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PurposePreoperative multidisciplinary team (MDT) meetings are recommended for patients at high risk for perioperative complications and mortality, although the underlying evidence is scarce. We aimed to investigate the effect of MDT decisions on patient management and patient outcome.MethodsWe conducted a single-centre retrospective cohort study including all noncardiac surgical patients selected for discussion at preoperative MDT meetings from January 2017 to December 2019 (N = 120). We abstracted preoperative data, MDT decisions, and patient outcomes from the electronic health records for analysis.ResultsOf the 120 patients registered for an MDT meeting, 43% did not undergo their initially planned surgery. Only 27% of patients received perioperative management as planned before the MDT meeting. Most surgery cancellations were the MDT’s decision (22%) or the patient’s decision before or after the MDT discussion (10%). Postoperative complications occurred in 28% of operated patients, and postoperative mortality was 4% at 30 days and 10% at three months, most of which was attributable to postoperative complications. Non-operated patients had a 7% mortality rate at 30 days and 9% at three months. Alterations of perioperative management following MDT discussion were associated with fewer cases of extended length of hospital stay (> ten days).ConclusionThis study shows that preoperative MDT meetings for high-risk noncardiac surgical patients altered the management of most patients. Management alterations were associated with fewer hospital admissions of long duration. These results should be interpreted with appropriate caution given the methodological limitations inherent to this small study.

Background Multiple preoperative calculators are available online to predict preoperative mortality risk for noncardiac surgical patients. However, it is currently unknown how these risk calculators perform across different raters. The current study investigated the interrater reliability of three preoperative mortality risk calculators in an elective high-risk noncardiac surgical patient population to evaluate if these calculators can be safely used for identification of high-risk noncardiac surgical patients for a preoperative multidisciplinary team discussion. Methods Five anesthesiologists assessed the preoperative mortality risk of 34 high-risk patients using the preoperative score to calculate postoperative mortality risks (POSPOM), the American College of Surgeons surgical risk calculator (SRC), and the surgical outcome risk tool (SORT). In total, 170 calculations per calculator were gathered. Results Interrater reliability was poor for SORT (ICC (C.I. 95%) = 0.46 (0.30–0.63)) and moderate for SRC (ICC = 0.65 (0.51–0.78)) and POSPOM (ICC = 0.63 (0.49–0.77). The absolute range of calculated mortality risk was 0.2–72% for POSPOM, 0–36% for SRC, and 0.4–17% for SORT. The coefficient of variation increased in higher risk classes for POSPOM and SORT. The extended Bland–Altman limits of agreement suggested that all raters contributed to the variation in calculated risks. Conclusion The current results indicate that the preoperative risk calculators POSPOM, SRC, and SORT exhibit poor to moderate interrater reliability. These calculators are not sufficiently accurate for clinical identification and preoperative counseling of high-risk surgical patients. Clinicians should be trained in using mortality risk calculators. Also, clinicians should be cautious when using predicted mortality estimates from these calculators to identify high-risk noncardiac surgical patients for elective surgery. Highlights -Interrater reliability for POSPOM, SRC and SORT preoperative mortality risk predictors is lower than expected. -Clinicians need to use preoperative mortality risk calculators with caution when using them for identification and preoperative counseling of high-risk noncardiac surgical patients. -In this study all raters using POSPOM, SRC and SORT for preoperative mortality risk calculation, contributed to variability in risk estimates.

Background As a result of increased life expectancy and improved care for patients suffering from chronic disease, the number of patients with multimorbidity requiring surgical intervention is increasing. For complex surgical patients, it is essential to balance the potential benefits of surgical treatment against the risk of permanent loss of functional capacity and quality of life due to complications. European and US guidelines on perioperative care recommend preoperative multidisciplinary team (MDT) discussions for high-risk noncardiac surgical patients. However, the evidence underlying benefits from preoperative MDT meetings with all relevant perioperative specialties present is limited. The current study aims to investigate the effect of implementation of preoperative MDT discussions for high-risk patients undergoing noncardiac surgery on serious adverse events. Methods/design PREPARATION is a stepped-wedge cluster randomized trial in 14 Dutch hospitals without currently established preoperative MDT meeting. The intervention, preoperative MDT meetings, will be implemented sequentially with seven blocks of 2 hospitals switching from control (preoperative screening as usual) to the intervention every 3 months. Each hospital will be randomized to one of seven blocks. We aim to include 1200 patients. The primary outcome is the incidence of serious adverse events at 6 months. Secondary outcomes include (cost)effectiveness, functional outcome, and quality of life for up to 12 months. Discussion PREPARATION is the first study to assess the effectiveness of a preoperative MDT meeting for high-risk noncardiac surgical patients in the presence of an anesthesiologist. If the results suggest that preoperative MDT discussions for high-risk patients are (cost)-effective, the current study facilitates implementation of preoperative MDT meetings in clinical practice. Trial registration ClinicalTrials.gov NCT05703230. Registered on 11/09/2022.

Background Medical schools seek the best curricular designs for the transition to postgraduate education, such as the Dutch elective-based final, ‘transitional’ year. Most Dutch graduates work a mean of three years as a physician-not-in-training (PNIT) before entering residency training. To ease the transition to selected specialties and to decrease the duration of the PNIT period, UMC Utrecht introduced an optional, thematic variant of the usual transitional year, that enables the development of theme-specific competencies, in addition to physicians’ general competencies. Methods We introduced an optional transitional year for interested students around the theme of acute care, called the Acute Care Transitional Year (ACTY). This study aimed to evaluate the ACTY by judging whether graduates meet postgraduate acute care expectations, indicating enhanced learning and preparation for practice. In a comprehensive assessment of acute care knowledge, clinical reasoning, skills, and performance in simulations, we collected data from ACTY students, non-ACTY students interested in acute care, and PNITs with approximately six months of acute care experience. Results ACTY graduates outperformed non-ACTY graduates on skills and simulations, and had higher odds of coming up to the expectations faculty have of a PNIT, as determined by global ratings. PNITs did better on simulations than ACTY graduates. Discussion ACTY graduates show better resemblance to PNITs than non-ACTY graduates, suggesting better preparation for postgraduate acute care challenges. Conclusion Transitional years, offering multidisciplinary perspectives on a certain theme, can enhance learning and preparedness for entering residency.

INTRODUCTION The prognostic value of subcortical gray matter structures for dementia beyond the hippocampus remains unclear. METHODS We included participants with subjective cognitive decline or mild cognitive impairment from two memory clinic‐based cohorts (Amsterdam Dementia Cohort and National Alzheimer's Coordinating Center) and one population‐based cohort (Rotterdam Study). We assessed volumes of subcortical structures on magnetic resonance imaging and determined 5‐year dementia risk using Cox models. RESULTS Of 7076 participants (mean age: 66–69 years, 58.8%–61.0% women; NSCC = 5425, NMCI = 1661), 622 developed dementia within 5 years. Smaller volumes of the hippocampus and amygdala were consistently associated with increased dementia risk, independent of other subcortical structures. Smaller hippocampal volume was predominantly associated with the clinical diagnosis of Alzheimer's disease, but the prognostic value did not differ by amyloid status. DISCUSSION Hippocampal and amygdalar volume are consistently associated with dementia risk in individuals with subjective cognitive decline or mild cognitive impairment, which may hold potential for personalized prognosis. Highlights Seven thousand seventy‐six participants from three large longitudinal cohorts were followed for a maximum of 5 years. Hippocampal volume is associated with 5‐year risk of dementia in subjective cognitive decline (SCD) or mild cognitive impairment (MCI). Amygdalar volume is associated with a 5‐year risk of dementia in SCD or MCI. Stratifying by SCD and MCI revealed no consistent major differences.

The Rotterdam Study is a prospective cohort study ongoing since 1990 in the city of Rotterdam in The Netherlands. The study targets cardiovascular, endocrine, hepatic, neurological, ophthalmic, psychiatric, dermatological, oncological, and respiratory diseases. As of 2008, 14,926 subjects aged 45 years or over comprise the Rotterdam Study cohort. The findings of the Rotterdam Study have been presented in over a 1,000 research articles and reports (see www. erasmus-epidemiology. nl/rotterdamstudy).This article gives the rationale of the study and its design. It also presents a summary of the major findings and an update of the objectives and methods.

Background Hippocampal volume is an acknowledged biomarker of neurodegenerative disease, including Alzheimer’s disease (AD). However, the relationship between other subcortical brain structures and dementia risk is uncertain and may differ by disease stage. We aimed to assess the prognostic value of subcortical volumes for dementia risk across different disease stages by investigating memory clinic‐based populations and community‐dwelling individuals. Method We included 9613 dementia‐free participants from a population‐based cohort (Rotterdam Study [n=5442, MCI:4.2%]) and two memory clinic‐based cohorts (Amsterdam Dementia Cohort [n=1964, MCI:36.1%] and the Alzheimer's Disease Research Centers of NACC: National Alzheimer’s Coordinating Center, funded by NIA/NIH Grant U24 AG072122 [n=2207, MCI:32.7%]). Mean age ranged from 62 to 65 years, and 40 to 61% were women. We performed automated segmentations of the nucleus accumbens, amygdala, caudate, hippocampus, pallidum, putamen and thalamus on T1‐MRI using Freesurfer. We determined the association between volumes of each subcortical structure and 5‐year risk of dementia in each cohort, using Cox proportional hazard models adjusted for various confounders and the other subcortical volumes. Result During 5 years of follow‐up, dementia was diagnosed in 371 individuals in NACC, 249 in ADC, and 321 in the Rotterdam Study. Consistently across all cohorts (Figure 1), smaller hippocampal volume was significantly associated with an increased dementia risk, driven by the progression to AD dementia rather than non‐AD dementia. Smaller amygdala volume was associated with an increased dementia risk in both memory clinic cohorts, with similar effect estimates in the population‐based cohort. Smaller thalamic volume was associated with dementia risk only in the population‐based cohort, driven by the progression from normal cognition to dementia (HR: 1.73 [95%CI:1.14‐2.63]), rather than from mild cognitive impairment to dementia (HR 0.83 [0.45‐1.54]). The association between the amygdala and dementia risk was similar for AD and non‐AD dementia in both memory clinic‐based populations, while in the population‐based cohort the association was only evident in progression to AD dementia. Conclusion Various subcortical structures play a role in the conversion to dementia. While the hippocampus and amygdala show consistent associations across populations, variation between populations for the thalamus and accumbens suggest differences in their role with underlying pathophysiology and disease stage.

Background Hippocampal volume is an acknowledged biomarker of neurodegenerative disease, including Alzheimer’s disease (AD). However, the relationship between other subcortical brain structures and dementia risk is uncertain and may differ by disease stage. We aimed to assess the prognostic value of subcortical volumes for dementia risk across different disease stages by investigating memory clinic‐based populations and community‐dwelling individuals. Method We included 9613 dementia‐free participants from a population‐based cohort (Rotterdam Study [n=5442, MCI:4.2%]) and two memory clinic‐based cohorts (Amsterdam Dementia Cohort [n=1964, MCI:36.1%] and the Alzheimer's Disease Research Centers of NACC: National Alzheimer’s Coordinating Center, funded by NIA/NIH Grant U24 AG072122 [n=2207, MCI:32.7%]). Mean age ranged from 62 to 65 years, and 40 to 61% were women. We performed automated segmentations of the nucleus accumbens, amygdala, caudate, hippocampus, pallidum, putamen and thalamus on T1‐MRI using Freesurfer. We determined the association between volumes of each subcortical structure and 5‐year risk of dementia in each cohort, using Cox proportional hazard models adjusted for various confounders and the other subcortical volumes. Result During 5 years of follow‐up, dementia was diagnosed in 371 individuals in NACC, 249 in ADC, and 321 in the Rotterdam Study. Consistently across all cohorts (Figure 1), smaller hippocampal volume was significantly associated with an increased dementia risk, driven by the progression to AD dementia rather than non‐AD dementia. Smaller amygdala volume was associated with an increased dementia risk in both memory clinic cohorts, with similar effect estimates in the population‐based cohort. Smaller thalamic volume was associated with dementia risk only in the population‐based cohort, driven by the progression from normal cognition to dementia (HR: 1.73 [95%CI:1.14‐2.63]), rather than from mild cognitive impairment to dementia (HR 0.83 [0.45‐1.54]). The association between the amygdala and dementia risk was similar for AD and non‐AD dementia in both memory clinic‐based populations, while in the population‐based cohort the association was only evident in progression to AD dementia. Conclusion Various subcortical structures play a role in the conversion to dementia. While the hippocampus and amygdala show consistent associations across populations, variation between populations for the thalamus and accumbens suggest differences in their role with underlying pathophysiology and disease stage.