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  1. Article ; Online: How to identify a high-risk surgical patient?

    Schmidt, André P / Stefani, Luciana C

    Brazilian journal of anesthesiology (Elsevier)

    2022  Volume 72, Issue 3, Page(s) 313–315

    MeSH term(s) Humans ; Postoperative Complications/diagnosis ; Postoperative Complications/prevention & control ; Risk Factors ; Surgical Procedures, Operative ; Surgical Wound Infection
    Language English
    Publishing date 2022-04-21
    Publishing country Brazil
    Document type Editorial
    ISSN 2352-2291
    ISSN (online) 2352-2291
    DOI 10.1016/j.bjane.2022.04.002
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  2. Article ; Online: The need for data describing the surgical population in Latin America.

    Stefani, Luciana C / Hajjar, Ludhmila / Biccard, Bruce / Pearse, Rupert M

    British journal of anaesthesia

    2022  Volume 129, Issue 1, Page(s) 10–12

    Abstract: Latin American countries have a huge diversity in sociocultural factors, ethnicity, geography, and political systems. Provision of healthcare varies widely in Latin America, and it is unclear how these disparities relate to outcomes for individual ... ...

    Abstract Latin American countries have a huge diversity in sociocultural factors, ethnicity, geography, and political systems. Provision of healthcare varies widely in Latin America, and it is unclear how these disparities relate to outcomes for individual patients undergoing surgery. The Latin American Surgical Outcome Study (LASOS), with its pragmatic design, will provide a snapshot of surgical activity throughout Latin America and identify the next steps needed to improve postoperative outcomes.
    MeSH term(s) Demography ; Developing Countries ; Geography ; Humans ; Latin America ; Population Dynamics
    Language English
    Publishing date 2022-03-21
    Publishing country England
    Document type Editorial
    ZDB-ID 80074-0
    ISSN 1471-6771 ; 0007-0912
    ISSN (online) 1471-6771
    ISSN 0007-0912
    DOI 10.1016/j.bja.2022.02.029
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  3. Article ; Online: Developing and validating a machine learning ensemble model to predict postoperative delirium in a cohort of high-risk surgical patients: A secondary cohort analysis.

    Neto, Paulo C S / Rodrigues, Attila L / Stahlschmidt, Adriene / Helal, Lucas / Stefani, Luciana C

    European journal of anaesthesiology

    2023  Volume 40, Issue 5, Page(s) 356–364

    Abstract: Background: Postoperative delirium (POD) has a negative impact on prognosis, length of stay and the burden of care. Although its prediction and identification may improve postoperative care, this need is largely unmet in the Brazilian public health ... ...

    Abstract Background: Postoperative delirium (POD) has a negative impact on prognosis, length of stay and the burden of care. Although its prediction and identification may improve postoperative care, this need is largely unmet in the Brazilian public health system.
    Objective: To develop and validate a machine-learning prediction model and estimate the incidence of delirium. We hypothesised that an ensemble machine-learning prediction model that incorporates predisposing and precipitating features could accurately predict POD.
    Design: A secondary analysis nested in a cohort of high-risk surgical patients.
    Setting: An 800-bed, quaternary university-affiliated teaching hospital in Southern Brazil. We included patients operated on from September 2015 to February 2020.
    Patients: We recruited 1453 inpatients with an all-cause postoperative 30-day mortality risk greater than 5% assessed preoperatively by the ExCare Model.
    Main outcome measure: The incidence of POD classified by the Confusion Assessment Method, up to 7 days postoperatively. Predictive model performance with different feature scenarios were compared with the area under the receiver operating characteristic curve.
    Results: The cumulative incidence of delirium was 117, giving an absolute risk of 8.05/100 patients. We developed multiple machine-learning nested cross-validated ensemble models. We selected features through partial dependence plot analysis and theoretical framework. We treated the class imbalance with undersampling. Different feature scenarios included: 52 preoperative, 60 postoperative and only three features (age, preoperative length of stay and the number of postoperative complications). The mean areas (95% confidence interval) under the curve ranged from 0.61 (0.59 to 0.63) to 0.74 (0.73 to 0.75).
    Conclusion: A predictive model composed of three indicative readily available features performed better than those with numerous perioperative features, pointing to its feasibility as a prognostic tool for POD. Further research is required to test the generalisability of this model.
    Trial registration: Institutional Review Board Registration number 04448018.8.0000.5327 (Brazilian CEP/CONEP System, available in https://plataformabrasil.saude.gov.br/ ).
    MeSH term(s) Humans ; Emergence Delirium ; Delirium/diagnosis ; Delirium/epidemiology ; Delirium/etiology ; Risk Factors ; Cohort Studies ; Postoperative Complications/diagnosis ; Postoperative Complications/epidemiology ; Postoperative Complications/etiology ; Machine Learning ; Retrospective Studies
    Language English
    Publishing date 2023-03-01
    Publishing country England
    Document type Journal Article
    ZDB-ID 605770-6
    ISSN 1365-2346 ; 0265-0215
    ISSN (online) 1365-2346
    ISSN 0265-0215
    DOI 10.1097/EJA.0000000000001811
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  4. Article ; Online: Troponin elevation as a marker of short deterioration and one-year death in a high-risk surgical patient cohort in a low and middle income country setting: a postoperative approach to increase surveillance.

    Stahlschmidt, Adriene / Passos, Sávio C / Dornelles, Debora D / Polanczyk, Carisi / Gutierrez, Claudia S / Minuzzi, Rosangela R / Castro, Stela M J / Stefani, Luciana C

    Canadian journal of anaesthesia = Journal canadien d'anesthesie

    2023  Volume 70, Issue 11, Page(s) 1776–1788

    Abstract: Purpose: Myocardial injury after noncardiac surgery is common and mostly asymptomatic. The ideal target population that will benefit from routine troponin measurements in low and middle income countries (LMICs) is unclear. This study aims to evaluate ... ...

    Title translation L’élévation de la troponine comme marqueur de détérioration rapide et de décès à un an dans une cohorte de patient·es de chirurgie à haut risque dans le contexte d’un pays à revenu faible et intermédiaire : une approche postopératoire pour accroître la surveillance.
    Abstract Purpose: Myocardial injury after noncardiac surgery is common and mostly asymptomatic. The ideal target population that will benefit from routine troponin measurements in low and middle income countries (LMICs) is unclear. This study aims to evaluate the clinical outcomes of a cohort of high-risk surgical patients according to high-sensitivity troponin T (hsTnT) in an LMIC setting.
    Methods: We conducted a prospective cohort study of 442 high-risk patients undergoing noncardiac surgery at a Brazilian hospital between February 2019 and March 2020. High-sensitivity troponin T levels were measured preoperatively, 24 hr, and 48 hr after surgery and stratified into three groups: normal (< 20 ng·L
    Results: Postoperative myocardial injury occurred in 45% of patients. Overall, 30-day mortality was 8%. Thirty-day and one-year mortality were higher in patients with hsTnT ≥ 20 ng·L
    Conclusion: This study supports evidence that hsTnT is an important prognostic marker and a strong predictor of all-cause mortality after surgery. Troponin measurement in high-risk surgical patients could potentially be used as tool to scale-up care in LMIC settings.
    Study registration: ClinicalTrials.gov (NCT04187664); first submitted 5 December 2019.
    MeSH term(s) Humans ; Troponin ; Developing Countries ; Troponin T ; Prospective Studies ; Risk Assessment ; Biomarkers
    Chemical Substances Troponin ; Troponin T ; Biomarkers
    Language English
    Publishing date 2023-10-18
    Publishing country United States
    Document type Journal Article
    ZDB-ID 91002-8
    ISSN 1496-8975 ; 0832-610X
    ISSN (online) 1496-8975
    ISSN 0832-610X
    DOI 10.1007/s12630-023-02558-4
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  5. Article ; Online: Development and validation of the Ex-Care BR model: a multicentre initiative for identifying Brazilian surgical patients at risk of 30-day in-hospital mortality.

    Passos, Sávio C / de Jezus Castro, Stela M / Stahlschmidt, Adriene / da Silva Neto, Paulo C / Irigon Pereira, Paulo J / da Cunha Leal, Plínio / Lopes, Maristela B / Dos Reis Falcão, Luiz F / de Azevedo, Vera L F / Lineburger, Eric B / Mendes, Florentino F / Vilela, Ramon M / de Araújo Azi, Liana M T / Antunes, Fabrício D / Braz, Leandro G / Stefani, Luciana C

    British journal of anaesthesia

    2024  

    Abstract: Background: Surgical risk stratification is crucial for enhancing perioperative assistance and allocating resources efficiently. However, existing models may not capture the complexity of surgical care in Brazil. Using data from various healthcare ... ...

    Abstract Background: Surgical risk stratification is crucial for enhancing perioperative assistance and allocating resources efficiently. However, existing models may not capture the complexity of surgical care in Brazil. Using data from various healthcare settings nationwide, we developed a new risk model for 30-day in-hospital mortality (the Ex-Care BR model).
    Methods: A retrospective cohort study was conducted in 10 hospitals from different geographic regions in Brazil. Data were analysed using multilevel logistic regression models. Model performance was assessed using the area under the receiver operating characteristic curve (AUROC), Brier score, and calibration plots. Derivation and validation cohorts were randomly assigned.
    Results: A total of 107,372 patients were included, and 30-day in-hospital mortality was 2.1% (n=2261). The final risk model comprised four predictors related to the patient and surgery (age, ASA physical status classification, surgical urgency, and surgical size), and the random effect related to hospitals. The model showed excellent discrimination (AUROC=0.93, 95% confidence interval [CI], 0.93-0.94), calibration, and overall performance (Brier score=0.017) in the derivation cohort (n=75,094). Similar results were observed in the validation cohort (n=32,278) (AUROC=0.93, 95% CI, 0.92-0.93).
    Conclusions: The Ex-Care BR is the first model to consider regional and organisational peculiarities of the Brazilian surgical scene, in addition to patient and surgical factors. It is particularly useful for identifying high-risk surgical patients in situations demanding efficient allocation of limited resources. However, a thorough exploration of mortality variations among hospitals is essential for a comprehensive understanding of risk.
    Clinical trial registration: NCT05796024.
    Language English
    Publishing date 2024-05-09
    Publishing country England
    Document type Journal Article
    ZDB-ID 80074-0
    ISSN 1471-6771 ; 0007-0912
    ISSN (online) 1471-6771
    ISSN 0007-0912
    DOI 10.1016/j.bja.2024.04.001
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  6. Article ; Online: Measuring emotional preoperative stress by an app approach and its applicability to predict postoperative pain.

    Schiavo, Carolina L / Borges, Rogério B / Castro, Stela M J / Wolmeister, Anelise S / de Souza, Andressa / Martins, Otávio R S / Galvão, Gabriela S / Nazario, Kahio C K / Nickel, Fabian J / Caumo, Wolnei / Stefani, Luciana C

    PloS one

    2022  Volume 17, Issue 2, Page(s) e0263275

    Abstract: Background: The Brief Measure of Emotional Preoperative Stress (B-MEPS) was developed to evaluate the preoperative individual vulnerability to emotional stress. To obtain a refined version of B-MEPS suitable for an app approach, this study aimed: (i) to ...

    Abstract Background: The Brief Measure of Emotional Preoperative Stress (B-MEPS) was developed to evaluate the preoperative individual vulnerability to emotional stress. To obtain a refined version of B-MEPS suitable for an app approach, this study aimed: (i) to identify items with more discriminant properties; (ii) to classify the level of preoperative emotional stress based on cut-off points; (iii) to assess concurrent validity through correlation with the Central Sensitization Inventory (CSI) score; (iv) to confirm whether the refined version of B-MEPS is an adequate predictive measure for identification of patients prone to intense postoperative pain.
    Methods: We include 1016 patients who had undergone surgical procedures in a teaching hospital. The generalized partial credit model of item response theory and latent class model were employed, respectively, to reduce the number of items and to create cut-off points. We applied the CSI and assessed pain by Visual Analog Scale (0-10) and by the amount of postoperative morphine consumption.
    Results: The refined B-MEPS shows satisfactory reliability (Cronbach's alpha 0.79). Preoperative emotional stress, according to the cut-off points, is classified into categories: low, intermediate or high stress. The refined B-MEPS exhibited a linear association with the CSI scores (r2 = 0.53, p < 0.01). Patients with higher levels of emotional stress displayed a positive association with moderate to severe pain and greater morphine consumption.
    Conclusion: The refined version of B-MEPS, along with an interface of easy applicability, assess emotional vulnerability at the bedside before surgery. This app may support studies focused on intervening with perioperative stress levels.
    MeSH term(s) Female ; Humans ; Male ; Middle Aged ; Mobile Applications/statistics & numerical data ; Pain Measurement/methods ; Pain, Postoperative/diagnosis ; Pain, Postoperative/epidemiology ; Pain, Postoperative/psychology ; Preoperative Period ; Prospective Studies ; Psychological Distress ; Psychometrics ; Surveys and Questionnaires
    Language English
    Publishing date 2022-02-16
    Publishing country United States
    Document type Journal Article ; Research Support, Non-U.S. Gov't
    ZDB-ID 2267670-3
    ISSN 1932-6203 ; 1932-6203
    ISSN (online) 1932-6203
    ISSN 1932-6203
    DOI 10.1371/journal.pone.0263275
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  7. Article ; Online: Perioperative mortality related to anesthesia within 48 h and up to 30 days following surgery: A retrospective cohort study of 11,562 anesthetic procedures.

    Stefani, Luciana C / Gamermann, Patricia W / Backof, Amanda / Guollo, Fernanda / Borges, Rafael M J / Martin, Adriana / Caumo, Wolnei / Felix, Elaine A

    Journal of clinical anesthesia

    2018  Volume 49, Page(s) 79–86

    Abstract: Study objective: Studying postoperative in-hospital mortality is crucial to the understanding of the perioperative process failures and to the implementation of strategies to improve patient outcomes. We intend to classify the causes of perioperative ... ...

    Abstract Study objective: Studying postoperative in-hospital mortality is crucial to the understanding of the perioperative process failures and to the implementation of strategies to improve patient outcomes. We intend to classify the causes of perioperative deaths up to 30 days after procedures requiring anesthesia and to evaluate the risk factors for early (48 h) or late (30 day) mortality.
    Design: Retrospective cohort study.
    Setting: A quaternary University Hospital from South Brazil.
    Patients: The information related to the perioperative care was collected from surgeries performed between January 2012 and December 2011.
    Interventions: None (observational study).
    Measurements: Three anesthesiologists classified the causes of deaths according to the ANZCA (Australian and New Zealand College of Anesthetists) classification, used in the report of Anesthesia-Related Mortality in Australia since 1985, which defines eight death categories. The risk factors for early or late death were analyzed in a regression model.
    Main results: 11.562 surgeries were performed, with a mortality incidence of 2.75% within 30 days (319 deaths). Most deaths were inevitable (50.7%), as they were related to advanced illnesses and would occur regardless of anesthetic or surgical procedures. The second most common cause was related to surgical complications (25%). The death rate having anesthesia as a likely contributor was 1.72:10.000 procedures, and as a potential contributor 7.78:10.000. These deaths occurred significantly earlier (<48 h) when compared to deaths from other causes. Transoperative vasopressor, extremes of age and out-of-hour surgery were independent variables associated to early deaths.
    Conclusions: The study confirms that postoperative mortality in which anesthesia was involved occurred earlier in the perioperative period. In addition, it was revealed that this involvement of anesthesia as a morbidity contributor shows higher frequency when considering the anesthesiologist perioperative role, and when assessing the mortality in the long term (30 days).
    MeSH term(s) Adolescent ; Adult ; Age Factors ; Aged ; Aged, 80 and over ; Anesthesia/adverse effects ; Anesthesia/methods ; Brazil/epidemiology ; Cause of Death ; Child ; Child, Preschool ; Female ; Hospital Mortality ; Humans ; Infant ; Infant, Newborn ; Male ; Middle Aged ; Outcome and Process Assessment (Health Care)/statistics & numerical data ; Perioperative Care/adverse effects ; Perioperative Care/methods ; Perioperative Care/statistics & numerical data ; Perioperative Period/statistics & numerical data ; Postoperative Complications/etiology ; Postoperative Complications/mortality ; Retrospective Studies ; Risk Factors ; Surgical Procedures, Operative/adverse effects ; Time Factors ; Vasoconstrictor Agents/adverse effects ; Young Adult
    Chemical Substances Vasoconstrictor Agents
    Language English
    Publishing date 2018-06-15
    Publishing country United States
    Document type Journal Article
    ZDB-ID 1011618-7
    ISSN 1873-4529 ; 0952-8180
    ISSN (online) 1873-4529
    ISSN 0952-8180
    DOI 10.1016/j.jclinane.2018.06.025
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  8. Article ; Online: Few and feasible preoperative variables can identify high-risk surgical patients: derivation and validation of the Ex-Care risk model.

    Gutierrez, Claudia S / Passos, Sávio C / Castro, Stela M J / Okabayashi, Lucas S M / Berto, Mariana L / Lorenzen, Marina B / Caumo, Wolnei / Stefani, Luciana C

    British journal of anaesthesia

    2020  Volume 126, Issue 2, Page(s) 525–532

    Abstract: Background: The development of feasible preoperative risk tools is desirable, especially for low-middle income countries with limited resources and complex surgical settings. This study aimed to derive and validate a preoperative risk model (Ex-Care ... ...

    Abstract Background: The development of feasible preoperative risk tools is desirable, especially for low-middle income countries with limited resources and complex surgical settings. This study aimed to derive and validate a preoperative risk model (Ex-Care model) for postoperative mortality and compare its performance with current risk tools.
    Methods: A multivariable logistic regression model predicting in-hospital mortality was developed using a large Brazilian surgical cohort. Patient and perioperative predictors were considered. Its performance was compared with the Charlson comorbidity index (CCI), Revised Cardiac Risk Index (RCRI), and the Surgical Outcome Risk Tool (SORT).
    Results: The derivation cohort included 16 618 patients. In-hospital death occurred in 465 patients (2.8%). Age, with adjusted splines, degree of procedure (major vs non-major), ASA physical status, and urgency were entered in a final model. It showed high discrimination with an area under the receiver operating characteristic curve (AUROC) of 0.926 (95% confidence interval [CI], 0.91-0.93). It had superior accuracy to the RCRI (AUROC, 0.90 vs 0.76; P<0.01) and similar to the CCI (0.90 vs 0.82; P=0.06) and SORT models (0.90 vs 0.92; P=0.2) in the temporal validation cohort of 1173 patients. Calibration was adequate in both development (Hosmer-Lemeshow, 9.26; P=0.41) and temporal validation cohorts (Hosmer-Lemeshow 5.29; P=0.71).
    Conclusions: The Ex-Care risk model proved very efficient at identifying high-risk surgical patients. Although multicentre studies are needed, it should have particular value in low resource settings to better inform perioperative health policy and clinical decision-making.
    MeSH term(s) Adolescent ; Adult ; Aged ; Aged, 80 and over ; Brazil ; Clinical Decision-Making ; Decision Support Techniques ; Feasibility Studies ; Female ; Hospital Mortality ; Humans ; Male ; Middle Aged ; Predictive Value of Tests ; Reproducibility of Results ; Risk Assessment ; Risk Factors ; Surgical Procedures, Operative/mortality ; Treatment Outcome ; Young Adult
    Language English
    Publishing date 2020-10-27
    Publishing country England
    Document type Comparative Study ; Journal Article ; Research Support, Non-U.S. Gov't ; Validation Study
    ZDB-ID 80074-0
    ISSN 1471-6771 ; 0007-0912
    ISSN (online) 1471-6771
    ISSN 0007-0912
    DOI 10.1016/j.bja.2020.09.036
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  9. Article: Effects of Transcranial Direct Current Stimulation Block Remifentanil-Induced Hyperalgesia: A Randomized, Double-Blind Clinical Trial.

    Braulio, Gilberto / Passos, Savio C / Leite, Fabricio / Schwertner, Andre / Stefani, Luciana C / Palmer, Ana C S / Torres, Iraci L S / Fregni, Felipe / Caumo, Wolnei

    Frontiers in pharmacology

    2018  Volume 9, Page(s) 94

    Abstract: Background: ...

    Abstract Background:
    Language English
    Publishing date 2018-02-19
    Publishing country Switzerland
    Document type Journal Article
    ZDB-ID 2587355-6
    ISSN 1663-9812
    ISSN 1663-9812
    DOI 10.3389/fphar.2018.00094
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  10. Article ; Online: Latin American surgical outcomes study: study protocol for a multicentre international observational cohort study of patient outcomes after surgery in Latin American countries.

    Hajjar, Ludhmila A / Quintão, Vinícius C / Vieira, Alexandra P Z / Nakada, Letícia N / Pearse, Rupert M / Ramirez, Martha B D / la Medina, Antonio R / Alvarez, Adrian / McLoghlin, Santiago / Boccalatte, Luis / Padmore, Greg / Feraudy, Israël / Martinez, Monica / Villablanca, Nicolas / Pérez, Carlos / Calvache, José A / Lincango, Eddy / Sosa, Rodrigo / Shu, Sebastian /
    Riva, Juan / Godinez, Lisbeth / Frias, Melba / Major, Don / Licea, Miguel / Batista, Sylvia / Charles, Shane / Vaca, Mayra / Rosado, Ismael D / Borunda, Delia / Zaky, Osama Bahsas / Cardona, Claudia M C / Carmona, Maria J C / Stefani, Luciana C

    BJA open

    2022  Volume 3, Page(s) 100030

    Abstract: Background: Reported data suggest that 4.2 million deaths will occur within 30 days of surgery worldwide each year, half of which are in low- and middle-income countries. Postoperative complications are a leading cause of long-term morbidity and ... ...

    Abstract Background: Reported data suggest that 4.2 million deaths will occur within 30 days of surgery worldwide each year, half of which are in low- and middle-income countries. Postoperative complications are a leading cause of long-term morbidity and mortality. Patients who survive and leave the hospital after surgical complications regularly experience reductions in long-term survival and functional independence, resulting in increased costs. With a high volume of surgery performed, there is a growing perception of the substantial impact of even minor enhancements in perioperative care. The Latin American Surgical Outcomes Study (LASOS) is an international, multicentre, prospective cohort study of adults submitted to in-patient surgery in Latin America aiming to provide detailed data describing postoperative complications and surgical mortality.
    Methods: LASOS is a 7 day cohort study of adults undergoing surgery in Latin America. Details of preoperative risk factors, intraoperative care, and postoperative outcomes will be collected. The primary outcome will be in-hospital postoperative complications of any cause. Secondary outcomes include in-hospital all-cause mortality, duration of hospital stay after surgery, and admission to a critical care unit within 30 days after surgery during the index hospitalisation.
    Results: The LASOS results will be published in peer-reviewed journals, reported and presented at international meetings, and widely disseminated to patients and public in participating countries
    Conclusions: The LASOS may augment our understanding of postoperative complications and surgial mortality in Latin America.
    Clinical trial registration: NCT05169164.
    Language English
    Publishing date 2022-08-19
    Publishing country England
    Document type Clinical Trial
    ISSN 2772-6096
    ISSN (online) 2772-6096
    DOI 10.1016/j.bjao.2022.100030
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