BACKGROUND:Intraoperative hypotension is a common occurrence in patients undergoing anaesthesia, although there is no standardised definition of hypotension. International consensus statements provide some guidelines for the management of intraoperative hypotension, but general clinical practice is unknown. We aimed to survey anaesthesiologists' values and preferences regarding intraoperative blood pressure management, including whether they would support future research on this topic. METHODS:We conducted an international, online survey of routine practice and opinion. The target population was anaesthesiologists who regularly anaesthetise adult patients. Results are reported descriptively and in accordance with the Consensus-Based Checklist for Reporting of Survey Studies (CROSS) checklist. RESULTS:A total of 1640 anaesthesiologists from 11 European countries participated in the survey. The majority of respondents were specialists (1322 of 1640, 80.6%, 95% CI 78.7-82.6). Almost all respondents worked in public hospitals (1613 of 1640, 98.4%). The overall response rate was 22.7%. Most respondents reported using absolute mean arterial pressure as their main unit of measurement to quantify hypotension (1098 of 1640, 67.0%, 95% CI 64.6-69.2). Respondents were most likely to initiate vasoactive treatment at a mean arterial pressure below 60 or 65 mmHg. Chronic arterial hypertension, traumatic brain injury and surgical procedures involving head-up positioning of the patient were the three most common scenarios where respondents would raise their threshold for treatment. Most respondents considered the establishment of safe intraoperative blood pressure thresholds a critical research question, and almost all respondents (1509 of 1640, 92.0%) indicated a willingness to randomise patients to specific blood pressure targets. For 72.9% (1196 of 1640), the lowest acceptable mean arterial pressure for randomisation was 60 mmHg. Respondents were also interested in the comparison of efficacy and safety of vasoactive agents, and the most sought-after comparison was phenylephrine versus noradrenaline (1252 of 1640, 76.3%). The willingness of respondents to administer these agents in peripheral venous access differed according to geography. CONCLUSION:In this international survey, mean arterial pressures of 60 or 65 mmHg were the most commonly reported blood pressure thresholds leading to initiation of treatment with vasoactive agents. Almost all respondents indicated patient groups for whom they would alter their treatment threshold, namely those suffering from chronic arterial hypertension, those undergoing surgery in a head-up position, and patients with traumatic brain injury. The majority of respondents supported future trials establishing optimal mean arterial pressure threshold and choice of vasoactive agent. We noticed a geographical variation in willingness to administer vasoactive agents in peripheral venous access. EDITORIAL COMMENT:This survey of anaesthesiologists from European countries queried practitioner perceptions of blood pressure management in adults during anaesthesia with focus on hypotension. Queries and responses also concerned circumstances and blood pressure levels which clinicians report being willing to treat actively, and how they might do this practically.
Abstract Background and Aims Hydralazine-isosorbide dinitrate (H-ISDN) has shown benefit in earlier randomized trials of patients with reduced left ventricular ejection fraction (LVEF) and chronic heart failure. This trial tested if H-ISDN could reduce worsening heart failure or mortality in patients with chronic heart failure with reduced ejection fraction (HFrEF) receiving contemporary treatment. Methods The Hydralazine-Isosorbide Dinitrate in Patients With Chronic Heart Failure Trial (H-HeFT) was a multicentre, randomized (1:1), double-blind, placebo-controlled trial in patients with HFrEF at 23 Danish hospitals (New York Heart Association class II–IV, elevated N-terminal pro-B-type natriuretic peptide and LVEF ≤40%). Target treatment was hydralazine 75 mg/isosorbide dinitrate 40 mg three times a day (t.i.d). The primary endpoint was a composite of hospitalization with worsening heart failure, an urgent outpatient visit resulting in intravenous/metolazone therapy for heart failure, heart transplantation, left ventricular assist device implantation, or death. Secondary endpoints included components of the primary outcome. Results Overall, 592 predominantly White patients (median age 72 years, 18% women) were randomized with a mean follow-up of 3.7 years. The primary outcome occurred in 90 of 294 patients (30.6%) in the H-ISDN group and in 91 of 298 patients (30.5%) in the placebo group [hazard ratio (HR) 0.90; 95% confidence interval (CI) 0.67–1.21; P = .48]. There were 57 deaths in the H-ISDN group vs 72 in the placebo group (HR 0.72; 95% CI 0.51–1.02); worsening heart failure events occurred in 52 vs 47 patients (HR 1.01; 95% CI 0.68–1.50). Conclusions Hydralazine-isosorbide dinitrate did not change the incidence of the composite endpoint of heart failure events or death in patients with heart failure and LVEF ≤40%.
Background Musculoskeletal disorders represent a significant global health burden, frequently leading to chronic pain, functional impairment and disability. Conventional treatment modalities, including rehabilitation, pharmacotherapy and surgical intervention, are often associated with suboptimal outcomes and prolonged recovery. Adipose-derived stem cells (ADSCs) have gained considerable attention due to their regenerative capacity, accessibility and immunomodulatory properties. Preclinical studies of ADSCs have demonstrated promising effects in skeletal muscle regeneration. However, the evidence from human orthopaedic shoulder surgery remains inconclusive. This scoping review aims to map the process of adipose tissue-derived treatments in orthopaedic surgery, especially shoulder surgery.Methods and analysis A scoping review will be conducted using the Joanna Briggs Institute methodology to systematically map existing evidence on the clinical use of ADSCs in orthopaedic shoulder surgery. The search strategy will use the Population–Concept–Context framework and will be applied across four bibliographic databases (Embase, MEDLINE, CENTRAL and Scopus) and ClinicalTrials.gov, with additional grey literature searches. Studies will be limited to adults (≥18 years) undergoing shoulder surgery. Both clinical and patient-reported outcomes will be extracted. Article screening and data extraction will be performed independently by two reviewers using Covidence software, with discrepancies resolved through consensus or third-party arbitration.Discussion The extensive mapping will provide a comprehensive synthesis of current evidence on the application of ADSCs in orthopaedic surgery, including preparation methods, intraoperative techniques, postoperative follow-up and outcome measures. Special attention will be paid to heterogeneity in clinical practice, methodological limitations and reported patient-centred outcomes. This review will also identify gaps in the literature and inform future research priorities.Ethics and dissemination This scoping review does not require ethics approval, as we will only include information from previously conducted studies and will not involve human participants.
Background: In 2020, we published the first randomized trial demonstrating the efficacy of trifluridine–tipiracil (FTD–TPI) with bevacizumab compared with FTD–TPI monotherapy in chemorefractory metastatic colorectal cancer. This study aims to: (i) analyze final survival data, (ii) perform post hoc analyses of the prognostic role of chemotherapy-induced neutropenia (CIN), and (iii) assess time to deterioration of performance status (PS) as a measure associated with quality of life in post hoc analyses. Materials and methods: The Kaplan–Meier method and Cox proportional hazards models were used to analyze final survival data for all 93 patients included in the trial. CIN was modeled as a time-varying covariate. Results: Progression-free survival was 4.6 months [95% confidence interval (CI) 3.7-6.5] with FTD–TPI plus bevacizumab versus 2.4 months (95% CI 1.8-3.6) with FTD–TPI; hazard ratio (HR) 0.47 (95% CI 0.31-0.73). Overall survival was 10.0 months (95% CI 8.1-12.7) with FTD–TPI plus bevacizumab versus 6.0 months (95% CI 5.5-7.9) with FTD–TPI; HR 0.55 (95% CI 0.36-0.84). CIN was associated with reduced hazard of progression; HR 0.32 (95% CI 0.15-0.70) for FTD–TPI and HR 0.22 (95% CI 0.10-0.52) for FTD–TPI plus bevacizumab. CIN was also associated with reduced hazard of death: HR 0.62 (95% CI 0.39-0.97) for FTD–TPI and HR 0.64 (95% CI 0.35-1.17) for FTD–TPI plus bevacizumab. Patients receiving FTD–TPI plus bevacizumab had longer time to PS worsening to ≥2: HR 0.39 (95% CI 0.25-0.61). Conclusions: Our findings support the superiority of FTD–TPI plus bevacizumab over FTD–TPI in prolonging survival and maintaining PS. CIN was associated with improved survival outcomes.
Incisional and parastomal hernias are frequent and significant complications following abdominal surgery, leading to reduced quality of life and substantial healthcare costs. This review provides a comprehensive review of the latest international guidelines, including the 2022 EHS/AHS guideline on abdominal wall closure and the 2023 EHS Rapid Guideline on parastomal hernia prevention. Key recommendations include risk stratification of patients, the superiority of the small-bites fascial closure technique for midline closure, and the selective use of prophylactic mesh.
