British Journal of Anaesthesia

BackgroundThere is disparity between the incidence of malignant hyperthermia (MH) reactions and the prevalence of variants in the RYR1 gene associated with susceptibility to MH (where susceptibility is determined by in vitro contracture tests). Our aims were to use clinical and genetic data from the UK to explain this disparity and to examine if these data are consistent with the clinical risk of MH being inherited as an autosomal dominant trait. MethodsClinical MH and genotyping data were extracted from the UK MH registry. The numbers of general anaesthetics delivered in the UK were estimated from national surveys and reports, with population data obtained from government statistics. The prevalence of RYR1 variants in the UK population was estimated using UK Biobank data. The incidence of MH reactions 1988-93 was used to estimate the prevalence of the clinical risk of MH in the UK. Bayesian modelling, calibrated against actual data, was used to evaluate the likely mode of inheritance of the clinical risk of MH and the relative risk of clinical MH associated with different RYR1 variants. ResultsThe probability of index cases developing MH with each general anaesthetic can be expressed as a constant hazard of 0.46 (95% CI 0.42 - 0.50, n=375). We used peak incidence data (1988-93) to estimate the prevalence of the risk of MH as 1 in 44,000 (95% credibility interval, 1 in 40,000 to 1 in 48,000). The incidence of MH has declined over the past 22 years but the rate of decline is inconsistent with autosomal dominant inheritance (P < 10-10). The risk of MH varied by up to 150-fold between carriers of 28 recurrent RYR1 variants. ConclusionThese findings support a threshold inheritance model for clinical MH and have implications for diagnostics, both genotyping and in vitro contracture test phenotyping.

BackgroundPropofol dosing guidelines recommend age-based reductions because hypnotic sensitivity increases in older adults. Most real-world evaluations of induction practice, however, have relied on total weight-normalized dose (mg/kg) rather than estimating cerebral exposure using pharmacokinetic models. Because age-related pharmacokinetic changes alter the relationship between administered dose and peak effect-site concentration (Ce,max), mg/kg surrogates may misrepresent true age-dependent exposure during induction. MethodsA retrospective reconstruction of 250,640 adult anesthetic inductions was performed using high-fidelity EHR medication timestamps. Propofol effect-site concentration trajectories were simulated at 1-second resolution using the Eleveld model. Ce,maxwas benchmarked against age-adjusted hypnotic requirements (Ce50) derived from the Eleveld model (standardized to a target Bispectral Index{approx} 47). Age-exposure relationships were estimated using covariate-adjusted natural cubic splines, controlling for BMI, sex, and ASA physical status. ResultsFrom young adulthood (18-24 years) to the oldest cohort (85-89 years), weight-normalized induction doses were reduced by 32% (3.16 to 2.16 mg/kg). However, modeled Ce,max declined by only 17% (3.70 to 3.06 {micro}g/mL), while the estimated physiological requirement declined by 34% (3.37 to 2.21 {micro}g/mL), creating a widening titration offset with age. At age 75, the adjusted probability of exceeding the individual hypnotic requirement was 89.6% (95% CI: 89.3-89.8%). Notably, 54.7% (95% CI: 54.2-55.2%) of 75-year-old patients achieved peak exposures exceeding the aver-age requirement of a healthy 20-year-old, indicating persistent anchoring of exposure to youthful levels. Findings were robust across model specifications and inclusion criteria. ConclusionsIn over a quarter-million inductions, real-world age-based dose re-ductions did not produce proportional reductions in peak propofol brain exposure. Achieved concentrations declined far more slowly than modeled geriatric sensitivity increases, consistent with systematic over-exposure in older adults. These findings suggest that weight-based dosing heuristics inadequately capture age-dependent exposure and support a transition toward exposure-informed and neurophysiologically guided induction titration in geriatric anesthesia.

Purpose To quantify and compare the peak force applied on the glottis during endotracheal intubation across five laryngoscopy techniques, two intubation conditions (standard and simulated laryngospasm), and two operator experience levels, and to assess the effects of stylet use and operator anthropometric characteristics on applied force. Methods This prospective, manikin-based experimental study enrolled 50 operators (30 experienced, 20 less experienced). Each performed endotracheal intubation using five techniques: direct laryngoscopy and videolaryngoscopy with a Macintosh blade, each with and without stylet, and videolaryngoscopy with a hyperangulated blade with stylet. A calibrated force sensor positioned at the glottis measured peak forces during standard and simulated laryngospasm conditions. Non-parametric statistical methods were used (Mann-Whitney U, Wilcoxon signed-rank, Friedman tests); effect sizes are reported as rank-biserial correlations. Results Across all techniques, median glottic forces ranged from 4.8 N (IQR: 3.3-6.5) for videolaryngoscopy without stylet to 11.1 N (IQR: 7.5-14.5) for direct laryngoscopy with stylet under standard conditions. No significant differences in applied force were observed between experienced and less experienced operators for any technique-condition combination (all adjusted p = 1.0; |r| < 0.27). Stylet use significantly increased glottic force across all conditions and groups (median increases 3.4-7.3 N; all p < 0.001; rank-biserial r > 0.75). Videolaryngoscopy with a Macintosh blade produced significantly lower forces than hyperangulated videolaryngoscopy under standard conditions (adjusted p = 0.049). Neither grip strength nor hand size correlated with applied force. Conclusion Glottic force during endotracheal intubation is determined primarily by technique and stylet use, not operator experience or anthropometrics. Stylet use is the single largest modifiable contributor to glottic force. These findings have implications for device selection, clinical training, and strategies to minimize airway trauma during intubation.

BackgroundPropofol exposure can produce heterogenous neural responses, from the expected suppression to transient paradoxical excitation. EEG measures of signal complexity and entropy have emerged as reliable markers of consciousness, but different types of complexity and entropy measures are often conflated. We used Type I and II complexity measures on the Complexity-Entropy Causal Plane (CECP) to characterize divergent neural trajectories during propofol-induced loss of consciousness. We hypothesized that paradoxical excitation is reflected in both Type I and Type II complexity; that divergent trajectories on the CECP separate paradoxical excitation from suppression; and that baseline EEG complexity is associated with susceptibility to propofol. MethodsWe analyzed EEG data from two independent cohorts of healthy adults receiving propofol: the Chennu dataset (n = 20), which included resting-state baseline, mild, and moderate sedation, followed by a recovery period; and the RecCognition dataset (n = 8), which used escalating infusions from baseline to deep sedation. For each participant and sedation level, we extracted Lempel-Ziv Complexity (LZC; Type I) and Statistical Complexity (SC; Type II) and projected them onto the CECP. Pearson correlations related baseline SC to changes in SC during moderate sedation; behavioral responsiveness; effect-site propofol concentration; and time-to-loss-of-consciousness. ResultsAt moderate sedation, participants who remained responsive showed paradoxical increases in LZC and decreases in SC, whereas unresponsive participants exhibited the opposite pattern. Baseline SC correlated negatively with both the change in SC (r = -0.88) and behavioural responsiveness, indicating that intrinsic brain dynamics influence individual susceptibility to sedation. CECP trajectories revealed a reproducible inflection point demarcating paradoxical excitation from suppression. ConclusionsMapping EEG trajectories on the CECP bridges anesthetic state transitions with underlying neural dynamics. Baseline neural complexity indexes individual sensitivity to propofol, determining whether brain dynamics transiently enter excitation or direct suppression.

BackgroundThe evolving nature of patient concerns during pregnancy and delivery, including labor pain, plays a key role in guiding antenatal counseling about labor and delivery, but the timing of these concerns has not been well characterized. Understanding when labor pain becomes a prominent concern for pregnant patients can inform the timing of antenatal education about labor analgesia. ObjectiveThis study aimed to determine how labor pain ranks among pregnancy-related concerns identified by nulliparous pregnant patients and how the relative prominence of these concerns changes across gestation. MethodWe conducted a prospective, single-center longitudinal cohort study of 53 English-speaking, nulliparous patients. Participants ranked their top seven concerns from a list of 13 pregnancy-related concerns, including labor pain, at 20, 24-, 28-, 32-, and 36-weeks gestation. Rankings were scored from 1 (lowest-ranked concern) to 7 (highest-ranked concern), with the six unranked concerns assigned a score of zero. Changes in labor pain concern scores over time were assessed using linear mixed-effects models, adjusting for maternal characteristics and pregnancy- and fetal-related complications. ResultsThe score for concern about labor pain management increased with advancing gestational age, with mean adjusted rank scores increasing from 1.4 at 20 weeks to 3.8 at 36 weeks (P < 0.001). No demographic or clinical covariates were significantly associated with labor pain score. Peak scores were most commonly reported at 28- and 36-weeks gestation. DiscussionWhile labor pain became a greater salient concern along pregnancy, for some nulliparous patients, concern about labor pain arose as early as 20th week gestation, with significant individual variation in the timing of these concerns.

BackgroundSpinal anesthesia for cesarean delivery commonly causes maternal hypotension, which may compromise uteroplacental perfusion and maternal comfort. Guidelines recommend maintaining maternal blood pressure near baseline with prophylactic vasopressor strategies, yet titration remains reactive. We evaluated an autoregressive with exogenous input (ARX) decision-support algorithm that provides real-time forecasts of maternal mean arterial pressure (MAP) to support vasopressor management during cesarean delivery under spinal anesthesia. MethodsIn this single-center, open-label, prospective pilot study, 20 pregnant patients at term undergoing elective cesarean delivery under spinal anesthesia received standard care supplemented by ARX-generated MAP predictions at 1-, 2- and 3-minute horizons. Clinicians titrated phenylephrine per institutional protocol while reviewing ARX predictions, retaining full autonomy for dosing decisions. Predictive performance was quantified using root mean square error (RMSE), mean absolute error (MAE), coefficient of determination (R{superscript 2}), and fraction of improvement in total error (FIT). ARX-guided patients were matched 1:2 to nonconcurrent controls (n = 40) on attending anesthesiologist and intrathecal bupivacaine dose, with nearest-neighbor matching on age and body mass index. Exploratory outcomes included hypotension (MAP <80% of baseline), phenylephrine dose, maternal nausea, and neonatal outcomes. For minute-level hypotension classification performance, sensitivity/specificity (and related metrics) were estimated using generalized estimating equations (GEE) to account for within-patient clustering of repeated observations. ResultsOne-minute-ahead ARX predictions achieved a mean ({+/-}SD) RMSE of 3.71 {+/-} 3.26 mmHg and MAE of 2.75 {+/-} 2.52 mmHg, with R{superscript 2} 0.34 {+/-} 0.63 and FIT 21.1% {+/-} 18.7%. Predictive performance decreased at longer horizons. For hypotension prediction, one-minute-ahead GEE-estimated population-average sensitivity and specificity were 57.39% and 99.74%, respectively. During the observation window, in exploratory comparisons with matched nonconcurrent controls, ARX-guided patients had a shorter duration of hypotension (0.8 {+/-} 1.9 vs 3.0 {+/-} 3.8 minutes; P = .005) and a lower incidence of hypotension (25.0% vs 52.5%; P = .033), but a higher phenylephrine dose (1823 {+/-} 659 vs 974 {+/-} 328 {micro}g; P = .001). Maternal nausea incidence was lower in the ARX group compared with matched nonconcurrent controls (5% vs 35%; P = .014), with similar neonatal outcomes. ConclusionsIn this prospective pilot study, an ARX decision-support algorithm provided accurate 1-minute-ahead MAP forecasts and was associated with higher phenylephrine dosing and shorter maternal hypotension duration compared with matched nonconcurrent controls. These findings support further evaluation in larger, randomized trials. Summary statementIn this prospective pilot study of 20 patients undergoing cesarean delivery under spinal anesthesia, an autoregressive with exogenous input (ARX) decision-support algorithm provided real-time blood pressure forecasts and was associated with a shorter hypotension duration but higher phenylephrine dose compared with matched nonconcurrent controls. These preliminary data support further evaluation of ARX-guided, algorithmic vasopressor management in larger, multicenter trials. Key PointsO_LIQuestion: In pregnant patients at term undergoing elective cesarean delivery under spinal anesthesia, can a real-time ARX algorithm accurately forecast MAP and support vasopressor management? C_LIO_LIFindings: One-minute-ahead forecasts were accurate (RMSE 3.71 mmHg), and ARX-guided care was associated with a shorter duration of hypotension and a higher phenylephrine dose versus matched nonconcurrent controls C_LIO_LIMeaning: Real-time MAP forecasting is feasible and warrants randomized evaluation to confirm clinical benefit and characterize trade-offs. C_LI

BackgroundIntraoperative opioid administration for cardiac surgery varies greatly, with most of this variability arising from anesthesiologist and institutional practices. Anesthesiologists administer intraoperative opioids via intermittent boluses and continuous infusions. Real-world data have shown infusion administration to be a strong determinant of high intraoperative opioid exposure, but whether bolus or infusion administration of sufentanil affects post-operative outcomes is unknown. MethodsWe conducted a prospective, randomized, single-blind controlled trial to compare the impact of intraoperative intermittent bolus administration versus continuous infusion of sufentanil on time to extubation in adult patients undergoing nonemergent cardiac surgery with cardiopulmonary bypass at a single tertiary referral university hospital in the United States. ResultsThe primary endpoint was the time from operating room departure to extubation in the intensive care unit. The study was terminated early for futility after an interim analysis of 50 subjects. The infusion group received statistically higher doses of intraoperative opioid. The per-protocol analysis found no statistical difference in time to extubation between the bolus group (median 2.9 hours) and infusion group (median 2.6 hours). Secondary outcomes, including post-operative pain scores, opioid consumption, ICU length of stay, and hospital stay, and adverse event rates were comparable between groups. ConclusionsIntraoperative administration of sufentanil via bolus or infusion results in similar time to extubation and recovery metrics. Since continuous infusions are a strong predictor of higher total intraoperative opioid doses, protocols emphasizing administration via intermittent boluses may reduce opioid exposure without compromising recovery. Key PointsO_ST_ABSQuestionC_ST_ABSDoes the method of intraoperative sufentanil administration, either by intermittent bolus or infusion, affect weaning from mechanical ventilation in the intensive care unit after cardiac surgery? FindingsThe method of sufentanil administration did not affect time to extubation after cardiac surgery, but the infusion group received significantly higher intraoperative opioid doses compared to the intermittent bolus group. MeaningIntermittent opioid bolus administration may reduce intraoperative opioid dosage without negatively impacting recovery after cardiac surgery.

BackgroundPostoperative delirium (POD) is a common complication of surgery. It is associated with a number of detrimental effects, including mortality and healthcare costs. We sought to determine whether common comorbidity indices are predictors of POD. MethodsUsing the Medical Information Mart for Intensive Care (MIMIC)-IV database, we identified 8022 abdominal surgery procedures across 7212 adult patients. We calculated both the Charlson comorbidity index (CCI) and the Elixhauser comorbidity index (ECI) for each procedure and used logistic regression to predict postoperative delirium, which was defined as delirium within 30 days following the procedure. ResultsModels based on either the CCI and ECI were predictive of postoperative delirium (area under the receiver-operator characteristic curve (AUC-ROC) of 0.622 and 0.652, respectively). However, the addition of other factors known to be associated with delirium improved model performance (AUC-ROC of 0.680). ConclusionsBoth the CCI and ECI are predictors of postoperative delirium in patients undergoing abdominal surgery. Addition of factors known to be associated with delirium renders additional predictive value and should be included in models that predict postoperative delirium.

Background: Cesarean section is one of the most commonly performed surgical procedures worldwide and is frequently associated with moderate to severe postoperative pain. While overall pain after cesarean delivery is well described, evidence comparing pain intensity and analgesic use between primary and repeat cesarean sections remains limited. Objective: To compare postoperative pain severity and total analgesic consumption within the first 24 hours among women undergoing primary versus repeat cesarean sections under spinal anesthesia at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia, from January 1 to March 30, 2025. Methods: A prospective cohort study was conducted among 203 women who underwent cesarean delivery under spinal anesthesia. Participants were selected using systematic random sampling and categorized into primary and repeat cesarean groups. Demographic and clinical characteristics were summarized using descriptive statistics. Group comparisons were performed using independent t-tests or Mann-Whitney U tests for continuous variables and Chi-square tests for categorical variables. A p-value < 0.05 was considered statistically significant. Results: Women undergoing repeat cesarean sections experienced significantly higher postoperative pain. During movement, 92.1% of women in the repeat group reported moderate to severe pain compared with 66.7% in the primary group (p < 0.001). At rest, moderate to severe pain occurred in 74.3% of the repeat group versus 52.9% of the primary group (p = 0.002). Pain scores within the first 6 hours were also higher in the repeat group (median NRS 7, IQR 7-8) than in the primary group (median NRS 5, IQR 4-7; p < 0.001). Total analgesic consumption was significantly greater among women in the repeat group (243.3 {+/-} 98.4 mg) compared with the primary group (146.3 {+/-} 82.5 mg; p < 0.001). Conclusions: Repeat cesarean sections are associated with higher early postoperative pain and increased analgesic requirements. These findings support the need for individualized and intensified pain management strategies for women undergoing repeat cesarean delivery. Clinical trial number : Not applicable

BackgroundPostoperative delirium is a common complication in surgical patients, and is associated with a multitude of negative outcomes, including mortality, dementia, and increased healthcare costs. Therefore, a better understanding of what factors contribute to postoperative delirium, especially those that can be easily obtained, is important. MethodsWe conducted a retrospective cohort study using patients from the Medical Information Mart for Intensive Care (MIMIC)-IV database. Adult patients undergoing procedures in abdominal surgery who did not have pre-existing delirium were included in the study. Overall, we included 8022 procedures across 7212 patients. For each admission, we extracted values obtained from common blood tests, the Charlson and Elixhauser comorbidity score, and patient demographic information. We used stepwise logistic regression to identify predictive factors of postoperative delirium in this cohort. ResultsThe model isolated factors well known to be associated with postoperative delirium, such as age, comorbidity (as represented by the Elixhauser comorbidity score), and Parkinsons disease. The model also selected variables that are less studied, such as minimum preoperative platelets and maximum preoperative sodium levels. We hypothesize that the former is associated with postoperative delirium as a surrogate marker for inflammation as an acute phase reactant, and the second due to it being a marker for cerebral edema and altered neurotransmission. ConclusionPreoperative blood tests contain valuable information that can be used alongside patient demographics and past medical history to better predict the risk of postoperative delirium.

BackgroundAlthough transnasal transsphenoidal (TNTS) resection is the standard treatment for pituitary adenomas, the procedure carries a risk of hypothalamic-pituitary-adrenal (HPA) axis disruption. This potential for hypocortisolism often prompts the empiric use of perioperative steroids to mitigate hemodynamic instability. However, there is a paucity of data strictly correlating serum cortisol concentrations with intraoperative blood pressure fluctuations. This study sought to evaluate the relationship between perioperative cortisol levels, hemodynamic stability, and the necessity for vasopressors, while also examining the efficacy of prophylactic steroid administration. MethodsWe conducted a prospective observational study involving 90 adult patients (aged 18-60) undergoing elective TNTS at a tertiary care center. Serial serum cortisol measurements were taken at baseline, on the morning of surgery, post-induction, post-sphenid drilling, and during episodes of refractory hypotension. Continuous hemodynamic monitoring included heart rate and arterial pressures (systolic, diastolic, and mean). Hydrocortisone prophylaxis was administered to high-risk patients or those with baseline cortisol <80 ng/ml. Statistical associations were determined using Spearman correlation and multivariate logistic regression models. ResultsOur analysis revealed no statistically significant association between perioperative cortisol levels and the incidence of hypotension or vasopressor requirements across any time point. Furthermore, the administration of prophylactic hydrocortisone failed to demonstrate a reduction in the occurrence of intraoperative hemodynamic instability.

BackgroundPost-anesthetic tracheal extubation can lead to critical adverse events (AEs) in children due to their intolerance to hypoxia. However, evidence from pediatric studies on the factors associated with safe tracheal extubation is limited. We will investigate the incidence and risk factors of AEs associated with tracheal extubation using real-world data from Japan. This study aims to test the following hypotheses: extubation-related AEs are associated with (a) several indicative signs of cranial nerve activity and upper airway reflexes, and (b) difficult airway features. MethodsThis prospective, multi-center, registry-based, cross-sectional study will be conducted at 17 hospitals in Japan from October 2025 to September 2028. It will include children aged <18 years undergoing surgical and/or diagnostic test procedures under general anesthesia or sedation by anesthesiologists. Data on the patient, surgery, and anaesthesia characteristics; provider discipline; airway management; and extubation methodology will be collected. The exposures of interest are the presence of clinical signs related to anesthesia emergence and features of difficult airway. The primary and secondary endpoints are AEs associated with extubation and reduced peripheral arterial oxygen saturation. Multilevel mixed-effects multivariable regression analysis will be performed to adjust for potential confounders associated with AEs attributed to extubation and variations related to the hospital type and institutional level. The required sample size was determined to be approximately 8500 based on the assumptions of a 99% probability of obtaining a 95% Wilson CI with a half-width of {+/-}0.3% and an incidence of any AE of 2.0%. DiscussionThis study is a prospective, registry-based, multicenter, cross-sectional study designed to describe the real-world incidence of AEs related to extubation and the associated risk factors in Japan. This study employs the validation system incorporating site-specific leaders and the REDCap(R) data registration system to minimize reporting and selection bias. We have conducted a pilot study to investigate feasibility and consulted research members regarding data collection and study methods. The findings will provide vital information on the risks associated with extubation-related AEs and contribute to the development of safer tracheal extubation strategies. Trail registration number: jRCT 1030250100

BackgroundEffective postoperative analgesia is therefore critical for patients undergoing thoracoscopic surgery. Ultrasound-guided erector spinae plane block (ESPB) has demonstrated efficacy in reducing postoperative pain following thoracoscopic procedures; however, limited research exists regarding the minimum effective volume (MEV) of local anesthetic required. This study employed the biased coin up-and-down sequential method (BCD-UDM) to determine the MEV of 0.5% ropivacaine for ESPB in patients undergoing thoracoscopic lobectomy, thereby providing robust clinical data for optimizing analgesic protocols. MethodsESPB was performed under ultrasound guidance using 0.5% ropivacaine hydrochloride. An initial volume of 26 mL was chosen. Utilizing the BCD-UDM, the volume administered to each subsequent patient was adjusted based on the analgesic efficacy observed in the previous patient. Specifically, if the prior patient did not achieve the predefined effective analgesia standard, the volume for the next patient was increased by 2 mL. Conversely, if the prior patient achieved effective analgesia, the subsequent volume was randomly reduced by 2 mL with an 11% probability, or left unchanged with an 89% probability. The study concluded upon reaching 45 successful block cases. ResultsA total of 50 patients successfully completed the study. Ordinal regression analysis determined that the MEV90 of 0.5% ropivacaine for ESPB in postoperative analgesia following thoracoscopic lobectomy was 21.1 mL (95% CI, 21.00-22.75 mL). Further adjustment via the pooled adjacent violators algorithm (PAVA) indicated that an ideal volume of 24 mL is optimal for achieving effective analgesia. ConclusionOur findings demonstrate that the MEV90 for 0.5% ropivacaine in ultrasound-guided ESPB for postoperative analgesia after thoracoscopic lobectomy is 21.1 mL (95% CI, 21.00-22.75 mL), with 24 mL representing the ideal volume for clinical application. These results provide valuable insights for optimizing postoperative pain management in thoracoscopic surgery.

Central venous pressure (CVP), a key component of hemodynamic monitoring, is widely used to guide fluid resuscitation in critically ill patients. It is typically measured using central venous line catheterization, which is the gold standard, but this method is invasive, time-consuming, and associated with complications. This study aims to investigate whether machine learning (ML)-based analysis of features extracted from a non-invasive, standard-of-care waveform--the photoplethysmography (PPG) signal--can identify patients with elevated CVP. We trained Light Gradient-Boosting Machine (LightGBM) model using a large perioperative dataset (MLORD), containing 17,327 surgical patients from 2019 to 2022 at UCLA. For this study, we selected 1665 patients with both PPG and CVP waveforms available. A total of 843 PPG features per cardiac cycle (CC) were extracted from the PPG waveforms using a signal processing-based feature extraction tool, along with the simultaneous maximum value calculated from the corresponding CCs in the CVP waveform. Additionally, for each patient, the average and standard deviation of each PPG feature, as well as the mean of the maximum CVP values, were calculated across all cardiac cycles, resulting in 843 averaged PPG features, 843 PPG feature standard deviations, and one averaged maximum CVP value per patient. The average maximum CVP value was used as the ground truth to classify patients as either normal (5 [&le;] CVP [&le;] 15 mmHg) or elevated (CVP > 15 mmHg). Of the 1,665 patients, 1,182 were normal and 483 were elevated. The dataset was split into 90% for training (1,063 normal and 435 elevated) and 10% for testing (119 normal and 48 elevated). From the 1686 PPG features (843 averaged and 843 standard deviation), 246 were selected for model development using the Recursive Feature Elimination with Cross-Validation (RFECV) approach. To further enhance performance, hyperparameters were tuned through 5-fold cross-validation on the training set. Finally, the best-performing configuration was retrained on the full training data, and its performance was evaluated on the held-out test set. To provide a robust estimate and confidence interval, a bootstrapping procedure with 100 iterations was performed on the test set. The LightGBM classifier achieved a mean area under the receiver operating characteristic curve (AUC) of 0.79 (95% CI: 0.71-0.84) and mean accuracy of 0.71 (95% CI: 0.65-0.77), demonstrating good discriminatory power in distinguishing between patients with normal and elevated CVP. This study highlights the ability of PPG-derived features to discriminate between patients with normal and elevated CVP using ML. These early findings lay the groundwork for future research aimed at developing non-invasive approaches to CVP assessment.

ObjectiveTo define contemporary medium and long term survival and durability outcomes after elective fenestrated and branched endovascular aortic repair (F/BEVAR) for complex abdominal and thoracoabdominal aneurysms and to assess the certainty of the available evidence. Data SourcesMEDLINE, Embase and the Cochrane Library were searched from January 2000 to February 2026, supplemented by citation screening. Review MethodsPublished Kaplan Meier time-to-event data were digitised and reconstructed into individual patient datasets. Pooled survival probabilities were generated using validated methods for meta-analytic methods for survival curves. Certainty of evidence was assessed using the GRADE framework. ResultsTwenty-four studies comprising 8,886 patients were included. Pooled overall survival was 91.3% (95% CI: 90.7, 91.9) at 1 year, 73.0% (95%CI: 71.9, 74.0) at 3 years and 55.4% (95% CI: 53.9, 56.8) at 5 years. Estimated median overall survival was 6.36 years. At 5 years, freedom from aneurysm-related mortality was 96.4% (95%CI: 95.3, 97.2), freedom from reintervention was 66.5% (95%CI: 64.6, 68.2), and target vessel patency (TVP) was 94.8% (95%CI: 93.3, 96.0). Certainty of evidence was low for overall survival, aneurysm related mortality and reintervention, and very low for TVP. ConclusionElective F/BEVAR provides durable aneurysm exclusion with low aneurysm related mortality; however, long term survival declines substantially. There is a need for more robust survival data and improved tools to support patient selection, shared decision making, and assessment of anticipated benefit when considering prophylactic complex endovascular repair. What this paper addsThis study provides a time-to-event synthesis of medium and long term outcomes after elective F/BEVAR for complex abdominal and thoracoabdominal aortic aneurysms, analysing reconstructed survival data from 8,886 patients across 24 studies published between 2000 and 2025. This analysis provides empirical survival data to inform recent European Society for Vascular Surgery guidance, demonstrating a median survival of 6.36 years and showing that most late deaths are not aneurysm related. These findings quantify the divergence between procedural durability and long term survival, supporting an individualised treatment strategy grounded in assessment of life expectancy, competing risk and shared decision making.

BackgroundMiddle meningeal artery embolization (MMAE) has emerged as an adjunct or alternative strategy for the management of chronic subdural hematoma (cSDH). Although accumulating studies suggest potential benefit, uncertainty remains regarding its safety profile, recurrence-prevention effect, and the reliability of adverse event reporting. This systematic review and meta-analysis re-evaluate contemporary evidence, incorporating new randomized trials and large observational cohorts. MethodsThis systematic review was conducted in accordance with PRISMA 2020 guidelines and prospectively registered in PROSPERO. PubMed, Scopus, Web of Science Core Collection, Embase, and CENTRAL were searched from inception to 12 September 2025 without language restrictions. Randomized controlled trials, prospective or retrospective cohort studies, and non-randomized clinical studies evaluating middle meningeal artery embolization (MMAE) for chronic subdural hematoma were eligible. Data extraction and risk-of-bias assessment were performed independently using Joanna Briggs Institute appraisal tools. Where outcomes were sufficiently comparable, quantitative synthesis was undertaken using random-effects single-arm proportion meta-analysis with logit transformation. Recurrence after MMAE was pooled across observational studies and MMAE arms of randomized trials with available event-level data, with prespecified subgroup analyses by study design. Mortality was synthesized from randomized trials reporting event-level data within a [&le;]90-day follow-up window. Complication rates and technical success were analyzed descriptively due to heterogeneity in definitions and follow-up durations. ResultsNineteen studies met eligibility criteria, including seven randomized controlled trials, sixteen retrospective cohorts, and one prospective cohort, comprising an elderly and medically complex population (mean ages 61-89 years). Common comorbidities included hypertension, diabetes, cardiovascular and cerebrovascular disease, renal dysfunction, and antithrombotic use. Technical success of middle meningeal artery embolization (MMAE) was consistently high, with a pooled success rate of 100% (95% CI 0.99-1.00; I2 = 0%). Recurrence after MMAE was consistently low across randomized and observational studies, including high-risk populations, and was uniformly lower than in comparator groups. Radiographic outcomes showed substantial hematoma volume reduction and high rates of complete or near-complete resolution, with favorable functional recovery. Complications were uncommon but heterogeneous; the pooled overall complication rate was 14% (95% CI 0.08-0.21). Pooled 90-day all-cause mortality from randomized trials was 8% (95% CI 0.07-0.10; I2 = 0%). ConclusionMMAE is a safe and effective adjunctive or alternative treatment for chronic subdural hematoma, demonstrating a reproducible and clinically meaningful reduction in recurrence across randomized and observational datasets with homogeneous outcome definitions. However, variability in adverse event reporting, insufficient documentation of rare complications, and inconsistent definitions of radiographic versus clinical recurrence highlight the need for standardized outcome frameworks and harmonized follow-up protocols. Future well-designed trials with robust adverse event adjudication are essential to define the long-term safety profile of MMAE and to guide its optimal integration into cSDH management pathways.

Preoperative anxiety affects 50-75% of pediatric surgical patients and can lead to adverse perioperative outcomes including difficult anesthesia induction, emergence delirium, and prolonged recovery. Virtual reality has emerged as a promising non-pharmacological intervention, yet evidence from real-world clinical implementation remains limited. We conducted a nine-month quality improvement initiative at VCU Childrens Hospital from October 2023 through June 2024, implementing custom-designed virtual reality interventions for pediatric patients aged 6-15 years undergoing elective surgical procedures. The intervention was refined through five iterative Plan-Do-Study-Act cycles before retrospective analysis of prospectively collected data from 80 pediatric patients, 65 parents or caregivers, and 29 preoperative nurses. Primary outcomes included distress measured via 0-10 Numerical Rating Scale and fear assessed using the 0-4 Childrens Fear Scale, both measured pre- and post-intervention. Secondary outcomes included physiological parameters, parent anxiety, and stakeholder satisfaction. VR intervention demonstrated significant reductions in both patient distress (median change: -2.0 points, 95% CI [-2.00, -1.00], p<0.001) and fear (median change: -1.0 point, 95% CI [-1.00, 0.00], p<0.001). A majority of patients achieved a clinically significant reduction ([&ge;]30%) in both distress (66.2%) and fear (52.5%). Physiological markers demonstrated significant reductions in heart rate (mean decrease 5.8 beats per minute, p<0.001) and systolic blood pressure (mean decrease 4.1 mmHg, p<0.0001). Baseline anxiety levels predicted treatment response, with higher initial scores associated with greater likelihood of improvement. Stakeholder satisfaction was consistently high across patients (91.2% willing to use virtual reality again), parents (95.4% would recommend), and nurses (100% endorsement, zero workflow disruption). Virtual reality intervention significantly reduces pediatric preoperative anxiety with high stakeholder acceptance and minimal workflow disruption, supporting integration into routine preoperative care protocols. AUTHOR SUMMARYWe developed and implemented a custom virtual reality intervention to reduce anxiety in children before surgery. Preoperative anxiety is extremely common in pediatric patients and can negatively affect their surgical experience and recovery. Over nine months, our team created child-friendly virtual reality environments and systematically integrated this technology into routine care at a busy pediatric surgical unit, refining our approach based on continuous feedback from patients, families, and healthcare providers. Our findings demonstrate that children using virtual reality showed substantial reductions in both self-reported anxiety and objective physiological measures like heart rate and blood pressure. Importantly, children who were most anxious before surgery experienced the greatest benefit from the intervention. Nearly all children expressed willingness to use virtual reality again in future procedures, and parents overwhelmingly recommended it for other families facing similar situations. Nursing staff found the technology easy to incorporate into their workflow without causing procedural delays or disrupting standard care. This work demonstrates that virtual reality can be successfully implemented in real-world clinical settings as a safe, effective, non-pharmacological approach to managing surgical anxiety in children. By reducing fear and distress during one of the most challenging moments in a childs healthcare journey, virtual reality has significant potential to improve the preoperative experience for pediatric patients and their families.

INTRODUCTIONRisks for postoperative cognitive dysfunction remain poorly understood. Traditional cognitive screening tools such as the Montreal Cognitive Assessment (MoCA) and the Mini-Mental State Examination (MMSE) are used for perioperative cognitive evaluation but have limited scope, whereas comprehensive in-person testing poses problems for long-term follow up. METHODSThis prospective cohort study assesses the feasibility of using a remotely performed comprehensive neurocognitive test battery, the Uniform Data Set tele-adapted neuropsychological battery version 3 (UDS v3.0 T-cog), administered at baseline and 1 week, 1 month, and 3 months postoperatively, to comprehensively study neurocognitive outcomes in older adults undergoing orthopedic joint arthroplasty. Patient satisfaction with T-cog was assessed through four survey questions evaluating technical issues, duration, willingness to participate in in-person assessment, and satisfaction with remote assessment at 3 months after surgery. Further assessment of pain and mood also included PROMIS scales, McGill Pain Questionnaire, and Pain Catastrophizing Scale, before and 3 months after surgery. RESULTS127 participants were enrolled, and out of 120 participants who completed baseline cognitive assessment and underwent surgery, 98 completed cognitive assessments at 3 months. At 3 months, 17% of participants showed an objective decline in cognitive function based on this comprehensive assessment. The remote assessment format was well-received with high participant satisfaction. The UDS v3.0 T-cog identified deficits in specific domains that would have been missed by brief screening instruments, supporting its values for perioperative use. DISCUSSIONThis is the first study to utilize this comprehensive remote cognitive assessment tool to study long-term cognitive function. The assessment can be combined with other preoperative outcome assessments in older adults undergoing surgery. HighlightsO_LICurrent detection of perioperative cognitive outcomes in older adults rely on in-person cognitive assessments that are varied in methodology and often lack sensitivity and specificity C_LIO_LIThe UDS v3.0 T-cog identified objective cognitive decline in 17% of patients after orthopedic arthroplasty while also detecting early non-memory cognitive decline through the more comprehensive test battery with high participant satisfaction and retention, supporting remote assessment feasibility. C_LIO_LIThese findings suggest that remote comprehensive cognitive assessments are an effective tool to provide early detection and risk stratification for perioperative neurocognitive dysfunction in older patients. C_LI

Why some surgical participants experience pain that extends beyond the original site of injury while others do not remains poorly understood. Both pain intensity and widespread pain contribute to recovery and quality of life, yet their psychosocial correlates are often examined separately. Using data from two large pre-surgical cohorts--participants preparing for knee replacement or thoracic surgery--we examined associations between sociodemographic and psychosocial factors, pain intensity at surgical and non-surgical sites, and widespread chronic pain. Across cohorts and outcomes, fatigue showed the strongest and most consistent associations with pain intensity and widespread pain, independent of other measured factors. Fatigue also occupied a central position in statistical association networks and accounted for substantial shared variance among multiple psychosocial variables, including sleep disturbance, depression, stress, and socioeconomic disadvantage. Pain at non-surgical sites was strongly associated with widespread pain and frequently accounted for observed associations between surgical-site pain and widespread pain. Together, these findings highlight robust patterns of association linking fatigue, pain intensity, and widespread pain in pre-surgical populations. One Sentence SummaryFatigue is the strongest and most consistent factor linked to how pain intensifies and spreads before surgery.

BackgroundOxycodone is widely prescribed for managing acute pain in emergency departments (ED), but the appropriateness of this prescription is not fully established. Although concerns about opioid misuse and dependence drive efforts to reduce inappropriate prescribing, there is increasing recognition of the importance of adequate pain management. Therefore, it is essential to develop appropriate prescribing criteria that balance the risks and benefits of opioids, ensuring their benefits are maximised while minimising potential harm. ObjectiveFollowing the recommended format for a research protocol paper, this protocol describes the process and methods used to develop evidence-based criteria for oxycodone prescribing in the ED, informed by scientific evidence and expert clinical judgment, using the RAND/UCLA Appropriateness Method. MethodThe process will be carried out in sequential stages. First, scope and key terms will be defined, and then a targeted literature review will be conducted to synthesise available evidence. Subsequently, based on this synthesis and the investigator teams clinical insights, clinical scenarios will be developed in collaboration with field experts. A multidisciplinary panel comprising specialists in emergency medicine, emergency nurses, and pharmacists will evaluate these scenarios in two rounds. Each scenario will be rated on a 1-9 scale, where 1 indicates that harm outweighs benefit and 9 indicates that benefit outweighs harm. The median rating score will fall between 1 and 9, where 1-3 without disagreement is inappropriate, 4-6 without disagreement is uncertain, and 7-9 without disagreement is appropriate. Disagreement is defined as at least three experts scoring in both extremes. Final scenario ratings will be presented according to their assessed appropriateness and used to inform appropriateness criteria for prescribing oxycodone in the adult ED. ConclussionThe RAND/UCLA Appropriateness Method offers a systematic and evidence-informed framework for developing prescribing criteria to support the appropriate use of oxycodone in adult ED.