Anterior Column Realignment Through Open Pre-posterior Release-Anterior-Posterior Fusion Versus Hybrid Minimally Invasive-Anterior-Posterior Fusion for Dynamic Sagittal Imbalance of the Spine.

STUDY DESIGN: Retrospective comparative study. OBJECTIVES: To investigate the clinical and radiological outcomes after anterior column realignment (ACR) through pre-posterior release-anterior-posterior surgery (PAP) and minimally invasive surgery -lateral lumbar interbody fusion (MIS-LLIF) using hybrid anterior-posterior surgery (AP). METHODS: A total of 91 patients who underwent ACR with long fusions from T10 vertebra to the sacropelvis with a follow-up period of at least 2 years after corrective surgery for adult spinal deformity were included and divided into two groups by surgical method: AP and PAP. AP was performed in 26 and PAP in 65 patients. Clinical outcomes and radiological parameters were investigated and compared. A further comparison was conducted after propensity score matching between the groups. RESULTS: The more increase of LL and decrease of PI-LL mismatch were observed in the PAP group than in the AP group postoperatively. After propensity score matching, total operation time and intraoperative bleeding were greater, and intensive care unit care and rod fracture were more frequent in the PAP group than in the AP group with statistical significance. Reoperation rate was higher in PAP (29.2%) than in AP (16.7%) without statistical significance. CONCLUSIONS: PAP provides a more powerful correction for severe sagittal malalignment than AP procedures. AP results in less intraoperative bleeding, operation time, and postoperative complications. Therefore, this study does not suggest that one treatment is superior to the other. LEVEL OF EVIDENCE: III.

Risk factors for mechanical complications after fusion extension surgery for lumbar adjacent segment disease.

PURPOSE: Adjacent segment disease (ASD) is a common complication in fusion surgery. In the event of solid segmental fusion, previous implants can be removed or preserved during fusion extension for ASD. To compare the surgical outcomes of patients with and without implants and analyzes the risk factors for postoperative mechanical complications. METHODS: Patients who underwent fusion extension for lumbar ASD from 2011 to 2019 with a minimum 2 year follow-up were retrospectively reviewed. Spinopelvic parameters were measured preoperatively and postoperatively. Clinical outcomes and surgical complications were compared between groups with implants preserved and removed. Risk factors for mechanical complications, including clinical, surgical, and radiographic factors were analyzed. RESULTS: Sixty-nine patients (mean age, 69.9 ± 6.9 years) were included. The mean numbers of initial and extended fused segments were 2.8 ± 0.7 and 2.7 ± 0.7, respectively. Previous implants were removed in 43 patients (R group) and preserved in 26 patients (P group). Both groups showed an improvement in clinical outcomes without between-group differences. The operation time was significantly longer in R group (260 vs 207 min, p < 0.001). Mechanical complications occurred in 13 patients (12 in R group and 1 in P group) and reoperation was needed in 3 patients (R group). Implant removal, index fusion surgery including L5-S1, and postoperative sagittal malalignment were risk factors for mechanical complications. CONCLUSION: Implant removal was a risk factor for mechanical complications. Index fusion surgery including L5-S1 and postoperative sagittal malalignment were also risk factors for mechanical complications.

Association of Mechanical Energy and Power with Postoperative Pulmonary Complications in Lung Resection Surgery: A Post Hoc Analysis of Randomized Clinical Trial Data.

BACKGROUND: Mechanical power (MP), the rate of mechanical energy (ME) delivery, is a recently introduced unifying ventilator parameter consisting of tidal volume, airway pressures, and respiratory rates, which predicts pulmonary complications in several clinical contexts. However, ME has not been previously studied in the perioperative context, and neither parameter has been studied in the context of thoracic surgery utilizing one-lung ventilation. METHODS: The relationships between ME variables and postoperative pulmonary complications were evaluated in this post hoc analysis of data from a multicenter randomized clinical trial of lung resection surgery conducted between 2020 and 2021 (n = 1,170). Time-weighted average MP and ME (the area under the MP time curve) were obtained for individual patients. The primary analysis was the association of time-weighted average MP and ME with pulmonary complications within 7 postoperative days. Multivariable logistic regression was performed to examine the relationships between energy variables and the primary outcome. RESULTS: In 1,055 patients analyzed, pulmonary complications occurred in 41% (431 of 1,055). The median (interquartile ranges) ME and time-weighted average MP in patients who developed postoperative pulmonary complications versus those who did not were 1,146 (811 to 1,530) J versus 924 (730 to 1,240) J (P < 0.001), and 6.9 (5.5 to 8.7) J/min versus 6.7 (5.2 to 8.5) J/min (P = 0.091), respectively. ME was independently associated with postoperative pulmonary complications (ORadjusted, 1.44 [95% CI, 1.16 to 1.80]; P = 0.001). However, the association between time-weighted average MP and postoperative pulmonary complications was time-dependent, and time-weighted average MP was significantly associated with postoperative pulmonary complications in cases utilizing longer periods of mechanical ventilation (210 min or greater; ORadjusted, 1.46 [95% CI, 1.11 to 1.93]; P = 0.007). Normalization of ME and time-weighted average MP either to predicted body weight or to respiratory system compliance did not alter these associations. CONCLUSIONS: ME and, in cases requiring longer periods of mechanical ventilation, MP were independently associated with postoperative pulmonary complications in thoracic surgery.

Machine learning-based predictor for neurologic outcomes in patients undergoing extracorporeal cardiopulmonary resuscitation.

Background: We investigated the predictors of poor neurological outcomes in extracorporeal cardiopulmonary resuscitation (ECPR) patients using machine learning (ML) approaches. Methods: This study was a retrospective, single-center, observational study that included adult patients who underwent ECPR while hospitalized between January 2010 and December 2020. The primary outcome was neurologic status at hospital discharge as assessed by the Cerebral Performance Categories (CPC) score (scores range from 1 to 5). We trained and tested eight ML algorithms for a binary classification task involving the neurological outcomes of survivors after ECPR. Results: During the study period, 330 patients were finally enrolled in this analysis; 143 (43.3%) had favorable neurological outcomes (CPC score 1 and 2) but 187 (56.7%) did not. From the eight ML algorithms initially considered, we refined our analysis to focus on the three algorithms, eXtreme Gradient Boosting, random forest, and Stochastic Gradient Boosting, that exhibited the highest accuracy. eXtreme Gradient Boosting models exhibited the highest accuracy among all the machine learning algorithms (accuracy: 0.739, area under the curve: 0.837, Kappa: 0.450, sensitivity: 0.700, specificity: 0.740). Across all three ML models, mean blood pressure emerged as the most influential variable, followed by initial serum lactate, and arrest to extracorporeal membrane oxygenation (ECMO) pump-on-time as important predictors in machine learning models for poor neurological outcomes following successful ECPR. Conclusions: In conclusion, machine learning methods showcased outstanding predictive accuracy for poor neurological outcomes in patients who underwent ECPR.

Diagnostic Performance of Cardiac CT and Transthoracic Echocardiography for Detection of Surgically Confirmed Bicuspid Aortic Valve: Effect of Calcium Extent and Valve Subtypes.

Purpose: This study aimed to compare the diagnostic performance of cardiac CT and transthoracic echocardiogram (TTE) depending on the degree of valvular calcification and bicuspid aortic valve (BAV) subtype. Materials and Methods: This retrospective study included 266 consecutive patients (106 with BAV and 160 with tricuspid aortic valve) who underwent cardiac CT and TTE before aortic valve replacement. Cardiac CT was used to evaluate the morphology of the aortic valve, and a calcium scoring scan was used to quantify valve calcium. The aortic valves were classified into fused and two-sinus types. The diagnostic accuracy of cardiac CT and TTE was calculated using a reference standard for intraoperative inspection. Results: CT demonstrated significantly higher sensitivity, negative predictive value, and accuracy than TTE in detecting BAV (p < 0.001, p < 0.001, and p = 0.003, respectively). The TTE sensitivity tended to decrease as valvular calcification increased. The error rate of TTE for CT was 10.9% for the two-sinus type of BAV and 28.3% for the fused type (p = 0.044). Conclusion: Cardiac CT had a higher diagnostic performance in detecting BAV than TTE and may help diagnose BAV, particularly in patients with severe valvular calcification.

Risk of age older than 65 years for 30-day cardiac complication may be comparable to low-to-moderate risk according to revised cardiac risk index in non-cardiac surgery.

Revised cardiac risk index (RCRI) is widely used for surgical patients without containing age as a risk factor. We investigated age older than 65 years with respect to low-to-moderate risk of RCRI. From January 2011 to June 2019, a total of 203,787 consecutive adult patients underwent non-cardiac surgery at our institution. After excluding high-risk patients defined as RCRI score > 2, we stratified the patients into four groups according to RCRI and age (A: age < 65 with RCRI < 2, [n = 148,288], B: age ≥ 65 with RCRI < 2, [n = 42,841], C: age < 65 with RCRI = 2, [n = 5,271], and D: age ≥ 65 with RCRI = 2, [n = 5,698]). Incidence of major cardiac complication defined as a composite of cardiac death, cardiac arrest and myocardial infarction was compared. After excluding 1,689 patients with high risk (defined as RCRI score > 2), 202,098 patients were enrolled. The incidence with 95% confidence interval of major cardiac complication for A, B, C, and D groups was 0.3% (0.2-0.3), 1.1% (1.0-1.2), 1.8% (1.6-1.8), and 3.1% (2.6-3.6), respectively. In a direct comparison between B and C groups, old patients with RCRI < 2 showed a significantly lower risk compared to younger patients with RCRI = 2 (odd ratio, 0.62; 95% confidence interval, 0.50-0.78; p < 0.001). In non-cardiac surgery, the risk of age older than 65 years was shown to be comparable with low-to-moderate risk according to RCRI.

Comparison of Early and Late Surgeries after Coronary Stent Implantation in Patients with Normal Preoperative Troponin Level: A Retrospective Study.

Current guidelines recommend delaying noncardiac surgery for 6 months after drug eluting stent implantation. However, this recommendation is largely based on limited evidence and various event definitions. Whether early surgery within 6 months of coronary stent implantation increases myocardial injury in patients with normal preoperative high-sensitivity cardiac troponin I (hs-cTnI) has not yet been investigated. This retrospective study assessed patients who received coronary stent implantation and underwent noncardiac surgery (vascular, abdominal, or thoracic) between 2010 and 2017 with normal preoperative hs-cTnI (n = 186). Patients were divided into early (within 6 months of PCI) and late (after 6 months of PCI) groups. The primary endpoint was the incidence of myocardial injury as diagnosed by hs-cTnI within 3 days post-operation. The secondary outcomes were myocardial infarction, stent thrombosis, emergent coronary revascularization, major bleeding (bleeding requiring transfusion or intracranial bleeding), stroke, renal failure, heart failure, or death within 30 days post-operation. Inverse probability treatment weighting (IPTW) was carried out to adjust for the intergroup baseline differences. Myocardial injury occurred in 28.6% (8/28) and 27.8% (44/158) of the early and late groups, respectively, with no difference between groups (odds ratio [OR] 1.067, 95% confidence interval [CI] 0.404, 2.482; p = 0.886). Secondary outcomes did not differ between the groups. IPTW analysis also showed no differences in myocardial injury and secondary outcomes between the groups. In conclusion, early surgery within 6 months after coronary stent implantation did not increase the incidence of myocardial injury in patients with normal preoperative hs-cTnI.

Impact of early nutrition and feeding route on clinical outcomes of neurocritically ill patients.

Early proper nutritional support is important to critically ill patients. Nutritional support is also associated with clinical outcomes of neurocritically ill patients. We investigate whether early nutrition is associated with clinical outcomes in neurocritically ill patients. This was a retrospective, single-center, observational study including neurosurgical patients who were admitted to the intensive care unit (ICU) from January 2013 to December 2019. Patients who started enteral nutrition or parenteral nutrition within 72 hours after ICU admission were defined as the early nutrition group. The primary endpoint was in-hospital mortality. The secondary endpoint was an infectious complication. Propensity score matching (PSM) and propensity score weighting overlap weights (PSOW) were used to control selection bias and confounding factors. Among 1,353 patients, early nutrition was performed in 384 (28.4%) patients: 152 (11.2%) early enteral nutrition (EEN) and 232 (17.1%) early parenteral nutrition (EPN). In the overall study population, the rate of in-hospital mortality was higher in patients with late nutrition than in those with early nutrition (P<0.001). However, there was no significant difference in in-hospital mortality and infectious complications incidence between the late and the early nutrition groups in the PSM and PSOW adjusted population (all P>0.05). In the overall study population, EEN patients had a low rate of in-hospital mortality and infectious complications compared with those with EPN and late nutrition (P<0.001 and P = 0.001, respectively). In the multivariable analysis of the overall, PSM adjusted, and PSOW adjusted population, there was no significant association between early nutrition and in-hospital mortality and infectious complications (all P>0.05), but EEN was significantly associated with in-hospital mortality and infectious complications (all P<0.05). Eventually, early enteral nutrition may reduce the risk of in-hospital mortality and infectious complications in neurocritically ill patients.

Sex differences in myocardial injury after non-cardiac surgery and postoperative mortality.

BACKGROUND: Myocardial injury after non-cardiac surgery (MINS) has recently been accepted as a predictor of mortality. However, sex differences in the incidence of MINS and survival thereafter are not fully understood. This study aimed to compare the incidence of MINS and mortality among male and female patients. METHODS: This single-center study was conducted using the database of a large tertiary referral hospital. Consecutive patients with cardiac troponin (cTn) detected within 30 days after non-cardiac surgery performed between January 2010 and June 2019 were grouped according to sex. The incidence of MINS and mortality of patients with MINS were compared between men and women. RESULTS: Of the 33,311 patients, 18,546 (55.7%) were men and 14,765 (44.3%) were women. In a multivariable analysis, women showed a significantly lower incidence of MINS than did men (17.9% vs. 14.2%; odds ratio, 0.76; 95% confidence interval [CI], 0.71-0.81; P < 0.001). In patients with MINS, the propensity-score-matched analysis showed that 30-day mortality did not differ according to sex, but mortality in females was significantly lower than that in males during the overall follow-up (33.0% vs. 25.7%; hazard ratio, 0.75; 95% CI, 0.66-0.84; P < 0.001). CONCLUSION: The incidence of MINS was lower in women than in men. In patients with MINS, female sex may be associated with a survival benefit. Further studies are needed to confirm these findings.

Association between inflammation-based prognostic markers and mortality of non-cardiac surgery.

BACKGROUND: To evaluate the association between inflammation and nutrition-based biomarkers and postoperative outcomes after non-cardiac surgery. METHODS: Between January 2011 and June 2019, a total of 102,052 patients undergoing non-cardiac surgery were evaluated, with C-reactive protein (CRP), albumin, and complete blood count (CBC) measured within six months before surgery. We assessed their CRP-to-albumin ratio (CAR), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and modified Glasgow Prognostic Score (mGPS). We determined the best cut-off values by using the receiver operating characteristic (ROC) curves. Patients were divided into high and low groups according to the estimated threshold, and we compared the one-year mortality. RESULTS: The one-year mortality of the entire sample was 4.2%. ROC analysis revealed areas under the curve of 0.796, 0.743, 0.670, and 0.708 for CAR, NLR, PLR, and mGPS, respectively. According to the estimated threshold, high CAR, NLR, PLR, and mGPS were associated with increased one-year mortality (1.7% vs. 11.7%, hazard ratio [HR]: 2.38, 95% CI [2.05, 2.76], P < 0.001 for CAR; 2.2% vs. 10.3%, HR: 1.81, 95% CI [1.62, 2.03], P < 0.001 for NLR; 2.6% vs. 10.5%, HR: 1.86, 95% CI [1.73, 2.01], P < 0.001 for PLR; and 2.3% vs. 16.3%, HR: 2.37, 95% CI [2.07, 2.72], P < 0.001 for mGPS). CONCLUSIONS: Preoperative CAR, NRL, PLR, and mGPS were associated with postoperative mortality. Our findings may be helpful in predicting mortality after non-cardiac surgery.

New Oral Anticoagulant Versus Vitamin K Antagonists for Thoracoscopic Ablation in Patients With Persistent Atrial Fibrillation: A Randomized Controlled Trial.

Anticoagulation could not be currently stopped even after successful thoracoscopic ablation of atrial fibrillation for at least 2 months. The aim of this study is to compare the safety and efficacy outcomes between a new oral anticoagulant and warfarin after thoracoscopic ablation. This trial was a single-center, prospective, randomized controlled study comparing edoxaban and warfarin in patients undergoing thoracoscopic ablation of atrial fibrillation. This study enrolled 60 patients randomly assigned into 2 groups. The primary endpoint was efficacy outcomes, including stroke and systemic thromboembolic events. The secondary endpoint was safety outcomes including major bleeding and pericarditis. The patients were evaluated at discharge, 2 weeks, 3 months, and 6 months postoperatively. No stroke and thromboembolic events were noted in both treatment groups during the follow-up period. During the 6 months follow-up period, 4 (13%) of 30 patients in the edoxaban group experienced minor bleeding events, whereas none were noted in the warfarin group. Five anticoagulation-related events (bleeding, and prolongation of international normalized ratio), including pericarditis, were noted in both the edoxaban and warfarin groups. No statistically significant difference existed between the 2 groups. In conclusion, this study showed the comparable results of edoxaban to warfarin during the window period of post-thoracoscopic ablation of atrial fibrillation. Moreover, anticoagulation-related events were rather affected by patient factors and not by the anticoagulant type.

Clinical Outcomes Associated with Degree of Hypernatremia in Neurocritically Ill Patients.

OBJECTIVE: Hypernatremia is a common complication encountered during the treatment of neurocritically ill patients. However, it is unclear whether clinical outcomes correlate with the severity of hypernatremia in such patients. Therefore, we investigated the impact of hypernatremia on mortality of these patients, depending on the degree of hypernatremia. METHODS: Among neurosurgical patients admitted to the intensive care unit (ICU) in a tertiary hospital from January 2013 to December 2019, patients who were hospitalized in the ICU for more than 5 days and whose serum sodium levels were obtained during ICU admission were included. Hypernatremia was defined as the highest serum sodium level exceeding 150 mEq/L observed. We classified the patients into four subgroups according to the severity of hypernatremia and performed propensity score matching analysis. RESULTS: Among 1146 patients, 353 patients (30.8%) showed hypernatremia. Based on propensity score matching, 290 pairs were included in the analysis. The hypernatremia group had higher rates of in-hospital mortality and 28-day mortality in both overall and matched population (both p<0.001 and p=0.001, respectively). In multivariable analysis of propensity score-matched population, moderate and severe hypernatremia were significantly associated with in-hospital mortality (adjusted odds ratio [OR], 4.58; 95% confidence interval [CI], 2.15-9.75 and adjusted OR, 6.93; 95% CI, 3.46-13.90, respectively) and 28-day mortality (adjusted OR, 3.51; 95% CI, 1.54-7.98 and adjusted OR, 10.60; 95% CI, 5.10-21.90, respectively) compared with the absence of hypernatremia. However, clinical outcomes, including in-hospital mortality and 28-day mortality, were not significantly different between the group without hypernatremia and the group with mild hypernatremia (p=0.720 and p=0.690, respectively). The mortality rates of patients with moderate and severe hypernatremia were significantly higher in both overall and matched population. Interestingly, the mild hypernatremia group of matched population showed the best survival rate. CONCLUSION: Moderate and severe hypernatremia were associated with poor clinical outcomes in neurocritically ill patients. However, the prognosis of patients with mild hypernatremia was similar with that of patients without hypernatremia. Therefore, mild hypernatremia may be allowed during treatment of intracranial hypertension using hyperosmolar therapy.

Preoperative left atrial volume index may be associated with postoperative atrial fibrillation in non-cardiac surgery.

Background: Postoperative atrial fibrillation (POAF) is related to mortality after non-cardiac surgery. Left atrial volume index (LAVI) is known to be associated with prognosis and development of atrial fibrillation, but it has not been fully investigated in patients undergoing non-cardiac surgery. Materials and methods: A total of 203,787 consecutive adult patients underwent non-cardiac surgery at our institution between January 2011 and June 2019. After identifying those with available LAVI estimated during preoperative echocardiography, we divided them into those with LAVI higher and lower than 34 mL/m2. The primary outcome was incidence of POAF. Results: A total of 83,097 patients were enrolled in this study. The study patients were divided into the low (57,838 [69.6%]) and high (25,259 [30.4%]) LAVI groups. After an adjustment, higher LAVI was associated with increased incidence of POAF (5.1% vs. 8.1%; odds ratio [OR], 1.33; 95% confidence interval [CI], 1.25-1.41; p < 0.001). In 24,549 pairs of propensity-score-matched population, the result was similar (6.2% vs. 7.9%; OR, 1.30; 95% CI, 1.21-1.39; p < 0.001). The estimated threshold of LAVI associated with POAF was 36.4 mL/m2 with an area under the curve of 0.571. Subgroup analysis in non-thoracic and thoracic surgery showed that the association between preoperative LAVI and POAF significantly interacted with diastolic dysfunction (p for interaction < 0.001), and the observed association was valid in patients without diastolic dysfunction. Conclusion: Preoperative LAVI was shown to be associated with POAF in non-cardiac surgery. Our result needs verification in further studies.

Association between Mortality and Sequential Organ Failure Assessment Score during a Short Stay in the Intensive Care Unit after Non-Cardiac Surgery.

Background: The sequential organ failure assessment (SOFA) score has been validated in various clinical situations. However, it has not been investigated during a short stay in the intensive care unit (ICU). This study aimed to evaluate the association between the SOFA score and outcomes in patients who were monitored for less than one day after non-cardiac surgery. Methods: From a total of 203,787 consecutive adult patients who underwent non-cardiac surgery between January 2011 and June 2019, we selected 17,714 who were transferred to the ICU immediately after surgery and stayed for less than 24 h. Patients were divided according to quartile value and change between the initial and follow-up levels of SOFA score. Results: Three-year mortality tended to increase with a higher initial SOFA score (11.7%, 11.8%, 15.1%, and 17.8%, respectively). The patients were divided according to changes in the SOFA score at the midnight postoperative follow-up check: 16,176 (91.3%) in the stable group and 1538 (8.7%) in the worsened group. The worsened group showed significantly higher three-year mortality and complications (13.2% vs. 18.6%; HR [hazard ratio]: 1.236; 95% CI [confidence interval]: 1.108−1.402; p ≤ 0.0021 for three-year mortality and 3.8% vs. 9.1%; HR: 2.13; 95% CI: 1.73−2.60; p < 0.001 for acute kidney injury). Conclusions: The SOFA score during a short stay in the ICU after non-cardiac surgery showed an association with mortality. The change in SOFA score may need to be considered at discharge from the ICU.

Association between High-Sensitivity Cardiac Troponin I and Clinical Prognosis of Neurosurgical and Neurocritically Ill Patients.

To investigate whether high-sensitivity troponin I (hs-TnI) elevation is associated with in-hospital mortality and major adverse cardiac events (MACEs) in neurosurgical and neurocritically ill patients. Among neurosurgical patients admitted to the intensive care unit (ICU) from January 2013 to December 2019, those whose serum hs-TnI levels were obtained within 7 days after ICU admission were included. Propensity score matching was used. Each patient with hs-TnI elevation was matched to a control patient. The primary endpoint was in-hospital mortality and the secondary outcome was MACEs. The hs-TnI elevation was shown in 848 (14.1%) of 6004 patients. After propensity score matching, 706 pairs of data were generated by 1:1 individual matching without replacement. In multivariable analysis of overall and propensity score-matched population, hs-TnI elevation was associated with in-hospital mortality (adjusted odds ratio (OR): 2.37, 95% confidence interval (CI): 1.68-3.33 and adjusted OR: 1.89, 95% CI: 1.28-2.81, respectively). In addition, hs-TnI elevation was associated with MACEs (adjusted OR: 2.73, 95% CI: 1.74-4.29 and adjusted OR: 2.64, 95% CI: 1.60-4.51, respectively). In this study, hs-TnI elevation was associated with in-hospital mortality and MACEs in neurosurgical and neurocritically ill patients.

Optimal Arterial Blood Gas Tensions for the Prognosis of Favorable Neurological Outcomes in Survivors after Extracorporeal Cardiopulmonary Resuscitation.

Our aim is to assess the optimal levels of oxygen and carbon dioxide for the prognosis of favorable neurologic outcomes in survivors after extracorporeal cardiopulmonary resuscitation (ECPR). We obtained the mean levels of PaCO2 and PaO2 in arterial blood gas samples 72 h after ECPR. The primary outcome was the neurological status, according to the Cerebral Performance Categories (CPC) scale, upon discharge. Of 119 (48.6%) survivors, 95 (38.8%) had favorable neurologic outcomes (CPC 1 or 2). There was a U-shaped relationship between mean arterial blood gas tensions and poor neurological outcomes. The risk of poor neurological outcome was lowest in patients with the second tertile of mean PaCO2 (30-42 mm Hg) and PaO2 (120-160 mm Hg). In a multivariable analysis, third tertile of mean PaCO2, third tertile of mean PaO2, age, shockable rhythm, out of hospital cardiac arrest, duration of cardiopulmonary resuscitation, and ECPR at cardiac catheterization lab were found to be significantly associated with poor neurologic outcomes. Additionally, hypercapnia and extreme hyperoxia were found to be significantly associated with poor neurological outcomes after ECPR. Therefore, maintaining adequate arterial levels of oxygen and carbon dioxide may be important for favorable neurological prognoses in survivors after ECPR.

Association between high preoperative body mass index and mortality after cancer surgery.

Despite an association between obesity and increased mortality in the general population, obesity has been paradoxically reported with improved mortality of surgery and some types of cancer. However, this has not been fully investigated in patients undergoing cancer surgery. Using a cohort consisting of mostly Asian population, we enrolled 87,567 adult patients who underwent cancer surgery from March 2010 to December 2019. They were divided into three groups according to body mass index (BMI): 53,980 (61.6%) in the normal (18.5-25 kg/m2), 2,787 (3.2%) in the low BMI (<18.5 kg/m2), and 30,800 (35.2%) in the high BMI (≥25 kg/m2) groups. The high BMI group was further stratified into overweight (25-30 kg/m2) and obese (≥30 kg/m2) groups. The primary outcome was mortality during three years after surgery. Following adjustment by inverse probability weighting, mortality during three years after surgery was significantly lower in the high BMI group than the normal (4.8% vs. 7.0%; hazard ratio [HR], 0.69; confidence interval [CI], 0.64-0.77; p < 0.001) and low BMI (4.8% vs. 13.0%; HR: 0.38; CI: 0.35-0.42; p < 0.001) groups. The mortalities of the overweight and obese groups were lower than that of the normal group (7.0% vs. 5.0%; HR: 0.72; CI: 0.67-0.77; p < 0.001 and 7.0% vs. 3.3%; HR: 0.57; CI: 0.50-0.65; p < 0.001, respectively). This association was not observed in female patients and those undergoing surgery for breast and gynecological cancers. High BMI may be associated with decreased mortality after cancer surgery. Further investigations are needed for clinical application of our finding.

Association Between Perioperative Adverse Cardiac Events and Mortality During One-Year Follow-Up After Noncardiac Surgery.

Background Cardiac complications are associated with perioperative mortality, but perioperative adverse cardiac events (PACEs) that are associated with long-term mortality have not been clearly defined. We identified PACE as a composite of myocardial infarction, coronary revascularization, congestive heart failure, arrhythmic attack, acute pulmonary embolism, cardiac arrest, or stroke during the 30-day postoperative period and we compared mortality according to PACE occurrence. Methods and Results From January 2011 to June 2019, a total of 203 787 consecutive adult patients underwent noncardiac surgery at our institution. After excluding those with 30-day mortality, mortality during a 1-year follow-up was compared. Machine learning with the extreme gradient boosting algorithm was also used to evaluate whether PACE was associated with 1-year mortality. After excluding 1203 patients with 30-day mortality, 202 584 patients were divided into 7994 (3.9%) patients with PACE and 194 590 (96.1%) without PACE. After an adjustment, the mortality was higher in the PACE group (2.1% versus 7.7%; hazard ratio [HR], 1.90; 95% CI, 1.74-2.09; P<0.001). Results were similar for 7839 pairs of propensity-score-matched patients (4.9% versus 7.9%; HR, 1.64; 95% CI, 1.44-1.87; P<0.001). PACE was significantly associated with mortality in the extreme gradient boostingmodel. Conclusions PACE as a composite outcome was associated with 1-year mortality. Further studies are needed for PACE to be accepted as an end point in clinical studies of noncardiac surgery.

The use of renin angiotensin aldosterone system inhibitors may be associated with decreased mortality after cancer surgery.

Renin-angiotensin-aldosterone system (RAAS) inhibitors are antihypertensive agents with conflicting results on protective effects against some types of cancer. In light of these controversies, we aimed to study the effects of RAAS inhibitors in patients undergoing cancer surgery. From March 2010 to December 2019, consecutive adult patients with antihypertensive drug prescription at discharge after cancer surgery were enrolled and divided into two groups according to RAAS inhibitors prescription. The primary outcome was 5-year mortality after surgery. Secondary outcomes included mortalities during 3-year and 1-year follow-ups and cancer-specific mortality and recurrence rates during 5-, 3-, and 1-year follow-ups. A total of 19,765 patients were divided into two groups according to RAAS inhibitor prescription at discharge: 8,374 (42.4%) patients in the no RAAS inhibitor group and 11,391 (57.6%) patients in the RAAS inhibitor group. In 5022 pairs of propensity-score matched population, 5-year mortality was significantly lower in the RAAS inhibitor group (11.4% vs. 7.4%, hazard ratio [HR] 0.73, 95% confidence interval [CI] 0.64-0.83, P < 0.001), and 5-year recurrence rate was also lower for the RAAS inhibitor group (5.3% vs. 3.7%, HR 0.82, 95% CI 0.68-0.99, P = 0.04). In our analysis, RAAS inhibitor was associated with decreased 5-year mortality in hypertensive patients who underwent cancer surgery. Prescription of RAAS inhibitor in accordance with current guidelines may be associated with improved mortality after cancer surgery.

Optimal Mean Arterial Pressure for Favorable Neurological Outcomes in Survivors after Extracorporeal Cardiopulmonary Resuscitation.

We evaluated the optimal mean arterial pressure (MAP) for favorable neurological outcomes in patients who underwent extracorporeal cardiopulmonary resuscitation (ECPR). Adult patients who underwent ECPR were included. The average MAP was obtained during 6, 12, 24, 48, 72, and 96 h after cardiac arrest, respectively. Primary outcome was neurological status upon discharge, as assessed by the Cerebral Performance Categories (CPC) scale (range from 1 to 5). Overall, patients with favorable neurological outcomes (CPC 1 or 2) tended to have a higher average MAP than those with poor neurological outcomes. Six models were established based on ensemble algorithms for machine learning, multiple logistic regression and observation times. Patients with average MAP around 75 mmHg had the least probability of poor neurologic outcomes in all the models. However, those with average MAPs below 60 mmHg had a high probability of poor neurological outcomes. In addition, based on an increase in the average MAP, the risk of poor neurological outcomes tended to increase in patients with an average MAP above 75 mmHg. In this study, average MAPs were associated with neurological outcomes in patients who underwent ECPR. Especially, maintaining the survivor's MAP at about 75 mmHg may be important for neurological recovery after ECPR.