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Abstract Decompensated cirrhotic patients experience severely increased intestinal permeability and bacterial translocation. Thus, autologous blood salvaged during deceased donor liver transplantation (DDLT) may be contaminated with enteric bacteria. We aimed to evaluate bacterial contamination of autologous blood salvaged during DDLT and its association with post-transplant bacteremia. In 30 patients undergoing DDLT, bacterial culture was performed in salvaged autologous blood samples: one before graft reperfusion (non-leukoreduced) and two after graft reperfusion (non-leukoreduced and leukoreduced). The primary outcome was bacterial contamination of salvaged autologous blood. Seven of 30 patients (23.3%) were positive for bacteria (3 enteric/4 non-enteric) before graft reperfusion while 11 patients (36.7%) were positive (5 enteric/6 non-enteric) after graft reperfusion. Six of 7 patients who were positive for bacteria before graft reperfusion were positive after graft reperfusion with the same bacteria. Only 4 of 11 contaminated blood samples were converted to negative after leukoreduction. Post-transplant bacteremia risk was insignificantly greater in patients who received autologous blood with bacteria than in patients without bacteria (30.0% vs. 5.0%, P = 0.06). We found contamination of salvaged autologous blood with enteric bacteria throughout DDLT and incomplete performance of leukoreduction, indicating high bacterial load. The potential association between contaminated autotransfusion and post-transplant bacteremia warrants further validation in a larger prospective study. Clinical trial notation: This study was registered at the Clinical Research Information Service (CRiS; https://cris.nih.go.kr ; No. KCT0007223; principal registration investigator: Sangbin Han, date of registration: April 25, 2022).

Abstract We aimed to evaluate the association between inflammation-based prognostic markers and mortality after hip replacement. From March 2010 to June 2020, we identified 5,369 consecutive adult patients undergoing hip replacement with C-reactive protein (CRP), albumin, and complete blood count measured within six months before surgery. Receiver operating characteristic (ROC) curves were generated to evaluate predictabilities and estimate thresholds of CRP-to-albumin ratio (CAR), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR). Patients were divided according to threshold, and mortality risk was compared. The primary outcome was one-year mortality, and overall mortality was also analyzed. One-year mortality was 2.9%. Receiver operating characteristics analysis revealed areas under the curve of 0.838, 0.832, 0.701, and 0.732 for CAR, NLR, PLR, and modified Glasgow Prognostic Score, respectively. The estimated thresholds were 2.10, 3.16, and 11.77 for CAR, NLR, and PLR, respectively. According to the estimated threshold, high CAR and NLR were associated with higher one-year mortality after adjustment (1.0% vs. 11.7%; HR = 2.16; 95% CI 1.32–3.52; p = 0.002 for CAR and 0.8% vs. 9.6%; HR = 2.05; 95% CI 1.24–3.39; p = 0.01 for NLR), but PLR did not show a significant mortality increase (1.4% vs. 7.4%; HR = 1.12; 95% CI 0.77–1.63; p = 0.57). Our study demonstrated associations of preoperative levels of CAR and NLR with postoperative mortality in patients undergoing hip replacement. Our findings may be helpful in predicting mortality in patients undergoing hip replacement.

Objective To investigate the hepatic effects of high-dose intravenous (IV) iron, including those on liver function and the degree of fibrosis, in a rat model of cirrhosis. Methods We evenly allocated 25 Sprague–Dawley rats into five groups: normal rats (control group), cirrhotic rats receiving IV normal saline (liver cirrhosis [LC] group), and cirrhotic rats receiving 20, 40, or 80 mg/kg IV ferric carboxymaltose (LC-iron20, LC-iron40, and LC-iron80 group, respectively). Biochemical parameters were compared at 0, 7, 14, 21, and 28 days. The degrees of hepatic fibrosis and iron deposition were evaluated. Inflammatory and oxidative stress markers were also compared. Results There were no significant differences in the 28-day serum alanine aminotransferase levels among the LC-iron20, LC-iron40, and LC-iron80 groups (69 ± 7, 1003 ± 127, 1064 ± 309, 919 ± 346, and 820 ± 195 IU/L in the control, LC, LC-iron20, LC-iron40, and LC-iron80 groups, respectively). Hepatic iron accumulation increased in a dose-dependent manner, but the degree of hepatic fibrosis was comparable among the groups. The inflammatory and oxidative stress marker levels did not differ significantly according to the IV iron dose. Conclusions Administration of IV iron at various high doses appears safe in our rat model of cirrhosis.

Background:Citrus reticulata Blanco essential oil (CBEO) has attracted increasing attention as a potential treatment for depression and anxiety in recent years. However, there is limited evidence regarding the active compounds responsible for its therapeutic effects. In addition, substantial amounts of CBEO and prolonged therapy are often required. This study aims to investigate the rapid acting antidepressant and anxiolytic effects of CBEO, identify the underlying composition as well as optimize its dosage and duration.Methods:CBEO composition was determined using gas chromatography–mass spectrometry (GC–MS), and the corresponding targets were obtained from the SwissTargetPrediction database. Depression-related targets were collected from DisGeNET, GeneCards, Therapeutic Target Database, and Online Mendelian Inheritance in Man. Subsequently, the overlap between CBEO and depression targets was utilized to build a network diagram depicting the relationship between the active ingredients and targets using Cytoscape software. The STRING database facilitated the construction of a protein–protein interaction network, and the Ma’ayan Laboratory Enrichment tool was employed for Gene Ontology (GO) enrichment, Kyoto Encyclopedia of Genes and Genomes (KEGG), and Wiki pathway analyses. Molecular docking was conducted using AutoDock Vina and Discovery Studio Visualizer. Topological analysis predicted the main antidepressant active ingredients in CBEO. A mixture of these compounds was prepared based on their relative GC–MS ratios. Tail suspension test, elevated plus maze, corticosterone-induced PC12 cells, and lipopolysaccharide (LPS)-induced BV2 cells were used to validate the antidepressant and anxiolytic potential of CBEO and CBEO’s main bioactive constituents.Results:CBEO contains 18 components that target 121 proteins. We identified 595 targets associated with depression; among them, 29 targets were located between essential oils and depression. Topological results revealed that linalool, p-cymene, α-terpinene, terpinen-4-ol, and α-terpineol were the major active compounds of CBEO in the management of depression. GO analysis identified G protein-coupled opioid receptor activity, phospholipase C-activating G protein-coupled receptor, and neuron projections that were mostly related to molecular functions, cellular components, and biological processes. Neuroactive ligand-receptor interactions, chemical carcinogenesis, and calcium signaling pathways were the major pathways identified in KEGG analysis. Molecular docking showed that the main bioactive ingredients of CBEO had favorable binding affinities for Protein-Protein Interaction’s hub proteins, including OPRM1, PTGS2, ESR1, SLC6A4, DRD2, and NR3C1. These five compounds were then mixed at 0.8:5:0.6:2:1 (w/w) ratio to form a CBEO antidepressant active compound mixture. An acute intranasal treatment of CBEO (25 mg/kg) only demonstrated an antidepressant effect, whereas the main bioactive compounds combination (12.5 mg/kg) illustrated both antidepressant and anxiolytic effects in mice. Linalool, p-cymene, and terpinene-4-ol exhibited neuroprotective and anti-neuroinflammation in the in vitro study, while these effects were not observed for α-terpinene and α-terpineol.Conclusion:Linalool, p-cymene, α-terpinene, terpinen-4-ol, and α-terpineol cymene might be mainly contributing to CBEO’s antidepressant effect by regulating neuroactive ligand-receptor interaction, neuron projection, and receptor signaling pathway. A mixture of these compounds showed rapid antidepressant potential via intranasal administration, which was comparable to that of CBEO. The mixture also exhibited an anxiolytic effect while not seen in CBEO.

BackgroundWe sought to investigate the prognostic value of preoperative C-reactive protein (CRP)-to-albumin ratio (CAR) for the prediction of mortality in patients undergoing off-pump coronary artery bypass grafting (OPCAB).MethodsFrom January 2010 to August 2016, adult patients undergoing OPCAB were analyzed retrospectively. In a total of 2,082 patients, preoperative inflammatory markers including CAR, CRP, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio were recorded. Receiver operating characteristic (ROC) curves were used to determine the optimal threshold and compare the predictive values of the markers. The patients were divided into two groups according to the cut-off value of CAR, and then the outcomes were compared. The primary end point was 1-year mortality.ResultsDuring the 1-year follow-up period, 25 patients (1.2%) died after OPCAB. The area under the curve of CAR for 1-year mortality was 0.767, which was significantly higher than other inflammatory markers. According to the calculated cut-off value of 1.326, the patients were divided into two groups: 1,580 (75.9%) patients were placed in the low CAR group vs. 502 (24.1%) patients in the high CAR group. After adjustment with inverse probability weighting, high CAR was significantly associated with increased risk of 1-year mortality after OPCAB (Hazard ratio, 5.01; 95% Confidence interval, 2.01–12.50; p

Abstract Background Compared with open surgery, laparoscopic liver resection is a minimally invasive surgical technique. However, a number of patients experience moderate-to-severe postoperative pain after laparoscopic liver resection. This study aims to compare the postoperative analgesic effects of erector spinae plane block (ESPB) and quadratus lumborum block (QLB) in patients undergoing laparoscopic liver resection. Methods One hundred and fourteen patients undergoing laparoscopic liver resection will be randomly allocated to three groups (control, ESPB, or QLB) in a 1:1:1 ratio. In the control group, participants will receive systemic analgesia consisting of regular NSAIDs and fentanyl-based patient-controlled analgesia (PCA) according to the institutional postoperative analgesia protocol. In the two experimental groups (ESPB or QLB group), the participants will receive preoperative bilateral ESPB or bilateral QLB in addition to systemic analgesia according to the institutional protocol. ESPB will be performed at the 8th thoracic vertebra level with ultrasound guidance before surgery. QLB will be performed in the supine position on the posterior plane of the quadratus lumborum with ultrasound guidance before surgery. The primary outcome is cumulative opioid consumption 24 h after surgery. Secondary outcomes are cumulative opioid consumption, pain severity, opioid-related adverse events, and block-related adverse events at predetermined time points (24, 48, and 72 h after surgery). Differences in plasma ropivacaine concentrations in the ESPB and QLB groups would be investigated, and the quality of postoperative recovery among the groups will be compared. Discussion This study will reveal the usefulness of ESPB and QLB in terms of postoperative analgesic efficacy and safety in patients undergoing laparoscopic liver resection. Additionally, the study results will provide information on the analgesic superiority of ESPB versus QLB in the same population. Trial registration Prospectively registered with the Clinical Research Information Service on August 3, 2022; KCT0007599.

Abstract 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

Backgrounds Myocardial injury after non-cardiac surgery (MINS) has recently been accepted as a common complication associated with increased mortality. However, little is known about the treatment of MINS. The aim of this study was to investigate an association between antiplatelet therapy and long-term mortality after MINS.Methods From 2010 to 2019, patients with MINS, defined as having a peak high-sensitivity troponin I higher than 40 ng/L within 30 days after non-cardiac surgery, were screened at a tertiary centre. Patients were excluded if they had a history of coronary revascularisation before or during index hospitalisation. Clinical outcomes at 1 year were compared between patients with and without antiplatelet therapy at hospital discharge. The primary outcome was death, and the secondary outcome was major bleeding.Results Of the 3818 eligible patients with MINS, 940 (24.6%) received antiplatelet therapy at hospital discharge. Patients with antiplatelet therapy had a significantly lower mortality at 1 year than those without antiplatelet therapy (7.5% vs 15.9%, adjusted HR 0.60, 95% CI 0.45 to 0.79, p

Abstract Days alive and out of hospital (DAOH) is a simple estimator based on the number of days not in hospital within a defined period. In cases of mortality within the period, DAOH is regarded as zero. It has not been validated solely in off-pump coronary artery bypass grafting (OPCAB). This study aimed to demonstrate a correlation between DAOH and outcome of OPCAB. We identified 2211 OPCAB performed from January 2010 to August 2016. We calculated DAOH at 30 and 60 days. We generated a receiver-operating curve and compared outcomes. The median duration of hospital stay after OPCAB was 6 days. The median DAOH values at 30 and 60 days were 24 and 54 days. The estimated thresholds for 3-year mortality for DAOH at 30 and 60 days were 20 and 50 days. Three-year mortality was higher for short DAOH (1.2% vs. 5.7% and 1.1% vs. 5.6% DAOH at 30 and 60 days). After adjustment, the short DAOH 30 group showed significantly higher mortality during 3-year follow-up (hazard ratio 3.07; 95% confidence interval 1.45–6.52; p = 0.004). DAOH at 30 days after OPCAB showed a correlation with 3-year outcomes. DAOH 30 might be a reliable long-term outcome measure that can be obtained within 30 days after surgery.

Abstract Increased vasoactive-inotropic score (VIS) is a reliable predictor of mortality and morbidity after cardiac surgery. Here, we retrospectively evaluated the association between VIS and adverse outcomes in adult patients after off-pump coronary artery bypass grafting (OPCAB). We included 2149 patients who underwent OPCAB. The maximal VIS was calculated for the initial 48 postoperative hours using standard formulae. The primary outcome was 1-year death. The composite adverse outcome was death, resuscitation or mechanical support, myocardial infarction, revascularization, new-onset atrial fibrillation, infection requiring antibacterial therapy, acute kidney injury, and stroke. Path-analysis was conducted using lactate and prognostic nutritional index (PNI). VIS was associated with 1-year death (odds ratio [OR] 1.07 [1.04–1.10], p

Background: Postoperative atrial fibrillation (POAF) is a common complication that has shown conflicting results regarding sex differences. The potential effect of age on this association has not been adequately explored. We hypothesized that younger males would have a higher risk of POAF than females and that this difference would vary by age group. Methods: In this observational cohort study, we enrolled consecutive patients who underwent non-cardiac surgery between January 2011 and June 2019 at our institution and excluded those with preoperative atrial fibrillation and those undergoing sex-specific surgery. We stratified the patients into four groups based on their sex and age: females younger than 50 years, females older than 50 years, males younger than 50 years, and males older than 50 years. The primary outcome was the incidence of POAF. Results: Of the 141,337 patients included in the study, 6414 (4.5%) were treated for POAF. The incidence of POAF was highest in males older than 50 years (7.4%), followed by females older than 50 years (4.6%), males younger than 50 years (2.1%), and females younger than 50 years (1.9%). After adjusting for potential confounding factors, the risk of POAF was significantly increased in all groups compared with females younger than 50 years, with an odds ratio (OR) of 2.43 (95% confidence interval [CI]: 2.17–2.73, p < 0.001) for females older than 50 years, 1.19 (95% CI: 1.05–1.35, p = 0.01) for males younger than 50 years, and 4.39 (95% CI: 3.91–4.94, p < 0.001) for males older than 50 years. The OR for POAF risk according to sex peaked between 60 and 70 years old and decreased gradually thereafter. Conclusions: Our study suggests that sex and age are important factors associated with the risk of POAF in non-cardiac surgery patients and that sex-specific and age-specific risk stratification and interventions might be needed to prevent and manage POAF in non-cardiac surgery patients. Further studies are needed to better understand the underlying mechanisms of sex and age differences in POAF and to develop more targeted and effective interventions to reduce the incidence of this common postoperative complication.

Many studies have reported that hypoalbuminemia could be associated with organ failure after liver transplantation. However, most of them focused on serum albumin levels measured at specific time points and not on the trend of serum albumin change. We investigated whether a cumulative postoperative change in serum albumin level up to postoperative day (POD) 5 is related to organ failure in patients who underwent living-donor liver transplantation (LDLT). Data of adult recipients who underwent LDLT between January 2016 and December 2020 at a single tertiary hospital were reviewed (n = 399). After screening, three patients were excluded because of insufficient data. A cumulative change in serum albumin level was demonstrated using the area under the threshold (AUT, threshold = 3.0 g/dL) of the serum albumin curve up to POD 5. Based on the AUT, the patients were divided into a high-decrease group (n = 156) and a low-decrease group (n = 240). All analyses were conducted using 1:1 propensity score matching. The primary endpoint was the Sequential Organ Failure Assessment (SOFA) score on POD 5. The secondary endpoints were postoperative hospital stay and postoperative 90-day mortality. A total of 162 patients were included. The SOFA score on POD 5 was significantly higher in the High-decrease group compared with the Low-decrease group (5.2 ± 2.6 vs. 4.1 ± 2.3; mean difference: 1.1, 95% CI: 0.3 to 1.8; P = 0.005). However, the length of postoperative hospital stay (P = 0.661) and 90-day mortality (P = 0.497) did not differ between the groups. In conclusion, a cumulative postoperative change in serum albumin level up to POD 5 could help predict postoperative organ failure on POD 5 in patients who underwent LDLT.

Background The clinical efficacy of preoperative 2D-echocardiographic assessment of pulmonary arterial pressure (PAP) has not been evaluated fully in liver transplantation (LT) recipients. Methods From October 2010 to February 2017, a total of 344 LT recipients who underwent preoperative 2D-echocardiography and intraoperative right heart catheterization (RHC) was enrolled and stratified according to etiology, disease progression, and clinical setting. The correlation of right ventricular systolic pressure (RVSP) on preoperative 2D-echocardiography with mean and systolic PAP on intraoperative RHC was evaluated, and the predictive value of RVSP > 50 mmHg to identify mean PAP > 35 mmHg was estimated. Results In the overall population, significant but weak correlations were observed (R = 0.27; P < 0.001 for systolic PAP, R = 0.24; P < 0.001 for mean PAP). The positive and negative predictive values of RVSP > 50 mmHg identifying mean PAP > 35 mmHg were 37.5% and 49.9%, respectively. In the subgroup analyses, correlations were not significant in recipients of deceased donor type LT (R = 0.129; P = 0.224 for systolic PAP, R = 0.163; P = 0.126 for mean PAP) or in recipients with poorly controlled ascites (R = 0.215; P = 0.072 for systolic PAP, R = 0.21; P = 0.079 for mean PAP). Conclusion In LT recipients, the correlation between RVSP on preoperative 2D-echocardiography and PAP on intraoperative RHC was weak; thus, preoperative 2D-echocardiography might not be the optimal tool for predicting intraoperative PAP. In LT candidates at risk of pulmonary hypertension, RHC should be considered.

Background Awake craniotomy is a well-tolerated procedure for the resection of brain tumors residing within or close to the eloquent cortical areas. Monitored anesthesia care (MAC) is a dominant anesthetic approach for awake craniotomy; however, it is associated with inherent challenges such as desaturation and hypercapnia, which may lead to various complications. The prevention of respiratory insufficiency is important for successful awake craniotomy. As measures to avoid respiratory depression, the use of high-flow nasal cannula (HFNC) can improve patient oxygenation and monitoring the oxygen reserve index (ORi) can detect hypoxia earlier. Case We report two cases of awake craniotomy with MAC using HFNC and ORi. We adjusted the fraction of inspired oxygen of the HFNC according to the ORi level. The patient underwent successful awake craniotomy without a desaturation event or additional airway intervention. Conclusions Combined HFNC and ORi monitoring may provide adequate oxygen reserves in patients undergoing awake craniotomy.

Abstract Myocardial injury after non-cardiac surgery (MINS) is a well-known and relevant indicator of early postoperative mortality, but factors related to increased mortality in MINS patients are as yet unknown. The Charlson Comorbidity Index (CCI) is widely used to classify various comorbid conditions and underlying diseases. Our study aimed to determine the prognostic value of CCI with regard to mortality of patients with MINS. This study comprises 5633 patients who had MINS as diagnosed by a rise of postoperative cardiac troponin I above the normal range (≥ 0.04 ng/mL) from January 2010 to June 2019. Patients were divided into two groups according to median weighted CCI score: low CCI (≤ 2) and high CCI (> 2) groups. The primary outcome was 30-day mortality after surgery, and secondary outcomes were 1-year and overall mortalities. Of the 5633 patients, 3428 (60.9%) were in the low CCI group (1.21 ± 0.84) and 2205 (39.1%) were in the high CCI group (4.17 ± 1.82). After propensity score matching, mortality during the first 30 days after surgery was significantly greater in the high CCI group than the low CCI group (9.4% vs. 6.0%, respectively; hazard ratio 1.56, 95% confidence interval 1.23–1.98, p

We aimed to evaluate the association between days alive and out of hospital (DAOH) and mortality at 15 days after a hip replacement. From March 2010 to June 2020, we identified 5369 consecutive adult patients undergoing hip replacements and estimated DAOH at 15, 30, 60, and 90 days after surgery. After excluding 13 patients who died within 15 days after surgery, receiver operating characteristic (ROC) curves were then generated to evaluate predictabilities for each follow-up period. We compared the mortality risk according to the estimated thresholds of DAOH at 15 days after hip replacement. ROC analysis revealed areas under the curve of 0.862, 0.877, 0.906, and 0.922 for DAOH at 15, 30, 60, and 90 days after surgery, respectively. The estimated threshold of DAOH during the 15 postoperative days was 6.5. Patients were divided according to this threshold, and propensity score matching was conducted. In a propensity score-matched population with 864 patients in each group, the risk of mortality increased in patients with a lower DAOH 15 (2.8% vs. 8.1%; hazard ratio [HR] = 3.96; 95% confidence interval [CI]: 2.24–6.99; p < 0.001 for one-year mortality, 5.2% vs. 13.0%; HR = 3.82; 95% CI: 2.33–6.28; p < 0.001 for three-year mortality, and 5.9% vs. 15.6%; HR = 3.07; 95% CI: 2.04–4.61; p < 0.001 for five-year mortality). In patients undergoing a hip replacement, DAOH at 15 days after surgery was shown to be associated with increased mortality. DAOH at 15 days may be used as a valid outcome measure for hip replacement.

Background Fontan-associated liver disease (FALD) is a hepatic disorder caused by hemodynamic changes and systemic venous congestion following the Fontan procedure. FALD includes liver cirrhosis and hepatocellular carcinoma (HCC), both of which may require liver transplantation (LT). However, the Fontan circulation, characterized by elevated central venous pressure and reduced cardiac output, is a challenging issue for surgeons and anesthesiologists. Case We report a living-donor LT for the treatment of HCC. The patient was a 24-year-old male who underwent the Fontan procedure for pulmonary atresia and right ventricle hypoplasia. We focused on maintaining enough blood volume for cardiac output without causing pulmonary edema, as the patient is not well adapted to changes in volume. Owing to a multidisciplinary approach, the surgery was successfully performed without fatal adverse events. Conclusions To our knowledge, this is the first case of isolated LT in a recipient who became an adult after having undergone the Fontan procedure.

Objective: To investigate the effect of Orostachys (O.) japonicus, a perennial herbaceous plant of the Family Crassulaceae, on biofilm formed by methicillin-resistant Staphylococcus aureus (MRSA). Methods: Powdered O. japonicus was extracted by 95% methanol, concentrated, and then, systematically fractionated with n-hexane, dichloromethane (DCM), ethyl acetate (EtOAc), n-butanol, and H2O according to polarity. Among them, the flavonoid-rich EtOAc fraction demonstrated the highest antibacterial activity and was used in this study. Using the biofilm inhibition assay, cell-surface attachment assay, confocal laser scanning microscopy, latex agglutination assay, and real time qRT-PCR, we examined whether the EtOAc fraction inhibited the formation of MRSA biofilm. Results: The EtOAc fraction exhibited distinct activity against biofilm formation and cell-surface attachment of MRSA up to 1 mg/mL through down-regulating the expression of mecA gene and the production and agglutination of penicillin-binding protein 2a as solidly observed in biofilm inhibition assay, cell-suface attachment assay, confocal laser scanning microscopy, latex agglutination assay, and real time qRT-PCR analysis. Conclusions: These results suggest that O. japonicus could be utilized as a potential resource for the development of new anti-biofilm formation of MRSA and antibacterial agents in the future.

Background Perioperative blood glucose level has shown an association with postoperative outcomes. We compared the incidences of myocardial injury after noncardiac surgery (MINS) and 30‐day mortality, according to preoperative blood glucose and hemoglobin A1c (HbA1c) levels. Methods and Results The patients were divided according to blood glucose level within 1 day before surgery. The hyperglycemia group was defined with fasting glucose >140 mg/dL or random glucose >180 mg/dL. In addition, we compared the outcomes according to HbA1c >6.5% among patients with available HbA1c within 3 months before surgery. The primary outcome was MINS, and 30‐day mortality was also compared. A total of 12 304 patients were enrolled and divided into 2 groups: 8324 (67.7%) in the normal group and 3980 (32.3%) in the hyperglycemia group. After adjustment with inverse probability of weighting, the hyperglycemia group exhibited significantly higher incidences of MINS and 30‐day mortality (18.7% versus 27.6%; odds ratio, 1.29; 95% CI, 1.18–1.42; P

BackgroundThis study aimed to evaluate the association between intraoperative blood loss and myocardial injury after non-cardiac surgery (MINS), which is a severe and common postoperative complication.MethodsWe compared the incidence of MINS based on significant intraoperative bleeding, defined as an absolute hemoglobin level < 7 g/dL, a relative hemoglobin level less than 50% of the preoperative measurement, or need for packed red cell transfusion. We also estimated a threshold for intraoperative hemoglobin level associated with MINS.ResultsWe stratified a total of 15,926 non-cardiac surgical patients with intraoperative hemoglobin and postoperative cardiac troponin (cTn) measurements according to the occurrence of significant intraoperative bleeding; 13,416 (84.2%) had no significant bleeding while 2,510 (15.8%) did have significant bleeding. After an adjustment with inverse probability weighting, the incidence of MINS was higher in the significant bleeding group (35.2% vs. 16.4%; odds ratio, 1.58; 95% confidence interval, 1.43-1.75; p < 0.001). The threshold of intraoperative hemoglobin associated with MINS was estimated to be 9.9 g/dL with an area under the curve of 0.643.ConclusionIntraoperative blood loss appeared to be associated with MINS. Further studies are needed to confirm these findings.Clinical registrationThe cohort was registered before patient enrollment at https://cris.nih.go.kr (KCT0004244).

PURPOSE:Perioperative myocardial injury is a predictor of postoperative mortality, but the clinical impact of chronic injury during the perioperative period has not been fully investigated. This study aimed to evaluate chronic myocardial injury during the perioperative period in comparison with normal and acute myocardial injury. METHODS:Patients with serial cardiac troponin measurements before and within 30 days following noncardiac surgery were divided into three groups: normal, acute injury, and chronic injury groups. Acute and chronic myocardial injuries were stratified according to 2018 recommendations by the International Federation of Clinical Chemistry and Laboratory Medicine's Task Force on Clinical Applications of Bio-Markers. Thirty-day and one-year mortalities after surgery were compared. RESULTS:Of the 22,969 patients reviewed, 17,671 (76.9%) were classified into the normal, 5,179 (22.5%) into the acute injury, and 119 (0.5%) into the chronic injury groups. The acute and chronic injury groups had higher 30-day mortalities compared with the normal group (0.8% vs. 8.0%; hazard ratio [HR], 11.00; 95% confidence interval [CI], 9.05-13.37; P < 0.001 and 0.8% vs. 7.6%; HR, 10.55; 95% CI, 5.37-20.72; P < 0.001, respectively). In a direct comparison between the acute and chronic injury groups using an inverse probability of weighting adjustments, the 30-day and one-year mortalities were not significantly different. CONCLUSION:Chronic myocardial injury during the perioperative period may show similar clinical impacts on postoperative mortality compared with acute injury. Further studies are needed.

We evaluated whether volatile anesthetics can improve the postoperative outcomes of non-cardiac surgery in patients with preoperative myocardial injury defined by the cardiac troponin elevation. From January 2010 to June 2018, 1254 adult patients with preoperative myocardial injury underwent non-cardiac surgery under general anesthesia and were enrolled in this study. Patients were stratified into following two groups according to anesthetic agents; 115 (9.2%) patients whose anesthesia was induced and maintained with continuous infusion of propofol and remifentanil (TIVA group) and 1139 (90.8%) patients whose anesthesia was maintainted with volatile anesthetics (VOLATILE group). The primary outcome was 30-day mortality. To diminish the remifentanil effect, a further analysis was conducted after excluding the patients who received only volatile anesthetics without remifentanil infusion. In a propensity-score matched analysis, 30-day mortality was higher in the TIVA group than the VOLATILE group (17.0% vs. 9.1%; hazard ratio [HR] 2.60; 95% confidence interval [CI], 1.14-5.93; p = 0.02). In addition, the TIVA group showed higher 30-day mortality than the VOLATILE group, even after eliminating the effect of remifentanil infusion (15.8% vs. 8.3%; HR 4.62; 95% CI, 1.82-11.74; p = 0.001). In our study, the use of volatile anesthetics showed the significant survival improvement after non-cardiac surgery in patients with preoperative myocardial injury, which appears to be irrelevant to the remifentanil use. Further studies are needed to confirm this beneficial effect of volatile anesthetics. Clinical trial number and registry URL: KCT0004349 (www.cris.nih.go.kr).

Objective: To investigate the anti-colon cancer effects of ethylacetate fraction from Orostachys japonicus (O. japonicus) on HT-29 cancer cells. Methods: The viability of HT-29 cells was assayed by the 3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium (MTS) method. Apoptosis induction and cell cycle inhibition were confirmed by fluorescein isothiocyanate and propidium iodide staining using flow cytometry. Morphological changes in the nucleus were observed, using a fluorescence microscope with 4′,6-diamidino-2-phenylindole (DAPI) nuclear staining. The expression levels of the upstream and downstream proteins involved in the anti-cancer mechanism were confirmed by Western blotting. Results: After treating HT-29 cells with different concentrations of ethylacetate fraction from O. japonicus, the viability of cells decreased in a concentration-dependent manner, while apoptosis induction and apoptotic body formation increased. Cell cycle analysis showed that the arrest occurred at the sub-G1 and S phase. Among the upstream and downstream proteins involved in anti-cancer activity, the level of B cell lymphoma-2 decreased, and the bcl-2-associated x protein increased. The level of pro-caspase-3, pro-caspase-8, and pro-caspase-9 decreased, while the level of cleaved-caspase-3, cleaved-caspase-8, and cleaved-caspase-9 increased. Moreover, the phosphorylation, that is, activation of extracellular signal regulated kinase 1/2, Jun-N-terminal kinase, and p38 increased. Conclusions: Combining the above results, it is thought that the survival of HT-29 cells is suppressed by ethylacetate fraction from O. japonicus through mitochondrial regulation-induced caspase cascade activation, induction of apoptosis and cell cycle arrest.

The incidence of hyperkalemia (>5.5 mEq/L) or high blood potassium (5–5.5 mEq/L) during living-donor liver transplantation (LDLT) is reported to be more than 10%. It occurs more frequently in the early post-reperfusion period and is a major cause of post-reperfusion arrhythmia and cardiac arrest. Unlike deceased-donor liver transplantation, the pattern of blood potassium changes immediately after reperfusion has not been described in LDLT. From January 2021 to March 2021, fifteen consecutive patients were enrolled. Baseline blood potassium was measured from blood samples obtained 10-min (T-10) and immediately before (T0) reperfusion. During the first 5 min after reperfusion, blood potassium measurements were conducted every one minute (T1–T5). The blood potassium levels at T-10 and T0 were 3.8 ± 0.4 and 3.9 ± 0.4 mEq/L, respectively. After reperfusion, mean increases (95% CI) in blood potassium from T-10 and T0 were 0.5 (0.4–0.6) and 0.4 (0.3–0.5) mEq/L, respectively. Blood potassium peaked at T1, returned to baseline at T3, and fell below the baseline at T5. Peak blood potassium after reperfusion showed strong correlations with blood potassium measured at T-10 (p < 0.001) and T0 (p < 0.0001). These findings can support the establishment of future research plans and perioperative management of blood potassium in LDLT.

Background: Oxygen demand–supply mismatch is supposed to be one of the major causes of myocardial injuries after noncardiac surgery (MINS). Impaired tissue oxygenation during the surgery can lead to intraoperative hyperlactatemia. Therefore, we aimed to evaluate the relationship between intraoperative lactate level and MINS. Methods: A total of 1905 patients divided into groups according to intraoperative hyperlactatemia: 1444 patients (75.8%) into normal (≤2.2 mmol/L) and 461 patients (24.2%) into hyperlactatemia (>2.2 mmol/L) groups. The primary outcome was the incidence of MINS, and all-cause mortality within 30 days was compared. Results: In the crude population, the risks for MINS and 30-day mortality were higher for the hyperlactatemia group than the normal group (17.7% vs. 37.7%, odds ratio [OR]: 2.83, 95% confidence interval [CI]: 2.24–3.56, p < 0.001 and 0.8% vs. 4.8%, hazard ratio [HR]: 5.86, 95% CI: 2.9–12.84, p < 0.001, respectively). In 365 propensity score-matched pairs, intraoperative hyperlactatemia was consistently associated with MINS and 30-day mortality (21.6% vs. 31.8%, OR: 1.69, 95% CI: 1.21–1.36, p = 0.002 and 1.1% vs. 3.8%, HR: 3.55, 95% CI: 1.71–10.79, p < 0.03, respectively). Conclusion: Intraoperative lactate elevation was associated with a higher incidence of MINS and 30-day mortality.

During emergence from general anesthesia, coughing caused by the endotracheal tube frequently occurs and is associated with various adverse complications. In patients undergoing endovascular neurointervention, achieving smooth emergence from general anesthesia without coughing is emphasized since coughing is associated with intracranial hypertension. Therefore, the up-and-down method was introduced to determine the effective effect-site concentration (Ce) of remifentanil to prevent coughing in 50% and 95% (EC50 and EC95) of patients during emergence from sevoflurane anesthesia for endovascular neurointervention. A total of 43 participants, American Society of Anesthesiologists class I or II participants, aged from 20 to 70 years who were undergoing endovascular neurointervention through transfemoral catheter for cerebrovascular disease were enrolled. Using the up-and-down method with isotonic regression, the EC50 and EC95 of remifentanil to prevent coughing during emergence from sevoflurane anesthesia were determined. We also investigated differences of hemodynamic and recovery profiles between the cough suppression group and the cough group. In total, 38 of 43 patients were included for estimation of EC50 and EC95. The EC50 and EC95 of remifentanil to prevent coughing were 1.42 ng/mL (95% confidence interval [CI], 1.28-1.56 ng/mL) and 1.70 ng/mL (95% CI, 1.67-2.60 ng/mL), respectively. There was comparable emergence and recovery data between the cough suppression group (n = 22) and the cough group (n = 16). However, the Ce of remifentanil and total dose of remifentanil were significantly higher in the cough suppression group (P = 0.002 and P = 0.004, respectively). Target-controlled infusion of remifentanil at 1.70 ng/mL could effectively prevent extubation-related coughing in 95% of neurointervention patients, which could ensure smooth emergence.

During laparoscopic surgery, carbon dioxide (CO2) pneumothorax can develop due to a congenital defect in the diaphragm. We present a case of a spontaneous massive left-sided pneumothorax that occurred during laparoscopy-assisted gastrectomy, because of an escape of intraperitoneal CO2 gas, under pressure, into the pleural cavity through a congenital defect in the esophageal hiatus of the left diaphragm. This was confirmed on intraoperative chest radiography and laparoscopic inspection. This CO2 pneumothorax caused tolerable hemodynamic and respiratory consequences, and was rapidly reversible after release of the pneumoperitoneum. Thus, a conservative approach was adopted, and the remainder of the surgery was completed, laparoscopically. Due to the high solubility of CO2 gas and the extra-pulmonary mechanism, CO2 pneumothorax with otherwise hemodynamically stable conditions can be managed by conservative modalities, avoiding unnecessary chest tube insertion or conversion to an open procedure.

Microglial cells are the resident macrophages and intrinsic arm of the central nervous system innate immune defense. Microglial cells become activated in response to injury, infection, environmental toxins, and other stimuli that threaten neuronal survival. Therefore, regulating microglial activation may have therapeutic benefits that lead to alleviating the progression of inflammatory-mediated neurodegeneration. In the present study, we investigated the effect of glaucocalyxin A (GLA) isolated from Rabdosia japonica on the production of pro-inflammatory mediators in lipopolysaccharide (LPS)-stimulated primary microglia and BV-2 cells. GLA significantly inhibited LPS-induced production of nitric oxide and reversed the morphological changes in primary microglia. Further, GLA suppressed expression of inducible nitric oxide synthase and cyclooxygenase-2 dose-dependently at the mRNA and protein levels. The production of proinflammatory cytokines such as tumor necrosis factor-α, interleukin-1β (IL)-1β, and IL-6 were inhibited by suppressing their transcriptional activity. Furthermore, GLA suppressed nuclear factor-κB activation by blocking degradation of IκB-α and inhibited the induction of lipocalin-2 expression in LPS-stimulated BV-2 cells. Mechanistic study revealed that the inhibitory effects of GLA were accompanied by blocking the p38 mitogen activated protein kinase signaling pathway in activated microglia. In conclusion, given that microglial activation contributes to the pathogenesis of neurodegenerative diseases, GLA could be developed as a potential therapeutic agent for treating microglia-mediated neuroinflammatory diseases.