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\"The first running book by [the] ... creator of the Air Force's Efficient Running program--the result of more than three decades of study, practice, and science that shows us [that you can] ... run efficiently and injury-free, whether you're in your 20s, 60s or 70s. For beginning runners and experienced marathoners\"-- Provided by publisher.
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Anaesthesia Management for Awake Craniotomy: Systematic Review and Meta-Analysis
Awake craniotomy (AC) renders an expanded role in functional neurosurgery. Yet, evidence for optimal anaesthesia management remains limited. We aimed to summarise the latest clinical evidence of AC anaesthesia management and explore the relationship of AC failures on the used anaesthesia techniques.
Two authors performed independently a systematic search of English articles in PubMed and EMBASE database 1/2007-12/2015. Search included randomised controlled trials (RCTs), observational trials, and case reports (n>4 cases), which reported anaesthetic approach for AC and at least one of our pre-specified outcomes: intraoperative seizures, hypoxia, arterial hypertension, nausea and vomiting, neurological dysfunction, conversion into general anaesthesia and failure of AC. Random effects meta-analysis was used to estimate event rates for four outcomes. Relationship with anaesthesia technique was explored using logistic meta-regression, calculating the odds ratios (OR) and 95% confidence intervals [95%CI].
We have included forty-seven studies. Eighteen reported asleep-awake-asleep technique (SAS), twenty-seven monitored anaesthesia care (MAC), one reported both and one used the awake-awake-awake technique (AAA). Proportions of AC failures, intraoperative seizures, new neurological dysfunction and conversion into general anaesthesia (GA) were 2% [95%CI:1-3], 8% [95%CI:6-11], 17% [95%CI:12-23] and 2% [95%CI:2-3], respectively. Meta-regression of SAS and MAC technique did not reveal any relevant differences between outcomes explained by the technique, except for conversion into GA. Estimated OR comparing SAS to MAC for AC failures was 0.98 [95%CI:0.36-2.69], 1.01 [95%CI:0.52-1.88] for seizures, 1.66 [95%CI:1.35-3.70] for new neurological dysfunction and 2.17 [95%CI:1.22-3.85] for conversion into GA. The latter result has to be interpreted cautiously. It is based on one retrospective high-risk of bias study and significance was abolished in a sensitivity analysis of only prospectively conducted studies.
SAS and MAC techniques were feasible and safe, whereas data for AAA technique are limited. Large RCTs are required to prove superiority of one anaesthetic regime for AC.
Journal Article
Postoperative delirium is an independent factor influencing the length of stay of elderly patients in the intensive care unit and in hospital
PurposePostoperative delirium (POD) is an often unrecognized adverse event in older people after surgery. The aim of this subgroup analysis of the PRe-Operative Prediction of postoperative DElirium by appropriate SCreening (PROPDESC) trial in patients aged 70 years and older was to identify preoperative risk factors and the impact of POD on length of stay (LOS) in intensive care unit (ICU) and hospital.MethodsOf the total 1097 patients recruited at a German university hospital (from September 2018 to October 2019) in the PROPDESC prospective observational study, 588 patients aged 70 years and older (mean age 77.2 ± 4.7 years) were included for subgroup analysis. The primary endpoint POD was considered positive if one of the following tests were positive on any of the five postoperative visit days: Confusion Assessment Method for ICU (CAM-ICU), Confusion Assessment Method (CAM), 4'A's (4AT) and Delirium Observation Scale (DOS). Trained doctoral students carried out these visitations and additionally the nursing staff were interviewed for completion of the DOS. To evaluate the independent effect of POD on LOS in ICU and in hospital, a multi-variable linear regression analysis was performed.ResultsThe POD incidence was 25.9%. The results of our model showed POD as an independent predictor for a prolonged LOS in ICU (36%; 95% CI 4–78%; < 0.001) and in hospital (22%; 95% CI 4–43%; < 0.001).ConclusionPOD has an independent impact on LOS in ICU and in hospital. Based on the effect of POD for the elderly, a standardized risk screening is required.Trail registrationGerman Registry for Clinical Studies: DRKS00015715.
Journal Article
Pre-Interventional Risk Assessment in The Elderly (PIRATE): Development of a scoring system to predict 30-day mortality using data of the Peri-Interventional Outcome Study in the Elderly
Risk assessment before interventions in elderly patients becomes more and more vital due to an increasing number of elderly patients requiring surgery. Existing risk scores are often not tailored to marginalized groups such as patients aged 80 years or older. We aimed to develop an easy-to-use and readily applicable risk assessment tool that implements pre-interventional predictors of 30-day mortality in elderly patients (≥80 years) undergoing interventions under anesthesia. Using Cox regression analysis, we compared different sets of predictors by taking into account their ease of availability and by evaluating predictive accuracy. Coefficient estimates were utilized to set up a scoring system that was internally validated. Model building and evaluation were based on data from the Peri-Interventional Outcome Study in the Elderly (POSE), which was conducted as a European multicenter, observational prospective cohort study. Our risk assessment tool, named PIRATE, contains three predictors assessable at admission (urgency , severity and living conditions ). Discriminatory power, as measured by the concordance index, was 0.75. The estimated prediction error, as measured by the Brier score, was 0.036 (covariate-free reference model: 0.043). PIRATE is an easy-to-use risk assessment tool that helps stratifying elderly patients undergoing interventions with anesthesia at increased risk of mortality. PIRATE is readily available and applies to a wide variety of settings. In particular, it covers patients needing elective or emergency surgery and undergoing in-hospital or day-case surgery. Also, it applies to all types of interventions, from minor to major. It may serve as a basis for multidisciplinary and informed shared decision-making.
Journal Article
General vs. neuraxial anaesthesia in hip fracture patients: a systematic review and meta-analysis
Background
Hip fracture is a trauma of the elderly. The worldwide number of patients in need of surgery after hip fracture will increase in the coming years. The 30-day mortality ranges between 4 and 14%. Patients’ outcome may be improved by anaesthesia technique (general vs. neuraxial anaesthesia). There is a dearth of evidence from randomised studies regarding to the optimal anaesthesia technique. However, several large non-randomised studies addressing this question have been published from the onset of 2010.
Methods
To compare the 30-day mortality rate, in-hospital mortality rate and length of hospital stay after neuraxial (epidural/spinal) or general anaesthesia in hip fracture patients (≥ 18 years old) we prepared a systematic review and meta-analysis. A systematic search for appropriate retrospective observational and prospective randomised studies in Embase and PubMed databases was performed in the time-period from 01.01.2010 to 21.11.2016. Additionally a forward searching in google scholar, a level one reference list searching and a formal searching of trial registries was performed.
Results
Twenty retrospective observational and three prospective randomised controlled studies were included. There was no difference in the 30-day mortality [OR 0.99; 95% CI (0.94 to 1.04),
p
= 0.60] between the general and the neuraxial anaesthesia group. The in-hospital mortality [OR 0.85; 95% CI (0.76 to 0.95),
p
= 0.004] and the length of hospital stay were significantly shorter in the neuraxial anaesthesia group [MD -0.26; 95% CI (−0.36 to −0.17);
p
< 0.00001].
Conclusion
Neuraxial anaesthesia is associated with a reduced in-hospital mortality and length of hospitalisation. However, type of anaesthesia did not influence the 30-day mortality. In future there is a need for large randomised studies to examine the association between the type of anaesthesia, post-operative complications and mortality.
Journal Article
Poor reporting quality of observational clinical studies comparing treatments of COVID-19 – a retrospective cross-sectional study
Background
During the COVID-19 pandemic, the scientific world is in urgent need for new evidence on the treatment of COVID patients. The reporting quality is crucial for transparent scientific publication. Concerns of data integrity, methodology and transparency were raised. Here, we assessed the adherence of observational studies comparing treatments of COVID 19 to the STROBE checklist in 2020.
Methods
Design: We performed a retrospective, cross-sectional study. Setting: We conducted a systematic literature search in the Medline database. This study was performed at the RWTH Aachen University Hospital, Department of Anaesthesiology Participants: We extracted all observational studies on the treatment of COVID-19 patients from the year 2020. Main outcome measures: The adherence of each publication to the STROBE checklist items was analysed. The journals’ impact factor (IF), the country of origin, the kind of investigated treatment and the month of publication were assessed.
Results
We analysed 147 observational studies and found a mean adherence of 45.6% to the STROBE checklist items. The percentage adherence per publication correlated significantly with the journals’ IF (point estimate for the difference between 1
st
and 4
th
quartile 11.07%, 95% CI 5.12 to 17.02,
p
< 0.001). U.S. American authors gained significantly higher adherence to the checklist than Chinese authors, mean difference 9.10% (SD 2.85%,
p
= 0.023).
Conclusions
We conclude a poor reporting quality of observational studies on the treatment of COVID-19 throughout the year 2020. A considerable improvement is mandatory.
Journal Article
Update of the organoprotective properties of xenon and argon: from bench to beside
The growth of the elderly population has led to an increase in patients with myocardial infarction and stroke (Wajngarten and Silva, Eur Cardiol 14: 111–115, 2019). Patients receiving treatment for ST-segment-elevation myocardial infarction (STEMI) highly profit from early reperfusion therapy under 3 h from the onset of symptoms. However, mortality from STEMI remains high due to the increase in age and comorbidities (Menees et al., N Engl J Med 369: 901–909, 2013). These factors also account for patients with acute ischaemic stroke. Reperfusion therapy has been established as the gold standard within the first 4 to 5 h after onset of symptoms (Powers et al., Stroke 49: e46-e110, 2018). Nonetheless, not all patients are eligible for reperfusion therapy. The same is true for traumatic brain injury patients. Due to the complexity of acute myocardial and central nervous injury (CNS), finding organ protective substances to improve the function of remote myocardium and the ischaemic penumbra of the brain is urgent. This narrative review focuses on the noble gases argon and xenon and their possible cardiac, renal and neuroprotectant properties in the elderly high-risk (surgical) population. The article will provide an overview of the latest experimental and clinical studies. It is beyond the scope of this review to give a detailed summary of the mechanistic understanding of organ protection by xenon and argon.
Journal Article
Systematic review of prediction models for delirium in the older adult inpatient
ObjectiveTo identify existing prognostic delirium prediction models and evaluate their validity and statistical methodology in the older adult (≥60 years) acute hospital population.DesignSystematic review.Data sources and methodsPubMed, CINAHL, PsychINFO, SocINFO, Cochrane, Web of Science and Embase were searched from 1 January 1990 to 31 December 2016. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses and CHARMS Statement guided protocol development. Inclusion criteria: age >60 years, inpatient, developed/validated a prognostic delirium prediction model. Exclusion criteria: alcohol-related delirium, sample size ≤50. The primary performance measures were calibration and discrimination statistics. Two authors independently conducted search and extracted data. The synthesis of data was done by the first author. Disagreement was resolved by the mentoring author.ResultsThe initial search resulted in 7,502 studies. Following full-text review of 192 studies, 33 were excluded based on age criteria (<60 years) and 27 met the defined criteria. Twenty-three delirium prediction models were identified, 14 were externally validated and 3 were internally validated. The following populations were represented: 11 medical, 3 medical/surgical and 13 surgical. The assessment of delirium was often non-systematic, resulting in varied incidence. Fourteen models were externally validated with an area under the receiver operating curve range from 0.52 to 0.94. Limitations in design, data collection methods and model metric reporting statistics were identified.ConclusionsDelirium prediction models for older adults show variable and typically inadequate predictive capabilities. Our review highlights the need for development of robust models to predict delirium in older inpatients. We provide recommendations for the development of such models.
Journal Article
CCR2 dependent recruited pro-inflammatory monocytes contribute to the development of left ventricular hypertrophy in mice upon transverse aortic constriction
C-C chemokine receptor type 2 positive monocytes are recruited from the circulation to infiltrate inflamed tissue. Left ventricular (LV) hypertrophy caused by pressure overload presents with a chronic myocardial inflammation in our mouse model of transverse aortic constriction (TAC). Recent analyses demonstrated that deficiency of fractalkine receptor CX3CR1 leads to a pro-inflammatory phenotype characterized by increased numbers of Ly6C high macrophages in the myocardium due to chemokine receptor CCR2 dependent monocyte recruitment from the circulation. Here, we analyzed the role of CCR2 in the development of left ventricular hypertrophy using Ccr2 -/- mice. We were able to show that a lack of CCR2 dependent recruited Ly6C high monocytes in the myocardium reveled cardioprotective effects resulting in less hypertrophy and reduced brain natriuretic peptide (BNP) expression, as biomarker of heart failure, in the myocardium. CCR2-deficiency caused an increase in neutrophil and a reduced macrophage accumulation in the myocardium in response to pressure overload. The cytokine pattern measured in the LV tissue indicates a significantly reduced release of IL1-β whereas TNF-α concentrations are increased following TAC. IL-6 secretion is not altered by the lack of CCR2 and the pro-remodeling cytokine IL-10 is not increased either. This study highlights the importance of CCR2 in the pathogenesis of LV hypertrophy and the relevance of CCR2 dependent recruited monocytes for the orchestration of the cardiac immune response.
Journal Article
Postoperative Long-Term Outcomes and Independent Risk Factors of Non-Small-Cell Lung Cancer Patients With Propofol versus Sevoflurane Anesthesia: A Retrospective Cohort Study
Background: Existing studies have shown that the relationship between anesthetic agents and non-small-cell lung cancer (NSCLC) prognosis remains controversial. Therefore, this retrospective cohort study was designed to investigate the effects of propofol or sevoflurane anesthesia on the long-term oncologic outcomes of NSCLC patients. Methods: We identified 1,778 eligible patients (propofol-based total intravenous anesthesia (TIVA) group, n = 686; sevoflurane-based inhalation anesthesia (INHA) group, n = 1,092) out of 2,388 patients undergoing elective NSCLC surgery from June 2013 to June 2016 in the Harbin Medical University Cancer Hospital. The primary endpoints were five-year overall survival and recurrence-free survival. The secondary endpoints were independent risk factors of cancer recurrence or all-cause mortality. The data were analyzed with propensity score matching, Kaplan–Meier survival, and Cox multivariate analyses as appropriate. Results: After propensity score matching, there were 672 patients in each group. The median follow-up period was 69 months (interquartile range: 68–70 months) for all patients. Five-year overall survival was 75.7% (95% confidence interval (CI) 72.4–79.1) in the TIVA group and 71.8% (68.4–75.4) in the INHA group ( p = 0.160) (hazard ratio (HR), 0.86; 95% CI, 0.70–1.06; p = 0.158), and five-year recurrence-free survival was 68.5% (65.0–72.2) and 62.7% (59.1–66.5 ( p = 0.108) (HR, 0.90; 95% CI, 0.75–1.08; p = 0.253), respectively. Subgroup analyses showed there were no significant difference in the overall survival or recurrence-free survival between the two groups in each TNM stage of NSCLC. The independent risk factors included age ≥60 years, male, blood transfusion, segmental/wedge resection and pneumonectomy, thoracotomy, postoperative complications, lung adenocarcinoma, TNM stages, high CEA and CYFRA211 levels, and postoperative radiotherapy. Conclusions: Our data indicated no difference between the propofol-based TIVA and sevoflurane-based INHA in terms of five-year overall survival and recurrence-free survival after NSCLC surgery.
Journal Article