Surgery remains the cornerstone of management in breast cancer patients. Regional anesthesia techniques, such as the erector spinae plane block (ESPB), have emerged as adjuncts to standard therapy for postoperative pain control. Studies comparing ESPB and standard procedure of general anesthesia and opioids were included. Primary outcomes were postoperative pain scores, analgesia duration, and postoperative morphine consumption. VAS pain scores were significantly reduced with the ESPB group. Similarly, longer analgesia duration (MD 7.03, 95
Chronic pain management requires complex multidisciplinary reasoning integrating pharmacological, interventional, rehabilitative, and psychosocial approaches across multiple guideline frameworks (International Association for the Study of Pain [IASP], American College of Rheumatology [ACR], European Alliance of Associations for Rheumatology [EULAR], American Academy of Neurology [AAN], American Society of Regional Anesthesia and Pain Medicine [ASRA], and Centers for Disease Control and Prevention [CDC]). Large language models (LLMs) show promise in clinical reasoning but lack any mechanism that records whether encoded guideline criteria were matched, are susceptible to hallucination, and cannot provide auditable decision chains—critical limitations where polypharmacy risks, opioid safety, and nuanced pain mechanism classification (nociplastic vs. nociceptive vs. neuropathic) demand the highest decision rigor. Some classical neuro-symbolic (NS) systems offer formal guarantees, yet such systems are heterogeneous and can lack contextual flexibility. We present PainNS-Prove, a guideline-provable neuro-symbolic clinical decision support system for chronic pain. We evaluate non-inferiority against 30 board-certified physicians from three pain-relevant specialties (10 anesthesiologists and algologists, 10 PM R specialists, and 10 rheumatologists), all in active chronic pain practice across 30 expert-validated clinical vignettes. The five-stage pipeline integrates Claude Opus 4.5, GPT-4.1, and Gemini 2.5 Pro: (1) multi-LLM structured chain-of-thought with pain-specific prompting, (2) knowledge graph constraint checking against a Neo4j pain ontology (52,418 nodes; 203,672 edges), (3) structured derivation-trace generation with a Lean 4-inspired rule engine, (4) adaptive compute allocation, (5) screening of factual claims via multi-source triangulation, designed to prevent unsupported content from reaching the output. Statistical analyses included non-inferiority testing (δ = 5
Despite the lung-protective ventilation strategy, high incidence of postoperative pulmonary complications (PPCs) after major non-cardiac surgery remains a major concern in the perioperative care due to high morbidity and mortality. The study aimed to evaluate the efficacy and safety of intraoperative nebulized lidocaine on PPCs in major abdominal surgery. Adults scheduled for major abdominal surgery were enrolled and randomised 1:1 into two groups from June 6, 2025, to January 23, 2026, and final follow-up was in January 30, 2026. Patients in the intervention group received nebulized lidocaine twice: once immediately after anesthesia induction and again before the end of surgery, with 100 mg of 2
Cardiac surgery with cardiopulmonary bypass (CPB) is associated with perioperative blood loss, coagulation disturbances, and increased allogeneic red blood cell (RBC) transfusion requirements. This study evaluated whether postoperative reinfusion of residual CPB circuit blood reduces allogeneic RBC transfusion requirements and affects rotational thromboelastometry (ROTEM) parameters. This single-center, two-arm, parallel-group randomized controlled trial enrolled 60 adults aged 18–70 years undergoing elective coronary artery bypass grafting with CPB at Atatürk University Research Hospital from April 2023 to April 2024. Participants were allocated 1:1 by computer-generated simple randomization to residual CPB circuit blood reinfusion (n = 30) or no reinfusion (n = 30). Patients, clinicians responsible for postoperative transfusion decisions, outcome assessors, and data analysts were blinded to group allocation. The primary outcome was allogeneic RBC transfusion requirement from the end of surgery until intensive care unit (ICU) discharge. Secondary outcomes included ROTEM parameters, chest tube drainage during the prespecified periods (0–4 h, cumulative 0–24 h, 24–48 h, and 48 h to ICU discharge), ICU length of stay, laboratory values, and in-hospital complications. Continuous variables were compared using Student’s t test or the Mann–Whitney U test, and categorical variables using the chi-square test or Fisher’s exact test, as appropriate. P values for the 20 between-group ROTEM comparisons were adjusted using Holm’s step-down procedure. The study was funded by Atatürk University Scientific Research Project Coordinator (TTU-2023-12558). All 60 patients completed follow-up and were analyzed (30 per group). The median volume of circuit-derived autologous blood reinfused was 625 [505–875] mL. RBC transfusion requirement was lower in the reinfusion group than in the control group (1 [0–2] vs. 2 [1–3] units; p = 0.030). After Holm adjustment for 20 ROTEM comparisons, FIBTEM clotting time was the only parameter that remained significantly different between groups and was longer in the reinfusion group (71 [66–77] vs. 65 [61–67] s; unadjusted p = 0.001; adjusted p = 0.020). The INTEM/HEPTEM clotting time ratio was higher in the reinfusion group (1.08 [1.03–1.09] vs. 1.02 [1.01–1.03]; unadjusted p = 0.010), but this difference was not statistically significant after adjustment (adjusted p = 0.190). Chest tube drainage during the prespecified periods (0–4 h, cumulative 0–24 h, 24–48 h, and 48 h to ICU discharge) and ICU length of stay were similar between groups. Postoperative reinfusion of residual CPB circuit blood was associated with lower allogeneic RBC transfusion requirements in this small trial. No between-group difference in chest tube drainage was detected, and no re-exploration for bleeding occurred in either group. FIBTEM clotting time was longer in the reinfusion group; the clinical significance of this finding is uncertain. Larger studies are needed to confirm the transfusion findings and assess potential harms. ClinicalTrials.gov, NCT06824753; retrospectively registered on 11 October 2024.
Preprocedural neuraxial ultrasonography improves the technical performance of spinal anesthesia, and ultrasound-assisted paramedian approaches may be particularly efficient. However, the paramedian technique requires a distinct entry point and needle trajectory that may be less familiar to some operators, whereas the midline approach remains familiar and widely used. Whether preprocedural ultrasound can enhance this familiar midline strategy compared with landmark-guided paramedian puncture in older patients remains uncertain. In this single-center randomized trial, 110 patients aged ≥ 65 years were allocated 1:1 to landmark-guided paramedian (PML) or preprocedural ultrasound-assisted midline (MUS) continuous spinal anesthesia for hip-fracture surgery. The primary outcome was needle passes. Secondary outcomes included insertion attempts, first-pass success, identification and procedure times, complications, and puncture level. Between-group comparisons used Mann–Whitney U, χ², or Fisher exact tests as appropriate. Needle passes were lower with MUS than PML (2 [1–3] vs. 3 [2–5]; Hodges–Lehmann difference, − 1 pass; 95
