Citations

Background Although regional anesthesia (RA) is associated with improved pain control, reduced opioid use, and accelerated recovery after arthroplasty, racial and geographic differences have been identified in hip and knee arthroplasty, with limited data for shoulder and ankle arthroplasty. We examined differences in RA utilization for shoulder, hip, knee, and ankle arthroplasty, based on patient-level and hospital-level characteristics. Methods Using the National Inpatient Sample, we conducted a cross-sectional study of adults who underwent shoulder, hip, knee, and ankle arthroplasties from 2016 to 2020. RA was defined using procedure codes for neuraxial anesthesia and peripheral nerve blocks. Weighted descriptive statistics summarized RA utilization and compared patient-level and hospital-level characteristics using standardized mean differences (SMDs), with ≥0.10 indicating meaningful differences. Results We identified 1132 011 unweighted admissions, representing approximately 5.7 million weighted arthroplasties. RA was used in 7.0% of cases. RA utilization varied by procedure type, with the highest rates in shoulder (11.4%) and ankle arthroplasty (11.4%), followed by knee (9.1%) and hip arthroplasty (2.4%). Variation in RA utilization was observed in ankle arthroplasty based on race (SMD=0.11) and primary payer (SMD=0.12). RA use also varied by hospital size for shoulder (SMD=0.13), hip (SMD=0.29), and knee arthroplasty (SMD=0.22), by hospital location and teaching status for shoulder (SMD=0.17), hip (SMD=0.18), knee (SMD=0.19), and ankle arthroplasty (SMD=0.12), and by geographic region for shoulder (SMD=0.26), hip (SMD=0.45), knee (SMD=0.24), and ankle arthroplasty (SMD=0.17). Conclusions There is notable variation in RA use for inpatient arthroplasty across hospitals and geographic regions, with limited variation based on patient characteristics. These findings highlight the presence of system-level variation in RA use and underscore the need for further research to better understand the drivers of these patterns.

ABSTRACT Objective To identify and compare how patient perceptions contribute to Type 1 Delays, defined as delays in deciding to seek care, among individuals with head and neck cancer (HNC) in high‐income countries (HICs) and low‐ and middle‐income countries (LMICs). Methods We conducted a scoping review and systematic search of MEDLINE, Embase, Cochrane Library, and Scopus from inception through November 20, 2023. Eligible studies included patients with HNC in HICs or LMICs who reported patient perceptions contributing to Type 1 Delays. Data extraction was performed in duplicate, and barriers were categorized thematically. Fisher's exact test was used to compare the frequency of reported barriers between HIC and LMIC studies. Results Seventeen studies met inclusion criteria, of which 64.7% ( n = 11) were conducted in HICs and 35.3% ( n = 6) in LMICs, representing 9 countries and 1410 participants. The most frequently cited perceptions contributing to delay were symptom unawareness, misinterpretation, and minimization. Additional barriers included fear of diagnosis, stigma, alternative medicine use, financial challenges, and geographic barriers. Transport/geographic barriers showed a trend toward being more common in LMIC studies ( p = 0.05). Descriptive patterns suggested LMIC patients more often reported structural and sociocultural barriers, whereas HIC patients more commonly cited psychosocial or perceptual barriers. Conclusion Type 1 Delays in HNC are common across both HICs and LMICs, with overlapping and region‐specific contributors. Tailored interventions, such as patient education, stigma reduction, and improved access to diagnostic services, may promote earlier detection and improve global HNC outcomes. Level of Evidence 3.

Objective In this case report, we discuss the rare manifestation of prolonged neuromuscular blockade in a patient with history of small cell lung cancer and undiagnosed Lambert-Eaton myasthenic syndrome (LEMS) who had previously received succinylcholine for general anesthesia without incident but subsequently exhibited prolonged neuromuscular blockade during a laparoscopic procedure. We aimed to emphasize the importance of reversal agent safety and precision as well as vigilant perioperative and postoperative care. Methods We used the patient's electronic medical record, direct patient care experiences, and comprehensive literature review for this case report. Results Sugammadex was administered with mild improvement. Suspecting undiagnosed LEMS, neostigmine was administered, yielding satisfactory muscle strength and successful extubation. In retrospect, the patient reported history of weakness when lifting weights that improved upon exertion. Conclusions Sugammadex is an efficient and effective agent for reversal of neuromuscular blockade. However, proper monitoring of the depth and recovery of blockade is imperative to when using sugammadex with optimal safety and precision in all patients. Perioperative care teams must remain vigilant with a high index of suspicion for neuromuscular junction pathology to properly plan perioperative care for patients at risk, especially those with small cell lung cancer who may have undiagnosed LEMS.

ABSTRACT Purpose: Evidence regarding the utility of systemic steroids in treating patients with cirrhosis and septic shock remains equivocal. This study aimed to evaluate and elucidate the association of steroid use with outcomes and adverse effects in a cohort of patients with cirrhosis and septic shock. Patients and methods: Retrospective cohort study of patients with cirrhosis and septic shock admitted to a tertiary hospital intensive care unit (ICU) from January 2007 to May 2017, using a validated ICU Datamart. Patients who received vasopressors within 6 h of ICU admission were included in the multivariate analysis. The effect of steroids on outcomes was evaluated using multivariable regression, adjusting for confounding variables. Results: Out of 179 admissions of patients with cirrhosis and septic shock, 56 received steroids during the ICU admission. Patients who received steroids received a higher total dose of vasopressors (91.2 mg vs. 39.1 mg, P = 0.04) and had a lower initial lactate level (1.8 mmol/L vs. 2.6 mmol/L, P = 0.007). The multivariate analysis included 117 patients and showed no significant differences in mortality, length of ICU admission, or length of hospital stay. Bleeding events, delirium, and renal-replacement therapy requirements were also not associated with the use of steroids. Conclusion: The use of systemic steroids was more prevalent in cirrhotic patients with higher vasopressor requirements. It was not associated with decreased mortality or increased ICU- and hospital-free days, or to adverse effects.