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Science, Medicine, and the Anesthesiologist  |   February 2015
Science, Medicine, and the Anesthesiologist
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Science, Medicine, and the Anesthesiologist
Science, Medicine, and the Anesthesiologist   |   February 2015
Science, Medicine, and the Anesthesiologist
Anesthesiology 2 2015, Vol.122, A21-A22. doi:10.1097/01.anes.0000459437.26633.68
Anesthesiology 2 2015, Vol.122, A21-A22. doi:10.1097/01.anes.0000459437.26633.68
Key Papers from the Most Recent Literature Relevant to Anesthesiologists
Clinical recovery from surgery correlates with single-cell immune signatures. Sci Transl Med 2014; 6:255ra131.
Summary: J.D. Clark. Image: J.P. Rathmell [monocyte micrograph by Dr. Graham Beards via Wikimedia Commons].
Summary: J.D. Clark. Image: J.P. Rathmell [monocyte micrograph by Dr. Graham Beards via Wikimedia Commons].
Summary: J.D. Clark. Image: J.P. Rathmell [monocyte micrograph by Dr. Graham Beards via Wikimedia Commons].
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In their recent publication, Gaudillière et al. demonstrate that specific immune cell subsets predict time to recovery from hip joint replacement surgery. To accomplish these analyses, single-cell mass cytometry was applied to whole blood taken from patients during and shortly after their procedures, and outcomes were followed for 6 weeks. The authors found that very early changes in specific populations of CD14+ monocytes correlated very strongly with fatigue, disability, and pain. The work implicated specific signaling pathways in these monocytes including STAT3, CREB, and NFκB. Unclear at this point is how these monocytes might be functioning to control the clinical recovery phenotypes. The work is of potentially very great significance as this approach might provide early biomarkers of long-term outcomes as well as provide novel insights as to why we see such large variability in recovery between patients after surgery.
Benzodiazepine use and the risk of Alzheimer’s disease: Case-control study. BMJ 2014; 349:g5205. doi: 10.1136/bmj.g5205.
Summary: J. Mantz. Image: ©Shutterstock.
Summary: J. Mantz. Image: ©Shutterstock.
Summary: J. Mantz. Image: ©Shutterstock.
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In a population-based study conducted in 2012, new use of benzodiazepines was associated with an increased risk of dementia (multivariable adjusted hazard ratio, 1.60; 95% confidence interval, 1.08–2.38). The present collaborative French-Canadian case-control study originating from the same group confirms and extends that benzodiazepine use of at least 5 yr is associated with an increased risk of Alzheimer disease (adjusted odds ratio, 1.51; 95% confidence interval, 1.36–1.69). The stronger association observed for long-term exposures (at least 5 yr of use) reinforces the suspicion of a possible direct association; however, the mechanisms involved in this phenomenon deserve further investigations.
Association between vancomycin minimum inhibitory concentration and mortality among patients with Staphylococcus aureus bloodstream infections: A systematic review and meta-analysis. JAMA 2014; 312:1552–64.
Summary: J. Mantz. Image: Reproduced from International Journal of Medical Sciences. Used with permission.
Summary: J. Mantz. Image: Reproduced from International Journal of Medical Sciences. Used with permission.
Summary: J. Mantz. Image: Reproduced from International Journal of Medical Sciences. Used with permission.
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Staphylococcus aureus bacteremia (SAB) and resistance of these bacteria to vancomycin leading to higher minimum inhibitory concentrations (MIC) are worldwide issues. Previous studies have shown conflicting results on whether there is a correlation between higher vancomycin MIC and mortality. This meta-analysis included 38 studies that involved 8,291 episodes of SAB, and found overall mortality to be 26.1%. While there was no statistically significant difference in the risk of death when comparing patients with SAB exhibiting high-vancomycin MIC (>1.5 mg/l) to those with low-vancomycin MIC (<1.5 mg/l), the risk of increased mortality could not be ruled out. These findings may help to guide the choice of antistaphylococcal antibiotics in patients with SAB.
Dual-antiplatelet treatment beyond 1 year after drug-eluting stent implantation (ARCTIC-Interruption): A randomised trial. Lancet 2014; 384:1577–85.
Summary: J. Mantz. Image: Cardiac stent adapted from image by Frank Muller via Wikimedia Commons.
Summary: J. Mantz. Image: Cardiac stent adapted from image by Frank Muller via Wikimedia Commons.
Summary: J. Mantz. Image: Cardiac stent adapted from image by Frank Muller via Wikimedia Commons.
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Whether dual antiplatelet therapy (DAPT) continuation beyond 1 yr after coronary stenting is beneficial is unknown. This analysis was a planned extension of the previously published ARCTIC-Monitoring trial, in which 2,440 patients were randomly allocated to a strategy of platelet function testing with antiplatelet treatment adjustment or a conventional strategy after coronary stenting with drug-eluting stent (DES). At 1-yr follow up, a second randomization (interruption of DAPT with aspirin maintenance vs. pursuing DAPT for 6–18 months) was performed. The primary endpoint was a composite of death and major cardiac adverse events. No difference between arms was observed in the composite after a 17-month median duration of follow up. In contrast, significantly more bleeding episodes were observed in the DAPT continuation group. These findings have impact for anesthesiologists and call for updating guidelines for DAPT after stenting with DES toward shorter duration of treatment.
Trial of the route of early nutritional support in critically ill adults. N Engl J Med 2014; 371:1673–84.
Summary: J. Mantz. Image: ©Shutterstock.
Summary: J. Mantz. Image: ©Shutterstock.
Summary: J. Mantz. Image: ©Shutterstock.
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Nutritional support is a standard of care in patients who are critically ill. Currently, the enteral route is the mainstay route of administration, largely on the grounds of physiological rationale and modest evidence suggesting an association with fewer infections. Conversely, it can also be associated with gastrointestinal intolerance and underfeeding. In this randomized multicenter prospective trial enrolling 2,400 patients, the effect of the enteral versus parenteral route initiated within 36 h after admission and continued up to 5 days was compared on all-cause mortality at 30 day. This trial did not find any significant difference either in mortality rates at 30 days (relative risk in parenteral group, 0.97; 95% confidence interval, 0.86–1.08; P = 0.57) or in septic complications, yet a 50% reduction in the incidence of hypoglycemia and vomiting in the parenteral arm.
Lower versus higher hemoglobin threshold for transfusion in septic shock. N Engl J Med 2014; 371:1381–91; Goal-directed resuscitation for patients with early septic shock. N Engl J Med 2014; 371:1496–506.
Summary: J. Mantz. Image: J.P. Rathmell.
Summary: J. Mantz. Image: J.P. Rathmell.
Summary: J. Mantz. Image: J.P. Rathmell.
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The benefits of optimization of oxygen delivery via goal-directed strategies for resuscitation of patients with septic shock are still controversial. The benefits and harms of different hemoglobin thresholds for transfusion in septic critically ills have not been established. The first paper provides results from a prospective randomized multicenter trial of 1,005 patients with septic shock that were allocated to receive 1 unit of leukoreduced red cells when the hemoglobin level was 7 g/dl or less (lower threshold) or when the level was 9 g/dl or less (higher threshold) during the intensive care unit (ICU) stay. The primary outcome measure was death by 90 days after randomization. No difference in mortality rates was observed between the two groups, and transfusion rates were reduced in the lower threshold arm. In the second paper, 1,600 ICU patients presenting in the emergency room with septic shock were randomly assigned to receive either early goal-directed therapy or usual care. The primary outcome was all-cause mortality within 90 days after randomization. No significant difference was found in rates of death at 90 days (18.6% vs. 18.8%, NS) as well as in any secondary objective. All in one, these papers challenge the benefits of early optimization of oxygen delivery in patients with septic shock.
It's not just what you know: The non-cognitive attributes of great clinical teachers. Pediatrics 2014; 134:852–4.
Summary: A.J. Schwartz. Image: J.P. Rathmell.
Summary: A.J. Schwartz. Image: J.P. Rathmell.
Summary: A.J. Schwartz. Image: J.P. Rathmell.
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We all remember our great teachers. We often think they were born with a genetic predisposition to be great teachers. That’s not exactly how it happens! Dudas and Bannister vividly point this out in their recent article about the noncognitive attributes of great teachers. Although they discuss teachers of medical students learning pediatrics, their message is universal and absolutely applicable to teaching anesthesiology to all variety of students. They tell us that it’s not only what you teach; it’s very much how you teach that elicits the best from your students. Encouraging students to be self-motivated, being an enthusiastic teaching role model, being a leader as a teacher, being a coach for your students, being a student as well as a teacher, and being able to evaluate and adapt teaching moments gone astray are the noncognitive characteristics of the best teachers emphasized by Dudas and Bannister.
Summary: J.D. Clark. Image: J.P. Rathmell [monocyte micrograph by Dr. Graham Beards via Wikimedia Commons].
Summary: J.D. Clark. Image: J.P. Rathmell [monocyte micrograph by Dr. Graham Beards via Wikimedia Commons].
Summary: J.D. Clark. Image: J.P. Rathmell [monocyte micrograph by Dr. Graham Beards via Wikimedia Commons].
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Summary: J. Mantz. Image: ©Shutterstock.
Summary: J. Mantz. Image: ©Shutterstock.
Summary: J. Mantz. Image: ©Shutterstock.
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Summary: J. Mantz. Image: Reproduced from International Journal of Medical Sciences. Used with permission.
Summary: J. Mantz. Image: Reproduced from International Journal of Medical Sciences. Used with permission.
Summary: J. Mantz. Image: Reproduced from International Journal of Medical Sciences. Used with permission.
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Summary: J. Mantz. Image: Cardiac stent adapted from image by Frank Muller via Wikimedia Commons.
Summary: J. Mantz. Image: Cardiac stent adapted from image by Frank Muller via Wikimedia Commons.
Summary: J. Mantz. Image: Cardiac stent adapted from image by Frank Muller via Wikimedia Commons.
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Summary: J. Mantz. Image: ©Shutterstock.
Summary: J. Mantz. Image: ©Shutterstock.
Summary: J. Mantz. Image: ©Shutterstock.
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Summary: J. Mantz. Image: J.P. Rathmell.
Summary: J. Mantz. Image: J.P. Rathmell.
Summary: J. Mantz. Image: J.P. Rathmell.
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Summary: A.J. Schwartz. Image: J.P. Rathmell.
Summary: A.J. Schwartz. Image: J.P. Rathmell.
Summary: A.J. Schwartz. Image: J.P. Rathmell.
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