JMIR perioperative medicine最新文献

Background: Virtual reality (VR) is a novel technology with implications for pain and sensory processing. VR may serve as a novel, scalable method to deliver clinically validated therapy for pain management as an alternative or adjunct to opioids for acute pain. Given that psychological factors and pain perception are both components of postoperative pain, it may also be beneficial to incorporate modalities that decrease anxiety, such as active relaxation and guided meditation with VR. Unfortunately, these therapies are not widely available due to multiple barriers. VR has the potential to deliver pain-reducing, psychologically based therapy to children, thereby enhancing multimodal analgesia and potentially decreasing opioid use. This study investigates the role of VR in reducing pain and anxiety after surgery. Given the substantial risks associated with opioid use, particularly in younger populations, alternative pain management strategies are crucial.

Objective: The primary aim of this study was to evaluate the efficacy of VR as a nonpharmacological intervention for managing postoperative pain intensity, pain unpleasantness, anxiety, and opioid use in children and adolescents undergoing Nuss repair of pectus excavatum.

Methods: A single-center, prospective, randomized, controlled trial was conducted at a tertiary care children's hospital and research center. Ninety children and adolescents (8-18 y) undergoing the Nuss procedure were randomized to guided relaxation or mindfulness VR (n=30) and distraction-based gaming VR (n=30), combined to form the VR group (n=60), and a control group using a passive 360° video (n=30). Patients received a 10-minute session on postoperative days 1 and 2. Pain intensity, pain unpleasantness, and anxiety were evaluated before and 0-, 15-, and 30-minute post-session. In-hospital pain scores, anxiety scores, and opioid use were collected.

Results: Children and adolescents who participated in VR reported a significantly greater decrease in pain intensity from baseline (0.41, SE 0.23) compared with those in the 360° video group at 30 minutes (P=.04) before multiplicity adjustment but not after multiplicity adjustment. There were no significant differences in pain scores or opioid use between the VR and control groups on postoperative day 1 or 2, nor were there changes in pain unpleasantness or anxiety at any time after the intervention.

Conclusions: Daily, 10-minute VR sessions provided some trends toward transient analgesic and anxiolytic effects, albeit none that were statistically significant. VR did not significantly decrease overall pain scores or opioid usage, possibly due to the limited intervention duration and high standardized opioid use. Future studies should investigate extended and more frequent VR sessions and the integration of VR with other therapeutic modalities.

Background: Total knee arthroplasty (TKA) is the primary treatment for advanced knee osteoarthritis. Despite its clinical success and favorable patient-reported outcome measures (PROMs), approximately 20% to 30% of patients continue to experience persistent functional limitations and muscle weakness. This highlights the need for a comprehensive evaluation of recovery parameters beyond pain and range of motion. Given the wide range of methods available for assessing TKA outcomes, clinicians often select tools based on personal preference and understanding, which may affect accuracy and consistency; for example, the Knee Injury and Osteoarthritis Outcome Score may overestimate function compared to gait analysis studies.

Objective: The aim of this study was to conduct a narrative review focusing on the use, strengths, and limitations of different outcome measures used in routine orthopedic practice to optimize post-TKA evaluation.

Methods: A literature search was conducted in February 2025 across 2 databases (PubMed and Web of Science). Eligible studies included original research articles, systematic reviews, and meta-analyses that focused on validated measures used to evaluate TKA. Case reports, conference abstracts, and studies focused exclusively on surgical techniques were excluded. Themes were identified across studies to structure the results according to types of assessments and clinical applicability.

Results: A total of 6831 studies were retrieved and screened in this review, with 4 themes emerging around muscle mass, strength, performance, and PROMs. The Oxford Knee Score is favored for its ease of use and minimal ceiling effects. Broader tools like the Knee Injury and Osteoarthritis Outcome Score and Western Ontario and McMaster Universities Osteoarthritis Index provide detailed insights but are less practical clinically. For muscle strength, the portable fixed dynamometer showed high reliability and comparability to isokinetic dynamometry. Dual-energy X-ray absorptiometry remains the gold standard for assessing muscle mass, while bioelectrical impedance analysis offers a practical alternative. The 5-Repetition Sit-to-Stand test effectively evaluates lower limb power and speed.

Conclusions: Clinicians should integrate both objective (muscle mass, strength, and performance) and subjective (PROMs) measures to improve TKA recovery assessment. This multidimensional approach has the potential to enhance the accuracy of patient evaluation and supports the development of tailored rehabilitation strategies that address individual deficits and optimize functional outcomes.

Background: Traditional statistical models often fail to capture the complex dynamics influencing survival outcomes in patients with bladder cancer after radical cystectomy, a procedure where approximately 50% of patients develop metastases within 2 years. The integration of artificial intelligence (AI) offers a promising avenue for enhancing prognostic accuracy and personalizing treatment strategies.

Objective: This study aimed to develop and evaluate a machine learning algorithm for predicting disease-free survival (DFS), overall survival (OS), and the cause of death in patients with bladder cancer undergoing cystectomy, using a comprehensive dataset of clinical and pathological variables.

Methods: Retrospective data of 370 patients with bladder cancer who underwent radical cystectomy at Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy, were collected. The dataset comprised 20 input variables, encompassing demographics, tumor characteristics, treatment variables, and inflammatory markers. For specific analyses and models, we used patient subcohorts. The CatBoost algorithm was used for regression tasks (DFS in 346 patients, OS in 347 patients) and a binary classification task (tumor-related death in 312 patients). Model performance was assessed using mean absolute error (MAE) for regression and F1-score for classification, prioritizing a minimum recall of 75% for tumor-related deaths. Five-fold cross-validation and Shapley additive explanations (SHAP) values were used to ensure robustness and interpretability.

Results: For DFS prediction, the CatBoost model achieved an MAE of 18.68 months, with clinical tumor stage and pathological tumor classification identified as the most influential predictors. OS prediction yielded an MAE of 17.2 months, which improved to 14.6 months after feature filtering, where tumor classification and the systemic immune-inflammation index (SII) were most impactful. For tumor-related death classification, the model achieved a recall of 78.6% and an F1-score of 0.44 for the positive class (tumor-related deaths), correctly identifying 11 of 14 cases. Bladder tumor position was the most influential feature for cause-of-death prediction.

Conclusions: The developed machine learning algorithm demonstrates promising accuracy in predicting survival and the cause of death in patients with bladder cancer after cystectomy. The key predictors include clinical and pathological tumor staging, systemic inflammation (SII), and bladder tumor position. These findings highlight the potential of AI in providing clinicians with an objective, data-driven tool to improve personalized prognostic assessment and guide clinical decision-making.

Background: Enhanced recovery after surgery (ERAS) programs bundle evidence-based interventions to standardize care, expedite recovery, and improve outcomes. As ERAS programs have expanded, it has become clear that a major challenge is monitoring the compliance of bundle elements and outcomes to feedback performance to stakeholders and guide changes. Manual data abstraction is onerous and not feasible. Reliance on receiving new reports from busy health system IT groups is challenging. Therefore, we sought to address this unmet need at our hospital by developing a novel ERAS Datamart system.

Objective: Our objectives were to develop a novel Datamart and Tableau dashboard to (1) enable continuous analysis of data, harvested directly from the electronic medical record (EMR), measure compliance and outcomes, and (2) enable end users (e.g., an ERAS coordinator) to create reports customized based on surgical procedure types, requested data variables, and custom date ranges.

Methods: After "buy-in" from hospital leadership and other stakeholders, data metrics were identified and categorized according to phase of care, that is, preoperative, intraoperative, and postoperative. A multidisciplinary team reviewed International Classification of Diseases, Tenth Revision procedure codes to capture EMR data for patients undergoing ERAS procedures. IT was given a master list with metric names, definitions, and screenshots of the discrete field in the EMR to assist with building the metrics. Validations of the novel Datamart were done against known ERAS patient populations maintained by the surgery clinic.

Results: The Datamart and Tableau dashboard has been built, is functional, and contains over 17,000 patients across 5 ERAS service lines: colorectal (n=1742), joint replacement (n=4235), surgical oncology (n=941), bariatric (n=1130), and cesarean section (n=9390). Currently, 56 metrics spanning the perioperative period have been validated across these populations. Reports can be tailored according to patients, time frames, and metrics. If desired, patient-level raw data can be exported for statistical analyses. Two use cases (total joint replacement and surgical oncology ERAS programs) are presented showing how the Datamart can be used.

Conclusions: Discrete fields within an EMR can be successfully captured into a novel Datamart and visualized using a custom Tableau dashboard for providing stakeholder feedback, facilitating quality improvement analyses, and auditing pathways.

Background: Hypothermia, defined as a core body temperature below 36 °C, is a common postoperative complication associated with adverse outcomes, including delayed wound healing, infections, and increased bleeding.

Objective: This randomized controlled trial evaluated the efficacy of different forced-air warming system temperature settings in treating postoperative hypothermia in the postanesthesia care unit.

Methods: A total of 132 patients undergoing elective surgery at Ramathibodi Hospital between April 2023 and May 2024 were randomized into 3 groups (n=44 per group): group C (warming set to 38 °C), group F1 (warming set to 42 °C), and group F2 (warming set to 42 °C, reduced to 38 °C after achieving 36 °C). Tympanic temperature was recorded at 5-minute intervals during rewarming and every 10 minutes after normothermia (≥36 °C) was achieved. The primary outcome was rewarming time. Secondary outcomes included the incidence of temperature drops, hemodynamic parameters, adverse events, and patient comfort scores.

Results: Baseline characteristics and clinical variables, including vital signs, were comparable among groups (P>.05). Group F2 achieved the shortest mean rewarming time of 33.3 (SD 13.81) min; however, differences between groups were not statistically significant (P=.460). Group F2 had the lowest incidence of temperature drops below 36 °C after normothermia (1/44, 2.27%; P=.009). Group C had the highest incidence of rewarming exceeding 1 hour (10/44, 22.73%; P=.017).

Conclusions: While rewarming times were similar across groups, the protocol using an initial setting of 42 °C followed by a reduction to 38 °C (group F2) effectively minimized temperature drops after normothermia, suggesting its superiority for managing postoperative hypothermia in the postanesthesia care unit.

Background: Health care provider burnout worsened during the COVID-19 pandemic.

Objective: This qualitative study described general surgery residents' perceptions of burnout and the impact of the COVID-19 pandemic and their attitudes toward wellness initiatives.

Methods: General surgery residents at a large training program in Canada completed a 21-item survey focused on self-reported burnout, mental health, perceptions of wellness resources, and the effects of the COVID-19 pandemic. Free-text responses were extracted for qualitative thematic content analysis. A coding framework was established, and emergent themes were identified.

Results: A total of 62% (51/82) of the residents completed the survey. Most respondents were senior residents (21/51, 41%) and identified as male (32/51, 63%). In total, 65% (33/51) of the residents met the criteria for burnout. Three themes were identified: (1) the culture of general surgery does not promote wellness, (2) the COVID-19 pandemic worsened existing access to vacation days and rest, and (3) wellness education in general surgery is ineffective and onerous to complete. General surgery residents emphasized the rigid lifestyle and culture of the specialty. Residents said that the idea of wellness was poorly executed. COVID-19 protocols increased the acceptance of taking sick days, but this was offset by staff shortages during the pandemic. Finally, residents emphasized the inefficacy of wellness education. They felt that they did not lack knowledge on reaching wellness but simply lacked the adequate time and resources to improve their well-being.

Conclusions: There are persistent concerns within the culture of general surgery that were further impacted by workload and stress during the pandemic. These results may inform future programmatic efforts to decrease resident burnout.

Background: The perioperative environment is complex and may be challenging for patients and guardians to navigate. The emotional burden and stressors inherent to the perioperative process commonly result in preoperative anxiety. Many studies have demonstrated the usefulness of virtual reality (VR) in various patient populations.

Objective: The aim of this study is to evaluate the impact of a VR-based preoperative education tool on anxiety levels in pediatric patients undergoing ambulatory ear, nose, and throat surgery, as well as in their guardians.

Methods: We performed a single-center prospective randomized controlled trial including children 6-12 years of age, presenting for ambulatory tonsillectomy and/or adenoidectomy, with or without bilateral ear tube insertion. The patients were randomized to receive VR instruction of the perioperative workflow or standard preoperative experience (non-VR). The primary outcome was patient and guardian preoperative anxiety, as measured by the 6-item State-Trait Anxiety Inventory.

Results: The study cohort included 107 patient-guardian dyads-51 in the intervention (VR) group and 56 in the control (non-VR) group. Baseline characteristics between the study and control groups were comparable; however, patients in the control group were more likely to report feeling upset compared to the VR group. The VR intervention was associated with reduced preoperative anxiety in patients and guardians compared to the control group. Patients exposed to the VR intervention had higher odds of feeling calm (OR 4.95, 95% CI 2.32-10.61; P<.001) and lower odds of feeling worried (OR 0.25, 95% CI 0.12-0.53; P<.001) compared to the control group. Similarly, guardians in the VR group had higher odds of feeling calm (OR 3.55, 95% CI 1.69-7.49; P=.001) and lower odds of feeling worried (OR 0.45, 95% CI 0.22-0.93; P=.03) compared to the control group. Both patients and guardians exposed to VR were significantly less likely to have moderate or high levels of preoperative anxiety than the control group (patients: OR 0.15, 95% CI 0.05-0.41, P<.001; guardians: OR 0.14, 95% CI 0.06-0.38, P<.001).

Conclusions: VR exposure may be effective in reducing pediatric and guardian anxiety. VR may be a suitable alternative to pharmacologic anxiolysis and future studies should compare the effect to premedication techniques.