Medicine and Pharmacology

Abstract: Background/Objectives: Bladder cancer is a disease of the elderly population, who often undergo transurethral bladder tumor resections (TURBT). Data on whether cognitive decline occurs after TURBT are limited. This study examined changes in cognitive status after TURBT, as measured by the Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE), and whether these changes were associated with frailty status, handgrip strength (HGS), and biomarkers. Methods: Biomarkers IL-4, IL-6, S100b, and NSE were measured preoperatively, at 2 hours, and at 24 hours after TURBT. MoCA, MMSE, and HGS were assessed preoperatively and at 24 and 48 hours postoperatively in 60 patients (51 male, 9 female; median age 70 (50-80 years); trial registration number: NCT07165236. Results: Both MMSE and MoCA declined significantly from preoperative 26 (26-27) to 24 (23-25) and 22 (21-23) at 24 and 48 h postoperatively (P<0.001). HGS decreased from 31.8 (27.2 – 32.9) to 27.2 (20.4 – 24.4) and 22.7 (20.4 – 24.4) kilograms at 24 and 48 h postoperatively (P<0.001). The biomarker change was statistically significant, but only IL-6 showed an association with MoCA 24 h after surgery (ρ=-0.419, P<0.001). Clinical frailty at admission showed the strongest correlation with MoCA (ρ=0.495, P<0.001) and MMSE (ρ=-0.520, P<0.001). Conclusion: Early cognitive decline occurs after TURBT in elderly patients with bladder cancer. Clinical frailty is the strongest predictor of postoperative cognitive impairment, while biomarker alterations provide limited prognostic information. Routine preoperative frailty assessment may improve risk stratification and perioperative care.

Abstract: Introduction: Large language models (LLMs) have demonstrated substantial performance on medical licensing and board examinations, but their application to anesthesiology remains less well studied. Prior evaluations have not compared current-generation models from different developers or assessed performance on figure-dependent questions that earlier models lacked the capability to interpret. This study evaluates the performance of two current-generation LLMs on a comprehensive anesthesiology in-training examination (ITE) review question bank, including figure-dependent items. Methods: A total of 1,001 single-best-answer questions from an anesthesiology ITE review text, spanning 11 content chapters, were administered to Claude Opus 5 and GPT-5.6. No questions were excluded. Each item was presented once in a fresh, stateless context with no tool access, retrieval, answer key, or explanation provided in the prompt. Performance was analyzed by question format, and all 27 figure-dependent items were administered with their published figures supplied. Accuracy between models was compared using McNemar’s test. Results: Claude Opus 5 answered 947/1,001 items correctly (94.6%; 95% CI, 93.0–95.8), and GPT-5.6 answered 946/1,001 correctly (94.5%; 95% CI, 92.9–95.8); the difference was not significant (McNemar p = 1.00). Accuracy was similar across most question formats. On standard questions, accuracy was 94.3% and 94.6% for Claude Opus 5 and GPT-5.6, respectively; on the 18 figure-based questions with figures supplied, accuracy was 94.4% and 83.3%, respectively; and both models achieved 100% accuracy on image-option items. Withholding figures from the same 18 figure-based questions reduced pooled accuracy from 88.9% to 52.8% (exact McNemar p = 0.03 and p = 0.04 for Claude Opus 5 and GPT-5.6, respectively). The models agreed on 957/1,001 items (95.6%). Of the 33 items both models answered incorrectly, they selected the same incorrect option on 32 (97%). Discussion: Current-generation LLMs achieved approximately 95% accuracy, substantially improving on our prior results with earlier-generation models and placing both models within the highest band of the ITE normative framework, corresponding approximately to the 99th percentile across training levels. By comparison, our prior work with previous models placed ChatGPT-3.5 at the 52nd, 3rd, and 1st percentiles and ChatGPT-4.0 at the 99th, 95th, and 84th percentiles across increasing levels of training. Multimodal capability now permits successful interpretation of many figure-dependent questions, although performance declines markedly when required visual information is unavailable, and highly concordant errors remain. These findings support an increasingly promising role for LLMs as accessible, on-demand educational adjuncts for anesthesiology trainees, provided complete source material is supplied and outputs are critically reviewed.

Abstract: Postoperative pain remains a common and clinically important problem, with inadequate control contributing to delayed recovery, prolonged opioid exposure, and risk of chronic postsurgical pain. Machine learning has been suggested as a strategy to improve postoperative pain management by predicting pain trajectories, estimating opioid requirements, identifying patients at risk for poor outcomes and improving the clinical management. This critical review examines current applications of machine learning in postoperative pain, including preoperative risk stratification, intraoperative and postoperative prediction, objective assessment, wearable monitoring, discharge opioid prescribing, and use in specialized populations.We found that although many models demonstrate moderate to strong predictive performance, their clinical utility remains uncertain. Most studies are retrospective, single-center, or procedure-specific, with limited external validation and heterogeneous outcome definitions. While many models incorporate postoperative variables, this influences the stage of care at which they can be applied, making them more useful for guiding postoperative management than for informing preoperative or intraoperative interventions. As a result, future work should move beyond prediction accuracy toward prospective validation, actionable hypothesis driven multi-modal models, and large-scale trials that determine whether machine learning–guided care improves pain control while reducing unnecessary opioid exposure.

Abstract: High-flow nasal cannula (HFNC) oxygen therapy is widely used in emergency, inten-sive care, perioperative, and procedural settings, but it is often conceptually assimilated to non-invasive positive pressure ventilation (NIPPV). This interpretation is physio-logically misleading. HFNC is an open high-flow oxygen system whose main effects derive from dead-space washout, improved stability of inspired oxygen fraction (FiO₂), heated humidification, patient comfort, and only modest flow-dependent positive airway pressure. Its open interface also facilitates eating, drinking, speaking, and se-cretion clearance. Clinical evidence supports HFNC mainly in selected patients with acute hypoxemic respiratory failure, where it may reduce intubation compared with conventional oxygen therapy. However, evidence is more heterogeneous in hypercap-nic respiratory failure, cardiogenic pulmonary edema, immunocompromised patients, obesity, and settings requiring substantial pressure support or ventilatory unloading. NIPPV or continuous positive airway pressure remain preferable when controlled positive pressure, alveolar recruitment, or ventilatory assistance are central to treat-ment. HFNC should therefore be regarded as optimized high-flow oxygen therapy rather than as “non-invasive ventilation through nasal prongs.” Recognizing this dis-tinction may improve patient selection, guide escalation, and avoid overinterpretation of its clinical effects.

Abstract: Background: Off-pump coronary artery bypass grafting (OPCAB) avoids cardiopulmonary bypass (CPB) and may reduce selected perioperative complications, but its technical and hemodynamic demands remain important limitations. Methods: We narratively reviewed literature indexed in PubMed/MEDLINE and Scopus, supplemented by Google Scholar and reference-list screening, covering January 2000 to September 2025. Priority was given to systematic reviews, meta-analyses, randomized trials, prospective studies, guidelines, and relevant landmark reports. Results: OPCAB may be particularly useful in selected patients at increased risk from CPB or aortic manipulation. Cardiac displacement and coronary stabilization can cause rapid changes in preload, ventricular function, myocardial perfusion, and cardiac output, making invasive monitoring, transesophageal echocardiography, and coordinated hemodynamic management central to anesthetic care. Current evidence does not establish superiority of volatile anesthesia or total intravenous anesthesia. Comparative studies suggest potential reductions in perioperative stroke, transfusion, renal complications, and hospital stay, but concerns remain regarding completeness of revascularization, graft durability, repeat revascularization, and long-term survival. Conclusions: OPCAB should be considered an individualized strategy rather than a universal alternative to on-pump CABG. Optimal outcomes depend on patient selection, surgical expertise, vigilant monitoring, and timely correction of hemodynamic compromise.

Abstract: Transcatheter tricuspid valve-in-valve replacement offers an alternative to high-risk redo surgery for failed tricuspid bioprostheses. We report a 36-year-old woman with severe right-heart failure, hepatic dysfunction, thrombocytopenia, and a mechanical mitral prosthesis after a previously abandoned transcatheter attempt. Redo implantation was performed under dexmedetomidine-ketamine sedation with spontaneous ventilation and a femoral nerve block. Transoesophageal echocardiography was avoided because of bleeding risk. Fluoroscopy and transthoracic echocardiography provided procedural guidance. Valve deployment was successful, the transvalvular gradient decreased and she was discharged on postoperative day 3, highlighting individualized management of competing haemorrhagic and thrombotic risks.

Abstract: Body Protection Compound-157 (BPC-157) is an unapproved synthetic peptide marketed directly to consumers despite limited human evidence on benefits and risks. We characterized the use of BPC-157 and patient-reported outcomes from 2020 through 2026 using Large Language Model (LLM) curation of de-identified clinical notes from a U.S. federated network with physician validation of each LLM-curation exercise. Of 1,536 patients with a note mentioning BPC-157, 1,039 (67.6%) had documented use, and quarterly newly confirmed users increased 33-fold between 2020 and 2026. Among 972 BPC-157 users with recorded race, 95.9% were White, compared with 78% of the background care population, representing a 1.23-fold enrichment (chi-square test across racial categories, P < 0.001). Among patients with newly documented BPC-157 use, the male proportion increased from 57% in 2020 to 70% in 2026 (Cochran–Armitage trend test across years, P < 0.001), while mean age decreased from 55 years in 2020 to 49 years in 2026. Among 205 patients with a documented consumer source (19.7% of confirmed users), BPC-157 was most commonly obtained from compounding pharmacies (36%) or gray-market peptide vendors (35%). Other therapeutic agents were co-used with BPC-157 by 525 of 1,039 users (50.5%), most commonly testosterone (17.0%), NSAIDs (14.7%), TB-500 (12.9%), and corticosteroids (11.7%), while physical therapy (15.3%), surgery (12.6%), exercise counseling (8.3%), and diet counseling (6.3%) were the documented non-drug co-interventions. Physician-adjudicated extraction accuracy was 96.0% for BPC-157 co-therapies and 74.4% for non-drug interventions, which were treated as exploratory. Reasons for use were documented for 644 patients and included pain (33% of all 1,039 users), gastrointestinal conditions including reflux, inflammatory bowel disease or gastritis (14%), prior injury (11%), and post-surgical healing (10%), physician adjudicated LLM accuracy of 83.9%. Among 80 users with ascertainable start timing, BPC-157 use preceded first clinician documentation by a mean of 60 days. Reported use averaged 2.2 months among 130 patients (12.5%) with an explicitly documented BPC-157 use duration, with 96.7% extraction accuracy. The specialties most often first documenting use were family medicine, internal medicine, gastroenterology, and orthopaedic surgery. Symptomatic improvement of pain, wound or tissue healing and functional return was documented in 79% of 354 BPC-157 users with a directional response, and symptomatic worsening in 5% of the users (LLM-extraction accuracy 78.4%). Response direction was unavailable for 685 of 1,039 users (65.9%). These reports cannot establish efficacy or distinguish BPC-157 effects from peptide stacking, other co-treatments, non-drug interventions, placebo effects or selection, reporting and confirmation biases. LLM-curated adverse events during BPC-157 use were infrequently noted and likely subject to under-reporting, with documented evidence of neuropsychiatric (1.4%), injection-site hypersensitivity (1.4%), and gastrointestinal (1.3%) events, with physician-adjudicated accuracy of 93.9% for drug-attributed adverse-events. With BPC-157 use rising rapidly despite minimal prospective studies and limited evidence-backed consumer awareness of its risk–benefit profile, this study highlights the need for facilitating structured EHR capture of broader gray-market peptide use and a continuous assessment of guidelines to better support healthcare practitioners.

Abstract: Background/Objectives: Because affect is challenging to quantify in fibrom-yalgia, previous network analyses have primarily relied on symptom-severity measures, whereas emotion regulation and affective hypersensitivity have rarely been included. We examined where emotional allodynia, the tendency to respond with disproportion-ate distress to neutral or low-intensity interpersonal cues, sits in this network. Methods: Cross-sectional analysis of 149 consecutive outpatients with fibromyalgia (2016 Ameri-can College of Rheumatology criteria; 91.9% women; mean age 57.5 years). A regularized partial correlation network (EBICglasso: extended Bayesian information criterion graphical lasso; γ = 0.5, Spearman) was estimated over twelve nodes: emotional allo-dynia, pain catastrophizing, central sensitization, depression, state and trait anxiety, and six facets of emotion dysregulation. Accuracy was assessed with 5000 bootstrap replica-tions. Results: The correlation of emotional allodynia with depression (ρ = 0.502) was shrunk to exactly zero in the network and under every sensitivity analysis, and was near zero when the penalty was removed (ρ = -0.033). Its two strongest edges were with pain catastrophizing (0.190) and the Impulse facet of emotion dysregulation (0.184), non-zero in 98.9% and 99.6% of replications. It was among the less connected nodes, but, forming a community of one, all its connectivity crossed a domain boundary. Of that, 59.8% went to emotion regulation and 30.2% to pain, the largest share of any node outside either domain (77.0% and 48.1% of replications). Depression and anxiety received 10.0% (24.6% for catastrophizing). Conclusions: In this exploratory analysis, emotional allodynia oc-cupied a bridging position directed at emotion regulation and pain rather than at de-pression and anxiety, and was not reducible to depressive symptom severity once the other measures were held constant. It overlapped substantially with catastrophizing, and these data do not adjudicate their separability. These preliminary single-centre findings are hypothesis-generating and require replication.

Abstract: Background/Objectives Hypoxaemia is the most common adverse event during procedural sedation. High-flow nasal ox-ygen (HFNO) may reduce desaturation through continuous positive airway pressure, elimination of anatomical dead space, and precise FiO₂ delivery. This study aimed to assess the association between HFNO and the incidence of desaturation (SpO₂ < 90% at any time) during deep seda-tion for colonoscopy in a high-risk population. Methods A single-centre retrospective cohort study with propensity score matching was performed. It in-cluded 200 consecutive adult patients at high risk of adverse respiratory events undergoing deep sedation, grouped by oxygen delivery device: HFNO via nasal cannula versus Venturi mask. Results After 1:1 nearest-neighbour propensity score matching, 71 matched pairs were obtained. In the matched cohort, desaturation occurred in 12.7% of patients receiving HFNO versus 22.5% of controls (matched-pairs OR 0.53; 95% CI: 0.23–1.23; p = 0.211; McNemar's test), an absolute risk reduction of 9.8 percentage points. A sensitivity analysis using conditional logistic regression confirmed the direction and magnitude of the effect (adjusted OR 0.52; 95% CI: 0.22–1.21; p = 0.129). Post hoc power analysis indicated 30.8% statistical power in the current sample; 265 matched pairs would be required to achieve 80% power. Conclusions HFNO was associated with a meaningful reduction in the likelihood of desaturation during deep sedation for colonoscopy in a high-risk population (OR 0.53), consistent with available me-ta-analytic evidence for this risk stratum. This study provides a data-derived sample size estimate (265 matched pairs) for a future prospective randomised trial.

Abstract: Introduction: Active scars can be defined as ‘pain generators’: the pain associated with them may have an important impact on the patient’s quality of life. During the healing process, several local and systemic neurochemical changes occur, leading to alterations in both the tissue and systemic levels, with changes in the central nervous system (CNS) implicated in the development of chronic pain. Clinically, the features that define a scar as a pathological one include increased firmness, increased tissue thickness, and increased reactivity of the skin after palpation. The therapeutic approach, therefore, includes both local treatments which interferes with structural changes in the scar tissue and systemic treatments. Materials and Methods: A critical review of the literature regarding the role of local anaesthetics in the clinical management of painful scars has been conducted. The paper also reports a series of cases involving patients affected by painful scars who were successfully treated with local lidocaine injections. A series of five cases of adult patients with active painful scars of post-traumatic and post-surgical aetiology, have been treated with intra-lesional infiltration of 0.5% lidocaine. When appropriate, we associated other techniques. Pain intensity has been assessed using the NRS scale before the start of treatment, at the end of treatment, and at 3 months’ follow-up. Results and Discussion: Lidocaine infiltration has been demonstrated effective in the treatment of painful scars, as it reduces the expression of inflammatory mediators. It also has a neuromodulatory effect by reducing the pain signal transduction. Eventually, a key role is the inhibition of NGF binding to its TyrkA receptor. In all patients, we observed a long-lasting reduction in pain symptoms, suggesting that changes had occurred in the tissue, in the peripheral nervous system and a modulation of central nervous system connectivity had been detected. No complications occurred. Conclusion: local treatment with intralesional infiltration with 0.5% lidocaine has demonstrated to be safe and effective in the treatment of painful scars, maintaining the benefit on pain over time, with no complications.

Abstract: Introduction: Induction agents such as propofol, ketamine, midazolam, and etomidate are routinely used in procedural sedation. With a variety of anesthetics being delivered, it is important to be aware of adverse drug reactions (ADRs). One possible ADR is a severe type 1 hypersensitivity reaction in which patients may develop anaphylaxis or angioedema. This study utilized the TriNetX database to assess and compare the incidence of such reactions across these four intravenous anesthetic agents. Methods: A retrospective cohort study was conducted from adult patients who received one of the four agents. Incidence of anaphylaxis or angioedema was measured. A chi-square test assessed global differences among drugs, followed by pairwise post hoc comparisons assessing differences between the drugs. Results: 608 patients who experienced anaphylaxis or angioedema when given etomidate (3.48%), ketamine (3.04%), propofol (2.51%), and midazolam (2.43%); n=1,351, n=3,846, n=9,444, n=8,537, respectively. The chi-square test showed a significant difference among the four agents (χ² = 8.31, p = 0.04). Pairwise post hoc chi-square comparisons revealed significantly higher rates of hypersensitivity with etomidate compared to propofol and midazolam (p < 0.05). Conclusion: Etomidate was significantly associated with a higher incidence of anaphylaxis and angioedema compared to propofol and midazolam. These results prompt further investigation into standardized protocols to aid in diagnosis and management of perioperative hypersensitivity reactions. The development of risk stratification and management tools could enhance patient safety and improve anesthetic care, especially those at a heightened risk.

Abstract: Airway management remains one of the few domains of anaesthetic practice still governed by universal, dichotomous screening thresholds applied to profoundly heterogeneous populations. Conventional bedside tests — the modified Mallampati test, thyromental distance and the upper lip bite test — retain modest and inconsistent diagnostic accuracy, leaving the majority of difficult intubations unanticipated while generating false alarms that drive resource-intensive contingency plans. This narrative review reframes preoperative airway evaluation as a problem of individualized risk stratification rather than population screening. We first summarize the performance limits of classical bedside predictors and the reasons for their ceiling effect, including low target prevalence, inter-observer variability, spectrum bias and heterogeneous outcome definitions. We then examine the data streams reshaping the field: point-of-care upper airway ultrasound, whose parameters provide operator-accessible and objective anatomical information; cross-sectional and craniofacial imaging; and machine-learning models based on clinical variables, facial images and voice analysis. For each we discuss accuracy, reproducibility, validation status and barriers to adoption. We then propose a phenotype-oriented framework in which assessment intensity is matched to pre-test probability, with dedicated pathways for obesity and obstructive sleep apnoea, obstetric, head-and-neck oncological and post-radiotherapy, critically ill and emergency, and paediatric populations. We map this framework onto the 2025 European Society of Anaesthesiology and Intensive Care and Difficult Airway Society recommendations and outline the validation, calibration and equity requirements — including algorithmic bias across skin tone, sex and ethnicity — that must be met before precision airway assessment can enter routine practice.

Abstract: Background: Pharmacological neuroprotection and adjuvant physical therapies, including piracetam and hyperbaric oxygen therapy, have emerged as potential strategies to enhance nerve regeneration. We aimed to assess the effects of piracetam and hyperbaric oxygen on peripheral nerve regeneration. Methods: Forty male Wistar Albino rats were randomly allocated to four groups following experimental sciatic nerve injury: standard care (Group K), hyperbaric oxygen therapy (Group HBO), intraperitoneal piracetam (Group P), and combined hyperbaric oxygen plus piracetam (Group C). After 14 days, the rats were sacrificed, and sciatic nerve tissues and blood samples were collected for histopathological and biochemical analyses. Results: No statistically significant differences were observed among the four groups with respect to axonal continuity, capillary formation, or myelin sheath regeneration. Fibroblast density was increased in Group P compared with Group K (p = 0.025), while no significant differences were detected among the remaining groups. Inflammatory cell counts were higher in Group P than in Group K (p = 0.037) and elevated in Group C compared with Group K (p = 0.014). Hypoxia-inducible factor-1 alpha (HIF-1α) expression was highest in Group K. Additionally, neuron-specific enolase levels were significantly increased in Group P compared with Group K (p = 0.006). Conclusion: In this experimental model, neither piracetam nor hyperbaric oxygen therapy resulted in significant improvements in structural nerve regeneration parameters. However, distinct alterations in inflammatory and biochemical markers were observed, indicating that these interventions may modulate cellular and metabolic responses following sciatic nerve injury rather than directly enhancing axonal repair.

Abstract:

Background/Objectives: Point-of-care ultrasound of the antral cross-sectional area (CSA) assesses perioperative aspiration risk. However, the standard 340mm² cut-off derived from healthy populations is inappropriate for chronic hepatitis B (CHB) patients due to disease-induced gastrointestinal alterations. This study aimed to determine a disease-specific CSA cut-off to confirm an empty stomach in CHB patients and identify factors influencing baseline CSA. Methods: In this prospective cohort study, 223 CHB patients underwent ultrasound CSA measurement in the right lateral decubitus (RLD) position. This was immediately followed by endoscopic gastric fluid aspiration (gold standard), defining an "empty stomach" as < 0.8 mL/kg. Receiver operating characteristic (ROC) curves evaluated diagnostic performance, while multivariate regression identified independent factors affecting the CSA. Results: Among 214 analyzed patients, the area under the ROC curve was 0.763 (95% confidence interval [CI]: 0.685–0.842). The optimal RLD CSA cut-off for an empty stomach was 835 mm², yielding 86.1% sensitivity, 61.1% specificity, 94.4% positive predictive value (PPV), and 36.3% negative predictive value (NPV). Multivariate analysis identified cholinesterase (CHE) and albumin (ALB) as independent predictors of baseline CSA. Conclusions: RLD antral CSA cut-off of 835 mm² provides excellent diagnostic confidence (94.4% PPV) for confirming an empty stomach in CHB patients. Utilizing this disease-specific threshold can optimize perioperative airway management and prevent unwarranted defensive anesthetic interventions.

Abstract: Background: Neuroanesthesia represents one of the most complex areas of modern anesthesiology because it involves continuous interactions between neuronal activity, anesthetic pharmacodynamics, cerebral metabolism, cardiovascular regulation, and functional connectivity. Current intraoperative neurological monitoring relies mainly on independent physiological parameters, which may not fully represent the global dynamic state of the brain during anesthesia. The human brain under anesthesia behaves as a nonlinear biological system characterized by multiple interacting variables, feedback mechanisms, temporal evolution, and adaptive responses. A mathematical framework capable of integrating these multidimensional components may therefore provide a new theoretical perspective for understanding neurophysiological stability. Objective: This article proposes the Unified Neuroanesthesia Neural Index (UNNI), a theoretical mathematical framework designed to describe and quantify the dynamic relationship between anesthesia-induced alterations and cerebral physiological stability. The objective is not to introduce a clinically validated score, but to establish a conceptual mathematical model that may serve as a foundation for future computational simulations, artificial intelligence applications, and clinical validation studies. Mathematical Approach: The proposed UNNI framework integrates: (1) Algebraic representation of physiological variables; (2) Differential calculus for temporal evolution; (3) Integral analysis for cumulative physiological effects; (4) Neural network modeling for predictive simulation. Results (Conceptual): Numerical simulation of the proposed equations over a hypothetical 180-minute anesthesia course produced biologically plausible trajectories: a rapid decline of neuronal activity and rise of anesthetic effect during induction, a stable plateau during maintenance, and coordinated recovery during emergence (Figure 2). Hypothetical sensitivity analysis identified anesthetic concentration and neuronal activity as the dominant contributors to the composite index, consistent with prior EEG-based depth-of-anesthesia literature. Conclusion: The Unified Neuroanesthesia Neural Index (UNNI) provides a theoretical mathematical architecture for describing brain behavior during anesthesia as a dynamic nonlinear system. Future research should evaluate this framework through computational simulations, retrospective datasets, prospective clinical studies, and artificial intelligence validation models.

Abstract: Background/Objectives: Mean arterial pressure (MAP) is an incomplete surrogate of systemic perfusion: cardiac index (CI) and MAP can become dissociated. Recent cardiac surgery studies report that the burden of low CI during normotensive periods is associated with acute kidney injury (AKI). Whether this pressure--flow dissociation occurs in major aortic surgery and is modulated by the choice of arterial-pressure-derived monitoring strategy (FloTrac vs Acumen IQ/Hypotension Prediction Index, HPI) is unknown. Methods: CI-focused secondary analysis of 100 major aortic surgery patients from a prior MAP-based cohort. Continuous CI signals were newly extracted from the original HemoSphere exports. The primary metric was the percentage of monitoring time with CI<2.2L/min/m² during MAP\(\geq\) 65mmHg; the primary outcome was AKI by KDIGO criteria. Multivariable logistic regression adjusted for baseline demographics, comorbidities, preoperative MAP, surgery duration, and monitoring strategy, with Holm–Bonferroni correction within test families. Reported per STROBE. Results: Pressure–flow dissociation was frequent: low CI during normotension occurred in 94% of patients at CI<2.5 (median burden 27%). The HPI group had numerically lower low-CI burden and higher mean MAP (87 vs 84mmHg, \(p_{\mathrm{raw}} = 0.008\)). AKI occurred in 34/99 evaluable patients (FloTrac 19/49, 38.8%; HPI 15/50, 30.0%). AKI patients did not have higher low CI burden than no-AKI patients (median 5.2% vs 7.6%, \(p = 0.73\)). In multivariable regression, neither low CI burden (adjusted OR 0.88 per 10-pp increase, 95% CI 0.67–1.12, \(p = 0.33\)) nor HPI assignment (adjusted OR 0.57, 95% CI 0.20--1.53, \(p = 0.27\)) was associated with AKI. Sensitivity, time-to-event, and heart rate × CI interaction analyses yielded uniformly null findings.Conclusions: Pressure–flow dissociation is frequent in major aortic surgery, and HPI monitoring modifies the haemodynamic pattern. However, neither the low CI burden nor the choice of monitoring strategy was associated with postoperative AKI, suggesting a boundary condition on the generalisability of recent cardiac surgery CI–AKI associations. Definitive evidence requires prospective randomised evaluation (HYPE-AORTA, NCT07510451).

Abstract: Background/Objectives: Total hip arthroplasty (THA) in older patients is commonly performed under general anesthesia (GA) or spinal anesthesia (SA). Although prior studies have emphasized postoperative outcomes, perioperative hemodynamic differences remain insufficiently characterized. This study compared intraoperative and early postanesthesia care unit (PACU) hemodynamic changes and in-hospital clinical outcomes between SA and GA in older patients undergoing elective THA. Methods: This single-center retrospective observational study included patients aged ≥65 years who underwent THA from 2020 to 2025. Exclusion criteria included below-normal left ventricular ejection fraction, moderate-to-severe valvular heart disease, atrial fibrillation, severe dementia, acute kidney injury, end-stage renal disease, wound infection, sepsis, or dexmedetomidine loading/high-dose maintenance exposure. The primary hemodynamic outcomes were the occurrences of SAP < 90 mmHg intraoperatively and in the PACU. Secondary outcomes included the difference between preanesthetic SAP and the lowest SAP recorded in the PACU (ΔSAP), PACU length of stay, vasopressor use, transfusion volume, hospital stay, and in-hospital complications. Results: SAP < 90 mmHg occurred more frequently with SA than GA intraoperatively (35.8% vs. 24.3%, p = 0.024) and in the PACU (39.3% vs. 24.9%, p = 0.005). SA was associated with lower estimated blood loss [400.0 (350.0–450.0) mL vs. 450.0 (400.0–500.0) mL, p < 0.001], greater phenylephrine and ephedrine requirements, longer PACU stay [30 (20–35) min vs. 25 (20–30) min, p < 0.001], and greater ΔSAP (46.98 ± 23.32 mmHg vs. 32.63 ± 23.12 mmHg, p < 0.001). Hospital stay, transfusion requirements, and 12-h visual analog scale scores did not differ significantly between groups, while major in-hospital complications were uncommon in both groups. Conclusions: In older patients undergoing elective THA, SA was associated with more frequent intraoperative and PACU hypotension than GA. These findings support closer blood pressure monitoring and timely hemodynamic intervention throughout surgery and early recovery.

Abstract: Horner's syndrome is an uncommon but recognised complication of neuroaxial analgesia in obstetrics procedures, with an incidence of 0.4-4%. The incidence is significantly higher than in non-obstetric patients. This case report describes a 28-year-old primigravida who developed unilateral Horner's syndrome approximately one hour after lumbar epidural analgesia placement for labour pain relief. Upon examination the patient presented with left-sided ptosis, anisocoria, and unexpected sensory blockade extending to the T3-T4 lev-el, accompanied by localised numbness in the left breast and transient upper limb paraesthesia. The pathophysiology of Horner's syndrome involves cephalad spread of local anaesthetic toward the superior cervical sympathetic chain, disrupting sympathetic innervation to the ocular and facial areas. Primary and secondary damage to the sympathetic pathways in the central nervous offer a wide differential diagnosis. The management was conservative, including reduction of epidural bolus infusion rates and careful monitoring. The patient experienced complete resolution of all symptoms within five hours and delivered vaginally without complications. This case demonstrates the charac-teristically benign and self-limited nature of this complication, emphasising the importance of clinical awareness, proper reassurance of patients, and avoidance of unnecessary diagnostic testing.

Abstract: Regenerative medicine restores tissue structure and function by regulating the biological processes that are involved in cellular survival, proliferation, differentiation, as well as tissue remodeling. Peptide-based therapeutics have gained popularity as regenerative tools related to their ability to precisely modulate the defined signaling pathways. Peptides provide high target specificity, biological activity, and translational flexibility while also serving as endogenous signaling molecules that can influence the regenerative processes. FGF-18, TB4, GHK-Cu, MOTS-c, and tesamorelin demonstrate diverse regenerative mechanisms which include cartilage repair, wound healing, extracellular matrix remodeling, and tissue remodeling. Current evidence supports strong regenerative effects in preclinical studies, with clinical translation seen as well. Major barriers include limited bioavailability and delivery challenges. Continued advances in peptide engineering, delivery, and clinical evaluation will all be necessary to establish their long-term therapeutic role in regenerative medicine. This review evaluates peptide-based regenerative therapies by examining mechanisms of action, clinical evidence, and current translational status.

Abstract: Background: Continuous epidural analgesia is widely used for postoperative pain management in neonates and small-weight infants. Epidural catheters may be inserted via a caudal-threaded approach or by direct lumbar/thoracic placement; however, comparative data on placement success, clinical use, postoperative analgesic outcomes, and complications remain limited. This study compared these two epidural techniques in neonates and small-weight infants undergoing surgery.Methods: This retrospective observational cohort study included all neonates and infants admitted to the Neonatal Intensive Care Unit at UPMC Children's Hospital of Pittsburgh who underwent attempted epidural catheter placement between January 2018 and December 2024. Demographic and perioperative data were extracted from the electronic medical record. Outcomes included patient, surgical, and epidural characteristics, epidural medications, postoperative pain and sedation scores, opioid consumption, technical success of catheter placement, and epidural catheter complications. Results: A total of 104 patients underwent attempted epidural catheter placement; five procedures were unsuccessful in four patients, resulting in 100 successful epidural catheter placements (70 caudal-threaded and 30 direct lumbar/thoracic). Epidural catheter placement was successful in 96.2% of patients. Patient and surgical characteristics, postoperative pain and sedation scores, and opioid consumption were similar between groups. Direct lumbar/thoracic epidural catheter placement required longer procedure times. Patients in the direct lumbar/thoracic epidural group were more likely than those in the caudal-threaded group to receive a ropivacaine/clonidine infusion (47% vs. 4%; p < 0.001) and a programmed intermittent bolus of epidural infusion (60% vs. 3%; p < 0.001). The direct lumbar/thoracic group experienced more postoperative catheter-related complications than the caudal-threaded group (20% vs. 4%; p = 0.02), primarily catheter leakage requiring premature catheter removal. Conclusions: Caudal-threaded and direct lumbar/thoracic epidural catheters provided comparable postoperative analgesic outcomes in neonates and small-weight infants when placed by a Pediatric Acute Pain Service. Direct lumbar/thoracic epidural catheters were associated with a higher incidence of postoperative catheter leakage and premature catheter removal. These findings may help clinicians select the most appropriate epidural technique for postoperative pain management in this population.