Clarifying Baseline Cognitive Eligibility and Cross-Scale Follow-Up in a Randomized Trial of Remimazolam Tosylate for Laparoscopic Surgery [Letter]

Liu et al 1 deserve credit for studying young and middle-aged adults undergoing laparoscopic surgery, a group overlooked in perioperative neurocognitive research.Remimazolam was associated with less postoperative memory decline than propofol on postoperative day 1, 36.4% versus 53.2%, and day 3, 23.6% versus 37.8%, while the month-1 cognitive endpoint was similar, 6.4% versus 8.1%.However, there are two issues warrant discussion.One concern is the mismatch between the eligibility criteria and the baseline table .The Methods exclude patients with preoperative MoCA <26.Yet Table 1 reports baseline Pre-MoCA scores of 26 (25)(26) in Group R and 26 (24-27) in Group P. The interquartile range includes values below the exclusion threshold.The Methods also state that one point should be added for participants with 12 years of education.That matters.In 665 community residents from Western China, education had a larger effect on MoCA than age, effect size 0.272 versus 0.037, and MoCA-based cognitive impairment rates varied from 25.1% to 52.8% depending on the reference approach. 2Ratcliffe et al 3 analyzed 18,410 participants and concluded that repeated MoCA interpretation should use demographic adjustment and reliable change methods, not a fixed threshold alone.The present report therefore needs an explicit statement on whether Table 1 shows raw MoCA values, education-adjusted values, or both.Otherwise, readers are left uncertain whether this is a reporting ambiguity or a protocol-execution issue.Another concern is the 1-month conclusion, because the outcome scale changed.In-hospital cognition was assessed with MoCA, but month-1 follow-up used TICS-m by telephone.Table 2 then lists "postoperative cognitive decline" at 1 month as 7/110 versus 9/111.Without a preoperative TICS-m baseline, however, this cannot strictly be called decline from baseline.It is better understood as a one-time screening result.The manuscript also provides two different TICS-m interpretive rules: page 4 states that >31 is normal and <28 indicates severe impairment, whereas page 5 states that an education-adjusted TICS-m score 31 is the optimal cutoff for cognitive impairment.That leaves the 28-31 interval unresolved and creates internal inconsistency.Truong et al 4 reported good TICS-m reliability in 432 older adults, with a Person Separation Index of 0.86, but this supports careful within-instrument interpretation, not direct interchangeability with MoCA across time.A 2024 perioperative guidance likewise emphasizes baseline neurocognitive assessment when postoperative neurocognitive outcomes are inferred. 5eporting both raw and adjusted baseline MoCA distributions, the number of patients below 26 before and after education correction, and a prespecified TICS-m classification scheme would materially strengthen this otherwise valuable study.