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.

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.

Prognosis of Myocardial Injury After Non-Cardiac Surgery in Adults Aged Younger Than 45 Years.

BACKGROUND: This study compared myocardial injury after non-cardiac surgery (MINS) and mortalities between patients under and over the age of 45 years.Methods and Results:From January 2010 and June 2019, patients with cardiac troponin measurement within 30 days after non-cardiac surgery were enrolled and divided into groups according to age: >45 (≥45 years) and <45 (<45 years). Further analyses were conducted only in patients who were diagnosed with MINS. The outcomes were MINS and 30-day mortality. Of the 35,223 patients, 31,161 (88.5%) patients were in the >45-year group and 4,062 (11.5%) were in the <45-year group. After adjustment with inverse probability of weighting, the <45-years group showed a lower incidence of MINS and cardiovascular mortality (16.6% vs. 11.7%; odds ratio, 0.77; 95% confidence interval [CI], 0.69-0.84; P<0.001 and 0.4% vs. 0.2%; hazard ratio [HR], 0.41; 95% CI, 0.19-0.88; P=0.02, respectively). In a comparison of only the <45-years group, MINS was associated with increased 30-day mortality (0.7% vs. 10.3%; HR, 10.48; 95% CI, 6.18-17.78; P<0.001), but the mortalities of patients with MINS did not differ according to age. CONCLUSIONS: MINS has a comparable prognostic impact in patients aged under and over 45 years; therefore, future studies need to also consider patients aged <45 years regarding risk factors of MINS and screening of perioperative troponin elevation.

Association Between High Body Mass Index and Mortality Following Myocardial Injury After Noncardiac Surgery.

BACKGROUND: Despite an association between obesity and increased risks for various diseases, obesity has been paradoxically reported to correlate with improved mortality in patients with established cardiovascular disease. However, its effect has not been evaluated to date in patients with myocardial injury after noncardiac surgery (MINS). METHODS: From January 2010 to June 2019, of a total of 35,269 adult patients with postoperative cardiac troponin level data, 5633 (16.0%) patients had MINS as diagnosed by postoperative cardiac troponin I above the 99th-percentile upper reference of 40 ng·L-1 using the TnI-Ultra immunoassay. Patients with MINS were divided into 3 groups according to body mass index (BMI), with 3246 (57.6%) were in the normal (18.5-25 kg·m-2), 425 (7.5%) in the low BMI (<18.5 kg·m-2), and 1962 (34.8%) in the high BMI (≥25 kg·m-2) groups, respectively. The primary outcome was mortality during the first year after surgery, and the mortality during 30 days was also compared. RESULTS: Following adjustment for confounding with inverse probability of treatment weighting, mortality within the first year appeared to be significantly lower in the high BMI group compared with the normal (14.8% vs 20.9%; hazard ratio [HR], 0.75; 95% confidence interval [CI], 0.66-0.85; P < .001) and the low BMI (14.8% vs 25.6%; HR: 0.56; 95% CI, 0.48-0.66; P < .001) groups. CONCLUSIONS: High BMI may be associated with decreased mortality following MINS. Further investigations are needed to support this finding.

Surgical correction for adult spinal deformity increases acetabular lateral coverage of femoral heads.

BACKGROUND: Studies explaining the relationship between hip and spine reported that spinal corrective surgery affected acetabular orientation and changes in pelvic tilt were capable of influencing radiographic measures of acetabular coverage. This study aimed to assess the change in coronal parameters for acetabular coverage as a result of adult spinal deformity (ASD) correction and to analyze the relationship between the postoperative changes in sagittal spinopelvic parameters and coronal acetabular coverage parameters. METHODS: Fifty-two consecutive patients who had undergone multilevel spinal surgical correction were enrolled and evaluated. Coronal acetabular coverage parameters included Tönnis angle (TA), lateral center edge angle (LCEA), and the angle of Sharp (SA). All radiographic parameters were evaluated at the preoperative and the postoperative 1 year. Paired t test was used to determine whether there were significant changes between the time points. Bivariate correlation and linear regression analysis were used to assess the relationship between the postoperative changes of spinal alignment and acetabular orientation. RESULTS: The surgical correction resulted in significant decrease of TA, increase of LCEA and SA, respectively (p < 0.001). The changes in pelvic tilt (PT) demonstrated weak correlation on TA (ß = 0.117, p < 0.001 for right; ß = 0.111, p < 0.001 for left). CONCLUSIONS: Although the surgical correction of ASD significantly changed PT resulting in increased acetabular lateral coverage parameters, the correlation between the changes of PT following sagittal correction of ASD and acetabular coverage parameters was low. TRIAL REGISTRATION: This study was retrospectively registered with approval by the institutional review board (IRB) of our institution (approval number: KHNMC-2020-10-010).

Use of iliac screw associated with more correction of lumbar lordosis than S2-alar-iliac screw for adult spinal deformity.

BACKGROUND: To date, there is a paucity of reports clarifying the change of spinopelvic parameters in patients with adult spinal deformity (ASD) who underwent long segment spinal fusion using iliac screw (IS) and S2-alar-iliac screw (S2AI) fixation. METHODS: A retrospective review of consecutive patients who underwent deformity correction surgery for ASD between 2013 and 2017 was performed. Patients were divided into two groups based on whether IS or S2AI fixation was performed. All radiographic parameters were measured preoperatively, immediately postoperatively, and the last follow-up. Demographics, intraoperative and clinical data were analyzed between the two groups. Additionally, the cohort was subdivided according to the postoperative change in pelvic incidence (PI): subgroup (C) was defined as change in PI ≥5° and subgroup (NC) with change < 5°. In subgroup analyses, the 2 different types of postoperative change of PI were directly compared. RESULTS: A total of 142 patients met inclusion criteria: 111 who received IS and 31 received S2AI fixation. The IS group (65.6 ± 26°, 39.8 ± 13.8°) showed a significantly higher change in lumbar lordosis (LL) and upper lumbar lordosis (ULL) than the S2AI group (54.4 ± 17.9°, 30.3 ± 9.9°) (p < 0.05). In subgroup (C), PI significantly increased from 53° preoperatively to 59° postoperatively at least 50% of IS cohort, with a mean change of 5.8° (p < 0.05). The clinical outcomes at the last follow-up were significantly better in IS group than in S2AI group in terms of VAS scores for back and leg. The occurrence of sacroiliac joint pain and pelvic screw fracture were significantly greater in S2AI group than in IS group (25.8% vs 9%, p < 0.05) and (16.1% vs 3.6%, p < 0.05). CONCLUSIONS: Compared with the S2AI technique, the IS technique usable larger cantilever force demonstrated more correction of lumbar lordosis, and possible increase in pelvic incidence. Further study is warranted to clarify the clinical impaction of these results.

Pre-operative anaemia and myocardial injury after noncardiac surgery: A retrospective study.

BACKGROUND: Pre-operative anaemia is associated with adverse outcomes of noncardiac surgery, but its association with myocardial injury after noncardiac surgery (MINS) has not been fully investigated. OBJECTIVE: The association between pre-operative anaemia and MINS. DESIGN: A single-centre retrospective cohort study. SETTING: Tertiary care referral centre. PATIENTS: Patients with measured cardiac troponin (cTn) I levels after noncardiac surgery. INTERVENTIONS: Patients were separated according to pre-operative anaemia (haemoglobin <13 g dl-1 in men and <12 g dl-1 in women). Anaemia was further stratified into mild and moderate-to-severe at a haemoglobin level threshold of 11 g dl-1. MAIN OUTCOME MEASURES: The primary outcome was MINS, defined as a peak cTn I level more than 99th percentile of the upper reference limit within 30 postoperative days. RESULTS: Data from a total of 35 170 patients were collected, including 22 062 (62.7%) patients in the normal group and 13 108 (37.3%) in the anaemia group. After propensity score matching, 11919 sets of patients were generated, and the incidence of MINS was significantly associated with anaemia [14.5 vs. 21.0%, odds ratio (OR) 1.57, 95% confidence interval (CI) 1.47 to 1.68, P < 0.001]. For the entire population, multivariable analysis showed a graded association between anaemia severity and MINS (OR 1.32, 95% CI 1.22 to 1.43, P < 0.001 for mild anaemia and OR 1.80, 95% CI 1.66 to 1.94, P < 0.001 for moderate-to-severe anaemia compared with the normal group) and a significantly higher incidence of MINS for moderate-to-severe anaemia than mild anaemia (18.6 vs. 28.6%, OR 1.37, 95% CI 1.25 to 1.50, P < 0.001). The estimated threshold for pre-operative haemoglobin associated with MINS was 12.2 g dl-1, with an area under the curve of 0.622. CONCLUSIONS: Pre-operative anaemia was independently associated with MINS, suggesting that MINS may be related to the association between anaemia and postoperative mortality. TRIAL REGISTRATION: SMC 2019-08-048.

Radiographic and clinical evidence: osteoarthritic knee can change surgical result for lumbar degenerative disease patient undergone surgery for 3-year follow-up: a retrospective comparative clinical study.

BACKGROUND: There is a paucity of reports clarifying the implication of knee osteoarthritis (OA) on spinal sagittal alignment of patients undergone surgery for lumbar spine. This study aimed to analyze how osteoarthritic knee affects radiographic and clinical results of degenerative lumbar disease patients undergone lumbar fusion. METHODS: We retrospectively reviewed the medical records and radiographs of 74 consecutive degenerative lumbar disease patients who underwent posterior instrumentation and fusion surgery between May 2016 and June 2017 and were followed up for minimum 3 years postoperatively. The patients were divided into 2 groups according to the severity of knee OA by Kellgren-Lawrence grading (KLG) scale (group I, KLG 1 or 2 [n = 39]; group II, KLG 3 or 4 [n = 35]). Patient demographic data, comorbidities, spinal sagittal parameters and clinical scores were extracted and compared at preoperative, postoperative 1 month and the ultimate follow-up between the groups. In radiographic assessment, sagittal alignment parameters and sagittal balance were used. In clinical assessment, the scores of Oswestry disability index (ODI) and Scoliosis Research Society questionnaire (SRS-22) were used. For the frequency analysis of categorical variables across the groups, chi-square test was used and student t tests was used to compare the differences of continuous variables. RESULTS: In radiographic assessment, TLK (thoracolumbar kyphosis), LL (lumbar lordosis), PT (pelvic tilt), C7 SVA (sagittal vertical axis) in both groups improved significantly after surgery (p <  0.05). However, LL, PT, C7SVA improved at postoperative 1 month in the group II were not maintained at the ultimate postoperative follow-up. In clinical assessment, preoperative Oswestry disability index (ODI, %) and all SRS-22 subscores of the group I and II were not different (p > 0.05). There were significant differences between the groups at the ultimate follow-up in ODI (- 25.6 vs - 12.1, p <  0.001), SRS total score (%) (28 vs 20, p = 0.037), function subscore (1.4 vs 0.7, p = 0.016), and satisfaction subscore (1.6 vs 0.6, p < 0.001). CONCLUSION: Osteoarthritic knee with KLG 3 or 4 have a negative influence on maintaining postoperative spinal sagittal alignment, balance, and the clinical outcomes achieved immediately by posterior instrumentation and fusion for lumbar degenerative disease. TRIAL REGISTRATION: This study was retrospectively registered with approval by the institutional review board (IRB) of our institution (approval number: 2018-11-007).

Revascularization vs. Medical Therapy for Coronary Chronic Total Occlusions in Patients With Chronic Kidney Disease.

BACKGROUND: We investigated whether the outcome of revascularization differed from the outcome of medical therapy in chronic kidney disease (CKD) and non-CKD patients with chronic total occlusion (CTO).Methods and Results:A total of 2,010 patients with CTO who underwent revascularization (n=1,355), including percutaneous coronary intervention (n=878) and coronary artery bypass grafting (n=477), or had medical therapy alone (n=655) were examined. The primary outcome was all-cause death during follow-up. Among the non-CKD patients (n=1,679), revascularization had a lower incidence of all-cause death (adjusted hazard ratio [HR] 0.54, 95% confidence interval [CI] 0.41-0.72, P<0.001) compared with medical therapy. Among the CKD patients (n=331), the difference in the incidence of all-cause death was not as marked between the 2 treatments (adjusted HR 0.71, 95% CI 0.48-1.06, P=0.09). There was a significant interaction between kidney function and treatment strategy (revascularization vs. medical therapy) on all-cause death (P for interaction=0.014). CONCLUSIONS: Based on the clinical outcomes, in CTO patients with preexisting CKD, revascularization via PCI or bypass surgery might not be as effective as in non-CKD patients.

Spontaneous spinal epidural hematoma of the thoracic spine after herbal medicine: a case report.

BACKGROUND: Spontaneous spinal epidural hematoma (SSEH) is an uncommon disease, but it can lead to acute cord compression with disabling consequences. Identifiable reasons for spontaneous hemorrhage are vascular malformations and bleeding disorders. However, SSEH after taking herbal medicines has not been described yet. CASE PRESENTATION: A 60-year-old female experienced sudden back pain combined with numbness and weakness in the lower limbs for several hours with no trauma, drug use, family history or any disease history. Her deep tendon reflexes were normoactive, and Babinski was negative. An emergent MRI showed a spinal epidural hematoma extending from T3 to T5. She was taken to surgery after immediate clinical and laboratory evaluations had been completed. Emergency decompression with laminectomy was performed and the patient recovered immediately after the surgery. Additional history taken from the patient at outpatient clinic after discharge revealed that she had been continuously taking herbal medicine containing black garlic for 8 weeks. CONCLUSION: To our knowledge, no report has been previously issued on SSEH after taking herbal medicines. Although contradictory evidence is present on bleeding risks with herbal uses, we believe that it's reasonable to ascertain if patients with SSEP are taking herbal medication before or during spinal surgery.

Classification and regression tree model for predicting tracheostomy in patients with traumatic cervical spinal cord injury.

PURPOSE: In patients with cervical spinal cord injury (CSCI), respiratory compromise and the need for tracheostomy are common. The purpose of this study was to identify common risk factors for tracheostomy following traumatic CSCI and develop a decision tree for tracheostomy in traumatic CSCI patients without pulmonary function test. METHODS: Data of 105 trauma patients with CSCI admitted in our institution from April, 2008 to February, 2014 were retrospectively analyzed. Patients who underwent tracheostomy were compared to those who did not. Stepwise logistic regression analysis and classification and regression tree model were used to predict the risk factors for tracheostomy. RESULTS: Tracheostomy was performed in 20% of patients with traumatic CSCI on median hospital day 4. Patients who underwent tracheostomy tended to be more severely injured (higher Injury Severity Score, lower Glasgow Coma Score, and lower systolic blood pressure on admission) which required more frequent intubation in the emergency room (ER) with a higher rate of complete CSCI compared to those who did not. Upon multiple logistic analysis, Age ≥ 55 years (OR: 6.86, p = 0.037), Car accident (OR: 5.8, p = 0.049), injury above C5 (OR: 28.95, p = 0.009), ISS ≥ 16 (OR: 12.6, p = 0.004), intubation in the ER (OR: 23.87, p = 0.001), and complete CSCI (OR: 62.14, p < 0.001) were significant predictors for the need of tracheostomy after CSCI. These factors can predict whether a new patient needs future tracheostomy with 91.4% accuracy. CONCLUSIONS: Age ≥ 55 years, injury above C5, ISS ≥ 16, Car accident, intubation in the ER, and complete CSCI were independently associated with tracheostomy after CSCI. CART analysis may provide an intuitive decision tree for tracheostomy.

Optimal Medical Therapy vs. Percutaneous Coronary Intervention for Patients With Coronary Chronic Total Occlusion - A Propensity-Matched Analysis.

BACKGROUND: Limited data are available on the long-term clinical outcomes of coronary chronic total occlusion (CTO) patients who receive optimal medical therapy (OMT) compared with percutaneous coronary intervention (PCI). METHODS AND RESULTS: Between March 2003 and February 2012, 2,024 patients with CTO were enrolled in a single-center registry. Among this patient group, we excluded CTO patients who underwent coronary artery bypass grafting and classified patients into the OMT group (n=664) or PCI group (n=883) according to initial treatment strategy. Propensity-score matching was also performed. The primary outcome was cardiac death. The median follow-up duration was 45.8 (interquartile range: 22.8-71.1) months. In the PCI group, 699 patients (79.2%) underwent successful revascularization. In the propensity-score matched population (533 pairs), there was no significant difference in the rate of cardiac death between the OMT and PCI groups (hazard ratio, 1.57; 95% confidence interval, 0.91-2.72, P=0.11). In the subgroup analysis, there were no significant interactions between the PCI strategy and cardiac death among several subgroups except that regarding collateral flow grades 0-2 vs. those with grade 3 (P=0.01). CONCLUSIONS: As an initial treatment strategy, PCI did not reduce cardiac death compared with OMT for the treatment of CTO in the drug-eluting stent era.

Obese children experience more extremity fractures than nonobese children and are significantly more likely to die from traumatic injuries.

UNLABELLED: Two of the most prevalent problems children facing worldwide are injuries and obesity. We conducted a systematic review of published studies that evaluated the effects of obesity on children with traumatic injuries. Six studies published between 2006 and 2014 were identified, comprising a total of 4594 children: 867 were obese and 3727 were not. Obese children were 25% more likely to have extremity fractures than nonobese children (p = 0.003), and their mortality rate was significantly higher at 4.7% versus 2.8% (p = 0.026). CONCLUSION: Our review showed that obese children were more likely to have extremity fractures and die of traumatic injuries than nonobese children.

Is magnetic resonance imaging necessary in isolated greater trochanter fracture? A systemic review and pooled analysis.

BACKGROUND: Isolated fractures of the greater trochanter (GT) of the femur are uncommon and few studies have assessed the diagnosis and appropriate therapeutic schedule for these fractures. The current data regarding assessment of isolated fractures of the GT are limited to a few reviews based on the experience of a single institution. Therefore, we asked the following questions: (1) what proportion of cases has an associated extension of the fracture into the intertrochanteric region in isolated GT fracture and (2) what are the treatment options and outcomes of GT fractures with occult intertrochanteric fractures. METHODS: We conducted a systematic review of published studies that evaluated patients who displayed isolated GT fracture on routine radiographic examination and underwent a magnetic resonance imaging (MRI) scan because of the suspicion of extension into the intertrochanteric region. A structured literature review of multiple databases (PubMed, EMBASE, CINAHL, and Cochrane systematic reviews) referenced articles from 1950 to 2015. RESULTS: A total of 110 patients were identified from 7 published studies. MRI documented isolated GT fractures diagnosed on initial radiographs in only 11 of 110 patients (10%). In 99 patients (90%), MRI examinations revealed extension of the fracture into the intertrochanteric region. Surgical fixation was necessary for 61 patients, with a pooled percentage of 55%. No complications were observed after surgery. CONCLUSIONS: Our study has helped to elucidate further the assessment of isolated fracture of the GT. We believe that MRI is a reasonable option for patients presenting with isolated GT fracture on plain radiographs.

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.

Restrictive calcium replacement in septic shock: a multicenter before-after intervention study. / Reposición restrictiva de calcio en pacientes con shock séptico: estudio de intervención antes-después.

OBJECTIVES: To study the impact of a restrictive calcium replacement protocol in comparison with a liberal one in patients with septic shock. MATERIAL AND METHODS: Multicenter retrospective before-after study that estimated the impact of implementing a restrictive calcium replacement protocol in patients with septic shock. Patients admitted to an intensive care unit between May 2019 and April 2021 were assigned to liberal calcium replacement, and those admitted between May 2021 and April 2022 were assigned to a restrictive protocol. The primary outcome measure was 28-day mortality. Patients were matched with propensity scores. RESULTS: A total of 644 patients were included; liberal replacement was used in 453 patients and the restrictive replacement in 191. We paired 553 patients according to propensity scores, 386 in the liberal group and 167 in the restrictive group. Mortality did not differ significantly between the groups at 28 days (35.3% vs 32.3%, respectively; hazard ratio, 0.97; 95% CI, 0.72-1.29) or after resolution of septic shock (81.5% vs 83.8%; hazard ratio, 0.89; 95% CI, 0.73-1.09). Nor did scores on the Sepsis-related Organ Failure Assessment scale differ (2.1 vs 2.6; P = 0.20). CONCLUSION: The implementation of a restrictive calcium replacement protocol in patients with septic shock was not associated with a decrease in 28-day mortality in comparison with use of a liberal protocol. However, we were able to reduce calcium replacement without adverse effects.

OBJETIVO: Investigar el efecto de un protocolo de reposición restrictiva de calcio frente a una estrategia liberal en pacientes con shock séptico. METODO: Estudio multicéntrico, antes-después y retrospectivo que evaluó el efecto de la implementación de un protocolo de reposición restrictiva de calcio en pacientes con shock séptico. Los pacientes que ingresaron en unidades de cuidados intensivos (UCI) entre mayo de 2019 y abril de 2021 se asignaron al grupo con administración liberal, y los que se presentaron entre mayo de 2021 y abril de 2022 ­tras la implementación del protocolo­ al grupo con administración restrictiva. La variable de resultado principal fue la mortalidad a 28 días. Se realizó un emparejamiento por puntuación de propensión. RESULTADOS: Se incluyeron 644 pacientes, 453 en el grupo liberal y 191 en el grupo restrictivo. De los que 553 se emparejaron (386 en el grupo liberal, y 167 en el grupo restrictivo). No hubo diferencias entre los dos grupos en la mortalidad a los 28 días (35,3% vs 32,3%; HR: 0,97; IC 95%: 0,72-1,29), en la finalización del shock (81,5% vs a 83,8%; HR: 0,89; IC 95%: 0,73-1,09) ni en la puntuación de la escala SOFA (2,1 vs 2,6; p = 0,20). CONCLUSIONES: La implementación de un protocolo de administración restrictiva de calcio, en pacientes con shock séptico, no se asoció a una disminución de la mortalidad a los 28 días en comparación con una administración liberal. No obstante, la reposición de calcio podría reducirse sin efectos adversos.

Serial CT findings of nodular bronchiectatic Mycobacterium avium complex pulmonary disease with antibiotic treatment.

OBJECTIVE: The objective of our study was to analyze the serial CT findings of patients with the nodular bronchiectatic form of Mycobacterium avium complex (MAC) pulmonary disease treated with antibiotic therapy. MATERIALS AND METHODS: Between January 2005 and December 2009, MAC lung disease was diagnosed in 475 patients at a single tertiary referral hospital. Of the 475 patients, 339 had a CT pattern of disease consistent with the nodular bronchiectatic form. Among these 339 patients, 110 patients treated with a combination of antibiotics for 1 year were selected for this study. Two independent chest radiologists reviewed retrospectively the chest CT scans of 101 patients (M. avium disease [n = 57] and M. intracellulare disease [n = 44]) in whom serial CT scans had been obtained at the beginning of and at 12 months after standardized therapy. Each CT study was assessed for the presence and extent of lung parenchymal abnormalities (maximum score, 30). RESULTS: After 12 months of antibiotic therapy, 84 patients (83%) had a decrease in the overall CT score, three (3%) had an increase, and 14 (14%) had no change in disease extent. The decrease in total CT score was statistically significant (overall score difference, 2.54; p < 0.0001). Cellular bronchiolitis showed the largest decrease in extent (difference in mean pre and posttreatment scores, -1.02, -1.07, and -0.94 for MAC, M. avium, and M. intracellulare diseases, respectively). Before treatment, patients with M. intracellulare disease showed more extensive disease than patients with M. avium disease (total CT score, 13.31 vs 11.10; p = 0.025). CONCLUSION: In the nodular bronchiectatic form of MAC pulmonary disease, lung parenchymal abnormalities show a significant decrease in extent on CT after antibiotic treatment and the decrease is mainly related to the improvement of cellular bronchiolitis.

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.

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.

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.