Key Papers from the Most Recent Literature Relevant to Anesthesiologists
Effect of a perioperative, cardiac output–guided hemodynamic therapy algorithm on outcomes following major gastrointestinal surgery: A randomized clinical trial and systematic review. JAMA 2014; 311:2181–90.
Small trials suggest the benefit of algorithms targeting optimized hemodynamics on outcome, but the evidence for this is thin. In this pragmatic multicenter randomized controlled trial (OPTIMISE), 734 high-risk patients undergoing major gastrointestinal surgery were allocated to receive either an optimized hemodynamic strategy during and 6 h after operation, or standard care. The primary outcome measure was a composite of predefined major or moderate complications and mortality. No difference in primary endpoint was found between groups, which suggests that major complications and mortality in this patient population may be influenced by additional factors rather than simply hemodynamic optimization.
Bariatric surgery versus intensive medical therapy for diabetes—3-year outcomes. N Engl J Med 2014; 370:2002–13.
Bariatric surgery has been associated with short-term, but not long-term, improved outcome in obese patients with uncontrolled type 2 diabetes. This randomized controlled trial of obese patients with uncontrolled type 2 diabetes compared an intervention consisting of intensive medical therapy plus bariatric surgery with intensive medical therapy alone to achieve a primary goal consisting of glycated hemoglobin less than 6%. At 3 yr, the primary endpoint was met by 5% of patients in the control group versus 38% in the gastric bypass group and 24% in the sleeve gastrectomy group. Quality of life was improved in the intervention arm in comparison with control.
Bacterial phylogeny structures soil resistomes across habitats. Nature 2014; 509:612–6.
Antibiotic resistance is a major concern for treating patients with sepsis in the perioperative period and in the intensive care unit. Forsberg and colleagues’ study demonstrates that the soil microbiota harbors an extraordinary diversity of genes that have the potential to confer antibiotic resistance in human pathogens such as Escherichia coli. However, these findings suggest that it may not be the availability of genes encoding proteins capable of conferring antibiotic resistance that limits the spread of resistance, but rather the mobilization and transfer of these genes, which provides new insights in the understanding of, and perhaps struggle against, antibiotic resistance.
Statin use and risk of delirium in the critically ill. Am J Respir Crit Care Med 2014; 189:666–73.
Neuroinflammation is believed to be a significant factor in delirium pathophysiology. Statins that have antiinflammatory properties have been investigated as a therapy for conditions related to systemic inflammation. The present study is a prospective cohort of consecutive patients admitted to a mixed medical and surgical critical care unit; the Confusion Assessment Method for ICU (intensive care unit) was used to determine the days each patient was assessed as being free of delirium during ICU admission. This observational study found a link between ongoing administration of statins and a reduction in risk of delirium, which could be mediated through a reduction in systemic inflammation.
Association between source of infection and hospital mortality in patients who have septic shock. Am J Respir Crit Care Med 2014; 189:1204–13.
Septic shock–induced mortality may be caused by a systemic inflammatory response either directly or indirectly related to the inciting infection. A retrospective, multicenter cohort study of 7,974 patients who had septic shock in 29 academic and community intensive care units was performed. Ischemic bowel was associated with the highest standardized hospital mortality (75%) whereas obstructive uropathy–associated urinary tract infection the lowest (26%). Residual variation in adjusted hospital mortality was not explained by APACHE II score, number of day 1 organ failures, bacteremia, appropriateness of empiric antimicrobials, or adjunct therapies, suggesting that anatomic source of infection should be considered in future trial designs and analyses, and in development of prognostic scoring systems.
Subphenotypes in acute respiratory distress syndrome: Latent class analysis of data from two randomised controlled trials. Lancet Respir Med May 19, 2014. doi: 10.1016/S2213-2600(14)70097-9 [Epub ahead of print].
Subphenotypes of a heterogeneous disease may help to find appropriate treatments and change outcome, such as asthma or breast cancer. Calfee and colleagues used modeling to identify subphenotypes from the ALVEOLI and ARMA studies of patients with acute respiratory distress syndrome (ARDS). After a smart statistical analysis, they showed that ARDS patients can be split into two subphenotypes having distinct outcomes and responses to treatment (i.e., positive end-expiratory pressure). Main differences between these two types of ARDS were not oxygenation or ARDS etiologies, as expected. Inflammation levels and other surrogates seem more relevant. It could markedly change study designs, and help physicians to manage ARDS patients.
Effect of physical therapy on pain and function in patients with hip osteoarthritis. A randomized clinical trial. JAMA 2014; 311:1987–97.
The management of musculoskeletal pain including that related to osteoarthritis usually begins with conservative approaches including physical therapy. Indeed, physical therapy is considered first line therapy for osteoarthritis pain from the shoulders, hips, knees, and other joints. This randomized, blinded sham-physical therapy controlled trial of 102 participants with hip pain provided 12 weeks of treatment and 24 additional weeks of follow-up to determine the efficacy of physical therapy on pain and physical function. Unfortunately, the active treatment group fared no better with respect to pain or function than did the sham group. The active treatment group participants did, however, experience more adverse effects. These results are surprising given the widely held belief that conservative physical therapy–based approaches are effective for the treatment of osteoarthritis of the large joints.
The gender gap in academic medicine: Comparing results from a multifaceted intervention for Stanford faculty to peer and national cohorts. Acad Med 2014; 89:904–11.
In 2001, a university committee identified four areas as deficient and contributory, holding female faculty behind their male counterparts: recruitment, resources to support scholarly activity, faculty career development, and programs to decrease social isolation. In 2004, a multipronged strategy was launched to address the four major areas of deficiency. The 2011 assessment of the success of the interventions documented that women faculty increased by 74%, while nationally and at peer institutions women faculty increased by about 30%. Reduction in the gender gap resulted from interventions that produced greater success for female faculty, and this group displayed a much greater professional satisfaction.