New trial adds high quality evidence on benefits of tranexamic acid for high-risk women
Photo by Jonathan Borba on Unsplash
Giving tranexamic acid to women with placenta praevia (when the placenta covers the cervical opening) undergoing caesarean birth leads to a significant yet modest reduction in severe bleeding after delivery with no evidence of an increase in serious adverse events, finds a trial from China published by The BMJtoday.
Tranexamic acid is widely used to prevent or reduce heavy bleeding usually after surgery or trauma. It works by inhibiting blood clot breakdown and is recommended for the treatment of severe bleeding after childbirth (postpartum haemorrhage).
But high quality evidence on its prophylactic use to prevent postpartum haemorrhage in high risk women remains scarce.
To address this gap, researchers in China set out to examine the effect of tranexamic acid in women with placenta praevia, a group at high risk of severe bleeding.
The trial included 1694 pregnant women with placenta praevia who were scheduled for caesarean delivery at 24 maternity units across China between July 2023 and March 2025.
Participants received prophylactic oxytocin – standard treatment to reduce blood loss after delivery – and were randomly assigned to receive either intravenous tranexamic acid (845 women) or placebo (849 women) over 10 minutes, starting within five minutes of umbilical cord clamping.
The main outcome measure was postpartum haemorrhage, defined as blood loss of at least 1000 mL or red blood cell transfusion within two days after delivery. Serious adverse events including blood clots, seizures, acute kidney or liver injury, and maternal death, were also recorded.
The results show that prophylactic tranexamic acid reduced the rate of postpartum haemorrhage by 15%, from 35.1% to 29.7% compared with placebo. This means that for every 19 women receiving prophylactic tranexamic acid, one case of postpartum haemorrhage would be prevented.
Rates of serious adverse effects were similar between the two groups.
The researchers acknowledge various limitations including that the findings are specific to women with placenta praevia receiving prophylactic oxytocin and therefore may not apply to other obstetric populations. However, this was a well-designed trial and results were consistent after further analyses, suggesting that the findings are robust.
As such, they conclude: “In a high risk population – specifically, women with placenta praevia undergoing caesarean delivery – prophylactic tranexamic acid leads to a statistically significant but modest reduction in the incidence of postpartum haemorrhage.”
“Future studies in diverse international settings are warranted to validate these results and to identify specific patient subgroups most likely to benefit from prophylactic use of tranexamic acid,” they add.
In a linked editorial, UK researchers point out that this modest reduction in bleeding understates the impact, particularly in women at high risk of harm from bleeding, for whom even modest relative risk reductions translate into worthwhile benefits.
The focus should now shift from whether tranexamic acid reduces bleeding to how it is used to maximise patient benefit, they say, noting that in non-obstetric surgery, tranexamic acid is given before incision, but in caesarean section trials it is delayed until after cord clamping to avoid placental transfer.
They recommend evaluating pre-incision administration for caesarean section, while carefully monitoring maternal and neonatal outcomes.
Trimming a degenerated meniscus, or partial meniscectomy, is one the most common orthopaedic surgeries in the world. Even though the number of procedures in Finland has decreased significantly in recent years, the surgery continues to be performed widely internationally.
A 10-year follow-up study has revealed that, compared to sham surgery, partial meniscectomy did not improve patients’ symptoms or function. On the contrary, the 10-year follow-up of patients who had undergone partial meniscectomy found them to have more symptoms, more reduced function, increased progression of osteoarthritis and a higher probability of subsequent knee surgery when compared to sham surgery.
The Finnish Degenerative Meniscal Lesion Study (FIDELITY) study is unique both with regard to its research design, ie, the sham surgery control group, and its 10-year patient follow-up. In the study, patients with degenerative meniscal tears were randomised to undergo a partial meniscectomy or sham surgery.
Teppo Järvinen, Professor at the University of Helsinki and the principal investigator of the FIDELITY emphasises the broader significance of the results: “Our findings suggest that this may be an example of what is known as a medical reversal, where broadly used therapy proves ineffective or even harmful.”
“The surgery is based on the assumption that pain in the inside of the knee is caused by a medial meniscus tear, which can be treated surgically. Such reasoning – assumption based on biological credibility – is still very common in medicine but in this case, the assumption does not withstand critical examination. Based on current understanding, pain in various joints, such as the knee joint in this case, is related to degeneration brought about by aging,” says Raine Sihvonen, Specialist in Orthopaedics and Traumatology and the other principal investigator of the FIDELITY study.
Concerns about the adverse effects of surgery
The registry and other observational data published in recent years have elicited concern about the potential harm caused by partial meniscectomy. Based on this data, the risk of arthroplasty, or joint replacement surgery, as well as a potentially higher risk of complications following the surgery has been associated with partial meniscectomy. However, the evidence provided by observational studies is inherently indirect and cannot be used to demonstrate a causal effect.
“Several randomised studies have already demonstrated that partial meniscectomy has not improved patients’ symptoms or function in the short (1–2 years) or medium (5 years) term. Regardless, the procedure has remained widely used in many countries,” says Doctoral Researcher and Specialist in Orthopaedics and Traumatology, Dr Roope Kalske.
“For nearly a decade, many independent, non-orthopaedic organisations providing clinical guidelines have recommended that the procedure should be discontinued. Still, for example, the American Academy of Orthopaedic Surgeons (AAOS) and the British Association for Surgery of the Knee (BASK) have continued to endorse the surgery.
This effectively illustrates how difficult it is to give up inefficient therapies,” Järvinen sums up.
“The study conducted in five hospitals is an example of smooth multicentre collaboration, as well as the commitment of research patients to an interesting project. Of the original 146 participants, more than 90% took part in the final stage of the study,” says the research manager Pirjo Toivonen.
A prevention strategy developed by Canadian researchers reduces the risk of the most common and deadly form of ovarian cancer by nearly 80%, according to a new study published today in JAMA Network Open.
The strategy, known as opportunistic salpingectomy (OS), involves proactively removing a person’s fallopian tubes when they are already undergoing a routine gynaecological surgery such as hysterectomy or tubal ligation, commonly called “having one’s tubes tied”.
British Columbia in Canada became the first jurisdiction in the world to offer OS in 2010, after a team of researchers from UBC, BC Cancer and Vancouver Coastal Health designed the approach when it was discovered that most ovarian cancers originate in the fallopian tubes rather than the ovaries. OS leaves a person’s ovaries intact, preserving important hormone production so there are minimal side effects from the added procedure.
The new study, led by a B.C.-based international collaboration called the Ovarian Cancer Observatory, provides the clearest evidence yet that the Canadian innovation saves lives.
“This study clearly demonstrates that removing the fallopian tubes as an add-on during routine surgery can help prevent the most lethal type of ovarian cancer,” said co-senior author Dr Gillian Hanley, an associate professor of obstetrics and gynaecology at UBC. “It shows how this relatively simple change in surgical practice can have a profound and life-saving impact.”
New hope against a deadly cancer
Ovarian cancer is the most lethal gynaecological cancer. Approximately 3100 Canadians are diagnosed with the disease each year and about 2000 will die from it.
There is currently no reliable screening test for ovarian cancer, meaning that most cases are diagnosed at advanced stages when treatment options are limited and survival rates are low.
The OS approach was initially developed and named by Dr Dianne Miller, an associate professor emerita at UBC and gynaecologic oncologist with Vancouver Coastal Health and BC Cancer. She co-founded B.C.’s multidisciplinary ovarian cancer research team, OVCARE.
“If there is one thing better than curing cancer it’s never getting the cancer in the first place,” said Dr. Miller.
The new study is the first to quantify how much OS reduces the risk of serous ovarian cancer – the most common and deadly subtype of the disease. It builds on previous research demonstrating that OS is safe, does not reduce the age of menopause onset, and is cost-effective for health systems.
The study analysed population-based health data for more than 85 000 people who underwent gynaecological surgeries in B.C. between 2008 and 2020. The researchers compared rates of serous ovarian cancer between those who had OS and those who had similar surgeries but did not undergo the procedure.
Overall, people who had OS were 78% less likely to develop serous ovarian cancer. In the rare cases where ovarian cancer occurred after OS, those cancers were found to be less biologically aggressive. The findings were validated by data collected from pathology laboratories from around the world, which suggested a similar effect.
From B.C. innovation to global impact
Since its introduction in B.C. in 2010, OS has been widely adopted, with approximately 80 per cent of hysterectomies and tubal ligation procedures in the province now including fallopian tube removal.
Globally, professional medical organizations in 24 countries now recommended OS as an ovarian cancer prevention strategy, including the Society of Obstetrics and Gynaecology of Canada, which issued guidance in 2015.
“This is the culmination of more than a decade of work that started here in B.C.,” said co- senior author Dr. David Huntsman, professor of pathology and laboratory medicine and obstetrics and gynaecology at UBC and a distinguished scientist at BC Cancer. “The impact of OS that we report is even greater than we expected.”
The researchers say expanding global adoption of OS could prevent thousands of ovarian cancer cases worldwide each year.
“This is a powerful example of how UBC research is changing clinical practice worldwide and saving lives,” said Dr Sharmila Anandasabapathy, dean of the faculty of medicine and vice-president, health, at UBC. “It speaks to the strength of our researchers and clinicians working together to translate discovery into real-world impact for patients here at home and around the world.”
Extending OS to other abdominal and pelvic surgeries where appropriate could further increase the number of people who could benefit from the prevention strategy. B.C. recently became the first province to expand OS to routine surgeries performed by general and urologic surgeons through a project supported by the Government of B.C. and Doctors of BC.
“Our hope is that more clinicians will adopt this proven approach, which has the potential to save countless lives,” said Dr Huntsman. “Not offering this surgical add-on may leave patients unnecessarily vulnerable to this cancer.”
Patient’s own bone treated and reimplanted in breakthrough procedure
Medical first: Dr Herman Breet, Dr Jadine Du Plessis, and Dr Jaco Viljoen (left to right) performed South Africa’s first liquid nitrogen limb salvage surgery at Netcare Unitas Hospital this week.
Thursday, 16 April 2026: In a South African first, a Centurion-based surgeon has successfully performed a hip and limb salvage procedure using a liquid nitrogen dipping technique.
This pioneering approach, performed at Netcare Unitas Hospital in Tshwane this week, could significantly expand treatment options for certain patients with orthopaedic cancers, particularly those who would typically require removal of the affected bone and its replacement with a large prosthesis.
The operation saved the leg of a 15-year-old boy with Ewing’s sarcoma, an aggressive bone cancer. Standard treatment usually involves removing the cancerous section of bone and replacing it with either a large metal prosthesis or the patient’s own bone after irradiation to destroy cancer cells.
“When I explained that conventional surgery meant no more contact sports, I saw the devastation in his eyes – and in his father’s. That’s when I knew we had to try something different,” recalls Dr Jaco Viljoen, an orthopaedic surgeon with a special interest in orthopaedic oncology.
“I’d been prepared for this exact scenario for ten years. When I mentioned there might be another way – a chance he could play sport again – their faces lit up,” says Dr Viljoen.
During the four-and-a-half-hour procedure, Dr Viljoen led a skilled team in removing a 24-centimetre section of the teenager’s femur (thigh bone) where the cancer had developed. Working alongside Dr Viljoen were assistants Dr Jadine Du Plessis and Dr Herman Breet, anaesthetist Dr Bianca Brits, and scrub nurses Registered Nurse Gloria Kgwete and Enrolled Nursing Assistants Leah Lekoane and Mahlatse Motheta.
The team treated the removed segment by immersing it in liquid nitrogen at -179°C to destroy cancer cells. The bone was then reimplanted, marking the first time this technique had been performed in South Africa.
“This kind of complex surgery is only possible with an exceptional team. Every person in that operating theatre played a crucial role in giving this young man his future back,” Dr Viljoen said.
Ewing’s sarcoma is the second most common bone tumour in children and adolescents, according to a recent study in The Lancet Oncology. This aggressive cancer primarily affects individuals aged 10 to 20, with about 80% of cases diagnosed before the age of 20. It most commonly arises in the long bones of the legs and arms, as well as in the pelvis and chest wall, accounting for 10 to 15% of all bone cancers. Without treatment, the disease progresses rapidly, making early intervention critical.
“A day after surgery, the patient was alert and showed good neurovascular function in the affected leg – promising early signs. He even managed a few assisted steps with his physiotherapist, Leonie De Lange. Follow-up tests will monitor how well the treated bone integrates, and we’re cautiously optimistic about his progress,” comments Dr Viljoen.
“This technique marks a significant departure from standard treatment. The traditional approach would have involved the complete removal of the affected bone, followed by a complex prosthetic reconstruction of the hip, which often limits long-term mobility and rules out a return to contact sports. A second alternative – irradiating the patient’s bone before reimplantation – can compromise bone integrity and increase the risk of non-union, often requiring further surgery. For this keen young rugby and cricket player, preserving his natural bone and joint function was a critical consideration,” he adds.
The ideal solution stemmed from a Japanese technique Dr Viljoen had been holding in reserve. The sophisticated procedure, though developed by specialists in Japan more than a decade ago, is rarely performed worldwide – particularly not in patients with Ewing’s sarcoma – and requires exceptional precision. The extreme cold destroys cancerous tumours while preserving the bone’s architecture, allowing it to heal naturally once reimplanted and secured with surgical pins.
“We’ve effectively preserved his bone and hip joint. His own bone will regenerate and integrate with the surrounding tissue. For a young person, that’s game-changing, as his leg can continue to develop normally.
By preserving his natural anatomy, this procedure offers him the possibility of returning to full activity once healed. This technique offers hope of avoiding amputation in other clinically appropriate patients,” explains Dr Viljoen.
Dr Viljoen previously headed the Tumour, Sepsis and Limb Reconstruction Unit at Steve Biko Academic Hospital. A graduate of the University of Pretoria, he completed his orthopaedic specialisation in 2015 and now practises privately at Netcare Unitas Hospital and Netcare Montana Hospital.
“Dr Viljoen and his colleagues have added another chapter to South Africa’s legacy of medical excellence. But, this is about more than innovation – it’s proof that worldclass orthopaedic care happens right here at home, offering hope to patients facing life-altering conditions such as Ewing’s sarcoma,” adds Dr Erich Bock, managing director of Netcare’s hospital division.
“This is what sets exceptional healthcare apart – seeing the whole person, not just the disease. Dr Viljoen and his team haven’t just treated cancer – they’ve preserved a young man’s dreams. That is the true essence of person centred healthcare,” concludes Dr Bock.
An anterior cruciate ligament injury is a serious knee injury that often affects young, physically active people. On April 30, Dzan Rizvanovic will defend his thesis “Anterior cruciate ligament reconstruction: rationale for graft choice and treatment of associated injuries” in which he has investigated how treatment choice affects outcomes after ACL reconstruction.
“An anterior cruciate ligament injury (ACL injury) is a serious knee injury that primarily affects young and physically active individuals and can have long-term consequences for knee function, work capacity, and quality of life. Each year, a large number of patients in Sweden undergo surgical reconstruction of the injured ligament (ACL reconstruction), and this is the focus of my thesis”, says Dzan Rizvanovic, doctoral student at the Sports Medicine research group at the Department of Molecular Medicine and Surgery, Karolinska Institutet and specialist in orthopaedic surgery at Capio Artro Clinic.
“Using data from the Swedish Knee Ligament Registry, we studied tens of thousands of patients to investigate which factors are associated with different treatment strategies, and how these in turn relate to patients’ perceived knee function and the need for further surgery (revision). The thesis also has a particular focus on how the surgical volume of both the surgeon and the clinic is associated with treatment choices and outcomes”.
Which are the most important results?
“The main findings show that treatment strategies in ACL reconstruction are not solely related to the patient’s injury, but also to organizational factors. Surgeons and clinics with higher surgical volume are more likely to use different types of grafts (tendons used to replace the injured ligament), which may increase the opportunity for individualized treatment. They also repair meniscal injuries more frequently, a strategy that has been shown to be beneficial for long-term knee health. The management of cartilage injuries is also partly influenced by surgical volume”.
“Patients operated on by high-volume surgeons report better knee function two years after surgery and experience shorter waiting times from injury to surgery as well as shorter operative times. In contrast, the need for additional ACL reconstruction in the same knee is more related to patient- and injury-factors than to surgical volume”.
“The thesis also shows that graft choice influences subjective knee function at two years after surgery, particularly among females, which is an important finding”.
How can this new knowledge contribute to the improvement of people’s health?
“This knowledge can contribute to more equitable and individualised care. By clarifying how surgical experience and surgical volume are associated with treatment decisions and outcomes, healthcare systems can better organise resources and create conditions for strengthened competence and improved decision-making in ACL reconstruction”.
“The results can also be used in the dialogue between patient and surgeon to select the treatment that best matches the individual’s needs and circumstances, which in the long term may improve knee function and increase quality of life in this young and working-age population”.
“Furthermore, the results from this thesis highlight the need for discussion regarding clearer national guidelines for referral pathways, minimum surgical volume requirements, and follow-up of treatment outcomes. It is also important that reporting to national quality registers is complete and made mandatory in order to enable transparency and continuous quality improvement”.
What are your future ambitions?
“I hope to continue combining research with my clinical work to drive development forward and contribute to ensuring that patients with knee and sports-related injuries receive the best possible treatment. I also aim to contribute to a more equitable organization of healthcare, in which access to the right expertise at the right time does not depend on where in the country a patient lives”, says Dzan Rizvanovic.
Dissertation
The dissertation seminar will be held on Thursday, April 30th 2026 at 09:00, CIFU, Capio Artro Clinic, Valhallavägen 91, lecture hall house R. The doctoral thesis has been supervised by Anders Stålman.
Thesis
Rizvanovic, Dzan (2026). Anterior cruciate ligament reconstruction : rationale for graft choice and treatment of associated injuries. Karolinska Institutet. Thesis. https://doi.org/10.69622/31333828.v1
Targeting immune cells with cold plasma to speed healing and enhance surgical outcomes
A handheld cold atmospheric plasma device. Frontiers in Dermatology, 2022. https://doi.org/10.3389/fonc.2022.918484
Cold plasma devices are increasingly used across surgical procedures, including skin rejuvenation, scar remodeling, liposuction and diabetic wounds. A recent study from Thomas Jefferson University found that using an FDA-approved cold plasma device can enhance tissue healing after surgery by activating a wound-healing response.
“Anecdotally, after receiving cold plasma treatment for dermatology procedures, patients have reported firmer and ‘younger’ feeling skin in the treatment area,” according to senior author Theresa Freeman, PhD. While several published reports support the idea that cold plasma could activate healing in cells, there was little evidence in living organisms. This motivated Dr Freeman and her team to figure out what was happening when injured muscle tissue was treated with a cold plasma device.
“We found that cold plasma produces bursts of ‘reactive species,’ which are molecules that can directly communicate with the immune cells and trigger them to start the healing process,” says Carly Smith, a recently graduated doctoral student in Dr Freeman’s lab and first author on this study.
Researchers treated rat surgical wounds with cold plasma, and within six hours, neutrophils increased in number and began repairing the wound. Cold plasma seemingly uses the natural wound-healing response to its advantage.
To understand how this spike in neutrophils could affect healing, the researchers compared cold plasma-treated to untreated rat muscle tissue at different time points. Repairing injured muscle tissue involves replacing it with new muscle or fat. Dr Freeman notes, “After six hours, plasma-treated tissue increased the expression of pathways and genes related to repairing and restoring muscle tissue. Fourteen days after treatment, plasma reduced the accumulation of fat in the healing muscle tissue. This could explain why patients said their skin feels firmer after cold plasma treatment.”
In addition to promoting healing, cold plasma can kill bacteria. In future studies, Dr Freeman hopes to combine cold plasma with standard-of-care antibiotics used in surgery to boost the healing process and prevent infections. “If we can show this combined treatment is effective, it can be used by clinicians to improve surgical outcomes,” says Dr Freeman.
The ‘mommy makeover’ is trending, and a growing number of patients are now asking whether cosmetic procedures such as a tummy tuck, liposuction, or breast augmentation can be performed at the same time as a Caesarean section. But surgeons warn that combining elective cosmetic surgery with a C-section can sharply escalate risk during an already vulnerable period for the body.
Professor Chrysis Sofianos, a triple-board certified plastic surgeon and Academic Head of the Division of Plastic and Restorative Surgery at the University of the Witwatersrand, says procedures such as a tummy tuck should only be considered once the body has adequately recovered after childbirth – typically around six months after delivery, depending on individual healing.
“Our practice is seeing a growing number of patients ask whether body-contouring surgery can be performed while they are already in theatre for a C-section. But this reflects a dangerous misunderstanding of surgical safety and postpartum physiology.
“While the idea may appear efficient or financially attractive, pairing medically necessary obstetric surgery with elective cosmetic procedures significantly increases operative risk at a time when the patient is physiologically vulnerable.”
Combining surgeries and compounding risks
C-sections account for around 75% of private sector hospital births in South Africa. Professor Sofianos notes that because there is often an overlap between women accessing private medical care and those who may later consider elective cosmetic procedures, more patients are likely to ask whether these operations can be combined.
“However, the more important question is whether they should. And the simple answer is no,” he says. “A C-section is already a major abdominal operation. Introducing additional surgical trauma before the body has recovered would introduce excessive strain and substantially raise the risk of complications.”
Pregnancy and the immediate postpartum period are associated with a hypercoagulable state, meaning the blood has an increased tendency to clot. Postpartum women therefore face a markedly elevated risk of venous thromboembolism, particularly in the first six weeks after delivery. Prolonging operative time and increasing tissue disruption may further elevate this risk by contributing to immobility, tissue stress, and inflammatory response.
A C-section on its own carries recognised complications, including haemorrhage, infection, anaesthetic complications, and clotting risk. Adding abdominoplasty (tummy tuck) can introduce additional risks such as bleeding, fluid accumulation, wound breakdown, delayed healing, and blood clots.
Liposuction also introduces risks, such as fluid imbalance, internal injury, infection, and, in rare but serious cases, fat embolism – a potentially life-threatening condition in which fat enters the bloodstream and compromises vital organs.
The false economy of combining procedures
Professor Sofianos also notes that combining procedures rarely provides the financial or practical advantages patients may assume.
“There is a common a misconception that theatre and anaesthetic fees can be consolidated if surgeries are combined into a single session. In reality, longer operative times, greater monitoring requirements, and the potential for complications may result in far higher medical costs. More importantly, financial reasoning should never supersede patient safety.”
He adds that the combined recovery period can also be far more demanding than patients anticipate.
“Recovery after a C-section already places significant physical, emotional, and psychological demands on a new mother. Adding major cosmetic surgery to that recovery period can complicate mobility, wound care, and pain management at a time when the patient must also care for a newborn.
“A more intensive recovery process may further require extended postoperative care, closer medical oversight, and additional support at home, all of which can add to the existing financial burden.”
Finally, he warns that operating during the immediate postpartum period might not produce the optimal long-term aesthetic result a patient may be looking for, and could expose them to unnecessary revision surgery later.
“Medically and ethically, I do not believe combined C-section and ‘mommy makeover’ surgeries should ever be considered. No responsible surgeon should minimise the compounded risks associated with performing such procedures. Ultimately, safe, staged care remains the gold standard for medical care, or allowing the body to recover fully before elective cosmetic surgery is undertaken.”
Depression and other psychological factors may be linked to the risk of postoperative confusion in older adults. This is shown in a new systematic review from Karolinska Institutet, published in the British Journal of Anaesthesia. The study summarises results from more than 6700 patients.
Older individuals undergoing surgery face an increased risk of developing cognitive complications, such as postoperative delirium. Delirium is characterised by sudden changes in attention and awareness, and can lead to longer hospital stays and reduced functioning. The new study analyses 30 previously published works in which researchers examined whether preoperative psychological factors, such as depression, anxiety, stress, and personality traits, may influence these complications.
Depression most common
The review identified four groups of psychological factors. Depression was the most common and appeared in nearly all studies. In the statistical meta-analysis, no clear association between depression and delirium was observed, but when the researchers used alternative statistical synthesis methods, they found evidence suggesting that psychological factors play a role.
“Our results show that depression is the most consistently reported psychological risk factor, even though the pooled statistical analyses did not demonstrate a significant effect,” says Anahita Amirpour, PhD at the Department of Neurobiology, Care Sciences and Society. “At the same time, we saw that anxiety, stress, and personality traits may also play a role, although the research base there is more limited.”
Postoperative delirium
In total, the study included 6714 patients from 16 different countries. Postoperative delirium was the most common outcome measure and occurred in between 9 and 55% of patients, depending on the study. Very few studies examined other cognitive complications, such as long-term effects on memory and attention.
The researchers emphasise that the results should be interpreted with caution. Many of the included studies varied greatly in how they measured both psychological factors and cognitive outcomes, and only two studies examined time periods extending beyond the immediate postoperative phase.
A major new study, led by Queen Mary University of London and funded by the National Institute for Health and Care Research (NIHR) has been published in The Lancet Public Health. It found that out of the five million surgical procedures performed each year by the NHS, around 300 000 are carried out on individuals considered high-risk, and within 90 days of surgery, these high-risk patients account for:
four out of five deaths
over half of all hospital bed days
nearly one-third of emergency readmissions
While surgery is safer than ever for most people and remains the best treatment option for many conditions, this study highlights the urgent need to identify high-risk patients earlier, to provide care that is better tailored to their individual needs, and for doctors and patients to have more open, honest conversations about the risks and long-term outcomes for surgery at an individual level.
It also shows that high-risk patients, who tend to be older and live with several long-term health conditions such as heart disease, have poor outcomes not because of technical failings in surgery or anaesthesia, but due to post-operative complications relating to chronic health conditions, age and frailty. Therefore, the findings demonstrate the need for greater investment in specialist perioperative services that focus on the care of older, high-risk patients before, during and after surgery.
Rupert Pearse, Professor and Consultant in Intensive Care Medicine at Queen Mary University of London and Barts Health NHS Trust, and co-lead of the study said: “While surgery is safer than ever before, our findings clearly show that high-risk patients are more likely to have poor outcomes and experience harm after surgery than those deemed low-risk.
“Although these patients make up fewer than one in ten surgical cases, their numbers are increasing as the population ages and more people live longer with chronic illness. It is therefore vital that we work to improve care for this group of patients, pre- and post-surgery, including having open conversations with patients about the individual risk of their procedure.”
He continues: “For many years, surgical success has often been judged by survival at thirty days. Our study shows that this measure does not give the full picture of what happens to many high-risk patients in the months and years after surgery. By looking at longer-term survival and other factors such as time spent in hospital and quality of life, we could make a real difference to patients and potentially help relieve pressure on the wider NHS.”
The study is one of the largest analyses of surgical outcomes ever carried out in the UK. It analysed health records from 13 million adults who had 16.1 million surgical procedures in England, Scotland and Wales between 2015 and 2019.
In a leap for personalised medicine, scientists have discovered a simple and valuable way to improve brain cancer surgeries.
Taylor Furst, MD, observes a brain mapping procedure in progress at the University of Rochester’s Strong Memorial Hospital. Credit: Matt Wittmeyer
When removing cancerous tissue in the brain, neurosurgeons often use “awake brain mapping” to minimise the risk of causing unintended disruptions to a patient’s quality of life while removing as much tumour as possible. This practice, which has been used for decades, involves waking a patient up mid-surgery to test their neurocognitive functions in real time by stimulating the brain surface and assessing for functional changes.
A new study published in the journal Science Advances details a promising new avenue toward improving awake brain mapping results by investigating the tiny, nearly imperceptible variabilities in patient behaviour that occur during the procedure. This work, led by Carnegie Mellon University researchers, points to a future where brain surgeries are not just safer, but more precisely tailored to protect each patient’s speech, movement and quality of life.
How awake brain mapping works
As cancer grows in the brain, it rarely keeps to itself. Cancerous cells can be found in the seemingly healthy brain tissue surrounding a tumour, presenting neurosurgeons with a dilemma. They need to remove as much tissue infiltrated by cancer as possible, but they also need to avoid the removal of too much tissue since it can cause permanent harm to a patient’s ability to hold a fork or a conversation.
During awake brain mapping, surgeons gently stimulate the brain with small electrical impulses while the patient completes planned tasks. One of the most common applications of awake brain mapping is to identify where language is represented in a patient’s brain, which is done by having the patient name pictures or read words while their brain is being stimulated. If the patient can respond quickly and correctly, the clinicians know the part of the brain they stimulated can be safely removed. If the patient slurs or becomes unable to speak, then that part of the brain may be essential for language. Surgeons require a significant amount of experience to understand the nuances of this complex technique.
While the method may sound extreme, the brain has no sensory nerves, so patients do not feel their brain surgery as it is happening. Recent research also shows that for some types of brain cancer, improving a patient’s quality of life after surgery extends their expected survival into the future. This means that anything that can make awake brain mapping even more effective will translate into improved outcomes for brain cancer patients.
New measures show how slight changes in procedure affect patient behaviour
Based on a decade of research, the study authors uncovered new insights from examining the answers patients get wrong – and right – while undergoing awake brain mapping.
“We found that if you measure both the types of errors that patients make, as well as how fast they respond even when they do not make errors, more granular inferences can be drawn about language organization from an awake brain mapping procedure,” said Bradford Mahon, a cognitive neuroscientist at CMU’s Neuroscience Institute and Department of Psychology and senior author of the study. “We also found that physical parameters of the direct electrical stimulation delivered to the patient’s brain – such as its duration, and when it started and stopped relative to the task the patient is performing – were tightly related to small changes in patient behaviour that we could measure.”
Mahon and his team don’t yet know exactly what combination of parameters should be used to maximise the effect of direct electrical stimulation mapping. But they have discovered an intriguing signal hidden inside of the data that, until now, has gone unnoticed.
“What we have measured and formalised in our study is how slight changes in the awake mapping procedure can cause slight changes in patient behaviour. This is exciting because it is a new and meaningful signal that can be extracted from the data already being generated during awake brain mapping procedures,” said Mahon.
A new level of personalised medicine
The new study suggests that awake brain mapping may offer more informative and more personalized guidance for surgery than has been possible in the past.
For example, stimulating a particular area of the brain might reliably cause an error, never affect behaviour at all, or – more subtly – slow a patient’s response without causing an obvious mistake. In some cases, stimulation may affect behaviour at one moment, but not when tested again just seconds later.
“In other words, brain mapping isn’t always black or white,” said Belkhir. “Sometimes the most important information lives in the grey area.”
The nuance matters because every brain is different, which means every surgery is different, too. Understanding why stimulation has variable effects across different patients, and even within the same patient from one part of the surgery to another part of the surgery, may be key to protecting outcomes for future patients.
“Surgeons are seeking to optimise the balance between removing all of the cancerous tissue while preserving critical functions that may be represented by nearby brain regions,” said Mahon. “This research shows that by measuring aspects of patient performance that were previously not considered relevant for awake brain mapping, even better predictive models of brain organisation can be developed.”
If clinical teams have better predictive models personalised to each patient, then the consequences of different surgical approaches on postoperative neurocognitive function can be simulated. This allows for patients and their caregivers to personalise decisions to what is most important to the patient.
In other words, Mahon said, a business manager may consent to a surgery that may diminish their motor skills, but not their speech, whereas a concert violinist may prefer the opposite.
Bringing standardisation to awake brain mapping surgery
Another important development from this research is the startup company MindTrace, which has built an integrated software platform that supports neurocognitive testing before, during and after surgery. It is working to build a longitudinal dataset of patient outcomes that will be used to train forecasting models.
Tyler Schmidt, MD, study co-author and neurosurgeon at the University of Rochester, has used MindTrace in over a dozen awake surgeries since its release this year.
“In the beginning of brain tumour surgery, it used to be, ‘Can we remove any of this tumour safely?’” said Schmidt. ”But now in some brain tumour cases it’s, ‘Can we get you back to work potentially? Can we keep your quality of life close to what it was prior to your diagnosis? Can we hone in on the things that are most important to you and then try and protect them while getting the same oncological outcome?’” said Schmidt. “I think it’s a positive paradigm shift in how we take care of this patient population.”
The options today are measurably better than they were even 20 years ago. Clinicians now understand how to maximise the likelihood that patients have the best possible outcomes from brain cancer surgery.
“Ultimately, we are contributing toward the set of tools that clinicians will have that will enable them to map the brain with even greater confidence and precision, and personalised to each patient,” said Mahon. “The big goal is to translate scientific insights into solutions that improve people’s lives. We will meet that goal by building tools that enable the best possible outcomes in neurosurgery patients, both in terms of neurocognitive function and quality of life, and ultimately, in terms of survival.”
