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Ju JW, Lee HJ, Nam K, Kim S, Hong H, Yoo SH, Lee S, Cho YJ, Jeon Y. Volatile Anesthetic Use Versus Total Intravenous Anesthesia for Patients Undergoing Heart Valve Surgery: A Nationwide Population-Based Study. Anesth Analg 2024; 139:114-123. [PMID: 38885399 DOI: 10.1213/ane.0000000000006760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
BACKGROUND Many studies have suggested that volatile anesthetic use may improve postoperative outcomes after cardiac surgery compared to total intravenous anesthesia (TIVA) owing to its potential cardioprotective effect. However, the results were inconclusive, and few studies have included patients undergoing heart valve surgery. METHODS This nationwide population-based study included all adult patients who underwent heart valve surgery between 2010 and 2019 in Korea based on data from a health insurance claim database. Patients were divided based on the use of volatile anesthetics: the volatile anesthetics or TIVA groups. After stabilized inverse probability of treatment weighting (IPTW), the association between the use of volatile anesthetics and the risk of cumulative 1-year all-cause mortality (the primary outcome) and cumulative long-term (beyond 1 year) mortality were assessed using Cox regression analysis. RESULTS Of the 30,755 patients included in this study, the overall incidence of 1-year mortality was 8.5%. After stabilized IPTW, the risk of cumulative 1-year mortality did not differ in the volatile anesthetics group compared to the TIVA group (hazard ratio, 0.98; 95% confidence interval, 0.90-1.07; P = .602), nor did the risk of cumulative long-term mortality (hazard ratio, 0.98; 95% confidence interval, 0.93-1.04; P = .579) at a median (interquartile range) follow-up duration of 4.8 (2.6-7.6) years. CONCLUSIONS Compared with TIVA, volatile anesthetic use was not associated with reduced postoperative mortality risk in patients undergoing heart valve surgery. Our findings indicate that the use of volatile anesthetics does not have a significant impact on mortality after heart valve surgery. Therefore, the choice of anesthesia type can be based on the anesthesiologists' or institutional preference and experience.
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Affiliation(s)
- Jae-Woo Ju
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ho-Jin Lee
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Karam Nam
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | | | - Hyunsook Hong
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seung Ho Yoo
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seohee Lee
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Youn Joung Cho
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yunseok Jeon
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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Hochhausen N, Mechelinck M, Kroh A, Rossaint R, Kork F. Chronic obstructive pulmonary disease affects outcome in surgical patients with perioperative organ injury: a retrospective cohort study in Germany. Respir Res 2024; 25:251. [PMID: 38902707 PMCID: PMC11191349 DOI: 10.1186/s12931-024-02882-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 06/12/2024] [Indexed: 06/22/2024] Open
Abstract
BACKGROUND The impact of chronic obstructive pulmonary disease (COPD) on outcome in perioperative organ injury (POI) has not yet been investigated sufficiently. METHODS This retrospective cohort study analysed data of surgical patients with POI, namely delirium, stroke, acute myocardial infarction, acute respiratory distress syndrome, acute liver injury (ALI), or acute kidney injury (AKI), in Germany between 2015 and 2019. We compared in-hospital mortality, hospital length of stay (HLOS) and perioperative ventilation time (VT) in patients with and without COPD. RESULTS We analysed the data of 1,642,377 surgical cases with POI of which 10.8% suffered from COPD. In-hospital mortality was higher (20.6% vs. 15.8%, p < 0.001) and HLOS (21 days (IQR, 12-34) vs. 16 days (IQR, 10-28), p < 0.001) and VT (199 h (IQR, 43-547) vs. 125 h (IQR, 32-379), p < 0.001) were longer in COPD patients. Within the POI examined, AKI was the most common POI (57.8%), whereas ALI was associated with the highest mortality (54.2%). Regression analysis revealed that COPD was associated with a slightly higher risk of in-hospital mortality (OR, 1.19; 95% CI:1.18-1.21) in patients with any POI. CONCLUSIONS COPD in patients with POI is associated with higher mortality, longer HLOS and longer VT. Especially patients suffering from ALI are susceptible to the detrimental effects of COPD on adverse outcome.
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Affiliation(s)
- Nadine Hochhausen
- Department of Anesthesiology, Medical Faculty, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany.
| | - Mare Mechelinck
- Department of Anesthesiology, Medical Faculty, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Andreas Kroh
- Department of General, Visceral, Pediatric, and Transplantation Surgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Rolf Rossaint
- Department of Anesthesiology, Medical Faculty, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Felix Kork
- Department of Anesthesiology, Medical Faculty, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
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Paredes S, Harb A, Rössler J, Nikoo MZ, Ruetzler K, Turan A, Pu X, Sessler DI. Metformin Use in Type 2 Diabetics and Delirium After Noncardiac Surgery: A Retrospective Cohort Analysis. Anesth Analg 2024; 138:1304-1312. [PMID: 38517762 DOI: 10.1213/ane.0000000000006863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
Abstract
INTRODUCTION The cause of postoperative delirium is unknown, but it is thought to result at least in part from inflammation. Metformin, besides its hypoglycemic properties, demonstrates anti-inflammatory effects systemically and in the brain. We tested the primary hypothesis that chronic metformin use in adults with type 2 diabetes is associated with less delirium during the first 5 days after major noncardiac surgery. Secondary outcomes were a composite of serious complications (myocardial infarction, cardiac arrest, stage 2-3 acute kidney injury [AKI], and mortality) and time to discharge alive. METHODS We considered adults with type 2 diabetes who did or did not routinely use metformin daily and had noncardiac surgery. Delirium was assessed by Confusion Assessment Method for Intensive Care Unit (CAM-ICU) or brief Confusion Assessment Method (bCAM) for 5 postoperative days. Postoperative AKI was defined by Kidney Disease Improving Global Guidelines. Logistic regression and generalized estimating equation models accounted for within-patient correlation across multiple surgeries and explored the association between metformin use and postoperative delirium and complications. Inverse propensity score weighting and propensity score calibration (PSC) adjusted for confounding variables. RESULTS No significant difference was observed in the incidence of postoperative delirium between the 2 groups, with 260 of 4744 cases (5.5%) among metformin users and 502 of 5918 cases (8.5%) cases in nonmetformin users, for an odds ratio of 0.88 (95% confidence interval [CI], 0.73-1.05; P = .155), number-needed-to-expose = 118 patients. Similarly, there were fewer composite complications in metformin users (3.3%) than in nonusers (11.7%); However, the common-effect odds ratio of 0.67 was not statistically significant (97.5% CI, 0.39-1.17; P = .106). Discharge from the hospital was significantly faster in patients who took metformin (3 [interquartile range, IQR, 1-5] days for metformin users and 3 [IQR, 2-6] days for nonmetformin users), with a hazard ratio of 1.07 for early discharge, and tight CIs (1.01-1.13). CONCLUSIONS Chronic metformin use was associated with slightly and nonsignificantly less delirium. However, patients who used metformin had clinically meaningfully fewer major complications, mostly stage 2 to 3 kidney injury. While not statistically significant, the reduction was substantial and warrants further investigation because there is currently no effective preventive measure for perioperative renal injury. Benefit would be especially meaningful if it could be produced by acute perioperative treatment. Finally, metformin was associated with faster hospital discharge, although not by a clinically meaningful amount.
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Affiliation(s)
- Stephania Paredes
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Ayoub Harb
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
- Ohio University Heritage College of Osteopathic Medicine, Cleveland, Ohio
| | - Julian Rössler
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | | | - Kurt Ruetzler
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
- Department of General Anesthesia, Cleveland Clinic, Cleveland, Ohio
| | - Alparslan Turan
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
- Department of General Anesthesia, Cleveland Clinic, Cleveland, Ohio
| | - Xuan Pu
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Daniel I Sessler
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
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Kršek A, Batičić L, Ćurko-Cofek B, Batinac T, Laškarin G, Miletić-Gršković S, Sotošek V. Insights into the Molecular Mechanism of Endothelial Glycocalyx Dysfunction during Heart Surgery. Curr Issues Mol Biol 2024; 46:3794-3809. [PMID: 38785504 PMCID: PMC11119104 DOI: 10.3390/cimb46050236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/13/2024] [Accepted: 04/18/2024] [Indexed: 05/25/2024] Open
Abstract
The endothelial glycocalyx (EGC) is a layer of proteoglycans (associated with glycosaminoglycans) and glycoproteins, which adsorbs plasma proteins on the luminal surface of endothelial cells. Its main function is to participate in separating the circulating blood from the inner layers of the vessels and the surrounding tissues. Physiologically, the EGC stimulates mechanotransduction, the endothelial charge, thrombocyte adhesion, leukocyte tissue recruitment, and molecule extravasation. Hence, severe impairment of the EGC has been implicated in various pathological conditions, including sepsis, diabetes, chronic kidney disease, inflammatory disorders, hypernatremia, hypervolemia, atherosclerosis, and ischemia/reperfusion injury. Moreover, alterations in EGC have been associated with altered responses to therapeutic interventions in conditions such as cardiovascular diseases. Investigation into the function of the glycocalyx has expanded knowledge about vascular disorders and indicated the need to consider new approaches in the treatment of severe endothelial dysfunction. This review aims to present the current understanding of the molecular mechanisms underlying cardiovascular diseases and to elucidate the impact of heart surgery on EGC dysfunction.
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Affiliation(s)
- Antea Kršek
- Faculty of Rijeka, University of Medicine, Braće Branchetta 20, 51000 Rijeka, Croatia;
| | - Lara Batičić
- Department of Medical Chemistry, Biochemistry and Clinical Chemistry, Faculty of Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia
| | - Božena Ćurko-Cofek
- Department of Physiology, Immunology and Pathophysiology, Faculty of Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia; (B.Ć.-C.); (G.L.)
| | - Tanja Batinac
- Department of Clinical Medical Sciences I, Faculty of Health Studies, University of Rijeka, Viktora Cara Emina 2, 51000 Rijeka, Croatia; (T.B.); (V.S.)
| | - Gordana Laškarin
- Department of Physiology, Immunology and Pathophysiology, Faculty of Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia; (B.Ć.-C.); (G.L.)
- Hospital for Medical Rehabilitation of Hearth and Lung Diseases and Rheumatism “Thalassotherapia-Opatija”, M. Tita 188, 51410 Opatija, Croatia;
| | - Silvija Miletić-Gršković
- Hospital for Medical Rehabilitation of Hearth and Lung Diseases and Rheumatism “Thalassotherapia-Opatija”, M. Tita 188, 51410 Opatija, Croatia;
| | - Vlatka Sotošek
- Department of Clinical Medical Sciences I, Faculty of Health Studies, University of Rijeka, Viktora Cara Emina 2, 51000 Rijeka, Croatia; (T.B.); (V.S.)
- Department of Anesthesiology, Reanimatology, Emergency and Intensive Care Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia
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Yuan X, Ruan W, Bobrow B, Carmeliet P, Eltzschig HK. Targeting hypoxia-inducible factors: therapeutic opportunities and challenges. Nat Rev Drug Discov 2024; 23:175-200. [PMID: 38123660 DOI: 10.1038/s41573-023-00848-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2023] [Indexed: 12/23/2023]
Abstract
Hypoxia-inducible factors (HIFs) are highly conserved transcription factors that are crucial for adaptation of metazoans to limited oxygen availability. Recently, HIF activation and inhibition have emerged as therapeutic targets in various human diseases. Pharmacologically desirable effects of HIF activation include erythropoiesis stimulation, cellular metabolism optimization during hypoxia and adaptive responses during ischaemia and inflammation. By contrast, HIF inhibition has been explored as a therapy for various cancers, retinal neovascularization and pulmonary hypertension. This Review discusses the biochemical mechanisms that control HIF stabilization and the molecular strategies that can be exploited pharmacologically to activate or inhibit HIFs. In addition, we examine medical conditions that benefit from targeting HIFs, the potential side effects of HIF activation or inhibition and future challenges in this field.
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Affiliation(s)
- Xiaoyi Yuan
- Department of Anaesthesiology, Critical Care and Pain Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA.
| | - Wei Ruan
- Department of Anaesthesiology, Critical Care and Pain Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
- Department of Anaesthesiology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Bentley Bobrow
- Department of Emergency Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Peter Carmeliet
- Laboratory of Angiogenesis & Vascular Metabolism, Center for Cancer Biology, VIB, Department of Oncology, KU Leuven, Leuven, Belgium
- Laboratory of Angiogenesis & Vascular Heterogeneity, Department of Biomedicine, Aarhus University, Aarhus, Denmark
- Center for Biotechnology, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates
| | - Holger K Eltzschig
- Department of Anaesthesiology, Critical Care and Pain Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA.
- Outcomes Research Consortium, Cleveland, OH, USA.
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Deslarzes P, Jurt J, Larson DW, Blanc C, Hübner M, Grass F. Perioperative Fluid Management in Colorectal Surgery: Institutional Approach to Standardized Practice. J Clin Med 2024; 13:801. [PMID: 38337495 PMCID: PMC10856154 DOI: 10.3390/jcm13030801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024] Open
Abstract
The present review discusses restrictive perioperative fluid protocols within enhanced recovery after surgery (ERAS) pathways. Standardized definitions of a restrictive or liberal fluid regimen are lacking since they depend on conflicting evidence, institutional protocols, and personal preferences. Challenges related to restrictive fluid protocols are related to proper patient selection within standardized ERAS protocols. On the other hand, invasive goal-directed fluid therapy (GDFT) is reserved for more challenging disease presentations and polymorbid and frail patients. While the perfusion rate (mL/kg/h) appears less predictive for postoperative outcomes, the authors identified critical thresholds related to total intravenous fluids and weight gain. These thresholds are discussed within the available evidence. The authors aim to introduce their institutional approach to standardized practice.
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Affiliation(s)
- Philip Deslarzes
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), 1005 Lausanne, Switzerland; (P.D.); (J.J.); (M.H.)
| | - Jonas Jurt
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), 1005 Lausanne, Switzerland; (P.D.); (J.J.); (M.H.)
| | - David W. Larson
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA;
| | - Catherine Blanc
- Department of Anesthesiology, Lausanne University Hospital CHUV, University of Lausanne (UNIL), 1005 Lausanne, Switzerland;
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), 1005 Lausanne, Switzerland; (P.D.); (J.J.); (M.H.)
| | - Fabian Grass
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), 1005 Lausanne, Switzerland; (P.D.); (J.J.); (M.H.)
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Tao S, Song Y, Ding S, He R, Shi Q, Hu F. Dendrobium officinale polysaccharide-based carrier to enhance photodynamic immunotherapy. Carbohydr Polym 2023; 317:121089. [PMID: 37364958 DOI: 10.1016/j.carbpol.2023.121089] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 05/31/2023] [Accepted: 06/01/2023] [Indexed: 06/28/2023]
Abstract
Photodynamic therapy (PDT) eradicates tumors via the generation of toxic reactive oxygen species (ROS) by activation of a photosensitizer (PS) with appropriate light. Local PDT toward tumors can trigger the immune response to inhibit distant tumors, but the immune response is usually insufficient. Herein, we used a biocompatible herb polysaccharide with immunomodulatory activity as the carrier of PS to enhance the immune inhibition of tumors after PDT. The Dendrobium officinale polysaccharide (DOP) is modified with hydrophobic cholesterol to serve as an amphiphilic carrier. The DOP itself can promote dendritic cell (DC) maturation. Meanwhile, TPA-3BCP are designed to be cationic aggregation-induced emission PS. The structure of one electron-donor linking to three electron-acceptors endows TPA-3BCP with high efficiency to produce ROS upon light irradiation. And the nanoparticles are designed with positively charged surfaces to capture antigens released after PDT, which can protect the antigens from degradation and improve the antigen-uptake efficiency by DCs. The combination of DOP-induced DC maturation and antigen capture-increased antigen-uptake efficiency by DCs significantly improves the immune response after DOP-based carrier-mediated PDT. Since DOP is extracted from the medicinal and edible Dendrobium officinale, the DOP-based carrier we designed is promising to be developed for enhanced photodynamic immunotherapy in clinic.
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Affiliation(s)
- Shengchang Tao
- Department of Pharmacy, The Tenth Affiliated Hospital of Southern Medical University (Dongguan People's Hospital), Dongguan 523059, China; Biomaterials Research Center, School of Biomedical Engineering, Southern Medical University, Guangzhou 510515, China
| | - Yuchen Song
- Biomaterials Research Center, School of Biomedical Engineering, Southern Medical University, Guangzhou 510515, China
| | - Shaobo Ding
- Department of Pharmacy, The Tenth Affiliated Hospital of Southern Medical University (Dongguan People's Hospital), Dongguan 523059, China
| | - Ruirong He
- Department of Pharmacy, The Tenth Affiliated Hospital of Southern Medical University (Dongguan People's Hospital), Dongguan 523059, China
| | - Qiankun Shi
- Biomaterials Research Center, School of Biomedical Engineering, Southern Medical University, Guangzhou 510515, China
| | - Fang Hu
- Biomaterials Research Center, School of Biomedical Engineering, Southern Medical University, Guangzhou 510515, China; Division of Laboratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China.
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Li Z, Yan X, Wei J, Pu L, Zhu G, Cao Y, Liu Z, Liu Y, Li Y, Li L, Li X, Wu Z. A novel colchicine-myricetin heterozygous molecule: design, synthesis, and effective evaluations on the pathological models of acute lung injury in vitro and in vivo. Front Pharmacol 2023; 14:1224906. [PMID: 37456754 PMCID: PMC10340118 DOI: 10.3389/fphar.2023.1224906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 06/19/2023] [Indexed: 07/18/2023] Open
Abstract
Acute lung injury (ALI) is an inflammatory condition and there are no effective treatments. A novel new compound----colchicine-myricetin hybrid (CMyrH) was herein designed and synthesized. To evaluate the activity of CMyrH in ALI, we used a bleomycin (BLM) induced BEAS-2B injury model in vitro and established a well-recognized rat model of BLM-induced lung injury in vivo. The results demonstrated that colchicine-myricetin hybrid protected BEAS-2B cells against BLM-induced cell injury in an increased dose manner, and reduced wet/dry weight ratio, histological scoring, and inflammation cytokines IL-1β, IL-6, IL-18, and TNF-α levels of lung tissue of the rats. Furthermore, we found colchicine-myricetin hybrid inhibited caspase-1, ASC, GSDMD, and NLRP-3 expression in vivo. Meanwhile, we used molecular docking to analyze the binding mode of colchicine-myricetin hybrid and human neutrophil elastase (HNE), it revealed that colchicine-myricetin hybrid showed strong binding affinity toward human neutrophil elastase when compared to its parent molecules. In conclusion, It is suggested that colchicine-myricetin hybrid antagonized acute lung injury by focusing on multi-targets via multi-mechanisms, and might be served as a potential therapeutic agent for acute lung injury.
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Affiliation(s)
- Zhiyue Li
- Shenzhen Institute of Translational Medicine, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
- Wu Zhengzhi Academician Workstation, Ningbo College of Health Sciences, Ningbo, China
- Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Xueqin Yan
- Shenzhen Institute of Translational Medicine, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
- Wu Zhengzhi Academician Workstation, Ningbo College of Health Sciences, Ningbo, China
| | - Jiangchun Wei
- Shenzhen Institute of Translational Medicine, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
- Wu Zhengzhi Academician Workstation, Ningbo College of Health Sciences, Ningbo, China
| | - Liuyang Pu
- Shenzhen Institute of Translational Medicine, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Guanbao Zhu
- Shenzhen Institute of Translational Medicine, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
- Graduate School, Guangxi University of Chinese Medicine, Nanning, China
| | - Yongkai Cao
- Shenzhen Institute of Translational Medicine, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Zhanyan Liu
- Shenzhen Institute of Translational Medicine, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Yaqian Liu
- Shenzhen Institute of Translational Medicine, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Yan Li
- Shenzhen Institute of Translational Medicine, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Limin Li
- Shenzhen Institute of Translational Medicine, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Xinping Li
- Shenzhen Institute of Translational Medicine, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Zhengzhi Wu
- Shenzhen Institute of Translational Medicine, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
- Wu Zhengzhi Academician Workstation, Ningbo College of Health Sciences, Ningbo, China
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Kouz K, Brockmann L, Timmermann LM, Bergholz A, Flick M, Maheshwari K, Sessler DI, Krause L, Saugel B. Endotypes of intraoperative hypotension during major abdominal surgery: a retrospective machine learning analysis of an observational cohort study. Br J Anaesth 2023; 130:253-261. [PMID: 36526483 DOI: 10.1016/j.bja.2022.07.056] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 07/27/2022] [Accepted: 07/30/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Intraoperative hypotension is associated with myocardial injury, acute kidney injury, and death. In routine practice, specific causes of intraoperative hypotension are often unclear. A more detailed understanding of underlying haemodynamic alterations of intraoperative hypotension may identify specific treatments. We thus aimed to use machine learning - specifically, hierarchical clustering - to identify underlying haemodynamic alterations causing intraoperative hypotension in major abdominal surgery patients. Specifically, we tested the hypothesis that there are distinct endotypes of intraoperative hypotension, which may help refine therapeutic interventions. METHODS We conducted a secondary analysis of intraoperative haemodynamic measurements from a prospective observational study in 100 patients who had major abdominal surgery under general anaesthesia. We used stroke volume index, heart rate, cardiac index, systemic vascular resistance index, and pulse pressure variation measurements. Intraoperative hypotension was defined as any mean arterial pressure ≤65 mm Hg or a mean arterial pressure between 66 and 75 mm Hg requiring a norepinephrine infusion rate exceeding 0.1 μg kg-1 min-1. To identify endotypes of intraoperative hypotension, we used hierarchical clustering (Ward's method). RESULTS A total of 615 episodes of intraoperative hypotension occurred in 82 patients (46 [56%] female; median age: 64 [57, 73] yr) who had surgery of a median duration of 270 (195, 335) min. Hierarchical clustering revealed six distinct intraoperative hypotension endotypes. Based on their clinical characteristics, we labelled these endotypes as (1) myocardial depression, (2) bradycardia, (3) vasodilation with cardiac index increase, (4) vasodilation without cardiac index increase, (5) hypovolaemia, and (6) mixed type. CONCLUSION Hierarchical clustering identified six endotypes of intraoperative hypotension. If validated, considering these intraoperative hypotension endotypes may enable causal treatment of intraoperative hypotension.
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Affiliation(s)
- Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lennart Brockmann
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lea Malin Timmermann
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alina Bergholz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Moritz Flick
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kamal Maheshwari
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Linda Krause
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Outcomes Research Consortium, Cleveland, OH, USA.
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10
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Lehmann M, Zarbock A, Rossaint J. [New aspects of perioperative organ protection]. DIE ANAESTHESIOLOGIE 2022; 71:741-749. [PMID: 36064976 DOI: 10.1007/s00101-022-01197-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/25/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Acutely occurring organ damage significantly contributes to morbidity and mortality in the perioperative context. OBJECTIVE This article highlights new clinical perspectives on how perioperative organ damage can be prevented and ameliorated by influencing the high mobility group box 1 protein (HMGB1) signaling. MATERIAL AND METHODS A MEDLINE search was performed in the fields of clinical and basic research. The presentation of basic mechanisms of perioperative organ damage and the discussion of the importance of HMGB1 in prevention and treatment by pharmaceutical and nonpharmaceutical interventions are the focus of the review. RESULTS The HMGB1 is a central element in the pathogenesis of septic and aseptic inflammation-induced organ damage. Remote ischemic preconditioning (RIPC) and dexmedetomidine are highly effective approaches to mitigate or prevent organ damage. CONCLUSION The RIPC and dexmedetomidine offer protective properties in ischemia-reperfusion injury as well as in inflammation-related organ damage, which are mediated by HMGB1, among others. This effectively protects the kidneys, heart, lungs, liver and brain. The application of these concepts should be considered in routine clinical practice.
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Affiliation(s)
- Martin Lehmann
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland
| | - Alexander Zarbock
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland
| | - Jan Rossaint
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland.
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11
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Ruan W, Ma X, Bang IH, Liang Y, Muehlschlegel JD, Tsai KL, Mills TW, Yuan X, Eltzschig HK. The Hypoxia-Adenosine Link during Myocardial Ischemia-Reperfusion Injury. Biomedicines 2022; 10:1939. [PMID: 36009485 PMCID: PMC9405579 DOI: 10.3390/biomedicines10081939] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 07/28/2022] [Accepted: 08/01/2022] [Indexed: 11/16/2022] Open
Abstract
Despite increasing availability and more successful interventional approaches to restore coronary reperfusion, myocardial ischemia-reperfusion injury is a substantial cause of morbidity and mortality worldwide. During myocardial ischemia, the myocardium becomes profoundly hypoxic, thus causing stabilization of hypoxia-inducible transcription factors (HIF). Stabilization of HIF leads to a transcriptional program that promotes adaptation to hypoxia and cellular survival. Transcriptional consequences of HIF stabilization include increases in extracellular production and signaling effects of adenosine. Extracellular adenosine functions as a signaling molecule via the activation of adenosine receptors. Several studies implicated adenosine signaling in cardioprotection, particularly through the activation of the Adora2a and Adora2b receptors. Adenosine receptor activation can lead to metabolic adaptation to enhance ischemia tolerance or dampen myocardial reperfusion injury via signaling events on immune cells. Many studies highlight that clinical strategies to target the hypoxia-adenosine link could be considered for clinical trials. This could be achieved by using pharmacologic HIF activators or by directly enhancing extracellular adenosine production or signaling as a therapy for patients with acute myocardial infarction, or undergoing cardiac surgery.
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Affiliation(s)
- Wei Ruan
- Department of Anesthesiology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
- Department of Anesthesiology, Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - Xinxin Ma
- Department of Anesthesiology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - In Hyuk Bang
- Department of Anesthesiology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Yafen Liang
- Department of Anesthesiology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Jochen Daniel Muehlschlegel
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Kuang-Lei Tsai
- Department of Biochemistry and Molecular Biology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Tingting W. Mills
- Department of Biochemistry and Molecular Biology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Xiaoyi Yuan
- Department of Anesthesiology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Holger K. Eltzschig
- Department of Anesthesiology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
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12
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Yuan X, Mills T, Doursout MF, Evans SE, Vidal Melo MF, Eltzschig HK. Alternative adenosine Receptor activation: The netrin-Adora2b link. Front Pharmacol 2022; 13:944994. [PMID: 35910389 PMCID: PMC9334855 DOI: 10.3389/fphar.2022.944994] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 06/28/2022] [Indexed: 11/25/2022] Open
Abstract
During hypoxia or inflammation, extracellular adenosine levels are elevated. Studies using pharmacologic approaches or genetic animal models pertinent to extracellular adenosine signaling implicate this pathway in attenuating hypoxia-associated inflammation. There are four distinct adenosine receptors. Of these, it is not surprising that the Adora2b adenosine receptor functions as an endogenous feedback loop to control hypoxia-associated inflammation. First, Adora2b activation requires higher adenosine concentrations compared to other adenosine receptors, similar to those achieved during hypoxic inflammation. Second, Adora2b is transcriptionally induced during hypoxia or inflammation by hypoxia-inducible transcription factor HIF1A. Studies seeking an alternative adenosine receptor activation mechanism have linked netrin-1 with Adora2b. Netrin-1 was originally discovered as a neuronal guidance molecule but also functions as an immune-modulatory signaling molecule. Similar to Adora2b, netrin-1 is induced by HIF1A, and has been shown to enhance Adora2b signaling. Studies of acute respiratory distress syndrome (ARDS), intestinal inflammation, myocardial or hepatic ischemia and reperfusion implicate the netrin-Adora2b link in tissue protection. In this review, we will discuss the potential molecular linkage between netrin-1 and Adora2b, and explore studies demonstrating interactions between netrin-1 and Adora2b in attenuating tissue inflammation.
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Affiliation(s)
- Xiaoyi Yuan
- Department of Anesthesiology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Tingting Mills
- Department of Biochemistry and Molecular Biology, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Marie-Francoise Doursout
- Department of Anesthesiology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Scott E. Evans
- Department of Pulmonology, MD Anderson Cancer Center, Houston, TX, United States
| | | | - Holger K. Eltzschig
- Department of Anesthesiology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
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13
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Rengel KF, Boncyk CS, Hughes CG. Postoperative Delirium Prevention and Novel Cognitive Therapy Interventions. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-021-00501-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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14
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Hsu AKW, Roman SS, Bagatini MD, Marafon F, do Nascimento Junior P, Modolo NSP. Intermittent Fasting before Laparotomy: Effects on Glucose Control and Histopathologic Findings in Diabetic Rats. Nutrients 2021; 13:nu13124519. [PMID: 34960070 PMCID: PMC8708415 DOI: 10.3390/nu13124519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 12/13/2021] [Accepted: 12/15/2021] [Indexed: 11/16/2022] Open
Abstract
(1) Background: Intermittent fasting is a nutrition practice in which individuals fast for several hours in a day, mainly with feeding time during the daylight hours. They seek to improve metabolic performance and cellular resistance to stress. In this study, we tested the fasting protocol to investigate the glycemic effect in a laparotomy perioperative period in diabetic rats and histopathologic findings. (2) Methods: The animals were diabetic-induced with alloxan. Two groups were set according to the feeding protocol: free food and intermittent fasting, whose rats could only eat 8 h in the daylight. Both groups were anesthetized, and a laparotomy was performed. We evaluated the glucose levels during the perioperative period, and we accessed organ histology seeking damage of kidney, bowel and liver after surgical trauma, and we evaluated the wound healing process. (3) Results: Glycemic levels were improved in the intermittent fasting group, especially in the post-operative period after laparotomy. Comparing both groups' tubular damage showed interdependency with mice with worse glycemic level (Z = 2.3; p = 0.0215) and wound-healing parameters showed interdependency with rats with better glycemic status for neovascularization (Z = 2.2; p = 0.0273) and the presence of sebaceous and sweat gland in the healing process (Z = 2.30; p = 0.0215). (4) Conclusions: Intermittent fasting before surgery can be a tool to improve glycemic levels in diabetic rats, with improvement especially in the post-operative period.
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Affiliation(s)
- André Keng Wei Hsu
- Anesthesia Department, São Paulo State University (UNESP)-Botucatu, Botucatu 18618683, Brazil; (P.d.N.J.); (N.S.P.M.)
- Pharmacology and Histology Department, Medical School, Integrated Regional University (URI), Erechim 99709910, Brazil;
- Correspondence:
| | - Silvane Souza Roman
- Pharmacology and Histology Department, Medical School, Integrated Regional University (URI), Erechim 99709910, Brazil;
| | - Margarete Dulce Bagatini
- Academic Coordination, Biomedical Sciencies Department, Federal University of Fronteira Sul, Chapecó 89802210, Brazil;
| | - Filomena Marafon
- Postgraduate Program in Biochemistry Department, Federal University of Santa Catarina, Florianopolis 88040900, Brazil;
| | - Paulo do Nascimento Junior
- Anesthesia Department, São Paulo State University (UNESP)-Botucatu, Botucatu 18618683, Brazil; (P.d.N.J.); (N.S.P.M.)
| | - Norma Sueli Pinheiro Modolo
- Anesthesia Department, São Paulo State University (UNESP)-Botucatu, Botucatu 18618683, Brazil; (P.d.N.J.); (N.S.P.M.)
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15
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Kimlinger MJ, Mace EH, Harris RC, Zhang MZ, Barajas MB, Hernandez A, Billings FT. Impact of Inhaled Oxygen on Reactive Oxygen Species Production and Oxidative Damage during Spontaneous Ventilation in a Murine Model of Acute Renal Ischemia and Reperfusion. MEDICAL RESEARCH ARCHIVES 2021; 9:2575. [PMID: 35419490 PMCID: PMC9005066 DOI: 10.18103/mra.v9i10.2575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Introduction Acute kidney injury (AKI) affects 10% of patients following major surgery and is independently associated with extra-renal organ injury, development of chronic kidney disease, and death. Perioperative renal ischemia and reperfusion (IR) contributes to AKI by, in part, increasing production of reactive oxygen species (ROS) and leading to oxidative damage. Variations in inhaled oxygen may mediate some aspects of IR injury by affecting tissue oxygenation, ROS production, and oxidative damage. We tested the hypothesis that provision of air (normoxia) compared to 100% oxygen (hyperoxia) during murine renal IR affects renal ROS production and oxidative damage. Methods We administered 100% oxygen or 21% oxygen (air) to 8-9 week-old FVB/N mice and performed dorsal unilateral nephrectomy with contralateral renal ischemia/reperfusion surgery while mice spontaneously ventilated. We subjected mice to 30 minutes of ischemia and 30 minutes of reperfusion prior to sacrifice. We obtained an arterial blood gas (ABG) by performing sternotomy and left cardiac puncture. We stained the kidney with pimonidazole, a marker of tissue hypoxia; 4-HNE, a marker of ROS-production; and we measured F2-isoprostanes in homogenized tissue to quantify oxidative damage. Results Hyperoxia during IR increased arterial oxygen content compared to normoxia, but both groups of mice were hypoventilating at the time of ABG sampling. Renal tissue hypoxia following reperfusion was similar in both treatment groups. ROS production was similar in the cortex of mice (3.8% area in hyperoxia vs. 3.1% in normoxia, P=0.19) but increased in the medulla of hyperoxia-treated animals (6.3% area in hyperoxia vs. 4.5% in nomoxia, P=0.02). Renal F2-isoprostanes were similar in treatment groups (2.2 pg/mg kidney in hyperoxia vs. 2.1 pg/mg in normoxia, P=0.40). Conclusions Hyperoxia during spontaneous ventilation in murine renal IR did not appear to affect renal hypoxia following reperfusion, but hyperoxia increased medullary ROS production compared to normoxia.
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Affiliation(s)
- Melissa J Kimlinger
- Vanderbilt University School of Medicine (MJK), the Department Surgery (EM), the Department of Medicine (RCH, MZ), and the Department of Anesthesiology (MBB, AH, FTB), Vanderbilt University Medical Center, Nashville, TN
| | - Eric H Mace
- Vanderbilt University School of Medicine (MJK), the Department Surgery (EM), the Department of Medicine (RCH, MZ), and the Department of Anesthesiology (MBB, AH, FTB), Vanderbilt University Medical Center, Nashville, TN
| | - Raymond C Harris
- Vanderbilt University School of Medicine (MJK), the Department Surgery (EM), the Department of Medicine (RCH, MZ), and the Department of Anesthesiology (MBB, AH, FTB), Vanderbilt University Medical Center, Nashville, TN
| | - Ming-Zhi Zhang
- Vanderbilt University School of Medicine (MJK), the Department Surgery (EM), the Department of Medicine (RCH, MZ), and the Department of Anesthesiology (MBB, AH, FTB), Vanderbilt University Medical Center, Nashville, TN
| | - Matthew B Barajas
- Vanderbilt University School of Medicine (MJK), the Department Surgery (EM), the Department of Medicine (RCH, MZ), and the Department of Anesthesiology (MBB, AH, FTB), Vanderbilt University Medical Center, Nashville, TN
| | - Antonio Hernandez
- Vanderbilt University School of Medicine (MJK), the Department Surgery (EM), the Department of Medicine (RCH, MZ), and the Department of Anesthesiology (MBB, AH, FTB), Vanderbilt University Medical Center, Nashville, TN
| | - Frederic T Billings
- Vanderbilt University School of Medicine (MJK), the Department Surgery (EM), the Department of Medicine (RCH, MZ), and the Department of Anesthesiology (MBB, AH, FTB), Vanderbilt University Medical Center, Nashville, TN
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16
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Slingo ME, Pandit JJ. Oxygen sensing, anaesthesia and critical care: a narrative review. Anaesthesia 2021; 77:213-223. [PMID: 34555179 DOI: 10.1111/anae.15582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2021] [Indexed: 12/01/2022]
Abstract
In 2019, the scientists who discovered how cells sense and adapt to oxygen availability were awarded the Nobel Prize. This elegant sensing pathway is conserved throughout evolution, and it underpins the physiology and pathology that we, as clinicians in anaesthesia and critical care, encounter on a daily basis. The purpose of this review is to bring hypoxia-inducible factor, and the oxygen-sensing pathway as a whole, to the wider clinical community. We describe how this unifying mechanism was discovered, and how it orchestrates diverse changes such as erythropoiesis, ventilatory acclimatisation, pulmonary vascular remodelling and altered metabolism. We explore the lessons learnt from genetic disorders of oxygen sensing, and the wider implications in evolution of all animal species, including our own. Finally, we explain how this pathway is relevant to our clinical practice, and how it is being manipulated in new treatments for conditions such as cancer, anaemia and pulmonary hypertension.
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Affiliation(s)
- M E Slingo
- Shackleton Department of Anaesthetics, Southampton University Hospitals NHS Trust, Southampton, UK
| | - J J Pandit
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,University of Oxford, Oxford, UK
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17
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Zarbock A, Hollmann MW. Perioperative Organ Failure: A Preventable Complication? Anesth Analg 2020; 131:1663-1665. [PMID: 33186154 DOI: 10.1213/ane.0000000000005244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Alexander Zarbock
- From the Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Münster, Germany
| | - Markus W Hollmann
- Department of Anesthesiology, Amsterdam University Medical Centers (AUMC), Location Academic Medical Center, Amsterdam, the Netherlands
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