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More than 70 years after its original report, the hypoxic pulmonary vasoconstriction (HPV) response continues to spark scientific interest on its mechanisms and clinical implications, particularly for anesthesiologists involved in thoracic surgery. Selective airway intubation and one-lung ventilation (OLV) facilitates the surgical intervention on a collapsed lung while the HPV redirects blood flow from the \"upper\" non-ventilated hypoxic lung to the \"dependent\" ventilated lung. Therefore, by limiting intrapulmonary shunting and optimizing ventilation-to-perfusion (V/Q) ratio, the fall in arterial oxygen pressure (PaO2) is attenuated during OLV. The HPV involves a biphasic response mobilizing calcium within pulmonary vascular smooth muscles, which is activated within seconds after exposure to low alveolar oxygen pressure and that gradually disappears upon re-oxygenation. Many factors including acid-base balance, the degree of lung expansion, circulatory volemia as well as lung diseases and patient age affect HPV. Anesthetic agents, analgesics and cardiovascular medications may also interfer with HPV during the perioperative period. Since HPV represents the homeostatic mechanism for regional ventilation-to-perfusion matching and in turn, for optimal pulmonary oxygen uptake, a clear understanding of HPV is clinically relevant for all anesthesiologists.

Perioperative fluid balance has a major impact on clinical and functional outcome, regardless of the type of interventions. In thoracic surgery, patients are more vulnerable to intravenous fluid overload and to develop acute respiratory distress syndrome and other complications. New insight has been gained on the mechanisms causing pulmonary complications and the role of the endothelial glycocalix layer to control fluid transfer from the intravascular to the interstitial spaces and to promote tissue blood flow. With the implementation of standardized processes of care, the preoperative fasting period has become shorter, surgical approaches are less invasive and patients are allowed to resume oral intake shortly after surgery. Intraoperatively, body fluid homeostasis and adequate tissue oxygen delivery can be achieved using a normovolemic therapy targeting a \"near-zero fluid balance\" or a goal-directed hemodynamic therapy to maximize stroke volume and oxygen delivery according to the Franck-Starling relationship. In both fluid strategies, the use of cardiovascular drugs is advocated to counteract the anesthetic-induced vasorelaxation and maintain arterial pressure whereas fluid intake is limited to avoid cumulative fluid balance exceeding 1 liter and body weight gain (~1-1.5 kg). Modern hemodynamic monitors provide valuable physiological parameters to assess patient volume responsiveness and circulatory flow while guiding fluid administration and cardiovascular drug therapy. Given the lack of randomized clinical trials, controversial debate still surrounds the issues of the optimal fluid strategy and the type of fluids (crystalloids versus colloids). To avoid the risk of lung hydrostatic or inflammatory edema and to enhance the postoperative recovery process, fluid administration should be prescribed as any drug, adapted to the patient's requirement and the context of thoracic intervention.

The \"moderate-to-high-risk\" surgical patient is typically older, frail, malnourished, suffering from multiple comorbidities and presenting with unhealthy life style such as smoking, hazardous drinking and sedentarity. Poor aerobic fitness, sarcopenia and \"toxic\" behaviors are modifiable risk factors for major postoperative complications. The physiological challenge of lung cancer surgery has been likened to running a marathon. Therefore, preoperative patient optimization or \" prehabilitation \" should become a key component of improved recovery pathways to enhance general health and physiological reserve prior to surgery. During the short preoperative period, the patients are more receptive and motivated to adhere to behavioral interventions (e.g., smoking cessation, weaning from alcohol, balanced food intake and active mobilization) and to follow a structured exercise training program. Sufficient protein intake should be ensured (1.5-2 g/kg/day) and nutritional defects should be corrected to restore muscle mass and strength. Currently, there is strong evidence supporting the effectiveness of various modalities of physical training (endurance training and/or respiratory muscle training) to enhance aerobic fitness and to mitigate the risk of pulmonary complications while reducing the hospital length of stay. Multimodal interventions should be individualized to the patient's condition. These bundle of care are more effective than single or sequential intervention owing to synergistic benefits of education, nutritional support and physical training. An effective prehabilitation program is necessarily patient-centred and coordinated among health care professionals (nurses, primary care physician, physiotherapists, nutritionists) to help the patient regain some control over the disease process and improve the physiological reserve to sustain surgical stress.

The administration of glucose-insulin-potassium (GIK) has demonstrated cardioprotective effects in cardiac surgery. A 58-year-old male with severe disabling back pain due to posterolateral lumbar pseudarthrosis was scheduled for spine surgery. He previously experienced two episodes of acute coronary syndrome that required percutaneous coronary interventions (PCIs). Coronary angiogram showed intrastent occlusions and multiple coronary lesions that were not suitable for percutaneous or surgical revascularization. During pharmacological stress imaging, myocardial ischemia developed in 19% of the ventricular mass and was reduced to 7% when GIK was administered. After anesthesia induction, the GIK solution was also infused and surgery was uneventful, with no signs of postoperative myocardial injury. Four days later, the patient was successfully discharged to a rehabilitation center. This is the first clinical report of GIK pretreatment during non-cardiac surgery in a patient with ischemic heart disease (IHD).The administration of glucose-insulin-potassium (GIK) has demonstrated cardioprotective effects in cardiac surgery. A 58-year-old male with severe disabling back pain due to posterolateral lumbar pseudarthrosis was scheduled for spine surgery. He previously experienced two episodes of acute coronary syndrome that required percutaneous coronary interventions (PCIs). Coronary angiogram showed intrastent occlusions and multiple coronary lesions that were not suitable for percutaneous or surgical revascularization. During pharmacological stress imaging, myocardial ischemia developed in 19% of the ventricular mass and was reduced to 7% when GIK was administered. After anesthesia induction, the GIK solution was also infused and surgery was uneventful, with no signs of postoperative myocardial injury. Four days later, the patient was successfully discharged to a rehabilitation center. This is the first clinical report of GIK pretreatment during non-cardiac surgery in a patient with ischemic heart disease (IHD).

Background:Fragile X syndrome (FXS) is the most common cause of inherited intellectual disabilities and autism. The reported prevalence of the full mutation (FM) gene FMR1 in the general population is 0.2–0.4 per 1000 males and 0.125–0.4 per 1000 females.Population screening for FMR1 expanded alleles has been performed in newborns and in an adult population. However, it has never been carried out in an entire town.Ricaurte is a Colombian district with 1186 habitants, with a high prevalence of FXS, which was first described by cytogenetic techniques in 1999.Methods:Using a PCR-based approach, screening for FXS was performed on blood spot samples obtained from 926 (502 males and 424 females) inhabitants from Ricaurte, accounting for 78% of total population.Results:A high prevalence of carriers of the expanded allele was observed in all FXS mutation categories. Using the Bayesian methods the carrier frequency of FM was 48.2 (95% Credibility Region CR: 36.3–61.5) per 1000 males and 20.5 (95% CR:13.5–28.6) per 1000 females; the frequency of premutation carrier was 14.1 (95% RC: 8.0–21.7) per 1000 males (95% RC: 8.0–21.7 per 1000 males) and 35.9 (95% RC: 26.5–46.2) per 1000 for females (95% RC: 26.5–46.2 per 1000 females), and gray zone carrier was 13.4 (95% RC: 7.4–20.7) per 1000 males (95% RC: 7.4–20.7 per 1000 males) and 42.2 (95% RC: 32.2–53.8) per 1000 for females (95% RC: 32.2–53.8 per 1000 females). Differences in carrier frequencies were observed for premutation and FM alleles between natives and non-natives.Conclusions:This study shows that in Ricaurte the carrier frequencies of FMR1 expanded alleles (premutations and FMs) are higher than those reported in the literature, suggesting that Ricaurte constitutes a genetic cluster of FXS.