Maternal mortality due to obstetric hemorrhage by surgical injury during cesarean section: A nationwide study.

INTRODUCTION: Obstetric hemorrhage remains a largely preventable cause of maternal mortality globally. The contribution of uterine atony to hemorrhage-related maternal mortality has decreased in France, while the contribution of other causes of obstetric hemorrhage such as surgical injury during cesarean has been reported to increase. However, little evidence exists regarding the risk factors and care processes of women who died from this cause of hemorrhage. Therefore, we aimed to describe the clinical profile, underlying mechanisms, and preventability factors among women who died from obstetric hemorrhage by surgical injury during cesarean section. MATERIAL AND METHODS: Nationwide analysis of all hemorrhage-related maternal deaths by surgical injury during cesarean in France identified by the nationwide permanent enhanced maternal mortality surveillance system (ENCMM) between 2007 and 2018. We described the characteristics of the women, delivery hospitals, circumstances of hemorrhage, features of obstetric and resuscitation/transfusion care, and main preventability factors. RESULTS: Between 2007 and 2018, hemorrhage-related maternal mortality in France decreased from 1.6/100 000 live births (95% CI 1.1-2.2) (39/2 472 650) in 2007-2009 to 0.8/100 000 live births (95% CI 0.5-1.3) (19/2 311 783) in 2016-2018. Hemorrhage-related maternal mortality ratio due to surgical injury during cesarean increased from 0.08 (95% CI 0.01-0.3) (2/2 472 650) to 0.2 (95% CI 0.07-0.5) (5/2 311 783) per 100 000 live births. Among the 18 women who died from surgical injury during cesarean over the 12-year study period, we report a high prevalence of obesity (67%, 12/18), previous cesarean (72%, 13/18), and second-stage cesareans (56%, 10/18). In 22% (4/18), cesarean section was performed in a hospital providing <1000 births annually, with no blood bank (39%, 7/18) or no adult intensive care (44%, 8/18) on-site. Overall preventability of deaths was 94% (17/18). Main preventability factors were related to delay in hemorrhage diagnosis (77%, 14/18) due to late recognition of abnormal parameters (33%, 6/18) and late bedside ultrasound (56%, 10/18), and delay in management due to insufficient surgical skills (56%, 10/18). CONCLUSIONS: In France, surgical injury during cesarean section is an increasing, largely preventable contributor to hemorrhage-related maternal mortality, as other causes of fatal hemorrhage have become less frequent. The profile of these women showed a high prevalence of obesity, previous cesarean, second-stage cesarean, and delivery in hospitals with limited medical and surgical resources, which suggests explanatory mechanisms for the fatal outcome and opportunities for prevention.

Effects of surgical trauma and intraoperative blood loss on tumour progression.

Surgery is the primary treatment of choice for tumours, and improves prognosis, prolongs survival and is potentially curative. Previous studies have described the effects of anaesthesia and changes in the neuroendocrine, circulatory and sympathetic nervous systems on postoperative cancer progression. There is growing evidence that intraoperative blood loss is an independent prognostic factor for tumour recurrence, postoperative inflammation is a predictor of cancer prognosis, and immunosuppressive status correlates with the degree of surgical damage. This paper outlines the potential mechanisms by which blood loss, surgical trauma and postoperative immunosuppressive status contribute to tumour growth and recurrence by reducing intraoperative haemorrhage and perioperative immunotherapy, thereby reducing tumour growth and recurrence, and improving long-term prognosis.

The updated surgical steps of gasless transaxillary endoscopic thyroidectomy with neck level and region orientation for thyroid cancer.

Introduction: We previously made a detailed expansion to the gasless transaxillary endoscopic thyroidectomy(GTET) procedure described in the previous literatures. In this study, we optimized the procedure focused on the limitation of the approach in terms of trauma and lymph node dissection and made a comparison with the early procedure. Materials and methods: This paper gave a detailed description of the updated procedure and prospectively collected data about patients with papillary thyroid carcinoma(PTC) performed by the two procedures from December 2020 to April 2023. The differences in surgical outcome, surgical trauma and parathyroid gland(PG) function protection were analyzed. Results: Of the 302 patients, 184 underwent with early procedure(EP), and 118 underwent with updated procedure(UP). The surgical outcomes of operative time, time of thyroidectomy and central neck dissection, blood loss, drainage and postoperative hospital stay were shorter in UP than that of the EP. The mean number of lymph nodes retrieved and weight of dissection lymphatic tissue in the UP were significantly more than that in EP without increasing the mean number of metastatic lymph nodes. Postoperative complications did not differ between the two procedures. The UP had more advantages in the identification and preservation of the superior parathyroid gland, however, it did not improve the preservation in situ of the inferior parathyroid gland. The visual analog scale score for pain and the changes among inflammation factors was lower in the UP. Conclusion: The UP of GTET could perform safely and efficiently while reducing surgical trauma in selected patients.

Management of an inadvertent late filtering bleb and hypotony in a scleral fixated intraocular lens implantation.

PURPOSE: To report a case of inadvertent cystic filtering bleb in a patient with scleral fixated intraocular lens (SFIOL) implantation 7 years after initial procedure. CASE PRESENTATION: A 14-year-old boy underwent lensectomy, vitrectomy and a sutured rigid SFIOL for microspherophakia in the right eye. Seven years later, the patient presented with hypotony related ocular changes. Examination revealed an inadvertent cystic filtering bleb at the scleral section. Anterior segment optical coherence tomography (ASOCT) revealed gap in inner lips of the scleral wound, bridged by a thin strip of scleral tissue. A conservative management with bandage contact lens (BCL) failed after an initial improvement. Injection of trypan blue dye in the anterior chamber confirmed the presence and site of wound filtration. Surgical closure of the fistula was done and patient showed both structural and visual improvement. CONCLUSION: Meticulous wound construction and water tight closure at the end of the surgery can avoid such complications. ASOCT can be helpful in diagnosing the area of fistula. A conservative management with BCL can help by tamponading the filtering bleb. However, in unresponsive cases, surgical closure of the fistula is recommended to improve the hypotony-related changes.

Early outcomes of oblique lateral interbody fusion with posterior fixation versus posterior interbody fusion with fixation for treating adult degenerative scoliosis.

OBJECTIVE: To compare the surgical trauma and outcomes between oblique lateral interbody fusion (OLIF) and posterior fixation and posterior lumbar interbody fusion (PLIF) with fixation for adult degenerative scoliosis (ADS). METHODS: We included ADS patients who underwent OLIF with fixation or PLIF with fixation treatment from June 2020 to December 2022. The preoperative and postoperative spinal pelvic parameters were measured using X-rays. Clinical symptoms were measured using the Oswestry Disability Index and a visual analog scale. We recorded operation time, intraoperative blood loss, blood transfusion, albumin infusion, surgical fixation segment, surgical osteotomy segment, time, and drainage volume. RESULTS: Forty patients with ADS were included: 20 with OLIF with posterior fixation and 20 with PLIF matched for age, sex, pelvic incidence, and Cobb angle with the OLIF group. There were no significant differences in age, gender, BMI, preoperative spinal parameters, or preoperative clinical symptoms between the groups (p > 0.05). There were no statistical differences in postoperative spinal parameters or clinical symptoms (p > 0.05). Patients in the OLIF group had less intraoperative blood loss (p < 0.01) and fewer intraoperative blood transfusions (p < 0.001) than the posterior surgery group. The number of fixed segments was fewer (p < 0.01), and there were fewer total osteotomy segments (p < 0.001). CONCLUSION: OLIF with posterior fixation surgery can achieve the same corrective effect and efficacy as a posterior internal fusion with fixation surgery for treating ADS. OLIF with posterior fixation surgery causes less trauma and reduces the number of fixation segments.

Post-Traumatic Stress Response and Appendicitis in Children-Clinical Usefulness of Selected Biomarkers.

Acute appendicitis is an inflammatory process which is one of the most frequent global causes of surgical interventions in children. The goal of the study was to determine whether acute phase proteins, that is, C-reactive protein (CRP), procalcitonin (PCT) and neutrophil gelatinase-associated lipocalin (NGAL), interleukin 6 (IL-6), transforming growth factor-beta1 (TGF-ß1) and cortisol (HC) play a role in the pathomechanism of post-trauma stress response of the organism and to establish the impact of the applied surgical procedure and/or of inflammation on their concentrations. An additional purpose was to establish the clinical usefulness of the studied biomarkers in the diagnostics of appendicitis. CRP concentrations were quantified via the immunoturbidimetric method, while the levels of IL-6 and PCT were assessed using a bead-based multiplexed immunoassay system in a microplate format (Luminex xMAP technology); NGAL, TGF-ß1 and cortisol concentrations were determined via the enzyme-linked immunosorbent assay (ELISA) technique. All the investigated biomarkers were assayed twice, i.e., immediately before the surgery and 12-24 h after its completion. Significant increases in CRP, IL-6 and PCT concentrations were found in all children subjected to laparoscopic surgeries (p = 0.001, p = 0.006, and p = 0.009, respectively) and open (classic) surgeries (p = 0.001, p = 0.016, and p = 0.044, respectively) compared to the initial concentrations. The patients undergoing classical surgery moreover presented with significant (p = 0.002, and p = 0.022, respectively) increases in NGAL and TGF-ß1 levels after the procedures. In a group of children undergoing laparoscopic surgery, the appendicitis induced an increase in cortisol concentration, whereas in patients undergoing classical surgery the increase in the levels of this biomarker was caused by the type of performed surgical procedure. Simultaneously assaying the levels of CRP, NGAL and IL-6 (p = 0.008, p = 0.022, and p = 0.000, respectively) may prove useful in clinical practice, enabling the diagnosis of appendicitis in paediatric patients reporting to a hospital with abdominal pains, in addition to data from anamnesis and from clinical or ultrasound examination. The performed study confirms the participation of examined biomarkers in the pathomechanism of post-injury stress reaction of the organism to surgical trauma.

Laparoscopic-Assisted Colorectal Resection Can Reduce the Inhibition of Immune Function Compared with Conventional Open Surgery: A Retrospective Clinical Study.

BACKGROUND: Immune function is an important indicator for assessing postoperative recovery and long-term survival in patients with malignancy, and laparoscopic surgery is thought to have a less suppressive effect on the immune response than open surgery. This study aimed to investigate this effect in a retrospective clinical study. METHODS: In this retrospective clinical study, we enrolled 63 patients with colorectal cancer in the Department of General Surgery of the First Affiliated Hospital of Soochow University and assessed the changes in their postoperative immune function by measuring CD3+T, CD4+T, CD8+T lymphocytes, and CD4+/CD8+ ratio. RESULTS: Compared with open surgery, laparoscopic colorectal surgery was effective in improving the postoperative decline in immune function. We determined that the number of CD4+, CD8+T lymphocytes, and the CD4+/CD8+ ratio was not significantly reduced in the laparoscopic group. CONCLUSION: Laparoscopic-assisted colorectal resection can reduce the inhibition of immune functions compared with conventional open surgery.

Parameters of Metabolic Response to Surgical Trauma Induced via Unilateral Total Mastectomy Associated or Not to Ovariohysterectomy in Dogs.

Surgical excision of solid tumors is required for local control of neoplasms. However, surgical trauma can stimulate the release of proangiogenic growth factors, suppressing cell-mediated immunity and favoring the development of micrometastases and progression of residual disease. The present study aimed to evaluate the intensity of the metabolic response to trauma induced via unilateral mastectomy in bitches with mammary neoplasia, the consequences of its joint performance with ovariohysterectomy, and their respective effects on the organic response. Two groups of animals were evaluated in seven perioperative moments, namely, unilateral mastectomy (G1) and unilateral mastectomy associated with ovariohysterectomy (G2). Thirty-two female dogs were selected, ten clinically healthy, and twenty-two diagnosed with mammary neoplasia. Surgical trauma reduced serum concentrations of albumin and interleukin-2 but increased blood levels of glucose and interleukin-6 in the postoperative of G1 and G2 patients. Moreover, serum cortisol levels increased after unilateral mastectomy associated with ovariohysterectomy. Our findings allowed us to conclude that unilateral mastectomy induces significant metabolic alterations in female dogs with mammary neoplasms and its joint performance with ovariohysterectomy increases the organic response to trauma.

Postoperative results after iris reconstruction with an Artificialiris® implant with consideration of the cause of the iris defects.

PURPOSE: To test the hypothesis that severely damaged eyes are more likely to experience postoperative complications after an ArtificialIris® (AI) implantation than other iris defects. METHODS: Patients after iris reconstruction with an AI were included in this consecutive case series of the Department of Ophthalmology, University of Mainz, Germany. Best-corrected visual acuity (BCVA), objective refraction (KR 8900 Topcon, Tokyo, Japan) and Scheimpflug imaging of the anterior segment with Pentacam® (Oculus, Wetzlar, Germany)and postoperative complications were evaluated. RESULTS: Thirty-two eyes of 32 patients after AI implantation were included, separated in partial or total aniridia in a closed globe (group 1, n = 16) and after perforating globe injury (group 2, n = 16). Two or more previous surgeries in the corresponding eye were found in two patients (12.5%) in group 1 and eleven patients (69%) in group 2 (p = 0.001). The time span between initial trauma or iris defect and AI implantation was not significantly related to the occurrence and severity of postoperative complications (p = 0.89). Postoperative complications were classified into mild and severe and showed no differences between group 1 and group 2 (mild: 1 vs. 0; p = 0.52; severe: 5 vs. 6 p = 0.8). CONCLUSION: AI implantation is a treatment option for various iris defects. An individual, case-based decision should be made with strict indication also considering other possible methods for pupil reconstruction. The postoperative outcome is not affected by the time point of AI implantation. So, an implantation is already possible as early as six weeks after the previous trauma.

Electroacupuncture alleviates perioperative hypothalamus-pituitary-adrenal axis dysfunction via circRNA-miRNA-mRNA networks.

Electroacupuncture (EA) has long been used to alleviate surgery-induced hypothalamic-pituitary-adrenal axis dysfunction. However, its downstream gene targets in the brain remain unclear. The aim of the present study was to clarify the potential targets of EA based on RNA sequencing techniques (RNA-seq). Rats were divided into normal control (NC), hepatectomy surgery (HT), HT + EA, and HT + sham EA groups followed by RNA-seq of two representative nuclei in the hypothalamus and amygdala. Weighted Gene Co-expression Network Analysis and Gene Set Enrichment Analysis identified six gene modules associated with neuroendocrine transmitters and neural remodeling in the hypothalamus. Furthermore, circRNA-miRNA-mRNA interaction networks revealed EA-related candidate miRNAs and circRNAs, of which opioid receptor mu 1 might be an EA-specific target, and showed regulation by competing endogenous RNA. We identified the neuroendocrine circRNA-miRNA-mRNA networks through which EA has an effect on HPA axis dysfunction, thus providing potential targets and future research directions for EA treatment.

An Individualized, Less-Invasive Surgical Approach Algorithm Improves Outcome in Elderly Patients Undergoing Mitral Valve Surgery.

BACKGROUND: For mitral valve surgery (MVS) in elderly, frail patients with increasing life expectancy, finding the least harmful means of access is a challenge. In the complexity of MVS approach evolution, using three different approaches (mini-thoracotomy (MT), partial upper-sternotomy (PS), full-sternotomy (FS), we developed a personalized, minimized-invasiveness algorithm for MVS. METHODS: In this retrospective analysis, 517 elderly patients (≥70 years) were identified who had undergone MVS ± TV repair. MVS was performed via MT (n = 274), FS (n = 128) and PS (n = 115). The appropriate access type was defined according to several clinical patient conditions. Using uni- and multivariate regression models, we analyzed combined operative success (residual MV regurgitation, conversion to MV replacement or larger thoracic incisions); perioperative success (30-days mortality, thoracotomy, ECMO, pacemaker implantation, dialysis, longer ventilation); and reoperation-free long-term survival. An additional EuroSCORE2 adjustment was performed to reduce the bias of clinical conditions between all access types. RESULTS: The EuroSCORE2-adjusted Cox regression analysis showed significantly increased reoperation-free survival in the MT cohort compared to FS (HR 0.640; 95% CI 0.442-0.926; p = 0.018). Mortality was additionally reduced after the implementation of PS (p = 0.023). Combined operative success was comparable between the three access types. The perioperative success was higher in the MT cohort compared to FS (OR 2.19, 95% CI 1.32-3.63; p = 0.002). CONCLUSION: Less-invasive approaches in elderly patients improve perioperative success and reoperation-free survival in those undergoing MVS procedures.

Plasma proteomic changes in response to surgical trauma and a novel transdermal analgesic treatment in dogs.

Assessment of pain responses and inflammation during animal surgery is difficult because traditional methods, such as visual analogue scores, are not applicable while under anaesthesia. Acute phase proteins (APPs), such as C-reactive protein and haptoglobin, that are typically monitored in veterinary research, do not show a significant change until at least 2 h post-surgery and therefore, immediate pathophysiological changes are uncertain. The current study used sequential window acquisition of all theoretical mass spectra (SWATH-MS) to investigate plasma proteome changes that occur immediately following surgery in dogs and also to assess the efficacy of a novel transdermal ketoprofen (TK) formulation. Castration was chosen as surgical model in this study. The procedure was performed on twelve dogs (n = 6 in two groups) and blood samples were collected at 0 h, 1 and 2 h after surgery for proteomic analysis. Following surgery, there was a general downregulation of proteins, including complement C- 3, complement factor B, complement factor D, transthyretin, and proteins associated with lipid, cholesterol, and glucose metabolisms, reflecting the systemic response to surgical trauma. Many of these changes were diminished in the transdermal group (TD) since ketoprofen, a non-steroidal anti-inflammatory drug (NSAID), inhibits prostanoids and the associated chemotactic neutrophil migration to site of tissue injury. SIGNIFICANCE: SWATH-MS Proteomic analysis revealed significant changes in plasma proteins, predominantly involved in early acute phase and inflammatory response at 1 & 2 h after surgery in castrated dogs. Pre-operative application of transdermal ketoprofen formulation had reduced the systemic immune response, which was confirmed by negligible alteration of proteins in transdermal treated group. A key outcome of this experiment was studying the efficacy of a novel transdermal NSAID formulation in dogs.

The Therapeutic Potential of Targeting Key Signaling Pathways as a Novel Approach to Ameliorating Post-Surgical Adhesions.

BACKGROUND: Peritoneal adhesions (PA) are a common complication of abdominal operations. A growing body of evidence shows that inhibition of inflammation and fibrosis at sites of peritoneal damaging could prevent the development of intra-abdominal adhesions. METHODS: A search of PubMed, Medline, CINAHL and Embase databases was performed using the keywords 'postsurgical adhesion', 'post-operative adhesion', 'peritoneal adhesion', 'surgery-induced adhesion' and 'abdominal adhesion'. Studies detailing the use of pharmacological and non-pharmacological agents for peritoneal adhesion prevention were identified, and their bibliographies were thoroughly reviewed to identify further related articles. RESULTS: Several signaling pathways, such as tumor necrosis factor-alpha, tissue plasminogen activator, and type 1 plasminogen activator inhibitor, macrophages, fibroblasts, and mesothelial cells play a key part in the development of plasminogen activator. Several therapeutic approaches based on anti-PA drug barriers and traditional herbal medicines have been developed to prevent and treat adhesion formation. In recent years, the most promising method to prevent PA is treatment using biomaterial-based barriers. CONCLUSION: In this review, we provide an overview of the pathophysiology of adhesion formation and various agents targeting different pathways, including chemical agents, herbal agents, physical barriers, and clinical trials concerning this matter.

Neuroinflammation as the Underlying Mechanism of Postoperative Cognitive Dysfunction and Therapeutic Strategies.

Postoperative cognitive dysfunction (POCD) is a common neurological complication following surgery and general anesthesia, especially in elderly patients. Severe cases delay patient discharge, affect the patient's quality of life after surgery, and are heavy burdens to society. In addition, as the population ages, surgery is increasingly used for older patients and those with higher prevalences of complications. This trend presents a huge challenge to the current healthcare system. Although studies on POCD are ongoing, the underlying pathogenesis is still unclear due to conflicting results and lack of evidence. According to existing studies, the occurrence and development of POCD are related to multiple factors. Among them, the pathogenesis of neuroinflammation in POCD has become a focus of research in recent years, and many clinical and preclinical studies have confirmed the correlation between neuroinflammation and POCD. In this article, we reviewed how central nervous system inflammation occurred, and how it could lead to POCD with changes in peripheral circulation and the pathological pathways between peripheral circulation and the central nervous system (CNS). Furthermore, we proposed some potential therapeutic targets, diagnosis and treatment strategies at the cellular and molecular levels, and clinical applications. The goal of this article was to provide a better perspective for understanding the occurrence of POCD, its development, and preventive strategies to help manage these vulnerable geriatric patients.

Tissue Damage, Not Infection, Triggers Hepatic Unfolded Protein Response in an Experimental Rat Peritonitis Model.

Background: Abdominal surgery is an efficient treatment of intra-abdominal sepsis. Surgical trauma and peritoneal infection lead to the activation of multiple pathological pathways. The liver is particularly susceptible to injury under septic conditions. Liver function is impaired when pathological conditions induce endoplasmic reticulum (ER) stress. ER stress triggers the unfolded protein response (UPR), aiming at restoring ER homeostasis, or inducing cell death. In order to translate basic knowledge on ER function into the clinical setting, we aimed at dissecting the effect of surgery and peritoneal infection on the progression of ER stress/UPR and inflammatory markers in the liver in a clinically relevant experimental animal model. Methods: Wistar rats underwent laparotomy followed by colon ascendens stent peritonitis (CASP) or surgery (sham) only. Liver damage (aspartate aminotransferase (AST), alanine aminotransferase (ALT) and De Ritis values), inflammatory and UPR markers were assessed in livers at 24, 48, 72, and 96 h postsurgery. Levels of inflammatory (IL-6, TNF-α, iNOS, and HO-1), UPR (XBP1, GRP78, CHOP), and apoptosis (BAX/Bcl-XL) mRNA were determined by qPCR. Splicing of XBP1 (XBP1s) was analyzed by gel electrophoresis, p-eIF2α and GRP78 protein levels using the western blots. Results: Aspartate aminotransferase levels were elevated 24 h after surgery and thereafter declined with different kinetics in sham and CASP groups. Compared with sham De Ritis ratios were significantly higher in the CASP group, at 48 and 96 h. CASP induced an inflammatory response after 48 h, evidenced by elevated levels of IL-6, TNF-α, iNOS, and HO-1. In contrast, UPR markers XBP1s, p-eIF2α, GRP78, XBP1, and CHOP did not increase in response to infection but paralleled the kinetics of AST and De Ritis ratios. We found that inflammatory markers were predominantly associated with CASP, while UPR markers were associated with surgery. However, in the CASP group, we found a stronger correlation between XBP1s, XBP1 and GRP78 with damage markers, suggesting a synergistic influence of inflammation on UPR in our model. Conclusion: Our results indicate that independent mechanisms induce ER stress/UPR and the inflammatory response in the liver. While peritoneal infection predominantly triggers inflammatory responses, the conditions associated with organ damage are predominant triggers of the hepatic UPR.

Effect of Upper Arm Position Changes on the Occurrence of Ipsilateral Shoulder Pain After Single-Operator Port Thoracoscopy.

BACKGROUND: The aim of this study was to explore the factors associated with the occurrence of ISP after VATS to reduce the incidence of ISP and improve patients' quality of life. METHODS: The data of patients were collected between June 2020 and August 2020 in the Department of Lung Cancer Surgery, Tianjin Medical University General Hospital. The angle of upper arm was measured intraoperatively. The patient's postoperative shoulder function was quantified using the Constant-Murley shoulder function rating score. The proportional hazards model was applied to identify multiple influence factors. RESULTS: A total of 140 eligible patients met criteria. At postoperative day 3, only the age influenced patients' shoulder pain. At postoperative day 14, univariate and multivariate logistic regression analyses showed that age (odds ratio [OR]: 1.098 [1.046-1.152]; P < 0.001) and upper arm Angle A (OR: 1.064 [1.011-1.121]; P = 0.018) were independent risk factors for low shoulder function scores. However, height was its protective factor (OR: 0.923 [0.871-0.977]; P = 0.006). At postoperative day 42, univariate and multivariate logistic regression analyses showed that age (OR: 1.079 [1.036-1.124]; P < 0.001) was a risk factor for low shoulder function scores, and height (OR: 0.933 [0.886-0.983]; P = 0.009) was its protective factor. In contrast, upper arm Angle B was not statistically associated with low shoulder function scores (P>0.05). In addition, the reduction in ipsilateral Shoulder scores after surgery was higher in patients with more than 113° of angle A (P = 0.025). CONCLUSION: ISP was closely related to the angle of anterior flexion of the upper arm on the patient's operative side intraoperatively. The increase in the degree of postoperative shoulder injury is more pronounced for an anterior flexion angle of >113°. Therefore, we recommend that the angle of anterior flexion of the upper extremity should be <113° intraoperatively.

Worsening COVID-19 Disease Course After Surgical Trauma: A Case Series.

Introduction: Current guidelines from the American Society of Anesthesiologists recommend postponing elective surgery on COVID-19-positive patients for a minimum of four to twelve weeks. However, literature focusing on the outcomes of COVID-19-positive patients undergoing surgery is scarce. In this case series, the outcome of asymptomatic COVID-19 patients undergoing acute or semi-urgent surgery was evaluated. Case Presentation: A case series of four patients between 32 and 82 years old with a confirmed SARS-CoV-2 infection undergoing acute or semi-urgent surgery was presented here. All four patients were asymptomatic for COVID-19, developing severe respiratory failure following endo CABG, caesarian section, a thyroidectomy, or abdominal surgery. ICU admission, together with invasive ventilation, was necessary for all patients. Two patients required venovenous extracorporeal membrane oxygenation treatment. A mortality of 50% was observed. Conclusions: In conclusion, the present case series suggests that elective surgery in asymptomatic SARS-CoV-2 infected patients might elicit an exacerbated COVID-19 disease course. This study endorses the current international guidelines recommending postponing elective surgery for SARS-CoV-2-positive patients for seven weeks, depending on the severity of the surgery and perioperative morbidities, to minimize postoperative mortality.

A singular case of iatrogenic gas-filled double anterior chamber after DALK.

AIM: To present a case of double anterior chamber after DALK and its surgical management. CASE DESCRIPTION: A 67-year-old healthy woman underwent deep anterior lamellar keratoplasty (DALK) in her right eye for keratoconus with the big-bubble technique. About 7 days after surgery a partial detachment of the Descemet membrane from the posterior corneal stroma was revealed using AS-OCT (double anterior chamber appearance). In spite of two injections in the anterior chamber of air and gas on the 7th and 9th post-operative days respectively, the double anterior chamber still persisted. Furthermore, both air and gas passed through the little perforation of the host Descemet membrane-endothelium complex and enlarged the space between the stroma and Descemet membrane. About 10 weeks after DALK, a spontaneous resolution of the double anterior chamber was observed. CONCLUSION: This case suggests that an injection of air or gas into the anterior chamber, to deal with a Descemet membrane detachment following perforation during DALK procedure, can enlarge the double anterior chamber by increasing the space between stroma and Descemet membrane. These cases can be managed with a "wait and see" strategy for a spontaneous resolution to Descemet membrane detachment.

Are Spanish surgeons prepared to treat trauma patients? Multicentre descriptive observational study.

PURPOSE: Specific training in the management of trauma patients is beneficial for surgeons. Training through specific courses in this area has a direct impact on the care of these patients. The aim of this work is to understand the participation and specific training in the care of trauma patients by Spanish surgeons. METHODS: A national survey was conducted and administered to all members of the Spanish Association of Surgeons. The survey assessed their degree of participation in emergency surgery, and therefore the probability of attending trauma patients, their assessment of the initial care of trauma patients in their centre, and their specific training in this field. RESULTS: The survey was completed by 510 surgeons from 47 Spanish provinces, with Catalonia and Andalusia being the most represented regions. In total, 456 (89.41%) of those surveyed work in the emergency department on a routine basis. Only 171 (33.53%) refer to having a registry of trauma patients in their hospital. While 79.02% of surgeons reported that general surgeons are not involved in care of severe trauma from the outset, only 66.47% have completed the ATLS course, 40.78% the DSTC course and 18.82% the MUSEC course. Despite this, 85.69% believe that the ATLS course should be compulsory during residency and 43.33% believe that severe trauma care in their hospital is poor or very poor. CONCLUSION: Only 40% have received specific training in definitive surgical management of severe trauma. Despite this, a large percentage of surgeons work in the emergency department on a routine basis and potentially face the challenge of managing these patients.

GluN2A/ERK/CREB Signaling Pathway Involved in Electroacupuncture Regulating Hypothalamic-Pituitary-Adrenal Axis Hyperactivity.

The hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis caused by stress will inevitably disrupt the homeostasis of the neuroendocrine system and damage physiological functions. It has been demonstrated that electroacupuncture (EA) can modulate HPA axis hyperactivity during the perioperative period. As the initiating factor of the HPA axis, hypothalamic corticotrophin-releasing hormone (CRH) is the critical molecule affected by EA. However, the mechanism by which EA reduces CRH synthesis and secretion remains unclear. Activated N-methyl-D-aspartate receptor (NMDAR) has been linked to over-secretion of hypothalamic CRH induced by stress. To determine whether NMDAR is involved in EA regulating the over-expression of CRH, a surgical model of partial hepatectomy (HT) was established in our experiment. The effect of EA on hypothalamic NMDAR expression in HT mice was examined. Then, we investigated whether the extracellular regulated protein kinases (ERK)/cyclic adenosine monophosphate response element-binding protein (CREB) signaling pathway mediated by NMDAR was involved in EA regulating HPA axis hyperactivity. It was found that surgery enhanced the expression of hypothalamic CRH and caused HPA axis hyperactivity. Intriguingly, EA effectively suppressed the expression of CRH and decreased the activation of GluN2A (NMDAR subunit), ERK, and CREB in HT mice. GluN2A, ERK, and CREB antagonists had similar effects on normalizing the expression of CRH and HPA axis function compared with EA. Our findings suggested that surgery enhanced the activation of the hypothalamic GluN2A/ERK/CREB signaling pathway, thus promoting the synthesis and secretion of CRH. EA suppressed the phosphorylation of GluN2A, ERK, and CREB in mice that had undergone surgery, indicating that the GluN2A/ERK/CREB signaling pathway was involved in EA alleviating HPA axis hyperactivity.