Clinical Outcomes Associated with Degree of Hypernatremia in Neurocritically Ill Patients

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

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

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

A New Method for Aortic Valve Planimetry with High-Resolution 3-Dimensional MRI and Its Comparison with Conventional Cine MRI and Echocardiography for Assessing the Severity of Aortic Valvular Stenosis

Objective@#We aimed to compare the aortic valve area (AVA) calculated using fast high-resolution three-dimensional (3D) magnetic resonance (MR) image acquisition with that of the conventional two-dimensional (2D) cine MR technique. @*Materials and Methods@#We included 139 consecutive patients (mean age ± standard deviation [SD], 68.5 ± 9.4 years) with aortic valvular stenosis (AS) and 21 asymptomatic controls (52.3 ± 14.2 years). High-resolution T2-prepared 3D steady-state free precession (SSFP) images (2.0 mm slice thickness, 10 contiguous slices) for 3D planimetry (3DP) were acquired with a single breath hold during mid-systole. 2D SSFP cine MR images (6.0 mm slice thickness) for 2D planimetry (2DP) were also obtained at three aortic valve levels. The calculations for the effective AVA based on the MR images were compared with the transthoracic echocardiographic (TTE) measurements using the continuity equation. @*Results@#The mean AVA ± SD derived by 3DP, 2DP, and TTE in the AS group were 0.81 ± 0.26 cm2 , 0.82 ± 0.34 cm2 , and 0.80 ± 0.26 cm2 , respectively (p = 0.366). The intra-observer agreement was higher for 3DP than 2DP in one observer: intraclass correlation coefficient (ICC) of 0.95 (95% confidence interval [CI], 0.94–0.97) and 0.87 (95% CI, 0.82–0.91), respectively, for observer 1 and 0.97 (95% CI, 0.96–0.98) and 0.98 (95% CI, 0.97–0.99), respectively, for observer 2. Inter-observer agreement was similar between 3DP and 2DP, with the ICC of 0.92 (95% CI, 0.89–0.94) and 0.91 (95% CI, 0.88–0.93), respectively. 3DP-derived AVA showed a slightly higher agreement with AVA measured by TTE than the 2DP-derived AVA, with the ICC of 0.87 (95% CI, 0.82–0.91) vs. 0.85 (95% CI, 0.79–0.89). @*Conclusion@#High-resolution 3D MR image acquisition, with single-breath-hold SSFP sequences, gave AVA measurement with low observer variability that correlated highly with those obtained by TTE.

A New Method for Aortic Valve Planimetry with High-Resolution 3-Dimensional MRI and Its Comparison with Conventional Cine MRI and Echocardiography for Assessing the Severity of Aortic Valvular Stenosis

Objective@#We aimed to compare the aortic valve area (AVA) calculated using fast high-resolution three-dimensional (3D) magnetic resonance (MR) image acquisition with that of the conventional two-dimensional (2D) cine MR technique. @*Materials and Methods@#We included 139 consecutive patients (mean age ± standard deviation [SD], 68.5 ± 9.4 years) with aortic valvular stenosis (AS) and 21 asymptomatic controls (52.3 ± 14.2 years). High-resolution T2-prepared 3D steady-state free precession (SSFP) images (2.0 mm slice thickness, 10 contiguous slices) for 3D planimetry (3DP) were acquired with a single breath hold during mid-systole. 2D SSFP cine MR images (6.0 mm slice thickness) for 2D planimetry (2DP) were also obtained at three aortic valve levels. The calculations for the effective AVA based on the MR images were compared with the transthoracic echocardiographic (TTE) measurements using the continuity equation. @*Results@#The mean AVA ± SD derived by 3DP, 2DP, and TTE in the AS group were 0.81 ± 0.26 cm2 , 0.82 ± 0.34 cm2 , and 0.80 ± 0.26 cm2 , respectively (p = 0.366). The intra-observer agreement was higher for 3DP than 2DP in one observer: intraclass correlation coefficient (ICC) of 0.95 (95% confidence interval [CI], 0.94–0.97) and 0.87 (95% CI, 0.82–0.91), respectively, for observer 1 and 0.97 (95% CI, 0.96–0.98) and 0.98 (95% CI, 0.97–0.99), respectively, for observer 2. Inter-observer agreement was similar between 3DP and 2DP, with the ICC of 0.92 (95% CI, 0.89–0.94) and 0.91 (95% CI, 0.88–0.93), respectively. 3DP-derived AVA showed a slightly higher agreement with AVA measured by TTE than the 2DP-derived AVA, with the ICC of 0.87 (95% CI, 0.82–0.91) vs. 0.85 (95% CI, 0.79–0.89). @*Conclusion@#High-resolution 3D MR image acquisition, with single-breath-hold SSFP sequences, gave AVA measurement with low observer variability that correlated highly with those obtained by TTE.

Mildly Elevated Cardiac Troponin below the 99th-Percentile Upper Reference Limit after Noncardiac Surgery

Background and Objectives@#In patients with perioperative cardiac troponin (cTn) I below the 99th-percentile upper range of limit (URL), mortality according to cTn I level has not been fully evaluated. This study evaluated the association between postoperative cTn I level above the lowest limit of detection but within the 99th-percentile URL and 30-day mortality after noncardiac surgery. @*Methods@#Patients with cTn I values below the 99th-percentile URL during the perioperative period were divided into a no-elevation group with cTn I at the lowest limit of detection (6 ng/L) and a minor elevation group with cTn I elevation below the 99th percentile URL (6 ng/L < cTn I < 40 ng/L). The primary outcome was 30-day mortality. @*Results@#Of the 5,312 study participants, 2,582 (48.6%) were included in the no-elevation group and 2,730 (51.4%) were included in the minor elevation group. After propensity scorematching, the minor elevation group showed significantly increased 30-day mortality (0.5% vs. 2.3%; hazard ratio, 4.30; 95% confidence interval, 2.23–8.29; p<0.001). The estimated cutoff value of cTn I to predict 30-day mortality was 6 ng/L with the area under the receiver operating characteristic curve 0.657. @*Conclusions@#A mild elevation of cTn I within the 99th-percentile URL after noncardiac surgery was significantly associated with increased 30-day mortality as compared with the lowest limit of detection.

Comparison of Cortical Ring Allograft and Plate Fixation with Autologous Iliac Bone Graft for Anterior Cervical Discectomy and Fusion

STUDY DESIGN: A retrospective cohort study. PURPOSE: To compare the clinical and radiological outcomes of patients who underwent anterior cervical discectomy and fusion (ACDF) supplemented with plate fixation using allograft with those who underwent ACDF using tricortical iliac autograft. OVERVIEW OF LITERATURE: As plate fixation is becoming popular, it is reported that ACDF using allograft may have similar outcomes compared with ACDF using autograft. METHODS: Forty-one patients who underwent ACDF supplemented with plate fixation were included in this study. We evaluated 24 patients who used cortical ring allograft filled with demineralized bone matrix (DBM) (group A) and 17 patients who used tricortical iliac autograft (group B). In radiological evaluations, fusion rate, subsidence of grafted material, cervical lordosis, fused segmental lordosis, and radiological adjacent segment degeneration (ASD) were observed and analyzed with preoperative and postoperative plain radiographs. Clinical outcomes were evaluated using the Neck Disability Index score, Odom criteria, and Visual Analog Scale score of neck and upper extremity pain. Radiological union was determined by dynamic radiographs using cutoff values of 1 mm of interspinous motion as the indication of pseudarthrosis. RESULTS: There was no significant difference in the fusion rate, graft subsidence, cervical lordosis, fused segmental lordosis, and ASD incidence between the groups. Operative time was shorter in group A (136 min) than in group B (141 min), but it was not significant (p>0.05). Blood loss was greater in group B (325 mL) than in group A (210 mL, p=0.013). There was no difference in the clinical outcomes before and after surgery. CONCLUSIONS: In ACDF with plate fixation, cortical ring allograft filled with DBM group showed similar radiological and clinical outcomes compared with those of the autograft group. If the metal plate is reinforced, using cortical ring allograft could be a viable alternative to autograft.

Outcomes of Degenerative Lumbar Spine Surgery in Patients with Chronic Kidney Disease Undergoing Hemodialysis

STUDY DESIGN: Retrospective study. OBJECTIVES: To analyze the outcomes of degenerative lumbar spine surgery in patients undergoing hemodialysis due to chronic kidney disease (CKD). SUMMARY OF LITERATURE REVIEW: Patients who undergo hemodialysis due to chronic renal disease tend to exhibit accelerated changes in bone quality, deterioration of spinal stenosis, and accompanying neurological degeneration. The surgical treatment of chronic spinal diseases is also becoming more necessary with the increased lifespan of these patients. MATERIALS AND METHODS: We reviewed the medical records and radiographs of patients with CKD undergoing hemodialysis who were followed-up for more than 1 year after posterior lumbar spinal surgery. We evaluated clinical, laboratory, and radiologic variables. For a comparative analysis, patients were classified into subgroups according to age (65 years old), duration of hemodialysis (10 years), and type of surgery (simple decompression or fusion). RESULTS: We included 21 patients (5 men, 16 women) with a mean age of 66.2 years (range, 48-87 years). The mean duration of hemodialysis and follow-up was 18.9 years and 43 months, respectively. Decompressions with fusion were performed in 11 patients and simple decompressions in the other 10. The mean visual analog scale (VAS) of leg pain and the Oswestry Disability Index (ODI) significantly improved after surgery at time of the last follow-up; meanwhile, the mean VAS score for lower back pain did not show a statistically significant improvement. The postoperative ODI was correlated with age (correlation coefficient=0.71, p=0.006). In patients less than 65 years old, the ODI improvement was greater (p=0.035) than in those 65 years of age or older. There was no significant difference in the clinical outcomes according to the duration of hemodialysis. Complications were observed in 11 patients (52.4%, 7 in fusion and 4 in simple decompression), of which 2 cases were infections, and reoperations were performed in 5 patients. The union rate of the fusion cases at the 1-year follow-up was 81.8%. CONCLUSIONS: Appropriate spine surgery improved radicular pain and the ODI in patients with degenerative lumbar disease undergoing hemodialysis. However, postoperative complications were frequent and the improvement of clinical outcomes was minimal, especially in patients over 65 years of age and in those who underwent fusion. Therefore, the surgical treatment of patients with chronic renal disease undergoing hemodialysis requires adequate consideration of age and the duration of hemodialysis.

A comparison of Decompression and Fusion Surgery in Lumbar Degenerative Spondylolisthesis

STUDY DESIGN: A retrospective, controlled study. OBJECTIVES: To assess clinical and radiologic results of decompression without fusion surgery in the treatment of stable lumbar degenerative spondylolisthesis (LDS) and to compare clinical outcomes of fusion surgery. SUMMARY OF LITERATURE REVIEW: Although it is reported that decompression surgery is effective in treating LDS, few reports have compared the outcomes of treatment using decompression and instrumented fusion. MATERIALS AND METHODS: A retrospective study was performed and fifty eight degenerative spondylolisthesis patients who received decompression treatment with or without fusion surgery with follow up for at least 2 years were included. The number of patients in the decompression and fusion groups were 23 each and they were selected with age and slip degree taken into account. Clinical factors were evaluated using the Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) of the back/leg and high risk of operation. Radiological factors were evaluated such as slippage, angulation, and disc height at the affected level in preoperative and final follow up. RESULTS: There was no statistical difference between the decompression and fusion groups in the VAS of the back/leg, slippage, and high risk of operation preoperatively (p>0.05). The mean operative time was 73.9 minutes in the decompression group and 123.7 minutes in the fusion group. The mean blood loss was 134.5mL in the decompression group and 323.5mL in the fusion group. VAS of the back/leg and ODI improved in both groups and there were no significant differences between the two groups statistically. CONCLUSIONS: Decompression with/without fusion had a favorable clinical outcome in stable degenerative spondylolisthesis patients. However, fusion involves more operative time and blood loss compared to simple decompression. Simple decompression is a good treatment option, especially in operative high risk patients.

A Comparison of Adjacent Segment Diseases Above One Versus Above Two Vertebral Segment after Spinal Fusion of the Degenerative Lumbar Disease

STUDY DESIGN: Retrospective study. OBJECTIVE: To compare patients who underwent spinal revision surgery of adjacent segment degeneration with above one and above two vertebral segment preceded by initial spinal fusion surgery. SUMMARY OF LITERATURE REVIEW: The adjacent segment disease(ASD) occurs more frequently at the more proximal segment of the spinal fusion. Also, the preexisting degenerative segments (with discs or facet joints) not included in the fusion procedure, fusion segmental sagittal angle, fixed appliances method, gender, and age, have been accepted as the causes. MATERIALS AND METHODS: The patients were watched over a year after the spinal revision operation followed by initial spinal fusion of single or multiple segments; the subjects were limited to 41 patients. The average age, entity of diseases, average duration between the initial spinal fusion and the revision surgery, multiple clinical and radiographic parameters were evaluated and compared. RESULTS: Using the UCLA grade of intervertebral disc degeneration, the average grade of 1 level upper segment was 2.2 in group A and 1.9 in group B without statistical significance(p=0.426). However, the average grade of 2-level upper segment was 1.8 in group A and 2.4 in group B with significant difference(p=0.021). There was no statistical difference in other factors between the two groups. CONCLUSIONS: Patients with ASD of above two-vertebral segment after spinal fusion were more severe in disc degeneration than those with ASD of above one vertebral segment before initial spinal fusions.

Sequential Hip Fractures in Elderly Osteoporotic Patients / 대한고관절학회지

PURPOSE: The purpose of this study was to evaluate the clinical features and risk factors of sequential bilateral hip fractures in elderly osteoporotic patients. MATERIALS AND METHODS: A total of 661 patients who had undergone surgical treatment for osteoporotic hip fractures from April 2001 to June 2011 were retrospectively reviewed. Thirty six patients who had experienced sequential bilateral hip fracture were classified as the BHF group and the rest of the patients were classified as the non-BHF group. Various clinical features, such as T-score of the proximal femur, dwelling pattern, any symptom of dizziness or dementia, health status by ASA classification, BMI, and history of osteoporosis treatment were reviewed and the risk factors of sequential bilateral hip fractures were evaluated. RESULTS: Mean age of subjects in the BHF group and the non-BHF group was 78.4 years(68-90 years) and 78.0 years(58-99 years), respectively. Mean time interval from initial fracture to second fracture in the BHF group was 29.9 months(2-102 months). No significant differences in T-score of proximal femur (P=0.276), dwelling pattern (P=0.623), dizziness or dementia (P=0.180), health status (P=0.399), and BMI (P=0.629) were observed between the two groups. Eight patients(22.0%) in the BHF group and 254 patients(40.6%) in the non-BHF group were treated with bisphosphonate medications due to osteoporosis during a period of at least one year or more (P=0.028). CONCLUSION: Sequential hip fractures in elderly osteoporotic patients over the age of 70 were the result of low energy trauma, and most second fractures occurred within three years from initial injury. A multidisciplinary approach to prevention of a slip and treatment for osteoporosis are considered important to prevention of second hip fractures.