Science, Medicine, and the Anesthesiologist

Key Papers from the Most Recent Literature Relevant to AnesthesiologistsSingle-nucleus RNA sequencing was performed in more than 116,000 cellular nuclei isolated during rapid autopsies lungs of 19 fatal cases COVID-19 and 7 control after surgical resection, develop a lung atlas comparing alterations composition, transcriptional cell states, cell-to-cell interactions. The goal this signaling is inform an understanding long-term pulmonary complications identify novel therapeutic targets. primary findings included abnormally activated, IL-1ß-producing monocytes/macrophages, impairment alveolar epithelial regeneration, expansion pathological form fibroblasts that facilitate fibrosis. Monoctye-derived macrophages showed genetic changes associated with impaired T-cell immunity. Impaired regeneration indicated by failure type II cells transition I cells. had greater subsets fibroblasts, known drivers fibrosis idiopathic scleroderma. Inferred protein activity single-nucleus transcriptomes predicted enhanced MMP14 STAT3 as druggable targets attenuate Additionally, despite apparent adequate humoral immune response generation neutralizing antibodies against receptor-binding domain SARS-CoV-2 spike protein, there were inadequate responses patients.Take home message: This pathways fatalities based on patients. may outcomes injury surviving patients targets.The differential effects balanced (Plasma-Lyte 148) versus 0.9% sodium chloride solution 90-day survival acute kidney critically ill remain controversial. double-blind, factorial (fluid type, infusion speed), randomized clinical trial 75 intensive care units (ICUs) Brazil at least one risk factor for adverse requiring episode fluid anticipated ICU admission 24 h. Patients either throughout their between May 2017 March 2020. outcome survival. A total 11,052 10,520 (95%) analyzed (mean age, 61 ± 17 yr; 44% women). There no significant interaction two interventions speed; P = 0.98). Planned admissions accounted 48% all patients; 61% hypotension or vasopressor use receiving mechanical ventilation enrollment. received median 1.5 l first day By 90, mortality occurred 26% group 27% saline (adjusted hazard ratio, 0.97; 95% CI, 0.90 1.05; 0.47). treatment-related severe events group.Take In large multicenter saline, difference post-ICU challenges.The rapidity challenges uncertain. h slower rate (333 ml/h) (999 assigned mean 1,162 ml 1,252 group. 26.6% 27.0% 1.03; 0.96 1.11; 0.46).Take large, challenges, infusing salt faster did not reduce mortality.In lumbar spinal stenosis degenerative spondylolisthesis, need decompression instrumented fusion surgery alone open-label, multicenter, noninferiority symptomatic single-level spondylolisthesis 3 mm fusion. reduction 30% score Oswestry Disability Index (range, 0 100; higher scores indicating impairment) over 2 yr surgery. margin −15 percentage points used. 267 randomized. change baseline −21 decompression-alone difference, 0.7; −2.8 4.3). intent-to-treat analysis, 71% 73% (difference, −1.4 points; −12.2 9.4), establishing alone. Similar noninferior results noted per-protocol analysis. Reoperation 12% 9% 3.4 −4.6 11.5).Take subjects period yr.The impact author sex subsequent literature citations research commentary articles published high-impact medical journals has been systematically evaluated. cross-sectional study original five (Annals Internal Medicine, British Medical Journal, JAMA, JAMA New England Journal Medicine) 2015 2018 recording senior authors each article number using Web Science. latter, stratified sex, compared. Of 5,554 analyzed, 36% women authors. statistically significantly lower (interquartile range) (primary 36 [17 82] vs. men 54 [22 141] citations; 37 93] 51 [20 128] < 0.001). addition, both (33 [15 68] 59 [23 149] .001). Differences time less pronounced among articles.Take Original highest-impact written cited frequently those men, particularly when women.The optimal drug inotropic support cardiogenic shock remains pragmatic double-blind compared milrinone dobutamine 192 admitted cardiac unit quaternary Canadian center diagnosed (Society Cardiovascular Angiography Interventions definition: stages B E). standardized dosing protocol (five steps) used; adjustment left judgement treating physician. composite in-hospital all-cause mortality, arrest, transplant; circulatory support, nonfatal myocardial infarction, transient ischemic attack, stroke; renal replacement therapy. Secondary individual components. Treatment groups well matched (ages 69 72; female 38% 35%; cardiomyopathy 69% 65%, dobutamine, respectively). participants (96 group) analyzed. Pulmonary artery catheters used only 23 subjects. Comparing outcome: 49% 54% (relative risk, 0.90; 0.69 1.19; No heterogeneity treatment effect prespecified subgroups noted. differences secondary outcomes. In-hospital similar (37% 43%; relative 0.85; 0.60 1.21).Take single-center unit, component outcomes.The strategy weaning infants children stepped-wedge, cluster 18 pediatric United Kingdom (February October 2019) sequentially intervention (n 4,688) usual 4,155). involved assessment sedation level, daily screening readiness undertake spontaneous breathing trial, test ventilator liberation potential, rounds review set patient-relevant duration invasive (initiation until successful extubation). ratio adjusted calendar hospital site. 8,843 (median 8 months [interquartile range, 1 46 months]; 42% female) completed trial. Protocol resulted shorter extubation (64.8 66.2 h, respectively; −6.1 −8.2 −5.3 h]; 1.11 [95% 1.02 1.20]; 0.02). incidence serious groups.Take prolonged ventilation, but marginally clinically important extubation.Preoperative advance planning undergoing major increasingly emphasized. However, extent which it occurs unknown. analysis multisite evaluated question prompt list (11 questions) preoperative communication adults 60 older comorbidity oncologic vascular diagnosis U.S. academic centers. From audio-recorded consultation, any statement regarding surgeon, patient, family member record examined presence directive. Interviews experiencing postoperative conducted. 213 (57% male; 72 yr), 13 conversations noted; 66% have associations directive patient comorbidities, procedure (oncologic [32%] [42%]; 0.22). documentation mailed 35% 33% (P 0.77). general, think discuss preferences surgeon preoperatively.Take life-sustaining treatments high-risk infrequently explored, addressed, documented preoperatively.Pain complex phenomenon involving perceptual (intensity), autonomic, motor expectation pain can amplify perception, although expectancy autonomic components understood. psychophysical testing paradigm high- low-intensity painful thermal stimuli paired simple visual cue impart 32 healthy Autonomic (skin conductance) distal (electromyography) transcranial magnetic stimulation cortex recorded. high-intensity stimulus led ratings intensity expected (F [1, 31] 16.88; Additional suppressed, expectancy. Modeling subject’s revealed perception mediated noxious responses. Expecting high level alters experienced intensity, changes, include protective reflexes.Take Pain expectations should be addressed therapy, patients’ cause them avoid movement such critical recovery injuries surgery.Genome-wide association studies suggested estimated creatinine-based glomerular filtration rate, most common measure function, strong heritable component, residual uncertainty attributed low-frequency variants. serum creatinine metabolite muscle metabolism confounding its function. It challenge genome-wide dissect mechanisms biomarker modulators Little data are available alternative biomarkers (blood urea nitrogen, cystatin C). Fine-mapping signals narrow down few variants driving will benefit increased sample size. Using databases 1,201,909 (CKDGen Consortium UK Biobank; 84% European ancestry), meta-analyses done looking gene loci could variations blood nitrogen. For measure, 424 (201 novel) identified 5×10–8), explained 9.8% variance. these, 82% validated other biomarkers. size credible sets (99% posterior probability association) genes.Take greatly previous studies, genes provide evidence mechanistic insights starting point biologic investigation.Abelacimab human monoclonal antibody binds catalytic XI locks inactive conformation, preventing activation XII thrombin. Abelacimab immediately lowers concentration functional dose-dependent manner. phase prospective antithrombotic three regimens abelacimab (30, 75, 150 mg) standard prophylactic dose enoxaparin (40 unilateral knee arthroplasty. endpoint deep vein thrombosis 12 days. principal safety relevant bleeding randomization through 30. Venous thromboembolism 102 (13%) 30-mg group, 5 99 (5%) 75-mg 4 98 (4%) 150-mg 22 101 (22%) superior Bleeding 2%, none 30-mg, 75-mg, groups, respectively, Factor inhibition effective prevent venous low bleeding.This systematic conducted summarize accuracy pressure measurement methods (office home) 24-h ambulatory diagnosing hypertension. latter reference given substantial demonstrating future cardiovascular events. 6,877) conventional office six 2,049) included; these 3,040) consecutive samples. Random summary sensitivity, specificity, likelihood ratios calculated Conventional oscillometric (1 measurements single visit 140/90 mmHg) sensitivity 51% (95% 67%), specificity 88% 80 96%), positive 4.2 2.5 6.0), negative 0.56 0.42 0.69). Mean (with 135/85 75% 65 86%), 76% 3.1 2.2 4.0), 0.33 0.20 0.47).Take reliable Home helpful, divergent, considered establish diagnosis.