Christian Grasshoff

The occurrence of phantom pain after surgical removal of male reproductive organs is a potential outcome. Indications for surgery may predict the probability of phantom pain after the procedure. These may vary between individuals undergoing tumor orchiectomy and those undergoing gender-affirming surgery. This study investigates the incidence of phantom pain after gender-affirming surgery. A retrospective questionnaire-based study was conducted with 55 transgender women who had undergone gender-affirming surgery, and the results were compared with those of 54 men who had undergone tumor orchiectomy, serving as a control group. The frequency, severity, risk factors, and characteristics of phantom pain in the testes and penis, painless phantom sensations in the genital area, and chronic postsurgical pain incidence were assessed. Phantom pain and painless phantom sensations in the testes were more frequent after tumor orchiectomy than after gender-affirming surgery. Transgender women did not experience persistent phantom pain after gender-affirming surgery. Chronic postsurgical pain incidence did not differ between the 2 groups. Preexisting genital pain affected the risk of chronic postsurgical pain in the tumor orchiectomy group but not the risk of phantom pain. In this study, we assessed whether transgender women experienced phantom pain after undergoing gender-affirming surgery. It appears that transgender women are less prone to phantom pain after gender-affirming surgery than are men after inguinal tumor orchiectomy. This may be attributed to alterations in the central representation of the unaccepted sex organs in the somatosensory cortex.

Context: European and German consensus guidelines advocate preoperative therapy with α-adrenoreceptor antagonists in symptomatic patients with catecholamine-producing pheochromocytomas and paragangliomas (PPGLs) to avoid hypertensive crisis during adrenalectomy. This practice has been questioned recently. Objective: This work aimed to assess current preoperative management of PPGLs across disciplines. Methods: The study was conducted from November 2023 to February 2024 using the Delphi technique. Two consecutive surveys were conceived by a steering group and 46 experts were consulted using REDCap web application (response: 74%). Results: There was general agreement about diagnostic tools and indication for adrenalectomy. In contrast, 20% of the panelists routinely administered α-adrenoreceptor antagonists to all patients, 50% only in case of symptoms, and about one-third of experts abandoned preoperative α-adrenoreceptor blockade. The prevention of anticipated intraoperative hypertensive crisis and cardiovascular complications (75%) as well as medicolegal considerations (25%) were the main motivations. Despite availability of short-acting α-adrenoreceptor antagonists, most experts (63%) continued to use phenoxybenzamine. Half of the experts preferred pretreatment in an outpatient setting, 13% routinely treated in the hospital, and 37% combined outpatient and inpatient treatment. Intraoperatively, urapidil and nitroprusside natrium were mainly used for blood pressure control. Postoperatively, around 60% of the experts routinely admitted patients to an intensive care or intermediate care unit. Conclusion: Current guideline recommendations for preoperative treatment with α-adrenoreceptor antagonists in patients with PPGLs are generally adopted by treating teams but current practice is very heterogeneous even among expert centers. With the improvement of surgical techniques and intraoperative management, a more individualized approach may be considered.

Background: In cases of terrorism, disasters, or mass casualty incidents, far-reaching life-and-death decisions about prioritizing patients are currently made using triage algorithms that focus solely on the patient’s current health status rather than their prognosis, thus leaving a fatal gap of patients who are under- or overtriaged. Objective: The aim of this proof-of-concept study is to demonstrate a novel approach for triage that no longer classifies patients into triage categories but ranks their urgency according to the anticipated survival time without intervention. Using this approach, we aim to improve the prioritization of casualties by respecting individual injury patterns and vital signs, survival likelihoods, and the availability of rescue resources. Methods: We designed a mathematical model that allows dynamic simulation of the time course of a patient’s vital parameters, depending on individual baseline vital signs and injury severity. The 2 variables were integrated using the well-established Revised Trauma Score (RTS) and the New Injury Severity Score (NISS). An artificial patient database of unique patients with trauma (N=82,277) was then generated and used for analysis of the time course modeling and triage classification. Comparative performance analysis of different triage algorithms was performed. In addition, we applied a sophisticated, state-of-the-art clustering method using the Gower distance to visualize patient cohorts at risk for mistriage. Results: The proposed triage algorithm realistically modeled the time course of a patient’s life, depending on injury severity and current vital parameters. Different casualties were ranked by their anticipated time course, reflecting their priority for treatment. Regarding the identification of patients at risk for mistriage, the model outperformed the Simple Triage And Rapid Treatment’s triage algorithm but also exclusive stratification by the RTS or the NISS. Multidimensional analysis separated patients with similar patterns of injuries and vital parameters into clusters with different triage classifications. In this large-scale analysis, our algorithm confirmed the previously mentioned conclusions during simulation and descriptive analysis and underlined the significance of this novel approach to triage. Conclusions: The findings of this study suggest the feasibility and relevance of our model, which is unique in terms of its ranking system, prognosis outline, and time course anticipation. The proposed triage-ranking algorithm could offer an innovative triage method with a wide range of applications in prehospital, disaster, and emergency medicine, as well as simulation and research.

Background: Perioperative hemodynamic instability is one of the most common adverse events in patients undergoing adrenalectomy for pheochromocytoma. The aim of this study was to analyze the impact of perioperative severe hemodynamic instability. Methods: We present a retrospective, single-center analysis in a major tertiary hospital of all consecutive patients undergoing elective adrenalectomy from 2005 to 2019 for pheochromocytoma. Severe perioperative hypertension and hypotension were evaluated, defined as changes in blood pressure larger than 30% of the preoperative patient-specific mean arterial pressure (MAP). Results: Unilateral adrenalectomy was performed in 67 patients. Intraoperative episodes of hemodynamic instability occurred in 97% of all patients (n = 65), severe hypertension occurred in 24 patients (36%), and severe hypotensive episodes occurred in 62 patients (93%). Patients with more than five severe hypotensive episodes (n = 29) received higher preoperative alpha-adrenergic blockades (phenoxybenzamine 51 ± 50 mg d⁻¹ vs. 29 ± 27 mg d⁻¹; p = 0.023) and had a longer mean ICU stay (39.6 ± 41.5 h vs. 20.6 ± 19.1 h, p = 0.015). Conclusion: Intraoperative hypotensive, rather than hypertensive, episodes occurred during adrenalectomy. The occurrence of more than five hypotensive episodes correlated well with a significantly longer hospital stay and ICU time.

BACKGROUND Background: In cases of terrorism, disasters or mass casualty incidents, far-reaching life-and-death decisions about prioritizing patients are currently made using triage algorithms that focus solely on the patient's current health status rather than their prognosis, thus leaving a fatal gap of patients who are under- or overtriaged. In this proof-of-concept study, we demonstrate a novel approach for triage that no longer classifies patients into triage categories but ranks their urgency according to the anticipated survival time without intervention. Using this approach, we aimed to improve prioritization of casualties by respecting individual injury patterns and vital signs, survival likelihoods and availability of rescue resources. OBJECTIVE Objective: The objective of this proof-of-concept study was to demonstrate a novel approach for triage that no longer classifies patients into triage categories but ranks their urgency according to the anticipated survival time without intervention. Using this approach, we aimed to improve prioritization of casualties by respecting individual injury patterns and vital signs, survival likelihoods and availability of rescue resources. METHODS Methods: A mathematical model was designed that allows dynamic simulation of the time course of a patient’s vital parameters depending on individual baseline vital signs and injury severity. The two variables are integrated by the well-established Revised Trauma Score (RTS) and New Injury Severity Score (NISS). An artificial patient database of unique trauma patients (n = 82,277) was generated and used for analysis of the time course modeling and triage classification. In addition, we applied a sophisticated, state-of-the-art clustering method using Gower Distance to visualize patient cohorts at risk for mistriage. RESULTS Results: The proposed triage model ranks patients according to their anticipated temporal course. Regarding the identification of patients at risk for mistriage, the model outperforms Simple Triage And Rapid Treatment (START)’s triage algorithm, but also exclusive stratification by RTS or NISS. Multidimensional analysis separated patients with similar patterns of injuries and vital parameters into clusters with different triage classifications. In this large-scale analysis, our algorithm confirmed the previously mentioned conclusions during simulation and descriptive analysis, and underlined the significance of this novel approach to triage. CONCLUSIONS Conclusions: The findings in this study suggest the feasibility and relevance of our model, which is unique in terms of its ranking system, prognosis outline and time course anticipation. The proposed triage ranking algorithm could offer an innovative triage method with a wide range of applications in prehospital, disaster and emergency medicine, as well as simulation and research. CLINICALTRIAL not needed

To the Editor The review by Drs Smilowitz and Berger¹ presented a concise overview of cardiovascular risk factors and risk assessment in patients undergoing noncardiac surgery. The authors assessed the importance of a comprehensive medical history, physical examination, and functional capacity during daily life as well as cardiovascular testing prior to noncardiac surgery. We would like to raise 2 points of concern regarding this review.

To the Editor Dr Guihard and colleagues¹ investigated 1248 patients requiring out-of-hospital rapid sequence tracheal intubation in a multicenter, single-blind, noninferiority randomized clinical trial comparing 1.2 mg/kg of rocuronium with 1 mg/kg of succinylcholine. The authors stated that rocuronium, compared with succinylcholine, failed to demonstrate noninferiority with regard to first-attempt intubation success rate.

The aim of the study was to evaluate peri-interventional complications and in-hospital complications in different team settings when performing transfemoral aortic valve replacement (TAVR) under local anaesthesia. We performed TAVR under local anaesthesia with a minimalist Heart Team consisting of two interventional cardiologists, an echocardiographer and two cardiac catheterisation laboratory nurses. In August 2015, new guidelines for TAVR were issued by the National Federal Joint Committee. In accordance with these guidelines, we began to perform TAVR using a complete Heart Team, consisting of two interventional cardiologists, an echocardiographer, a cardiac surgeon, an anaesthesiologist, a cardiovascular perfusionist, two cardiac catheterisation laboratory nurses, a surgical nurse and an anaesthetist nurse. In this study, we retrospectively analysed periprocedural and in-hospital outcomes. Two hundred and ninety-two (55.1%) patients were treated by the minimalist Heart Team, whereas 238 (44.9%) were treated by the complete Heart Team. There were no significant differences in periprocedural (1.4% vs. 1.3%, p=1.0) and in-hospital mortality (4.8% vs. 5.0%, p=0.9) as well as in conversion to open heart (0.3% vs. 0.8%, p=0.59) or immediate vascular surgery (0.3% vs. 2.1%, p=0.1) for minimalist versus complete Heart Team, respectively. TAVR under local anaesthesia can be safely performed by a minimalist Heart Team. We did not observe any differences in fatal periprocedural complications and mortality when compared with those of a complete Heart Team.

Transcatheter aortic valve implantation (TAVI) is a standard therapy for aortic valve stenosis in patients at intermediate-to-high surgical risk. Previously, TAVI at our site was performed by a minimalist heart team (MHT), comprised of two interventional cardiologists, echocardiography staff and two cardiac catheterization laboratory nurses. After revision of German Federal Joint Committee (G-BA) guidelines in September 2015, the presence of an extended heart team (EHT; including a full cardiac surgical team) became mandatory throughout the TAVI procedure. We aimed to evaluate the impact of the EHT on clinical and economical outcomes.