for preoperative airway planning with 3D modelling. Patient files were reviewed for correlation between the model-based airway plan and the actual airway plan, the type of model used, and any anesthetic complications related to airway management.
Twenty patients were referred for 3D modelling. Of these, 15 models were printed, including 12 children requiring one lung ventilation. Five patients had VR reconstructions, including three with mediastinal masses. One patient had both a 3D-printed model and a VR reconstruction. There were two cases (10%) where the model plan did not correlate with the final airway plan and one case where a model could not be created because of poor underlying imaging. For the remaining 17 cases, the plan devised on the model matched the final airway plan. There were no anesthetic complications.
Three-dimensional modelling and subsequent printing or VR reconstruction are feasible in clinical anesthesia. Its routine use for patients with challenging airway anatomy correlated well with the final clinical outcome in most cases. High-quality imaging is essential.
RéSUMé: OBJECTIF: Des modèles anatomiquement corrects spécifiques à un·e patient·e réalisés à partir de l’imagerie médicale peuvent être imprimés sur une imprimante tridimensionnelle (3D) ou transformés en programme de réalité virtuelle (RV). Jusqu’à récemment, l’utilisation de cette modalité était limitée en anesthésie. En 2019, le service d’anesthésie du centre médical de Tel Aviv a lancé un programme 3D dans le but d’utiliser la modélisation 3D pour faciliter la planification préopératoire de l’anesthésie. MéTHODE: Nous avons réalisé un examen rétrospectif de toute la patientèle concernée référée pour une planification préopératoire des voies aériennes avec modélisation 3D entre juillet 2019 et juin 2021. Les dossiers des patient·es ont été examinés pour déterminer la corrélation entre le plan de prise en charge des voies aériennes fondé sur le modèle et le plan fondé sur les voies aériennes réelles, le type de modèle utilisé et toute complication anesthésique liée à la prise en charge des voies aériennes. RéSULTATS: Vingt patient·es ont été référé·es pour la modélisation 3D. À partir de cette cohorte, 15 modèles ont été imprimés, dont 12 pour des enfants nécessitant une ventilation pulmonaire. Cinq patient·es ont bénéficié de reconstructions en RV, dont trois avec des masses médiastinales. Un modèle imprimé en 3D et une reconstruction en RV ont été créés pour une personne. Il y a eu deux cas (10 %) où le plan modèle n’était pas corrélé avec le plan des voies aériennes final et un cas où il n’a pas été possible de créer un modèle en raison d’une mauvaise imagerie sous-jacente. Pour les 17 cas restants, le plan conçu sur le modèle correspondait au plan final de prise en charge des voies aériennes. Il n’y a pas eu de complications anesthésiques. CONCLUSION: La modélisation tridimensionnelle et l’impression ultérieure ou la reconstruction en RV sont réalisables en anesthésie clinique. Leur utilisation systématique pour les patient·es présentant une anatomie difficile au niveau des voies aériennes était bien corrélée avec le résultat clinique final dans la plupart des cas. Une imagerie de haute qualité est essentielle.

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Orthopedic fractures in adults 65 and older are common and can lead to functional decline and increased morbidity and mortality. Falls are often the precipitating event for fractures in this population, linked to common aging physiology with increasing comorbid conditions and advancing frailty. Managing falls and orthopedic fractures in the geriatric population is complex, requiring a systematic and collaborative approach spearheaded by a multidisciplinary team focused on improving patient outcomes.

Successful outcomes after colorectal surgery result not only from technique in the operating room, but also from optimization of the patient prior to surgery. This article will discuss the role of preoperative assessment and optimization in the colorectal surgery patient. Through discussion of the various clinical models, readers will understand the range of options available for optimization. This study will also present information on how to design a preoperative clinic and the barriers to success.

Appropriate preoperative screening techniques are needed to safely provide anesthesia to increasing numbers of cannabis using surgical patients.
This was a quasi-experimental quality improvement project.
Preoperative identification of cannabis users by registered nurses (RNs) and certified registered nurse anesthetists (CRNAs) was compared to baseline identification rates. CRNAs\' compliance with evidenced base guidelines was recorded. Perioperative medication requirements were recorded and compared between cannabis-users and noncannabis users.
Identification of cannabis users by CRNAs conducting preanesthetic assessments increased from 4.08% to 14.36% while RN identification improved from 11.22% to 13.81%. Compliance with identification guidelines was 69.2% among CRNAs. There were no differences in anesthetic requirements, complications, or postanesthesia care unit (PACU) length of stay between cannabis users and nonusers.
Preoperative identification of cannabis users allows for safer, more effective perioperative care by CRNAs, registered nurses, and surgical staff.

The accuracy and timeliness of documenting a medication history is an important aspect to ensure appropriate medication reconciliation during transitions of care. Surgical patients often have their medication history recorded just moments before surgery which may be rushed, incomplete or missed entirely. Between January and May 2020, 76.7% of surgical patients admitted to our institution had a medication history completed by a pharmacist prior to surgery.
The objective of this work is to improve the pharmacist medication history completion rates for pre-surgical patients before surgery by integrating pharmacist-led medication histories into the pre-operative pathway.
Through interdisciplinary collaboration, the pre-operative pathway for surgical patients was evaluated for opportunities to complete medication histories days prior to their scheduled procedure. Plan-Do-Study-Act (PDSA) cycles were utilized to make incremental improvements in practice.
Through an iterative process, the pathway for cardiovascular surgery (CVS) patients was modified to include a scheduled pharmacist phone appointment in the days leading up to their surgical procedure. Utilizing these phone appointments, pharmacists complete patient medication history reviews and share a feedback loop to cardiovascular and peri-operative health care providers.
The iterative PDSA cycles revealed challenges to completing pre-surgical medication history calls without advance notice. Patient responsiveness to pre-surgical medication history calls improved with the incorporation of scheduled phone appointments. Between January 18 and May 31, 2021, pharmacists completed 359 of 376 scheduled CVS appointments (95.5%), improving the medication history completion rates for cardiovascular surgery patients from 84.8 to 93.0% (p = 0.000025). The completion rate for all surgical patients also improved from 76.7 to 85.1% (p < 0.00001).
Incorporating scheduled pharmacist medication history appointments as a part of the pre-operative pathway was shown to expand the capacity for pharmacists to complete medication histories for patients prior to surgery. By reducing pharmacist workload on the morning of surgery, fewer patients were admitted to surgery without having their medication history reviewed by pharmacy. Future investigation should be considered to evaluate the impact on patient outcomes.

BACKGROUND: Despite the prevalence of renal impairments, the existing literature examining fracture healing in the upper limb in patients with renal impairment is sparse. This study hence aims to investigate the effect of renal impairment on time to fracture healing after distal radius fracture fixation surgery.
METHODS: Patients above 50 years old who underwent distal radius fracture fixation via volar plating were included. Time to fracture healing was defined as duration between day of surgery and presence of radiographic union as evidence by bridging of callus or osseous bone. To assess for renal impairment, estimated glomerular filtration rate (eGFR) was calculated based on the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Pre-existing comorbidities were also collected and analysed.
RESULTS: Ninety-nine consecutive patients took mean 65.5 ± 8.0 days to fracture healing post-operatively. Patients with renal impairment had longer time to fracture healing than patients without (67.1 ± 50.4 days versus 50.4 ± 31.8 days, p = 0.044). Patients ≥ 65 years also had a longer duration to fracture healing compared to patients < 65 years (mean 63.7 ± 53.0 days versus 50.2 ± 27.2 days, p = 0.033). Similarly, patients with ASA Class I had a shorter mean time to fracture healing than patients with ASA Class II and above (mean 42.5 ± 22.8 days versus 62.8 ± 47.6 days, p = 0.028).
CONCLUSIONS: Time to fracture healing post-distal radius fracture fixation was significantly related to renal impairment, age and ASA classification.