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Anesthesiology:
doi: 10.1097/01.anes.0000444098.84209.85
Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist: Key Papers from the Most Recent Literature Relevant to Anesthesiologists

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Impact of contact isolation for multidrug resistant organisms on the occurrence of medical errors and adverse events. Intensive Care Med 2013; 39:2153–60.

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Contact isolation of infected or colonized hospitalized patients is a standard practice used to interrupt multiple drug-resistant organism transmission. However, a large body of recent work suggests an increased rate of adverse events associated with isolation. This study used the large database of the Iatroref III study to compare the incidence of adverse events and medical errors occurring in isolated versus nonisolated intensive care unit patients. A subdistribution hazard regression model with careful adjustment on confounders was used. The results indicate a higher rate of errors in anticoagulant prescription, in the occurrence of hypo- or hyperglycemia, and in rate of ventilator-acquired pneumonia in isolated patients.
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Acute liver failure. N Engl J Med 2013; 369:2525–34.

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Acute liver failure is a rare, but life-threatening condition. This article reviews common causes, diagnostic approaches, and therapeutic interventions for acute liver failure in a clear and understandable presentation. Particular effort has been made to bridge the gap between unresolved pathophysiologic issues and pragmatic therapeutic approaches. Anesthesiologists will find here an attractive, nicely illustrated, state-of-the-art document on this topic.
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Induced hypothermia in severe bacterial meningitis: A randomized clinical trial. JAMA 2013; 310:2174–83.

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This French open-label multicenter randomized controlled trial tested the hypothesis that mild hypothermia may improve outcome in patients with severe meningitis (particularly that due to streptococcus pneumonia). Patients in the hypothermia group (n=49) were cooled to 32–34°C for 48 h by a loading dose of 4°C saline while controls received standard care (n=49). The trial was stopped prematurely because of a higher rate of mortality in the intervention group (51% vs. 31%, relative risk =1.99; 95% confidence interval = 1.05–3.77, P<0.04). Hypothermia was found futile, and even perhaps harmful, in patients with comatose bacterial meningitis.
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Association of β-blocker therapy with risks of adverse cardiovascularevents and deaths in patients with ischemic heart disease undergoing noncardiac surgery: A Danish nationwide cohort study. JAMA Intern Med. 2013 Nov 18.doi: 10.1001/jamainternmed.2013.11349.

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The proper use of perioperative β-blocker therapy in noncardiac surgical patients at cardiovascular risk remains an ongoing debate. This large retrospective cohort study of nearly 37,000 patients examined the association of β-blocker therapy with mortality and major adverse cardiac events in noncardiac surgical patients with ischemic heart disease. The use of perioperative β-blockers reduced mortality and major cardiac adverse events at 30 days only in patients with heart failure or recent myocardial infarction. These results call for a thorough personalized prescription of perioperative β-blockers in patients with ischemic heart disease undergoing noncardiac surgery.
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Cessation of dual antiplatelet treatment and cardiac event after percutaneous coronary intervention (PARIS): 2 year results from a prospective observational study. Lancet 2013; 382:1714–22.

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Cessation of dual antiplatelet therapy increases the risk of adverse events after percutaneous coronary intervention, but whether this risk changes with time or depends on other factors remains unclear. This prospective observational cohort study enrolled 5,031 patients from the patterns of nonadherence to antiplatelet regimens in stented patients (PARIS) registry with a follow-up of 24 months after implantation. Over 2 yr, the overall incidence of any cessation of dual antiplatelet therapy was 57%. Cardiovascular risk due to treatment cessation was increased only in the case of disruption due to noncompliance or bleeding, with a largely attenuated risk within 30 days from the time of cessation. Interestingly, no significant increase of adverse events was found for brief periods of interruption (<14 days) for surgical procedures. These results may help to guide the management of perioperative dual antiplatelet therapy in surgical patients.
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Substance use disorder among anesthesiology residents, 1975-2009. JAMA 2013; 310:2289–96.

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The aim of this retrospective cohort study was to describe the incidence and outcomes of drug abuse disorders among anesthesiology residents in the United States between 1975 and 2009. Among the approximately 45,000 residents the overall incidence was 2.16 (95% confidence interval [CI] = 1.95–2.39) per 1,000 resident-years (2.68, 95% CI = 2.41–2.98, men; 0.65, 95% CI = 0.44–0.93, women). The most commonly used substance category was intravenous opioids, followed by alcohol, marijuana or cocaine, anesthetics/hypnotics, and oral opioids. Death rate related to drug abuse among residents was 7.3% during the training period. Substance use disorder remains a problem for some anesthesiologists during the training period, and the risk of relapse during the follow-up period was high, indicating persistence of risk post training.
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Remote optogenetic activation and sensitization of pain pathways in freely moving mice. J Neurosci 2013;33:18631–40.

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Image: From Wiese AJ...
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Although we have learned much about the functioning of these nociceptors using pharmacologic and electrophysiologic approaches, issues such as temporal resolution of effects and nonspecific pharmacologic interactions have limited our progress. To address this problem, Daou et al. developed a strain of mice expressing the light-sensitive channelrhodopsin-2 (ChR2) protein in nociceptors also expressing the Nav 1.8 sodium ion channel. In this way the authors were able to selectively activate these pain fibers using simple blue light. When exposed to blue light the animals rapidly exhibited several types of nocifensive behaviors. This new animal reagent developed using popular optogenetic technology may greatly accelerate our understanding of the peripheral nervous system as it initiates and maintains pain after injuries such as surgery.
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A molecular machine for neurotransmitter release: Synaptotagmin and beyond. Nature Medicine 2013; 19:1227–31.

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This outstanding review describes the mechanisms explaining how membranes undergo rapid fusion during transmitter release, its regulation by calcium, and its spatial organization within the synaptic vesicles. The body of the manuscript consists of telling a story reporting a logical experimental approach developed over 30 yr in a top-level lab and includes magnificent descriptive illustrations. Anesthesiologists will find here robust basic science data that shed light on one of the most important biologic phenomena relevant to interactions of anesthetics with the central and autonomic nervous system.

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