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With a well-established role in inflammation and immune function, vitamin D status has emerged as a potential factor for coronavirus disease-2019 (COVID-19).The purpose of this study was to evaluate the moderating effect of race on the relationship between vitamin D status and the risk of COVID-19 test positivity, and to compare propensity score (PS) model results to those obtained from classical bivariate and multivariable models, which have primarily comprised the literature to date.Electronic health record (EHR) data from TriNetX (unmatched n = 21,629; matched n = 16,602) were used to investigate the effect of vitamin D status, as measured by 25-hydroxyvitamin D [25(OH)D], on the odds of experiencing a positive COVID-19 test using multivariable logistic regression models with and without PS methodology.Having normal (Models which use weighting and matching methods resulted in smaller estimated effect sizes than models which do not use weighting or matching. These findings suggest a minimal protective effect of vitamin D status on COVID-19 test positivity in White individuals and no protective effect in Black individuals.

Previous studies have demonstrated superior patency of no-touch as compared to conventional saphenous vein grafts in coronary artery bypass grafting. We aimed to compare mid-term clinical outcomes of both techniques in a large cohort of routine patients. We identified all patients undergoing non-emergent primary coronary artery bypass grafting with either no-touch or conventional saphenous vein grafts at our institution between 2000 and 2020. Propensity score matching was used to create adjusted cohorts based on 5,288 eligible patients. The primary outcome was the combined endpoint of all-cause mortality and repeat revascularization. Secondary outcomes were individual rates of all-cause mortality and repeat revascularization, surgical complications, and short-term mortality. Propensity score matching resulted in cohorts of no-touch (n=923) and conventional (n=923) saphenous vein grafted patients with comparable baseline characteristics. Mean follow-up time was significantly shorter for the no-touch compared to the conventional cohort (4.9 ± 2.3 versus 8.3 ± 2.6 years, p< 0.001). Up to seven-year follow-up, neither the rate of the primary composite endpoint nor death differed significantly between the cohorts. The rate of repeat revascularization was significantly higher in patients in the no-touch cohort (12.9% versus 9.3% at seven-year follow-up, p=0.022. Post-hoc analysis of percutaneous coronary intervention during follow-up revealed comparable rates of saphenous vein graft failure (no-touch 42/923 (4.6%) versus conventional 32/923 (3.5%), p=0.286). In this large propensity score matched registry study, coronary artery bypass with no-touch compared to conventional saphenous vein grafting did neither enhance mid-term survival nor reduce the rate of repeat revascularization.

Acute kidney injury (AKI) frequently complicates cardiac surgery and is more common among Black patients. We evaluated determinants of race-based differences in AKI rates.Serum creatinine-based criteria were used to identify adult cardiac surgical patients having postoperative AKI in the Perfusion Measures and Outcomes (PERForm) Registry (July 1, 2014, to June 30, 2019). Patient characteristics, operative details, and outcomes were compared by race (Black vs White) after excluding patients with preoperative dialysis, missing preoperative or postoperative creatinine, or other races. A mixed effects model (adjusting for demographics, comorbidities, surgical factors) used hospital as a random effect to predict postoperative stage 2 or 3 AKI. Propensity score analyses were conducted to evaluate robustness of the primary analyses.The study cohort included 34 520 patients (8% Black). More Black patients than White patients were female (43% vs 27%, P.001), and had hypertension (93% vs 87%, P.001) and diabetes mellitus (51% vs 41%, P.001). Acute kidney injury of stage 2 or greater occurred in 1697 patients (5%), more often among Black than White patients (8% vs 5%, P.001). Intraoperatively, Black patients had lower nadir hematocrits (23 vs 26, P.001), and were more likely to be given transfusions (22% vs 14%, P.001). After adjustment, Black race (compared with White) independently predicted odds for postoperative AKI (adjusted odds ratio 1.50; 95% confidence interval, 1.26 to 1.78). The multivariable findings were similar in propensity score analyses.Despite accounting for differences in risk factors and intraoperative practices, Black patients had a 50% increased odds for having moderate-severe postoperative AKI compared with White patients. Additional evaluations are warranted to identify potential targets to address racial disparities in AKI outcomes.

BACKGROUND This study sought to examine the real-world impact of multimodality cyclical-pressure topical wound oxygen therapy (TWO2) on hospitalizations and amputations in patients with diabetic foot ulcer (DFU) compared to patients without TWO2. METHODS We conducted a retrospective review of deidentified patient medical records at 2 US Veterans Affairs hospitals between January 2012 and January 2020. DFU patients were assigned to TWO2 or NO TWO2 cohorts based on their treatment records. Patients received appropriate standard of care and may have received other advanced wound treatments, including skin substitutes, negative pressure wound therapy, and growth factors. Primary study outcomes were patients requiring hospitalization and/or amputation within 360 days of initial wound documentation. FINDINGS Among unmatched cohorts of 202 patients with DFU (91 TWO2, 111 NO TWO2), 66% and 121% of TWO2 patients had hospitalizations and amputations, respectively, compared to 541% and 414% of NO TWO2 patients within 360 days (P < 00001, P < 00001), representing 88% and 71% reductions. Among propensity score matched cohorts of 140 DFU patients (70 TWO2, 70 NO TWO2), compared to NO TWO2, 82% fewer TWO2 patients were hospitalized (71% vs 400%, P < 00001) and 73% fewer TWO2 patients had amputations (86% vs. 314%, P = 00007). Logistic regression among matched cohorts demonstrated nearly 9-fold and 5-fold higher risk of hospitalization and amputation, respectively, for NO TWO2 vs. TWO2. INTERPRETATION This retrospective cohort study demonstrates that treating patients with DFU with TWO2 is associated with significant reductions in hospitalizations and amputations in the real-world setting.

Background Treatment options for metastatic renal cell carcinoma (mRCC) include cytoreductive nephrectomy (CN) and systemic therapy (ST). Results from the CARMENA and SURTIME trials suggest that CN before ST may not be the optimal treatment strategy for mRCC. Objective To use real-world data to evaluate and compare outcomes for patients with mRCC who underwent CN before, after, or without ST to those patients who only received ST. Design, setting, and participants The Canadian Kidney Cancer information system (CKCis) database was used to identify patients diagnosed with mRCC between January 2011 and April 2020. Only patients with synchronous disease, treated within 12 mo from their initial RCC diagnosis, with International Metastatic Renal Cell Carcinoma Database Consortium intermediate/high risk, and confirmed RCC histology were included. Outcome measurements and statistical analysis Patients were classified into four groups according to the initial treatment received for mRCC. Inverse probability of treatment weighting using propensity scores was used to balance the treatment groups. Cox proportional hazards models were used to assess the impact of CN after adjusting for potential confounding variables in the weighted cohorts. Results and limitations A total of 788 patients were included in the study cohort. Of these 383 patients underwent CN before ST, 73 underwent CN after ST, 80 underwent CN only, and 252 patients received ST only. The median patient age was 63 yr and 73% of the cohort were men. In weighted analysis, the groups undergoing CN before ST (hazard ratio [HR] 0.65, 95% confidence interval [CI] 0.52–0.82) and CN after ST (HR 0.41, 95% CI 0.28–0.60) both had better survival compared to the ST only group. No survival benefit was observed for CN only compared to ST only, or for CN before ST compared to CN after ST. Conclusions We evaluated the association between different sequences of treatment with CN and survival in patients with mRCC using CKCis real world data. The results demonstrate that the selected patients who undergo CN, whether performed before or after ST, have an associated improvement in survival. Patient summary Two of the treatment options for metastatic kidney cancer are surgery and systemic therapy (chemotherapy or immunotherapy). We used data from the Canadian Kidney Cancer information system to determine whether there are differences in survival according to the sequencing of these treatments. Patients who had both surgery and systemic therapy, regardless of which treatment was first, had better survival than patients who only received systemic therapy.

Background This study assessed associations between processed electroencephalographic (pEEG) use during anesthesia, surgery- and anesthesia-related risk factors, and neurologic outcomes and mortality after cardiac surgery. Methods Drawing from the Society of Thoracic Surgeons Adult Cardiac Surgery Database and its Adult Cardiac Anesthesiology Section, we identified 42,932 records for elective, urgent, and emergency cardiac surgery procedures between July 1, 2017, to December 31, 2019. Using propensity score weighted regression analysis, we analyzed the associations between pEEG use during anesthesia on the primary outcome, postoperative delirium (POD), and secondary outcomes (stroke, encephalopathy, coma, and operative mortality). Results The rate of pEEG use during anesthesia use was 32.8% (n=14,086), and its use was not associated with decreased odds for POD (odds ratio [OR], 0.88; 95%CI, 0.78-1.02) or encephalopathy (OR, 0.85; 95%CI, 0.70-1.03). Intraoperative pEEG monitoring use was also not associated with increased odds for stroke (OR, 1.17; 95%CI, 0.97-1.42) or coma (OR, 1.44; 95%CI, 0.82-2.52). In contrast, pEEG use during anesthesia was associated with higher odds for operative mortality (OR, 1.23; 95%CI, 1.05-1.44). This association remained significant after adjusting for POD (OR: 1.21, 95%CI: 1.03-1.41), stroke (OR: 1.21, 95%CI:1.04-1.42), and encephalopathy (OR: 1.28, 95%CI: 1.07-1.52). Conclusions This large retrospective database study found no association between pEEG use during cardiac surgery and postoperative neurologic outcomes such as POD, stroke, encephalopathy, or coma. However, patients who underwent pEEG monitoring during anesthesia experienced higher mortality, even after adjustment for neurologic outcomes.

The risk of osteoporosis in patients with rheumatoid arthritis (RA) is frequently overlooked, and investigating a simple indicator in routine care may be beneficial to motivate osteoporosis examination. The aim of this retrospective, case-controlled study was to identify the correlation between serum albumin concentrations and the prevalence of osteoporosis in postmenopausal patients with RA.This study enrolled 197 patients who underwent dual-energy X-ray absorptiometry of lumbar spine (LS) and proximal femur without osteoporosis treatment [mean age, 67.5 years; disease duration, 12.8 years; Disease Activity Score assessing 28 joints with C-reactive protein, 2.0; prednisolone dose, 4.9 mg/day (usage, 42.6%); and LS T-score, -1.9]. Patients were classified into 2 groups: osteoporosis, defined as ≥ 1 part bone mineral density T-score ≤ -2.5 or history of fragility fracture of the vertebra or proximal femur (121 patients), and non-osteoporosis (76 patients). Groups were then matched by propensity score using clinical backgrounds affecting bone metabolism.In non-matched model, serum albumin concentration was significantly associated with osteoporosis-related factors such as aging, inflammation, physical disability, and glucocorticoid dose. Multivariate logistic regression revealed that serum albumin concentration was independently and significantly associated with osteoporosis risk (odds ratio = 0.22, 95% confidence interval = 0.08, 0.61, p = 0.0033). After propensity score matching, 57 patients for each group showed that in addition to the LS and femoral neck T-scores (p 0.001), serum albumin concentrations (p = 0.01) remained lower in the osteoporosis group compared to non-osteoporosis group. Receiver operating characteristic curve analysis in non-matched model revealed that when cut-off value of serum albumin concentration for indicating osteoporosis was set at 4.2 g/dl, the area under the curve was 0.69, sensitivity 0.74, and specificity 0.58.Low serum albumin concentration was significantly and independently associated with the prevalence of osteoporosis, which may be considered as one of the osteoporosis-related factors in postmenopausal patients with RA.

When treating cancer patients, the progression of symptoms is accompanied by the deterioration of systemic conditions and motor function. From a risk-benefit perspective, a certain level of physical function must be maintained to continue cancer treatment. Recently, outpatient cancer treatment has become more common. Motor function is important to determine the feasibility of continuing cancer treatment. The study aimed to evaluate the motor function of patients with visceral cancer using locomo tests established by Japanese Orthopaedic Association.Locomo tests were performed, and the results were compared with data from non-cancer individuals. Background data were matched by propensity score matching. Data from 53 cancer patients (group C) were compared with that of 75 non-cancer patients (group N).The average score in the two-step test of group C was lower than that of group N (1.27: 1.37, p = 0.004). The average function in the stand-up test of group C was worse than that of group N (p = 0.001). The average score in the 25-question geriatric locomotive function scale (GLFS) of group C was significantly higher than that of group N (19.92: 5.29, SE 2.21, p 0.001). Higher 25-question GLFS scores indicate reduced mobility. The proportion of the locomo stage 2 in group C was significantly higher than in group N (51%: 13%, p 0.001). The results of the two field tests revealed a clinically minimal difference between the two groups, but a statistically significant difference. Locomo tests may be detect potential motor dysfunction in outpatient cancer patients with apparently maintained motor function.Even in cancer patients who attend outpatient clinics, their motor functions could be potentially impaired. Therapeutic interventions to maintain and enhance motor function for cancer patients could be useful for continuing cancer treatment, and furthermore, improving prognosis.

We performed a nationwide population-based cohort study to investigate sex differences in the rate of permanent pacemaker implantation after surgical aortic valve replacement (AVR).This study included all adult patients who underwent primary AVR in Sweden between 2005 and 2018. Study data were obtained from the Swedish Web system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART) registry and other Swedish national health-data registers. The rate of permanent pacemaker implantation within 30 days of surgery AVR was compared between men and women. We estimated propensity scores that were used for inverse probability of treatment weighting to account for sex differences in patient characteristics.A total of 18 131 patients were included, 11 657 men (64%) and 6474 women (36%). The rate of permanent pacemaker implantation did not differ between women (3.8%; 95% CI, 3.2%-4.3%) and men (3.7%; 95% CI, 3.3%-4.1%; P = .831). In patients aged60 years, the rate of permanent pacemaker implantation was significantly higher in women (6.2%; 95% CI, 4.3%-8.0%) than in men (3.6%; 95% CI, 2.8%-4.4%; P = .006). The odds of pacemaker implantation in patients aged60 years was significantly higher in women (odds ratio, 1.76; 95% CI, 1.17-2.63; P = .006). In patients aged 60 to 79 years and ≥80 years, the rate of pacemaker implantation did not differ between men and women.The rate of permanent pacemaker implantation after surgical AVR in patients aged60 years was higher in women than in men. The susceptibility to conduction disturbances requiring permanent pacemaker implantation in women aged60 years warrants further investigation and should be recognized as transcatheter aortic valve replacement expands into younger patients.

Summary Introduction Prehabilitation is defined as preoperative conditioning of patients in order to improve post-operative outcomes. Some studies showed an increase in functional recovery following colorectal surgery, but its effect in hepato-pancreato-biliary (HPB) surgery is unclear. The aim of this study was to realize a systematic literature review and meta-analysis on the current available evidence on prehabilitation in HPB surgery. Materials and methods A systematic review and a metanalysis were carried out on prehabilitation (physical, nutritional and psychological interventions) in HPB surgery (2009-2019). Assessed outcomes were postoperative complications, length of stay (LOS), 30-day readmission, and mortality. Main results Four studies among the 191 screened were included in this systematic review (3 randomized controlled trials, 1 case-control propensity score study), involving 419 patients (prehabilitation group, n = 139; control group, n = 280). After pooling, no difference was observed on LOS ((−4.37 days [95% CI: −8.86; 0.13]) or postoperative complications (RR 0.83 [95%CI: 0.62; 1.10]), reported by all the included studies. Two trials reported on readmission rate, but given the high heterogeneity, a meta-analysis was not realized. No deaths were reported among the included studies. Conclusion No effect of prehabilitation programs in HPB surgery was observed on LOS or postoperative complications rate. Future trials with standardized outcomes of measure, and adequately powered samples calculations are thus required. PROSPERO registration CRD42020165218.

The aim of this study was to evaluate the survival benefits of adjuvant chemotherapy in patients with positive lymph nodes after esophagectomy for esophageal squamous cell carcinoma.Patients who underwent esophagectomy for esophageal cancer in the Affiliated Cancer Hospital of Zhengzhou University (Henan Cancer Hospital) in Zhengzhou, China from 2013 to 2017 were selected for this retrospective cohort study. Patients with positive lymph nodes were grouped into the surgery alone group or the adjuvant chemotherapy group. Propensity score matching (1:1) was used to minimize baseline differences.Among the 5118 patients who underwent esophagectomy, 792 patients were enrolled in the study. After matching, 253 (of 476) patients (adjuvant chemotherapy group) and 253 (of 316) patients (surgery alone group) were included. The median overall survival was significantly prolonged in the adjuvant chemotherapy group (54.0 months; 95% CI, 41.1-66.9 months) compared with the surgery alone group (28.0 months; 95% CI, 22.4-33.6 months) (P.001). A significant difference was also observed in median disease-free survival between the 2 groups (adjuvant chemotherapy group, 33.0 months [95% CI, 20.8-45.2 months] compared with the surgery alone group, 22.0 months [95% CI, 17.0-27.0 months]; P = .007). In a multivariable analysis, receiving adjuvant chemotherapy (P.001) was significantly associated with a reduced risk of death, and dissection of more than 6 lymph node stations (P = .05) was marginally associated with a reduced risk of death.Postoperative adjuvant chemotherapy improves the overall survival and disease-free survival of patients with resected esophageal squamous cell carcinoma with positive lymph nodes.

We examined the safety and efficacy of del Nido cardioplegic solution compared with histidine-tryptophan-ketoglutarate cardioplegic solution in minimally invasive cardiac surgery.Patients who underwent minimally invasive cardiac surgery using del Nido or histidine-tryptophan-ketoglutarate from 2015 to 2019 were enrolled. Various clinical outcomes were compared between the groups. Postoperative laboratory findings including the levels of electrolytes, cardiac enzymes (creatine kinase-MB and troponin I), and serial blood lactate were also measured and compared. Based on 28 baseline covariates, propensity score matching was performed to reduce selection bias.Among 766 patients, del Nido and histidine-tryptophan-ketoglutarate were used in 330 patients (43.1%) and 436 patients (56.9%), respectively. There were no significant intergroup differences in postoperative clinical outcomes and early adverse outcomes among 228 pairs of propensity score-matched patients. Immediate postoperative sodium levels were within the normal range in both groups without a significant difference (P = .50). However, peak creatine kinase-MB (median, 31.9 vs 37.7 ng/mL, P = .026) and troponin I (6.9 vs 9.1 ng/mL, P = .014) levels were significantly lower in the del Nido group. Linear regression analysis revealed a significant association between the peak cardiac enzyme levels and the cardiac ischemic time depending on the cardioplegia type, with lower cardiac isoenzymes for del Nido over histidine-tryptophan-ketoglutarate (P .001) until the crossover point at the cardiac ischemic time over 100 minutes.In comparison with histidine-tryptophan-ketoglutarate solution, del Nido solution seems to have acceptable safety and efficacy with good myocardial protection in minimally invasive cardiac surgery. Further studies focusing on complex surgeries requiring longer cardiac ischemic time are needed.

Background The surgical strategy of lumbar degenerative spondylolisthesis (LDS) is controversial, especially regarding whether or not fusion should be used. Although some reports have indicated that decompression combined with fusion may be better than decompression alone in the treatment of LDS, the effect of fusion status after uninstrumented posterolateral lumbar fusion (PLF) on the outcomes of patients with stable LDS remains unknown. This study aimed to evaluate the surgical outcomes of uninstrumented PLF for stable LDS and clarify whether radiographic fusion status could affect surgical outcomes. Methods A total of 93 consecutive patients who had undergone single-level uninstrumented PLF for Meyerding grade I LDS without preoperative dynamic instability with a minimum follow-up period of 5 years were retrospectively studied. Patients were divided into two groups: nonunion (52 patients) and union (41 patients). The primary outcomes were the 5-year percent recovery of postoperative Japanese Orthopaedic Association (JOA) scores, Oswestry Disability Index (ODI), Visual analog scale (VAS) scores, and reoperation rate. The outcome scores were compared between the groups using the inverse probability weighting method using propensity scores. Results The union and nonunion groups had comparable weighted means of the 5-year postoperative clinical score for the percent recovery of the JOA score (70.2% vs. 71.1%, P = 0.86), ODI (14.5 vs.14.6, P = 0.98), VAS of low back pain (20.3 vs. 18.7 mm, P = 0.72), and VAS of leg pain (24.0 vs. 19.4 mm, P = 0.43). The reoperation rate was 2.4% (one case of adjacent segment pathology) in the union group and 0% in the nonunion group (P = 0.44). Conclusion The fusion status following uninstrumented PLF had no significant effect on the 5-year postoperative clinical outcomes and reoperation rate in patients with Meyerding grade I LDS without dynamic instability.

BACKGROUND: This study compared clinical and hemodynamic in-hospital outcomes of patients undergoing sutureless vs rapid deployment aortic valve replacement (SURD-AVR) in the large population of the Sutureless and Rapid Deployment International Registry (SURD-IR). METHODS: We examined 4695 patients who underwent isolated or combined SURD-AVR. The "sutureless" Perceval valve (LivaNova PLC, London, United Kingdom) was used in 3133 patients and the "rapid deployment" Intuity (Edwards Lifesciences, Irvine, CA) in 1562. Potential confounding factors were addressed by the use of propensity score matching. After matching, 2 well-balanced cohorts of 823 pairs (isolated SURD-AVR) and 467 pairs (combined SURD-AVR) were created. RESULTS: Patients who received Perceval and Intuity valves showed similar in-hospital mortality and rate of major postoperative complications. Perceval was associated shorter cross-clamp and cardiopulmonary bypass times. In the isolated SURD-AVR group, patients receiving Perceval were more likely to undergo anterior right thoracotomy incision. Postoperative transvalvular gradients were significantly lower for the Intuity valve compared with those of the Perceval valve, either in isolated and combined SURD-AVR. The Intuity valve was associated with a lower rate of postoperative mild aortic regurgitation. CONCLUSIONS: Our results confirm the safety and efficacy of SURD-AVR regardless of the valve type. The Perceval valve was associated with reduced operative times and increased anterior right thoracotomy incision. The Intuity valve showed superior hemodynamic outcomes and a lower incidence of postoperative mild aortic regurgitation. ispartof: ANNALS OF THORACIC SURGERY vol:114 issue:3 pages:758-+ ispartof: location:Netherlands status: published

This study aimed to investigate the oncologic outcomes of video-assisted thoracoscopic (VATS) left upper trisegmentectomy (LTS) vs left upper lobectomy (LUL) for patients presenting with stage I non-small cell lung cancer (NSCLC).A retrospective analysis identified 1543 consecutive patients presenting to Shanghai Pulmonary Hospital (Shanghai, China) with NSCLC for VATS LTS or LUL from 2013 to 2017. After propensity-score matching for patient demographics and tumor characteristics, 273 pairs were identified. Disease-free survival (DFS) and overall survival (OS) were estimated by the Kaplan-Meier method and compared using the log-rank test.The median follow-up time was 51.5 months. There were no significant differences in operative duration (2.11 ± 0.64 hours vs 2.49 ± 5.96 hours; P = .30), total blood loss (106.19 ± 170.83 mL vs 97.07 ± 149.34 mL; P = .51), and operative complications (10% vs 8%; P = .37) between the LUL and LTS groups. Patients undergoing LUL had longer postoperative hospital stays (5.55 ± 3.00 days vs 4.87 ± 2.33 days; P = .003), greater tumor margin distance (3.3 ± 1.2 cm vs 3.1 ± 0.9 cm; P.001), and greater number of lymph nodes harvested (8.0 ± 3.2 vs 6.8 ± 3.3; P.001) than patients undergoing LTS, but the margin-to-tumor ratio was not statistically different (2.5 ± 1.6 vs 2.3 ± 1.1; P = 0.11). Median DFS (49.5 months vs 54.3 months; P = .77) and OS (49.5 months vs 55.0 months; P = .88) were not significantly different between patients undergoing LTS and those undergoing LUL, and similar outcomes were noted across subgroups of patients stratified by tumor stage, pathologic type, and radiographic manifestations.VATS LTS and LUL had comparable oncologic outcomes for stage I NSCLC, regardless of tumor pathologic types and radiologic findings, as long as negative margins were confirmed.

BackgroundResection of colorectal liver metastasis (CLM) is beneficial when feasible. However, the benefit of second hepatectomy for hepatic recurrence in CLM remains unclear.MethodsThe Colorectal Liver Operative Metastasis International Collaborative retrospectively examined 1004 CLM cases from 2000 to 2018 from a total of 953 patients. Hepatic recurrence after initial hepatectomy was identified in 218 patients. Kaplan-Meier analysis was performed for overall survival (OS) and recurrence-free survival (RFS). Propensity score matching (PSM) was performed to offset selection bias. Cox proportional-hazards regression was performed to identify risk factors associated with OS.ResultsA total of 51 patients underwent second hepatectomy. Unadjusted median OS was 60.1 months in repeat-hepatectomy versus 38.3 months in the single-hepatectomy group (p = 0.015). In the PSM population, median OS remained significantly better in the repeat-hepatectomy group (60.1 vs. 33.1 months; p = 0.0023); median RFS was 12.4 months for the repeat-hepatectomy group, versus 9.8 months in the single-hepatectomy group (p = 0.0050). Repeat hepatectomy was associated with lower risk of death (hazard ratio: 0.283; p = 0.000012). Obesity, tobacco use, and high intraoperative blood loss were associated with significant risk of death (p

ObjectivesTo investigate the impact of a CT-first strategy on all-cause and cardiovascular mortality in patients presenting with chest pain in outpatient cardiology clinics.MethodsPatients with a first presentation of suspected angina pectoris were identified and their data linked to the registrations of Statistics Netherlands for information on mortality. The linked database consisted of 33 068 patients. CT-first patients were defined as patients with a CT calcium score and coronary CT angiography, within 6 weeks after their initial visit. Propensity score matching (1:5) was used to match patients with and without a CT-first strategy. After matching, 12 545 patients were included of which 2308 CT-first patients and 10 237 patients that underwent usual care.ResultsMean age was 57 years, 56.3% were women and median follow-up was 4.9 years. All-cause mortality was significantly lower in CT-first patients (n=43, 1.9%) compared with patients without CT (n=363, 3.5%) (HR: 0.51, 95% CI 0.37 to 0.70). Furthermore, CT-first patients were more likely to receive cardiovascular preventative and antianginal medication (aspirin: 44.9% vs 27.1%, statins: 48.7% vs 30.3%, beta-blockers: 37.8% vs 25.5%, in CT-first and without CT-first patients, respectively) and to undergo downstream diagnostics and interventions (coronary interventions: 8.5% vs 5.7%, coronary angiography: 16.2% vs 10.6% in CT-first and without CT-first patients, respectively).ConclusionsIn a real-world regular care database, a CT-first strategy in patients suspected of angina pectoris was associated with a lowering of all-cause mortality.

Introduction Outcomes after the introduction of surgical innovations can be impaired by learning periods. The aim of this study is to compare the short-term outcomes of a recently implemented RATS approach to a standard VATS program for anatomical lung resections. Methods Retrospective review of consecutive patients undergoing pulmonary anatomical resection through a minimally invasive approach since RATS approach was applied in our department (June 01, 2018, to November 30, 2019). Propensity score matching was performed according to patients’ age, gender, ppoFEV1, cardiac comorbidity, type of malignancy, and type of resection. Outcome evaluation includes: overall morbidity, significant complications (cardiac arrhythmia, pneumonia, prolonged air leak, and reoperation), 30-day mortality, and length of hospital stay. Data were compared by two-sided chi-square or Fisher's exact test for categorical and Mann–Whitney U test for continuous variables. Results A total of 273 patients (206 VATS, 67 RATS) were included in the study. After propensity score matching, data of 132 patients were analyzed. The thirty-days mortality was nil. Overall morbidity (RATS: 22.4%, VATS: 29.2%; p = 0.369), major complications (RATS: 9% vs VATS: 9.2%; p = 0.956) and the rates of specific major complications (cardiac arrhythmia RATS: 4.5%, VATS: 4.6%, p = 1; pneumonia RATS:0%, VATS:4.6%, p = 0.117; prolonged air leak RATS: 7.5%; VATS: 4.6%, p = 0.718) and reoperation (RATS: 3%, VATS: 1.5%, p = 1) were comparable between both groups. The median length of stay was 3 days in both groups (p = 0.101). Conclusions A RATS program for anatomical lung resection can be implemented safely by experienced VATS surgeons without increasing morbidity rates.

The purpose of the present study was to compare survival outcomes in propensity score-matched patients aged 70 years or greater receiving a bilateral internal thoracic artery graft with patients receiving a single internal thoracic artery graft.Among 4083 consecutive patients with isolated coronary artery bypass grafting who underwent operation between January 2001 and December 2018, we identified 1300 patients aged 70 years or greater; of these, 968 received a bilateral internal thoracic artery (bilateral internal thoracic artery group) and 332 received a single internal thoracic artery (single internal thoracic artery group). Propensity score matching was used to reduce the preoperative patient differences. The 10-year survival and postoperative complications were compared between the 2 groups.A Kaplan-Meier curve at 10 years of follow-up showed that crude survival was significantly superior in patients with bilateral internal thoracic artery grafts than in patients with single internal thoracic artery grafts (67.0% ± 2.5% vs 56.0% ± 3.4%, respectively; P .016). In the actuarial survival, estimates for propensity score-matched patients with a bilateral internal thoracic artery showed a significantly higher rates of survival than patients with a single internal thoracic artery by the end of follow-up (66.0% ± 5.3% vs 53.0% ± 3.9%, respectively; hazard ratio, 0.64; 95% confidence interval, 0.44-0.94; P = .022, univariable Cox Model and multivariable analysis hazard ratio, 0.66; 95% confidence interval, 0.45-0.97; P = .036 Cox model). Postoperative complications were all similar between the single internal thoracic artery and bilateral internal thoracic artery groups.The use of bilateral internal thoracic artery grafting in older patients improves 10-year survival, with similar postoperative morbidity. This surgical technique might have beneficial effects in survival in patients aged more than 70 years. Its use could be considered more frequently.

Background: In recent decades, laparoscopic liver resection (LLR) has been gradually adopted at high-volume centers, particularly for hepatocellular carcinoma and liver metastasis. However, LLR in patients with gallbladder cancer (GBC) is a controversial issue, and there are few studies of LLR for GBC. Our aim was to compare the outcomes of patients who underwent laparoscopic or open liver resection for GBC. Materials and Methods: All patients admitted with stage II or III GBC requiring liver resection, together with cholecystectomy and lymphadenectomy, were analyzed retrospectively. Patients with thickness of the resected liver specimen >2 cm in pathology reports were included. Results: A total of 56 patients with stage II or III GBC were included in this study; 23 (41.1%) underwent laparoscopic surgery and 33 (58.9%) underwent open surgery. Propensity score matching was performed using a 1:1 matching scheme. After matching, 12 patients were included in each group. The preoperative characteristics of both groups were similar, as were the operative times (laparoscopic versus open group: 237.5 minutes versus 272.5 minutes, respectively; P = .319) and blood loss (300 mL versus 275 mL, respectively; P = .307). The laparoscopic group had a significantly shorter postoperative hospital stay than the open surgery group (4.5 days versus 8 days, respectively; P = .012). There were no major complications in either group. There was no difference between the groups in the number of lymph nodes harvested at surgery (P = .910). There were no differences between the two groups in disease-free (P = .503) or overall (P = .719) survival. Conclusion: LLR extended to GBC provides outcomes similar to those of open surgery. With increasing experience, LLR can be a viable alternative to open surgery for GBC.

Purpose The usefulness of rehabilitation in patients with reduced lung function before lung surgery remains unclear, and there is no adequate method for evaluating the effect of rehabilitation. We aimed to evaluate the usefulness of rehabilitation in patients with non-small cell lung cancer (NSCLC) undergoing lung cancer surgery.Materials and Methods We retrospectively analyzed the medical records of NSCLC patients at Korea University Guro Hospital between 2018 and 2020. Patients were divided into two groups depending on whether they underwent rehabilitation. Pulmonary function test (PFT) data and muscle determined using chest computed tomography (CT) images were analyzed. Because the baseline characteristics were different between the two groups, propensity score matching was performed.Results Of 325 patients, 75 (23.1%) and 250 (76.9%) were included in the rehabilitation and non-rehabilitation (control) groups, respectively. The rehabilitation group had a worse general condition at baseline. After propensity score matching, 45 patients remained in each group. Pulmonary function (forced expiratory volume in 1 second, %) (p=0.001) and the Hounsfield unit of erector spinae muscle (p=0.001) were better preserved in the rehabilitation group. Muscle loss of 3.4% and 0.6% was observed in the control and rehabilitation groups, respectively (p=0.003). In addition, the incidence of embolic events was lower in the rehabilitation group (p=0.044).Conclusion Pulmonary rehabilitation is useful in patients with NSCLC undergoing lung surgery. Pulmonary rehabilitation preserves lung function, muscle and reduces embolic events after surgery. Pulmonary rehabilitation is recommended for patients with NSCLC undergoing surgery.

Background Differences in left ventricular mass regression (LVMR) between transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) have not been studied. We present clinical and echocardiographic data from veterans who underwent TAVR and SAVR, evaluating the degree of LVMR and its association with survival. Methods We retrospectively reviewed TAVR (n = 194) and SAVR (n = 365) procedures performed in veterans from 2011 to 2019. After 1:1 propensity matching, we evaluated mortality and secondary outcomes. Echocardiographic data (median follow-up 957 days, interquartile range 483-1652 days) were used to evaluate LVMR, its association with survival, and predictors of LVMR. Results There was no difference between SAVR and TAVR patients in mortality (for up to 8 years), stroke at 30 days, myocardial infarction, renal failure, prolonged ventilation, reoperation, or structural valve deterioration. SAVR patients (67.3% [101/150]) were more likely to have LVMR than TAVR patients (55.7% [44/79], p = 0.11). The magnitude of LVMR was greater for the SAVR patients (median = −23.3%) than for the TAVR patients (median = −17.8%, p = 0.062). SAVR patients with LVMR had a survival advantage over SAVR patients without LVMR (p = 0.016). However, LVMR was not associated with greater survival in TAVR patients (p = 0.248). Conclusions SAVR patients were more likely to have LVMR and had a greater magnitude of LVMR than TAVR patients. LVMR was associated with better survival in SAVR patients, but not in TAVR patients.

The role of local surgery in patients with metastatic soft tissue sarcoma (STS) remains unknown. The study aims to assess the clinical outcomes and impact of surgical resection on survival in patients with metastatic STS and elucidate the survival differences between synchronous and metachronous metastatic groups.Among the 272 patients with STS treated between 2000 and 2018, 84 with synchronous or metachronous metastasis were included. Associations between overall survival and primary tumor resection and metastasectomy were assessed using multivariate Cox regression analyses to adjust for baseline differences between surgically and non-surgically treated patients. Propensity score matching was applied to compare synchronous and metachronous metastasis.Among the 84 patients included, 69 (82%) and 41 (49%) underwent primary tumor resection and metastasectomy, respectively. The 2- and 5-year overall survivals of all patients after first detection of metastasis were 51.1% and 24.4%, respectively. Multivariate analysis showed that size8 cm, grade3, and number of metastases4 were associated with longer overall survival. After adjusting for baseline demographic and tumor characteristics, primary tumor resection and metastasectomy still had favorable effects on survival. Tumor subtypes, grade, and number of metastases differed significantly between synchronous and metachronous groups. However, after adjusting for these valuables, both groups exhibited comparable survival.Approximately one fourth of the patients with metastatic STS survived for5 years. Our results showed that surgical resection of primary tumors or metastatic lesions had favorable impact on survival even after adjusting for patient backgrounds, with comparable survival observed between those with synchronous and metachronous metastases.

We investigated patient outcomes in relation to their postoperative length of stay after minimally invasive valve surgery.All adults who survived elective, uncomplicated minimally invasive aortic or mitral valve surgery at a single center between 2012 and 2019 were classified by postoperative length of stay: early discharge (≤3 days) or late discharge (3 days). The trend in early discharge was investigated over the study period, predictors of early discharge were identified using multivariate logistic regression modeling, and 1:1 propensity score matching was used to determine which patients in the late-discharge cohort had similar health to patients discharged early. Adjusted outcomes of 30-day mortality, readmission, and direct costs were analyzed.Among 1262 consecutive patients undergoing minimally invasive valve surgery, 618 were elective and uncomplicated, 25% (n = 162) of whom were discharged early. The proportion of early-discharge patients increased over time (P for trend.05). A history of congestive heart failure, stroke, or smoking and higher Society of Thoracic Surgeons predictive risk of mortality score negatively predicted early discharge (P.05). Propensity score matching identified 101 (22%) late-discharge patients comparable with early-discharge patients. Adjusted 30-day mortality and readmission rates were comparable between cohorts. The median direct costs per patient ($20,046 vs $22,124, P.05) were significantly lower in the early-discharge cohort.In well-selected patients early discharge after minimally invasive valve surgery was associated with lower costs but comparable postoperative outcomes. About one-fifth of patients who remain in the hospital beyond postoperative day 3 may be candidates for earlier discharge.

Objectives To investigate the outcome of retzius-sparing robotic-assisted radical prostatectomy (RS-RARP) compared with conventional RARP in the early learning curve. Methods Consecutive patients with prostate cancer who underwent RS-RARP were included to compare against conventional RARP of the same period. Propensity-score matching was performed based on age, prostate size, nerve-sparing approach, and final pathological risk categories. All patients were re-admitted to undergo trial without Foley catheter from post-operative day 7-10. Clinical follow-up was performed with monitoring of continence (day 0, 3 months, and the latest continence during the study period) and surveillance of PSA level. Results Between July 2017 and August 2019, 24 consecutive patients received RS-RARP in our centre. Propensity score matching was performed with the best matched 24 controls receiving conventional RARP. Overall median follow-up duration was 15.5 months. A majority of the patients belonged to the intermediate-risk group, with most of them harbouring pT2 disease (RS-RARP: 87.5%; conventional RARP: 79.2%). More patients in RS-RARP group achieved day-0 continence (33.3% vs 0%, p = 0.002) and 3-month continence (66.7% vs 12.5%, p = 0.001). During the whole study period, more RS-RARP achieved continence with 0 pad (91.7% vs 66.7%, p = 0.033). The mean months to continence is shorter in RS-RARP group (4.0 months vs 13.6 months, p = 0.002). No statistically significant differences between the two groups with respect to surgical margins, post-operative PSA detection, and the use of adjuvant radiotherapy. Conclusions RS-RARP showed better continence rates when compared to conventional RARP even during the learning curve phase.

Aims Mismatches between the risk status of a patient and coronary imaging data can lead to conflicting strategies to prevent a cardiovascular event. We evaluated whether statin use was associated with cardiovascular benefit in high-risk individuals whose coronary computed tomography angiography (CCTA) results showed normal coronary arteries. Methods Among asymptomatic individuals whose CCTA showed normal or near normal coronary arteries, 3,389 persons with high- or very-high-risk status were included in this retrospective study. After 1:2 propensity score matching, 906 individuals (302 new statin users and 604 controls; mean age 61 years; male 58%) were analysed. The primary outcome variable was major adverse cardiovascular and cerebrovascular events (MACCEs) that consisted of cardiovascular death, nonfatal myocardial infarction, coronary revascularisation, and nonfatal ischemic stroke. Results At a median follow-up of 5.8 years, 20 statin users and 17 controls (7.4 and 5.6 events/1,000 person-year, respectively; hazard ratio [HR) 1.04; p=0.92) experienced MACCE. Kaplan-Meier curves showed similar MACCE rates in both groups (p=0.91). In separate analyses for persons with normal (p=0.29) or near normal coronary arteries (p=0.67), MACCE rates did not differ between the groups. Age (HR 1.04; p=0.044), male sex (HR 3.06, p=0.018), and smoking (HR 2.87, p=0.019) were independently associated with MACCEs. In subgroup analyses, no significant factors affected the relationship between statin use and MACCEs. Conclusions Statin use was not associated with cardiovascular risk reduction in high-risk persons with normal or near normal coronary arteries. More individualised lipid-lowering therapy may benefit this population.

BACKGROUND: In the STOP2 (Standardized Treatment of Pulmonary Exacerbations-2) study, intravenous (IV) antimicrobial treatment duration for adults with cystic fibrosis (CF) experiencing pulmonary exacerbations (PEx) was determined based on initial treatment response. The impact of home vs hospital care remains an important clinical question in CF. Our hypothesis was that STOP2 participants treated at home would have less improvement in lung function compared to those treated in the hospital. METHODS: Treating clinicians determined PEx treatment location, which was a stratification factor for STOP2 randomization. Lung function, weight, and symptom recovery were evaluated by treatment location. Propensity scores and inverse probability treatment weighting were used to test for differences in clinical response by treatment location. RESULTS: In all, 33% of STOP2 participants received IV antimicrobials in the hospital only, 46% both in the hospital and at home, and 21% at home only. Mean (95% CI) ppFEV(1) improvement was significantly (p

The futility of liver transplantation in elderly recipients remains under debate in the HCV eradication era.The aim was to assess the effect of older age on outcome after liver transplantation. We used the ELTR to study the relationship between recipient age and post-transplant outcome. Young and elderly recipients were compared using a PSM method.A total of 10,172 cases were analysed. Recipient age65 years was identified as an independent risk factor associated with reduced patient survival (HR:1.42 95%CI:1.23-1.65,p 0.001). After PSM, 2124 patients were matched, and the same association was found between elderly recipients and patient survival and graft survival (p 0.001). As hepatocellular carcinoma and alcoholic cirrhosis were independent prognostic factors for patient and graft survival a propensity score-matching was performed for each. Patient and graft survival were significantly worse (p 0.05) in the alcoholic cirrhosis elderly group. However, patient and graft survival in the hepatocellular carcinoma cohort were similar (p 0.05) between groups.Liver transplantation is an acceptable and safe curative option for elderly transplant candidates, with worse long-term outcomes compare to young candidates. The underlying liver disease for liver transplantation has a significant impact on the selection of elderly patients.

Background The optimal treatment strategy for resectable cervical esophageal cancer (CEC) remains controversial. This study aimed to explore prognostic factors and optimal treatment strategies in the context of staging. Methods In this population-based study, 1371 patients with resectable CEC were identified in the SEER database. Univariate analysis and multivariable Cox regression model were performed to evaluate factors related to overall survival (OS). Subgroup analysis based on staging was performed to assess the effect of treatments on survival and propensity score matching (PSM) was conducted to adjust confounding factors. Results Univariate and multivariable analyses revealed that age, sex, year of diagnosis, histological type, tumor size, cN stage, surgery, radiotherapy and chemotherapy are independent prognostic factors. After PSM, patients with local disease (cT1-2N0M0) who received surgery alone had a higher 10-year OS rate than those received chemoradiotherapy (CRT) (20.7% vs. 11.4%, p = 0.023). Compared with CRT, surgery-based multimodal therapy did not increase the OS rate of patients (14.8% vs. 11.1%, p = 0.084). For regional disease (cT3-4aN0M0/cT1-4aN1-3M0), although surgery alone did not improve the OS rate of patients compared with CRT (7.3% vs. 8.2%, p = 0.18), we observed a significant difference in 10-year OS among patients who underwent surgery-based multimodal therapy versus those who underwent CRT (20.4% vs. 9.0%, p = 0.031). Conclusions Compared with CRT, surgery alone improves the long-term survival of patients with localized disease, and surgery-based multimodal therapy increases the survival rate of patients with regional disease. Further studies are required to confirm our findings.

OBJECTIVES To determine the effect of recombinant human bone morphogenetic protein-2 (rhBMP-2) with hydroxyapatite (HA) carrier augmentation in managing critical-sized bone defect (CSBD) with induced membrane technique (IMT). DESIGN Retrospective comparative study. SETTING Academic level I trauma center.Patients/Participants: The study included 14 patients who underwent rhBMP-2 with HA carrier (rhBMP-2/HA) augmentation in IMT for managing CSBD (BMP group). Moreover, 14 patients who underwent IMT without rhBMP-2 augmentation were matched by propensity score analysis (non-BMP group). INTERVENTION IMT with or without rhBMP-2/HA augmentation. MAIN OUTCOME MEASUREMENT Changes in quality and quantity measurements of grafted bone to regenerated bone using serial computed tomography. RESULTS In the BMP and non-BMP groups, the changes in densities from grafted bone to regenerated bone were +379.63 Hounsfield unit (HU) and +248.55 HU (P = 0.034), changes in dense bone percentage were +37.52% and +23.31% (P = 0.027), corticalization rates under the plate were 79.70% and 39.30% (P = 0.007), changes in volume were -20.77% and -23.35% (P = 0.812), union rates were 85.71% and 78.57% (P = 0.622), numbers of patients requiring additional procedures were 4 and 3 (P = 0.663), and time to union were 316.3 and 585.45 days (P = 0.040), respectively. CONCLUSIONS RhBMP-2/HA augmentation increases the density of regenerated bone, enhances corticalization under the plate, and shortens the time to union while managing CSBD with IMT.