The trace element selenium is of high importance for many of the body's regulatory and metabolic ... more The trace element selenium is of high importance for many of the body's regulatory and metabolic functions. Balanced selenium levels are essential, whereas dysregulation can cause harm. A rapidly increasing number of studies characterizes the wide range of selenium dependent functions in the human body and elucidates the complex and multiple physiological and pathophysiological interactions of selenium and selenoproteins. For the majority of selenium dependent enzymes, several biological functions have already been identified, like regulation of the inflammatory response, antioxidant properties and the proliferation/differentiation of immune cells. Although the potential role of selenium in the development and progression of cardiovascular disease has been investigated for decades, both observational and interventional
When planning clinical trials, it is a key element to choose appropriate outcomes that ensure the... more When planning clinical trials, it is a key element to choose appropriate outcomes that ensure the comparability of effects of interventions in ways that minimise bias. We hypothesise that outcome measures in cardiothoracic surgical trials are inconsistent and without standard. Therefore, comparing the relative effectiveness of interventions across studies is problematic. We surmise that cardiothoracic research has focused habitually on the identification of risk factors and on the reduction of adverse outcomes with less consideration of factors that contribute to well being and positive health outcomes (salutogenesis). We conducted a systematic review of reviews to determine both the type and number of outcomes reported in current cardiothoracic surgery interventional research, in order to identify a list of potential outcomes for a minimum core outcome set (COS). Special focus was placed on outcomes that emphasise salutogenesis. We interpreted salutogenic outcomes as those relating...
Randomised controlled trials (RCTs) are the gold standard for measuring the efficacy of any medic... more Randomised controlled trials (RCTs) are the gold standard for measuring the efficacy of any medical intervention. The present study assesses the implementation of the CONSORT statement in the top 11 anaesthesiology journals in 2011. We designed this study in order to determine how well authors in the top 11 ranked anaesthesiology journals follow the CONSORT statement's criteria. A retrospective cross-sectional data analysis. The study was performed at the RWTH Aachen University Hospital. Journals included Pain, Anesthesiology, British Journal of Anaesthesia, Regional Anesthesia and Pain Medicine, European Journal of Pain, Anesthesia and Analgesia, Anaesthesia, Minerva Anestesiologica, Canadian Journal of Anesthesia, Journal of Neurosurgical Anesthesiology and the European Journal of Anaesthesiology. All articles in the online table of contents from the top 11 anaesthesiology journals according to the ISI Web of Knowledge were screened for RCTs published in 2011. The RCTs were assessed using the CONSORT checklist. We also analysed the correlation between the number of citations and the adherence to CONSORT items. We evaluated 319 RCTs and found that, more than ten years after the publication of the CONSORT statement, the RCTs satisfied a median of 60.0% of the CONSORT criteria. Only 72.1% of the articles presented clearly defined primary and secondary outcome parameters. The number of citations is only weakly associated with the fulfilment of the CONSORT statement (r = 0.023). Adherence to the CONSORT criteria remains low in top-ranked anaesthesiology journals. We found only a very weak correlation between the number of citations and fulfilment of the requirements of the CONSORT statement.
Introduction: Calibrated arterial pulse contour analysis has become an established method for the... more Introduction: Calibrated arterial pulse contour analysis has become an established method for the continuous monitoring of cardiac output (PCCO). However, data on its validity in hemodynamically instable patients beyond the setting of cardiac surgery are scarce. We performed the present study to assess the validity and precision of PCCO-measurements using the PiCCO™-device compared to transpulmonary thermodilution derived cardiac output (TPCO) as the reference technique in neurosurgical patients requiring high-dose vasopressor-therapy.
Introduction: Ischemia-reperfusion injury following cardiopulmonary resuscitation (CPR) is associ... more Introduction: Ischemia-reperfusion injury following cardiopulmonary resuscitation (CPR) is associated with a systemic inflammatory response, resulting in post-resuscitation disease. In the present study we investigated the response of the pleiotropic inflammatory cytokine macrophage migration inhibitory factor (MIF) to CPR in patients admitted to the hospital after out-of-hospital cardiac arrest (OHCA). To describe the magnitude of MIF release, we compared the blood levels from CPR patients with those obtained in healthy volunteers and with an aged-and gender-matched group of patients undergoing cardiac surgery with the use of extracorporeal circulation.
The postoperative cognitive function is impaired in elderly patients after general anaesthesia. T... more The postoperative cognitive function is impaired in elderly patients after general anaesthesia. The fast recovery after xenon anaesthesia was hypothesized to be advantageous in this scenario. We compared early postoperative cognitive function after xenon and sevoflurane anaesthesia in this study. The study was approved by the local ethics committee and written informed consent was obtained from each patient. Patients aged 65-75 years (ASA I-III) scheduled for elective surgery (duration 60-180 min) were enrolled. Investigators performing cognitive testing and patients were blinded towards allocation to either xenon or sevoflurane anaesthesia. Baseline assessment of cognitive function was carried out 12-24 h before the operation. The results were compared to follow-up tests 6-12 and 66-72 h after surgery. Primary outcome parameter was the subtest "Alertness" of the computerized Test of Attentional Performance (TAP). Secondary outcome parameters included further subtests of t...
Ischemia-reperfusion injury following cardiopulmonary resuscitation (CPR) is associated with a sy... more Ischemia-reperfusion injury following cardiopulmonary resuscitation (CPR) is associated with a systemic inflammatory response, resulting in post-resuscitation disease. In the present study we investigated the response of the pleiotropic inflammatory cytokine macrophage migration inhibitory factor (MIF) to CPR in patients admitted to the hospital after out-of-hospital cardiac arrest (OHCA). To describe the magnitude of MIF release, we compared the blood levels from CPR patients with those obtained in healthy volunteers and with an aged- and gender-matched group of patients undergoing cardiac surgery with the use of extracorporeal circulation. Blood samples of 17 patients with return of spontaneous circulation (ROSC) after OHCA were obtained upon admission to the intensive care unit, and 6, 12, 24, 72 and 96 h later. Arrest and treatment related data were documented according to the Utstein style. In patients after ROSC, MIF levels at admission (475.2±157.8 ng/ml) were significantly h...
Anesthetic-induced preconditioning (AIP) is known to elicit cardioprotective effects that are med... more Anesthetic-induced preconditioning (AIP) is known to elicit cardioprotective effects that are mediated at least in part by activation of the kinases AMPK and PKCε as well as by inhibition of JNK. Recent data demonstrated that the pleiotropic cytokine macrophage migration inhibitory factor (MIF) provides cardioprotection through activation and/or inhibition of kinases that are also known to mediate effects of AIP. Therefore, we hypothesized that MIF could play a key role in the AIP response. Cardiomyocytes were isolated from rats and subjected to isoflurane preconditioning (4 h; 1.5 vol. %). Subsequently, MIF secretion and alterations in the activation levels of protective kinases were compared to a control group that was exposed to ambient air conditions. MIF secretion was quantified by ELISA and AIP-induced activation of protein kinases was assessed by Western blotting of cardiomyocyte lysates after isoflurane treatment. In cardiomyocytes, preconditioning with isoflurane resulted i...
Cardiac surgery is accompanied by an increase of oxidative stress, a significantly reduced antiox... more Cardiac surgery is accompanied by an increase of oxidative stress, a significantly reduced antioxidant (AOX) capacity, postoperative inflammation, all of which may promote the development of organ dysfunction and an increase in mortality. Selenium is an essential co-factor of various antioxidant enzymes. We hypothesized a less pronounced decrease of circulating selenium levels in patients undergoing off-pump coronary artery bypass (OPCAB) surgery due to less intraoperative oxidative stress. In this prospective randomised, interventional trial, 40 patients scheduled for elective coronary artery bypass grafting were randomly assigned to undergo either on-pump or OPCAB-surgery, if both techniques were feasible for the single patient. Clinical data, myocardial damage assessed by myocard specific creatine kinase isoenzyme (CK-MB), circulating whole blood levels of selenium, oxidative stress assessed by asymmetric dimethylarginine (ADMA) levels, antioxidant capacity determined by glutathi...
ABSTRACT Hintergrund Therapierelevante Hypoxämien stellen eine der häufigsten Komplikationen im A... more ABSTRACT Hintergrund Therapierelevante Hypoxämien stellen eine der häufigsten Komplikationen im Aufwachraum (AWR) dar. Ziel dieser Studie war es, die Effizienz einer Sauerstoff(O2)-Gabe via Gesichtsmaske mit einer O2-Gabe mithilfe des EzPAP®-Systems zu vergleichen. Patienten und Methode In einem Zeitraum von 2 Monaten wurden 210 Patienten mit postoperativ persistierender Hypoxämie [pulsoxymetrisch gemessene Sauerstoffsättigung (SpO2) < 93%] in diese prospektiv observationelle Studie aufgenommen. Es wurden 105 Kontrollpatienten mit Sauerstoff (O2) über eine Gesichtsmaske (6 l/min) und 105 Patienten mit einer O2-Gabe über das EzPAP®-System behandelt. Nach 1 h wurde die O2-Gabe gestoppt. Bei erneutem und länger als 5 min persistierendem SpO2-Abfall (< 93%) erhielten beide Gruppen O2 via Gesichtsmaske. Die SpO2-Werte, Sauerstoffpflichtigkeit, Verweildauer im AWR und die Inzidenz an postoperativen Komplikationen wurden zwischen beiden Gruppen verglichen. Daneben wurde eine Subgruppenanalyse in Abhängigkeit von dem Status in der Klassifikation der American Society of Anesthesiologists (ASA), dem Body-Mass-Index (BMI), Vorerkrankungen, der Art der intraoperativen Atemwegssicherung und der Verwendung von Muskelrelaxanzien durchgeführt. Ergebnisse Mit Ausnahme vom ersten Messzeitpunkt (0,5 min nach O2-Gabe, EzPAP-Gruppe: Mittelwert (MW) 96% ± Standardabweichung (SD) 3,7% vs. Kontrollgruppe: 93,8 ± 4,4%; p < 0,001) unterschieden sich die Teilnehmer der Kontroll- und der EzPAP-Gruppe nicht in ihren SpO2-Werten. Allerdings wurden die Patienten der EzPAP-Gruppe während des Auslassversuchs seltener sauerstoffpflichtig (25 vs. 41 Patienten; p = 0,03) und hatten eine geringere Inzidenz an postoperativen Komplikationen (13 vs. 25; p = 0,02), wie nosokomiale Pneumonien (0 vs. 4) und Wundinfektionen (2 vs. 3). In der EzPAP-Gruppe wiesen die Subgruppen mit erhöhtem BMI und pulmonalen Vorerkrankungen postoperativ höhere SpO2-Werte als präoperativ auf. Die AWR-Verweildauer unterschied sich zwischen den beiden Gruppen nicht (p = 0,2). Schlussfolgerungen Diese erste observationelle Studie legt nahe, dass das EzPAP®-System ein effektives System zur Therapie der postoperativen Hypoxämie darstellt, das der O2-Gabe via Gesichtsmaske mindestens ebenbürtig ist und möglicherweise den pulmonalen Gasaustausch bei Patienten mit erhöhtem BMI sowie pulmonalen Vorerkrankungen langfristig verbessert. Diese Daten rechtfertigen eine prospektiv randomisierte klinische Studie.
Cardiac surgery is associated with release of the pleiotropic cytokine macrophage migration inhib... more Cardiac surgery is associated with release of the pleiotropic cytokine macrophage migration inhibitory factor (MIF). The trigger for MIF release has not yet been elucidated. Owing to its intrinsic antioxidative activity, MIF might reduce oxidative stress and protect from myocardial ischemia and reperfusion (I/R) injury. In the present study, patients scheduled for elective cardiac surgery (n=46) were randomized to undergo coronary artery bypass grafting either conventionally with cardiopulmonary bypass and cardioplegic arrest-induced I/R (cCABG) or in an off-pump procedure (OPCAB) with minimized I/R. We report that only patients who underwent cCABG exhibited a postoperative increase of MIF (p=0.024), while both groups showed an increase in interleukin-6. MIF release appears to be primarily mediated by I/R and to a lesser extent by inflammation. Endogenous peroxidase activity (p=0.021) and serum levels of thioredoxin (p=0.003) were significantly higher in patients who underwent cCABG...
Background: Cardiac surgery has been shown to result in a significant decrease of the antioxidant... more Background: Cardiac surgery has been shown to result in a significant decrease of the antioxidant selenium, which is associated with the development of multiorgan dysfunction and increased mortality. Thus, a large-scale study is needed to investigate the effect of perioperative selenium supplementation on the occurrence of postoperative organ dysfunction.
The trace element selenium is of high importance for many of the body's regulatory and metabolic ... more The trace element selenium is of high importance for many of the body's regulatory and metabolic functions. Balanced selenium levels are essential, whereas dysregulation can cause harm. A rapidly increasing number of studies characterizes the wide range of selenium dependent functions in the human body and elucidates the complex and multiple physiological and pathophysiological interactions of selenium and selenoproteins. For the majority of selenium dependent enzymes, several biological functions have already been identified, like regulation of the inflammatory response, antioxidant properties and the proliferation/differentiation of immune cells. Although the potential role of selenium in the development and progression of cardiovascular disease has been investigated for decades, both observational and interventional
When planning clinical trials, it is a key element to choose appropriate outcomes that ensure the... more When planning clinical trials, it is a key element to choose appropriate outcomes that ensure the comparability of effects of interventions in ways that minimise bias. We hypothesise that outcome measures in cardiothoracic surgical trials are inconsistent and without standard. Therefore, comparing the relative effectiveness of interventions across studies is problematic. We surmise that cardiothoracic research has focused habitually on the identification of risk factors and on the reduction of adverse outcomes with less consideration of factors that contribute to well being and positive health outcomes (salutogenesis). We conducted a systematic review of reviews to determine both the type and number of outcomes reported in current cardiothoracic surgery interventional research, in order to identify a list of potential outcomes for a minimum core outcome set (COS). Special focus was placed on outcomes that emphasise salutogenesis. We interpreted salutogenic outcomes as those relating...
Randomised controlled trials (RCTs) are the gold standard for measuring the efficacy of any medic... more Randomised controlled trials (RCTs) are the gold standard for measuring the efficacy of any medical intervention. The present study assesses the implementation of the CONSORT statement in the top 11 anaesthesiology journals in 2011. We designed this study in order to determine how well authors in the top 11 ranked anaesthesiology journals follow the CONSORT statement's criteria. A retrospective cross-sectional data analysis. The study was performed at the RWTH Aachen University Hospital. Journals included Pain, Anesthesiology, British Journal of Anaesthesia, Regional Anesthesia and Pain Medicine, European Journal of Pain, Anesthesia and Analgesia, Anaesthesia, Minerva Anestesiologica, Canadian Journal of Anesthesia, Journal of Neurosurgical Anesthesiology and the European Journal of Anaesthesiology. All articles in the online table of contents from the top 11 anaesthesiology journals according to the ISI Web of Knowledge were screened for RCTs published in 2011. The RCTs were assessed using the CONSORT checklist. We also analysed the correlation between the number of citations and the adherence to CONSORT items. We evaluated 319 RCTs and found that, more than ten years after the publication of the CONSORT statement, the RCTs satisfied a median of 60.0% of the CONSORT criteria. Only 72.1% of the articles presented clearly defined primary and secondary outcome parameters. The number of citations is only weakly associated with the fulfilment of the CONSORT statement (r = 0.023). Adherence to the CONSORT criteria remains low in top-ranked anaesthesiology journals. We found only a very weak correlation between the number of citations and fulfilment of the requirements of the CONSORT statement.
Introduction: Calibrated arterial pulse contour analysis has become an established method for the... more Introduction: Calibrated arterial pulse contour analysis has become an established method for the continuous monitoring of cardiac output (PCCO). However, data on its validity in hemodynamically instable patients beyond the setting of cardiac surgery are scarce. We performed the present study to assess the validity and precision of PCCO-measurements using the PiCCO™-device compared to transpulmonary thermodilution derived cardiac output (TPCO) as the reference technique in neurosurgical patients requiring high-dose vasopressor-therapy.
Introduction: Ischemia-reperfusion injury following cardiopulmonary resuscitation (CPR) is associ... more Introduction: Ischemia-reperfusion injury following cardiopulmonary resuscitation (CPR) is associated with a systemic inflammatory response, resulting in post-resuscitation disease. In the present study we investigated the response of the pleiotropic inflammatory cytokine macrophage migration inhibitory factor (MIF) to CPR in patients admitted to the hospital after out-of-hospital cardiac arrest (OHCA). To describe the magnitude of MIF release, we compared the blood levels from CPR patients with those obtained in healthy volunteers and with an aged-and gender-matched group of patients undergoing cardiac surgery with the use of extracorporeal circulation.
The postoperative cognitive function is impaired in elderly patients after general anaesthesia. T... more The postoperative cognitive function is impaired in elderly patients after general anaesthesia. The fast recovery after xenon anaesthesia was hypothesized to be advantageous in this scenario. We compared early postoperative cognitive function after xenon and sevoflurane anaesthesia in this study. The study was approved by the local ethics committee and written informed consent was obtained from each patient. Patients aged 65-75 years (ASA I-III) scheduled for elective surgery (duration 60-180 min) were enrolled. Investigators performing cognitive testing and patients were blinded towards allocation to either xenon or sevoflurane anaesthesia. Baseline assessment of cognitive function was carried out 12-24 h before the operation. The results were compared to follow-up tests 6-12 and 66-72 h after surgery. Primary outcome parameter was the subtest "Alertness" of the computerized Test of Attentional Performance (TAP). Secondary outcome parameters included further subtests of t...
Ischemia-reperfusion injury following cardiopulmonary resuscitation (CPR) is associated with a sy... more Ischemia-reperfusion injury following cardiopulmonary resuscitation (CPR) is associated with a systemic inflammatory response, resulting in post-resuscitation disease. In the present study we investigated the response of the pleiotropic inflammatory cytokine macrophage migration inhibitory factor (MIF) to CPR in patients admitted to the hospital after out-of-hospital cardiac arrest (OHCA). To describe the magnitude of MIF release, we compared the blood levels from CPR patients with those obtained in healthy volunteers and with an aged- and gender-matched group of patients undergoing cardiac surgery with the use of extracorporeal circulation. Blood samples of 17 patients with return of spontaneous circulation (ROSC) after OHCA were obtained upon admission to the intensive care unit, and 6, 12, 24, 72 and 96 h later. Arrest and treatment related data were documented according to the Utstein style. In patients after ROSC, MIF levels at admission (475.2±157.8 ng/ml) were significantly h...
Anesthetic-induced preconditioning (AIP) is known to elicit cardioprotective effects that are med... more Anesthetic-induced preconditioning (AIP) is known to elicit cardioprotective effects that are mediated at least in part by activation of the kinases AMPK and PKCε as well as by inhibition of JNK. Recent data demonstrated that the pleiotropic cytokine macrophage migration inhibitory factor (MIF) provides cardioprotection through activation and/or inhibition of kinases that are also known to mediate effects of AIP. Therefore, we hypothesized that MIF could play a key role in the AIP response. Cardiomyocytes were isolated from rats and subjected to isoflurane preconditioning (4 h; 1.5 vol. %). Subsequently, MIF secretion and alterations in the activation levels of protective kinases were compared to a control group that was exposed to ambient air conditions. MIF secretion was quantified by ELISA and AIP-induced activation of protein kinases was assessed by Western blotting of cardiomyocyte lysates after isoflurane treatment. In cardiomyocytes, preconditioning with isoflurane resulted i...
Cardiac surgery is accompanied by an increase of oxidative stress, a significantly reduced antiox... more Cardiac surgery is accompanied by an increase of oxidative stress, a significantly reduced antioxidant (AOX) capacity, postoperative inflammation, all of which may promote the development of organ dysfunction and an increase in mortality. Selenium is an essential co-factor of various antioxidant enzymes. We hypothesized a less pronounced decrease of circulating selenium levels in patients undergoing off-pump coronary artery bypass (OPCAB) surgery due to less intraoperative oxidative stress. In this prospective randomised, interventional trial, 40 patients scheduled for elective coronary artery bypass grafting were randomly assigned to undergo either on-pump or OPCAB-surgery, if both techniques were feasible for the single patient. Clinical data, myocardial damage assessed by myocard specific creatine kinase isoenzyme (CK-MB), circulating whole blood levels of selenium, oxidative stress assessed by asymmetric dimethylarginine (ADMA) levels, antioxidant capacity determined by glutathi...
ABSTRACT Hintergrund Therapierelevante Hypoxämien stellen eine der häufigsten Komplikationen im A... more ABSTRACT Hintergrund Therapierelevante Hypoxämien stellen eine der häufigsten Komplikationen im Aufwachraum (AWR) dar. Ziel dieser Studie war es, die Effizienz einer Sauerstoff(O2)-Gabe via Gesichtsmaske mit einer O2-Gabe mithilfe des EzPAP®-Systems zu vergleichen. Patienten und Methode In einem Zeitraum von 2 Monaten wurden 210 Patienten mit postoperativ persistierender Hypoxämie [pulsoxymetrisch gemessene Sauerstoffsättigung (SpO2) < 93%] in diese prospektiv observationelle Studie aufgenommen. Es wurden 105 Kontrollpatienten mit Sauerstoff (O2) über eine Gesichtsmaske (6 l/min) und 105 Patienten mit einer O2-Gabe über das EzPAP®-System behandelt. Nach 1 h wurde die O2-Gabe gestoppt. Bei erneutem und länger als 5 min persistierendem SpO2-Abfall (< 93%) erhielten beide Gruppen O2 via Gesichtsmaske. Die SpO2-Werte, Sauerstoffpflichtigkeit, Verweildauer im AWR und die Inzidenz an postoperativen Komplikationen wurden zwischen beiden Gruppen verglichen. Daneben wurde eine Subgruppenanalyse in Abhängigkeit von dem Status in der Klassifikation der American Society of Anesthesiologists (ASA), dem Body-Mass-Index (BMI), Vorerkrankungen, der Art der intraoperativen Atemwegssicherung und der Verwendung von Muskelrelaxanzien durchgeführt. Ergebnisse Mit Ausnahme vom ersten Messzeitpunkt (0,5 min nach O2-Gabe, EzPAP-Gruppe: Mittelwert (MW) 96% ± Standardabweichung (SD) 3,7% vs. Kontrollgruppe: 93,8 ± 4,4%; p < 0,001) unterschieden sich die Teilnehmer der Kontroll- und der EzPAP-Gruppe nicht in ihren SpO2-Werten. Allerdings wurden die Patienten der EzPAP-Gruppe während des Auslassversuchs seltener sauerstoffpflichtig (25 vs. 41 Patienten; p = 0,03) und hatten eine geringere Inzidenz an postoperativen Komplikationen (13 vs. 25; p = 0,02), wie nosokomiale Pneumonien (0 vs. 4) und Wundinfektionen (2 vs. 3). In der EzPAP-Gruppe wiesen die Subgruppen mit erhöhtem BMI und pulmonalen Vorerkrankungen postoperativ höhere SpO2-Werte als präoperativ auf. Die AWR-Verweildauer unterschied sich zwischen den beiden Gruppen nicht (p = 0,2). Schlussfolgerungen Diese erste observationelle Studie legt nahe, dass das EzPAP®-System ein effektives System zur Therapie der postoperativen Hypoxämie darstellt, das der O2-Gabe via Gesichtsmaske mindestens ebenbürtig ist und möglicherweise den pulmonalen Gasaustausch bei Patienten mit erhöhtem BMI sowie pulmonalen Vorerkrankungen langfristig verbessert. Diese Daten rechtfertigen eine prospektiv randomisierte klinische Studie.
Cardiac surgery is associated with release of the pleiotropic cytokine macrophage migration inhib... more Cardiac surgery is associated with release of the pleiotropic cytokine macrophage migration inhibitory factor (MIF). The trigger for MIF release has not yet been elucidated. Owing to its intrinsic antioxidative activity, MIF might reduce oxidative stress and protect from myocardial ischemia and reperfusion (I/R) injury. In the present study, patients scheduled for elective cardiac surgery (n=46) were randomized to undergo coronary artery bypass grafting either conventionally with cardiopulmonary bypass and cardioplegic arrest-induced I/R (cCABG) or in an off-pump procedure (OPCAB) with minimized I/R. We report that only patients who underwent cCABG exhibited a postoperative increase of MIF (p=0.024), while both groups showed an increase in interleukin-6. MIF release appears to be primarily mediated by I/R and to a lesser extent by inflammation. Endogenous peroxidase activity (p=0.021) and serum levels of thioredoxin (p=0.003) were significantly higher in patients who underwent cCABG...
Background: Cardiac surgery has been shown to result in a significant decrease of the antioxidant... more Background: Cardiac surgery has been shown to result in a significant decrease of the antioxidant selenium, which is associated with the development of multiorgan dysfunction and increased mortality. Thus, a large-scale study is needed to investigate the effect of perioperative selenium supplementation on the occurrence of postoperative organ dysfunction.
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