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Coeckelenbergh S, Boelefahr S, Alexander B, Perrin L, Rinehart J, Joosten A, Barvais L. Closed-loop anesthesia: foundations and applications in contemporary perioperative medicine. J Clin Monit Comput 2024; 38:487-504. [PMID: 38184504 DOI: 10.1007/s10877-023-01111-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 11/21/2023] [Indexed: 01/08/2024]
Abstract
A closed-loop automatically controls a variable using the principle of feedback. Automation within anesthesia typically aims to improve the stability of a controlled variable and reduce workload associated with simple repetitive tasks. This approach attempts to limit errors due to distractions or fatigue while simultaneously increasing compliance to evidence based perioperative protocols. The ultimate goal is to use these advantages over manual care to improve patient outcome. For more than twenty years, clinical studies in anesthesia have demonstrated the superiority of closed-loop systems compared to manual control for stabilizing a single variable, reducing practitioner workload, and safely administering therapies. This research has focused on various closed-loops that coupled inputs and outputs such as the processed electroencephalogram with propofol, blood pressure with vasopressors, and dynamic predictors of fluid responsiveness with fluid therapy. Recently, multiple simultaneous independent closed-loop systems have been tested in practice and one study has demonstrated a clinical benefit on postoperative cognitive dysfunction. Despite their advantages, these tools still require that a well-trained practitioner maintains situation awareness, understands how closed-loop systems react to each variable, and is ready to retake control if the closed-loop systems fail. In the future, multiple input multiple output closed-loop systems will control anesthetic, fluid and vasopressor titration and may perhaps integrate other key systems, such as the anesthesia machine. Human supervision will nonetheless always be indispensable as situation awareness, communication, and prediction of events remain irreplaceable human factors.
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Affiliation(s)
- Sean Coeckelenbergh
- Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Saclay, Université Paris-Saclay, Hôpital Paul-Brousse, Assistance Publique Hôpitaux de Paris, Villejuif, France.
- Outcomes Research Consortium, Cleveland, OH, USA.
| | - Sebastian Boelefahr
- Department of Anesthesiology and Intensive Care, Klinikum Aschaffenburg-Alzenau, Frankfurt University and Wuerzburg University Affiliated Academic Training Hospital, Aschaffenburg, Germany
| | - Brenton Alexander
- Department of Anesthesiology & Perioperative Care, University of California San Diego, San Diego, CA, USA
| | - Laurent Perrin
- Department of Anaesthesia and Resuscitation, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Joseph Rinehart
- Outcomes Research Consortium, Cleveland, OH, USA
- Department of Anesthesiology & Perioperative Care, University of California Irvine, Irvine, CA, USA
| | - Alexandre Joosten
- Department of Anesthesiology & Perioperative Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Luc Barvais
- Department of Anaesthesia and Resuscitation, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Ilfeld BM, Finneran JJ, Alexander B, Abramson WB, Sztain JF, Ball ST, Gonzales FB, Abdullah B, Cha BJ, Said ET. Percutaneous auricular neuromodulation (nerve stimulation) for the treatment of pain following total knee arthroplasty: a randomized, double-masked, sham-controlled pilot study. Reg Anesth Pain Med 2024:rapm-2023-105028. [PMID: 38388019 DOI: 10.1136/rapm-2023-105028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 12/08/2023] [Indexed: 02/24/2024]
Abstract
BACKGROUND Percutaneous auricular nerve stimulation (neuromodulation) is an analgesic technique involving the percutaneous implantation of multiple leads at various points on/around the ear followed by the delivery of electric current using an external pulse generator. A device is currently available within the USA cleared to treat symptoms from opioid withdrawal, and multiple reports suggest a possible postoperative analgesic effect. The current randomized, controlled pilot study was undertaken to (1) determine the feasibility and optimize the protocol for a subsequent definitive clinical trial and (2) estimate the treatment effect of auricular neuromodulation on postoperative pain and opioid consumption following total knee arthroplasty. METHODS Within the recovery room following primary, unilateral, total knee arthroplasty, an auricular neuromodulation device (NSS-2 Bridge, Masimo, Irvine, California, USA) was applied using three percutaneous leads and one ground electrode. Participants were randomized to 5 days of either electrical stimulation or sham stimulation in a double-masked fashion. Participants were discharged with the stimulator in situ and removed the disposable devices at home. The dual primary treatment effect outcome measures were the cumulative opioid use (oral oxycodone) and the mean of the "average" daily pain measured with the Numeric Rating Scale for the first 5 postoperative days. RESULTS During the first five postoperative days, oxycodone consumption in participants given active stimulation (n=15) was a median (IQR) of 4 mg (2-12) vs 13 mg (5-23) in patients given sham (n=15) treatment (p=0.039). During this same period, the average pain intensity in patients given active stimulation was a median (IQR) of 2.5 (1.5-3.3) vs 4.0 (3.6-4.8) in those given sham (p=0.014). Awakenings due to pain over all eight postoperative nights in participants given active stimulation was a median (IQR) of 5 (3-8) vs 11 (4-14) in those given sham (p<0.001). No device-related localized cutaneous irritation, systemic side effects, or other adverse events were identified. CONCLUSIONS Percutaneous auricular neuromodulation reduced pain scores and opioid requirements during the initial week after total knee arthroplasty. Given the ease of application as well as the lack of systemic side effects and reported complications, a definitive clinical trial appears warranted. TRIAL REGISTRATION NUMBER NCT05521516.
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Affiliation(s)
- Brian M Ilfeld
- Department of Anesthesiology, University of California San Diego, La Jolla, California, USA
- Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - John J Finneran
- Department of Anesthesiology, University of California San Diego, La Jolla, California, USA
- Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Brenton Alexander
- Department of Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - Wendy B Abramson
- Department of Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - Jacklynn F Sztain
- Department of Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - Scott T Ball
- Department of Orthopedic Surgery, University California San Diego, San Diego, California, USA
| | - Francis B Gonzales
- Department of Orthopedic Surgery, University California San Diego, San Diego, California, USA
| | - Baharin Abdullah
- Department of Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - Brannon J Cha
- Department of Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - Engy T Said
- Department of Anesthesiology, University of California San Diego, La Jolla, California, USA
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Ilfeld BM, Abramson WB, Alexander B, Sztain JF, Said ET, Broderick RC, Sandler BJ, Doucet JJ, Adams LM, Abdullah B, Cha BJ, Finneran JJ. Percutaneous auricular neuromodulation (nerve stimulation) for the treatment of pain following cholecystectomy and hernia repair: a randomized, double-masked, sham-controlled pilot study. Reg Anesth Pain Med 2024:rapm-2024-105283. [PMID: 38388014 DOI: 10.1136/rapm-2024-105283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 01/22/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND Percutaneous auricular nerve stimulation (neuromodulation) involves implanting electrodes around the ear and administering an electric current. A device is currently available within the USA cleared to treat symptoms from opioid withdrawal, and multiple reports suggest a possible postoperative analgesic effect. The current randomized controlled pilot study was undertaken to (1) determine the feasibility and optimize the protocol for a subsequent definitive clinical trial; and (2) estimate the treatment effect of auricular neuromodulation on postoperative pain and opioid consumption following two ambulatory surgical procedures. METHODS Within the recovery room following cholecystectomy or hernia repair, an auricular neuromodulation device (NSS-2 Bridge, Masimo, Irvine, California, USA) was applied. Participants were randomized to 5 days of either electrical stimulation or sham in a double-blinded fashion. RESULTS In the first 5 days, the median (IQR) pain level for active stimulation (n=15) was 0.6 (0.3-2.4) vs 2.6 (1.1-3.7) for the sham group (n=15) (p=0.041). Concurrently, the median oxycodone use for the active stimulation group was 0 mg (0-1), compared with 0 mg (0-3) for the sham group (p=0.524). Regarding the highest pain level experienced over the entire 8-day study period, only one participant (7%) who received active stimulation experienced severe pain, versus seven (47%) in those given sham (p=0.031). CONCLUSIONS Percutaneous auricular neuromodulation reduced pain scores but not opioid requirements during the initial week after cholecystectomy and hernia repair. Given the ease of application as well as a lack of systemic side effects and reported complications, a definitive clinical trial appears warranted. TRIAL REGISTRATION NUMBER NCT05521516.
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Affiliation(s)
- Brian M Ilfeld
- Anesthesiology, University of California San Diego, La Jolla, California, USA
- Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Wendy B Abramson
- Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - Brenton Alexander
- Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - Jacklynn F Sztain
- Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - Engy T Said
- Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - Ryan C Broderick
- Department of Surgery, University of California San Diego, La Jolla, California, USA
| | - Bryan J Sandler
- Department of Surgery, University of California San Diego, La Jolla, California, USA
| | - Jay J Doucet
- Department of Surgery, University of California San Diego, La Jolla, California, USA
| | - Laura M Adams
- Department of Surgery, University of California San Diego, La Jolla, California, USA
| | - Baharin Abdullah
- Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - Brannon J Cha
- Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - John J Finneran
- Anesthesiology, University of California San Diego, La Jolla, California, USA
- Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
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Chan JK, Parasurama S, Atlas R, Xu R, Jongebloed UA, Alexander B, Langenhan JM, Thornton JA, Riffell JA. Olfaction in the Anthropocene: NO 3 negatively affects floral scent and nocturnal pollination. Science 2024; 383:607-611. [PMID: 38330103 DOI: 10.1126/science.adi0858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 01/04/2024] [Indexed: 02/10/2024]
Abstract
There is growing concern about sensory pollutants affecting ecological communities. Anthropogenically enhanced oxidants [ozone (O3) and nitrate radicals (NO3)] rapidly degrade floral scents, potentially reducing pollinator attraction to flowers. However, the physiological and behavioral impacts on pollinators and plant fitness are unknown. Using a nocturnal flower-moth system, we found that atmospherically relevant concentrations of NO3 eliminate flower visitation by moths, and the reaction of NO3 with a subset of monoterpenes is what reduces the scent's attractiveness. Global atmospheric models of floral scent oxidation reveal that pollinators in certain urban areas may have a reduced ability to perceive and navigate to flowers. These results illustrate the impact of anthropogenic pollutants on an animal's olfactory ability and indicate that such pollutants may be critical regulators of global pollination.
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Affiliation(s)
- J K Chan
- Department of Biology, University of Washington, Seattle, WA 98195, USA
- Department of Atmospheric Sciences, University of Washington, Seattle, WA 98195, USA
| | - S Parasurama
- Department of Biology, University of Washington, Seattle, WA 98195, USA
| | - R Atlas
- Department of Atmospheric Sciences, University of Washington, Seattle, WA 98195, USA
| | - R Xu
- Department of Atmospheric Sciences, University of Washington, Seattle, WA 98195, USA
- Center for Earth System Science, Tsinghua University, Beijing 100084, China
| | - U A Jongebloed
- Department of Atmospheric Sciences, University of Washington, Seattle, WA 98195, USA
| | - B Alexander
- Department of Atmospheric Sciences, University of Washington, Seattle, WA 98195, USA
| | - J M Langenhan
- Department of Chemistry, Seattle University, Seattle, WA 98122, USA
| | - J A Thornton
- Department of Atmospheric Sciences, University of Washington, Seattle, WA 98195, USA
| | - J A Riffell
- Department of Biology, University of Washington, Seattle, WA 98195, USA
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Delmotte L, Desebbe O, Alexander B, Kouz K, Coeckelenbergh S, Schoettker P, Turgay T, Joosten A. Smartphone-Based versus Non-Invasive Automatic Oscillometric Brachial Cuff Blood Pressure Measurements: A Prospective Method Comparison Volunteer Study. J Pers Med 2023; 14:15. [PMID: 38276230 PMCID: PMC10817276 DOI: 10.3390/jpm14010015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/06/2023] [Accepted: 12/18/2023] [Indexed: 01/27/2024] Open
Abstract
Introduction: Mobile health diagnostics have demonstrated effectiveness in detecting and managing chronic diseases. This method comparison study aims to assess the accuracy and precision of the previously evaluated OptiBP™ technology over a four-week study period. This device uses optical signals recorded by placing a patient's fingertip on a smartphone's camera to estimate blood pressure (BP). Methods: In adult participants without cardiac arrhythmias and minimal interarm blood pressure difference (systolic arterial pressure (SAP) < 15 mmHg or diastolic arterial pressure (DAP) < 10 mmHg), three pairs of 30 s BP measurements with the OptiBP™ (test method) were simultaneously compared using three pairs of measurements with the non-invasive oscillometric brachial cuff (reference method) on the opposite arm over a period of four consecutive weeks at a rate of two measurements per week (one in the morning and one in the afternoon). The agreement of BP values between the two technologies was analyzed using Bland-Altman and error grid analyses. The performance of the smartphone application was investigated using the International Organization for Standardization (ISO) definitions, which require the bias ± standard deviation (SD) between two technologies to be lower than 5 ± 8 mmHg. Results: Among the 65 eligible volunteers, 53 participants had adequate OptiBP™ BP values. In 12 patients, no OptiBP™ BP could be measured due to inadequate signals. Only nine participants had known chronic arterial hypertension and 76% of those patients were treated. The mean bias ± SD between both technologies was -1.4 mmHg ± 10.1 mmHg for systolic arterial pressure (SAP), 0.2 mmHg ± 6.5 mmHg for diastolic arterial pressure (DAP) and -0.5 mmHg ± 6.9 mmHg for mean arterial pressure (MAP). Error grid analyses indicated that 100% of the pairs of BP measurements were located in zones A (no risk) and B (low risk). Conclusions: In a cohort of volunteers, we observed an acceptable agreement between BP values obtained with the OptiBPTM and those obtained with the reference method over a four-week period. The OptiBPTM fulfills the ISO standards for MAP and DAP (but not SAP). The error grid analyses showed that 100% measurements were located in risk zones A and B. Despite the need for some technological improvements, this application may become an important tool to measure BP in the future.
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Affiliation(s)
- Lila Delmotte
- Department of Anesthesiology, Erasme University Hospital, Université Libre de Bruxelles, 808 Route de Lennik, 1070 Brussels, Belgium; (L.D.); (T.T.)
| | - Olivier Desebbe
- Department of Anesthesiology & Perioperative Medicine, Sauvegarde Clinic, Ramsay Santé, 69009 Lyon, France;
| | - Brenton Alexander
- Department of Anesthesiology, University of California San Diego, La Jolla, CA 92103, USA;
| | - Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Sean Coeckelenbergh
- Department of Anesthesiology, Université Paris-Saclay, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), 94800 Villejuif, France
- Outcomes Research Consortium, Cleveland, OH 44195, USA
| | - Patrick Schoettker
- Biospectal SA, 1003 Lausanne, Switzerland;
- Department of Anesthesiology, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Tuna Turgay
- Department of Anesthesiology, Erasme University Hospital, Université Libre de Bruxelles, 808 Route de Lennik, 1070 Brussels, Belgium; (L.D.); (T.T.)
| | - Alexandre Joosten
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA
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Desebbe O, Vallier S, Gergelé L, Alexander B, Marx A, Ben Jaoude E, Kato H, Toubal L, Berna A, Duranteau J, Vincent JL, Joosten A. Diagnostic accuracy of the peripheral venous pressure variation induced by an alveolar recruitment maneuver to predict fluid responsiveness during high-risk abdominal surgery. BMC Anesthesiol 2023; 23:249. [PMID: 37481588 PMCID: PMC10362688 DOI: 10.1186/s12871-023-02194-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 07/01/2023] [Indexed: 07/24/2023] Open
Abstract
BACKGROUND In patients undergoing high-risk surgery, it is recommended to titrate fluid administration using stroke volume or a dynamic variable of fluid responsiveness (FR). However, this strategy usually requires the use of a hemodynamic monitor and/or an arterial catheter. Recently, it has been shown that variations of central venous pressure (ΔCVP) during an alveolar recruitment maneuver (ARM) can predict FR and that there is a correlation between CVP and peripheral venous pressure (PVP). This prospective study tested the hypothesis that variations of PVP (ΔPVP) induced by an ARM could predict FR. METHODS We studied 60 consecutive patients scheduled for high-risk abdominal surgery, excluding those with preoperative cardiac arrhythmias or right ventricular dysfunction. All patients had a peripheral venous catheter, a central venous catheter and a radial arterial catheter linked to a pulse contour monitoring device. PVP was always measured via an 18-gauge catheter inserted at the antecubital fossa. Then an ARM consisting of a standardized gas insufflation to reach a plateau of 30 cmH2O for 30 s was performed before skin incision. Invasive mean arterial pressure (MAP), pulse pressure, heart rate, CVP, PVP, pulse pressure variation (PPV), and stroke volume index (SVI) were recorded before ARM (T1), at the end of ARM (T2), before volume expansion (T3), and one minute after volume expansion (T4). Receiver-operating curves (ROC) analysis with the corresponding grey zone approach were performed to assess the ability of ∆PVP (index test) to predict FR, defined as an ≥ 10% increase in SVI following the administration of a 4 ml/kg balanced crystalloid solution over 5 min. RESULTS ∆PVP during ARM predicted FR with an area under the ROC curve of 0.76 (95%CI, 0.63 to 0.86). The optimal threshold determined by the Youden Index was a ∆PVP value of 5 mmHg (95%CI, 4 to 6) with a sensitivity of 66% (95%CI, 47 to 81) and a specificity of 82% (95%CI, 63 to 94). The AUC's for predicting FR were not different between ΔPVP, ΔCVP, and PPV. CONCLUSION During high-risk abdominal surgery, ∆PVP induced by an ARM can moderately predict FR. Nevertheless, other hemodynamic variables did not perform better.
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Affiliation(s)
- Olivier Desebbe
- Department of Anesthesiology and Perioperative Medicine, Sauvegarde Clinic, Ramsay Sante, Lyon, France
| | - Sylvain Vallier
- Department of Anesthesiology and Intensive Care, Elsan Alpes-Belledonne Clinic, Grenoble, France
| | - Laurent Gergelé
- Department of Anesthesiology and Intensive Care, Ramsay Sante HPL Clinic, Saint-Etienne, France
| | - Brenton Alexander
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Alexandre Marx
- Department of Anesthesiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Elias Ben Jaoude
- Department of Anesthesiology and Intensive Care, Université Paris-Sud, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), 12 Avenue Paul Vaillant Couturier, Villejuif, 94800, France
| | - Hiromi Kato
- Department of Anesthesiology and Intensive Care, Université Paris-Sud, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), 12 Avenue Paul Vaillant Couturier, Villejuif, 94800, France
| | - Leila Toubal
- Department of Anesthesiology and Intensive Care, Université Paris-Sud, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), 12 Avenue Paul Vaillant Couturier, Villejuif, 94800, France
| | - Antoine Berna
- Department of Anesthesiology and Perioperative Medicine, Sauvegarde Clinic, Ramsay Sante, Lyon, France
| | - Jacques Duranteau
- Department of Anesthesiology and Intensive Care, Université Paris-Sud, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), 12 Avenue Paul Vaillant Couturier, Villejuif, 94800, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexandre Joosten
- Department of Anesthesiology and Intensive Care, Université Paris-Sud, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), 12 Avenue Paul Vaillant Couturier, Villejuif, 94800, France.
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Combs M, McInnis M, Simpson S, Kazerooni E, Alexander B, Martinu T, Diamond J, Galbán C, Lama V. Evaluating Inter-Rater Agreement of Radiographic Features and Diagnoses Across Lung Transplant Centers. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.1617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Elhalawani H, Hammoudeh L, Cagney D, Qian J, Martin A, Zgrabik J, Meyers J, Pataki K, Martin K, Khouj Y, Verry C, Bi W, Arnaout O, Christ S, Alexander B, Tanguturi S, Rahman R, Haas-Kogan D, Aizer A. Leveraging Serial MRI Radiomics and Machine Learning to Predict Risk of Radiation Necrosis in Patients with Brain Metastases Managed with Stereotactic Radiation and Immunotherapy. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Alexander B, Foisy M, Abdollah H, Chacko S, Enriquez A, Redfearn D, Simpson C, Baranchuk A. DEACTIVATION OF IMPLANTABLE CARDIOVERTER-DEFIBRILLATORS AT DISTANCE FOR THE DIGNITY OF DYING (THE 4D STUDY). Can J Cardiol 2022. [DOI: 10.1016/j.cjca.2022.08.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Joosten A, Carrier FM, Menioui A, Van der Linden P, Alexander B, Coilly A, Golse N, Allard MA, Lucidi V, Azoulay D, Naili S, Toubal L, Moussa M, Karam L, Pham H, Laukaityte E, Amara Y, Lanteri-Minet M, Samuel D, Sitbon O, Humbert M, Savale L, Duranteau J. Incidental finding of elevated pulmonary arterial pressures during liver transplantation and postoperative pulmonary complications. BMC Anesthesiol 2022; 22:300. [PMID: 36131247 PMCID: PMC9490933 DOI: 10.1186/s12871-022-01839-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 09/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In patients with end stage liver disease (ESLD) scheduled for liver transplantation (LT), an intraoperative incidental finding of elevated mean pulmonary arterial pressure (mPAP) may be observed. Its association with patient outcome has not been evaluated. We aimed to estimate the effects of an incidental finding of a mPAP > 20 mmHg during LT on the incidence of pulmonary complications. METHODS We examined all patients who underwent a LT at Paul-Brousse hospital between January 1,2015 and December 31,2020. Those who received: a LT due to acute liver failure, a combined transplantation, or a retransplantation were excluded, as well as patients for whom known porto-pulmonary hypertension was treated before the LT or patients who underwent a LT for other etiologies than ESLD. Using right sided pulmonary artery catheterization measurements made following anesthesia induction, the study cohort was divided into two groups using a mPAP cutoff of 20 mmHg. The primary outcome was a composite of pulmonary complications. Univariate and multivariable logistic regression analyses were performed to identify variables associated with the primary outcome. Sensitivity analyses of multivariable models were also conducted with other mPAP cutoffs (mPAP ≥ 25 mmHg and ≥ 35 mmHg) and even with mPAP as a continuous variable. RESULTS Of 942 patients who underwent a LT, 659 met our inclusion criteria. Among them, 446 patients (67.7%) presented with an elevated mPAP (mPAP of 26.4 ± 5.9 mmHg). When adjusted for confounding factors, an elevated mPAP was not associated with a higher risk of pulmonary complications (adjusted OR: 1.16; 95%CI 0.8-1.7), nor with 90 days-mortality or any other complications. In our sensitivity analyses, we observed a lower prevalence of elevated mPAP when increasing thresholds (235 patients (35.7%) had an elevated mPAP when defined as ≥ 25 mmHg and 41 patients (6.2%) had an elevated mPAP when defined as ≥ 35 mmHg). We did not observe consistent association between a mPAP ≥ 25 mmHg or a mPAP ≥ 35 mmHg and our outcomes. CONCLUSION Incidental finding of elevated mPAP was highly prevalent during LT, but it was not associated with a higher risk of postoperative complications.
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Affiliation(s)
- Alexandre Joosten
- Department of Anesthesiology and Intensive Care, Paris-Saclay University, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), 12 Avenue Paul Vaillant Couturier, 94800, Villejuif, France.
| | - François Martin Carrier
- Department of Anesthesiology and Department of Medicine, Critical Care Division, Centre Hospitalier de L'Université de Montréal, Montréal, Québec, Canada.,Carrefour de L'innovation Et Santé Des Populations, Centre de Recherche du Centre Hospitalier de L'Université de Montréal, Montréal, Québec, Canada
| | - Aïmane Menioui
- Department of Anesthesiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Philippe Van der Linden
- Department of Anesthesiology, Brugmann Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Brenton Alexander
- Department of Anesthesiology, University of California San Diego, La Jolla, San Diego, CA, USA
| | - Audrey Coilly
- Department of Intensive Care, Paris-Saclay University, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), Villejuif, France.,Department of Hepatology, Paris-Saclay University, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), Villejuif, France
| | - Nicolas Golse
- Department of Hepatobiliary Surgery and Liver Transplantation, Paris-Saclay University, Paul Brousse hospital, Assistance Publique Hôpitaux de Paris (APHP), Villejuif, France
| | - Marc-Antoine Allard
- Department of Hepatobiliary Surgery and Liver Transplantation, Paris-Saclay University, Paul Brousse hospital, Assistance Publique Hôpitaux de Paris (APHP), Villejuif, France
| | - Valerio Lucidi
- Department of Hepatobiliary Surgery and Liver Transplantation, Erasme Hospital, Brussels, Belgium
| | - Daniel Azoulay
- Department of Hepatobiliary Surgery and Liver Transplantation, Paris-Saclay University, Paul Brousse hospital, Assistance Publique Hôpitaux de Paris (APHP), Villejuif, France
| | - Salima Naili
- Department of Anesthesiology and Intensive Care, Paris-Saclay University, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), 12 Avenue Paul Vaillant Couturier, 94800, Villejuif, France
| | - Leila Toubal
- Department of Anesthesiology and Intensive Care, Paris-Saclay University, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), 12 Avenue Paul Vaillant Couturier, 94800, Villejuif, France
| | - Maya Moussa
- Department of Anesthesiology and Intensive Care, Paris-Saclay University, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), 12 Avenue Paul Vaillant Couturier, 94800, Villejuif, France
| | - Lydia Karam
- Department of Anesthesiology and Intensive Care, Paris-Saclay University, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), 12 Avenue Paul Vaillant Couturier, 94800, Villejuif, France
| | - Hung Pham
- Department of Anesthesiology and Intensive Care, Paris-Saclay University, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), 12 Avenue Paul Vaillant Couturier, 94800, Villejuif, France
| | - Edita Laukaityte
- Department of Anesthesiology and Intensive Care, Paris-Saclay University, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), 12 Avenue Paul Vaillant Couturier, 94800, Villejuif, France
| | - Youcef Amara
- Department of Anesthesiology and Intensive Care, Paris-Saclay University, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), 12 Avenue Paul Vaillant Couturier, 94800, Villejuif, France
| | - Marc Lanteri-Minet
- Department of Anesthesiology and Intensive Care, Paris-Saclay University, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), 12 Avenue Paul Vaillant Couturier, 94800, Villejuif, France
| | - Didier Samuel
- Department of Intensive Care, Paris-Saclay University, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), Villejuif, France.,Department of Hepatology, Paris-Saclay University, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), Villejuif, France
| | - Olivier Sitbon
- Faculty of Medicine, Paris-Saclay University, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Le Kremlin-Bicêtre, France.,Department of Pneumology and Respiratory Intensive Care, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Marc Humbert
- Faculty of Medicine, Paris-Saclay University, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Le Kremlin-Bicêtre, France.,Department of Pneumology and Respiratory Intensive Care, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Laurent Savale
- Faculty of Medicine, Paris-Saclay University, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Le Kremlin-Bicêtre, France.,Department of Pneumology and Respiratory Intensive Care, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Jacques Duranteau
- Department of Anesthesiology and Intensive Care, Paris-Saclay University, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), 12 Avenue Paul Vaillant Couturier, 94800, Villejuif, France
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11
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Alexander B, Mehdipour S, Lee SW, Said ET, Gabriel RA. The association of Serratus Anterior Plane blocks with postoperative opioid use and analgesia following simple lumpectomy: a retrospective cohort analysis. BMC Anesthesiol 2022; 22:291. [PMID: 36109719 PMCID: PMC9476687 DOI: 10.1186/s12871-022-01834-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 09/05/2022] [Indexed: 11/22/2022] Open
Abstract
Background The potential benefit of regional interventions for simple lumpectomy breast cancer surgeries has not been well investigated. Understanding which patients to not offer a regional intervention to can be just as important as knowing which would benefit. It is unclear whether fascial plane blocks, such as serratus anterior plane (SAP) block, should be routinely performed for less extensive breast surgeries. Therefore, our goal in this retrospective cohort study was to evaluate the association of integrating SAP blocks into a standard perioperative multimodal analgesia plan in patients undergoing simple lumpectomies (without node biopsies) with perioperative opioid consumption. As secondary outcomes, we also analyzed postoperative pain scores and post-anesthesia care unit (PACU) length of stay. Methods This was a single institution retrospective cohort study (surgical site infiltration only versus SAP block cohorts) assessing the association of SAP blocks to our outcomes of interest. In the adjusted analysis, we created matched cohorts using 1:1 (surgical site infiltration only: SAP block) propensity-score matching using nearest neighbor-matching without replacement. To compare the primary and secondary outcomes in the matched cohorts, we used the Wilcoxon signed rank test. A P-value of < 0.05 was considered statistically significant. Results There were 419 patients included in the analysis, in which 116 (27.7%) received a SAP block preoperatively in addition to our standard perioperative analgesia plan. In an unadjusted analysis, no differences were seen in perioperative opioid consumption, PACU pain scores, and PACU length of stay. Among the matched cohorts, the median [quartile] perioperative opioid consumption in the surgical site infiltration only versus SAP block cohorts were 10 mg [10, 13.25 mg] and 10 mg [7, 15 mg], respectively (P = 0.16). No differences were seen in the other outcomes. Conclusions In this study, we evaluated the impact of SAP blocks on patients undergoing simple lumpectomies, which are relatively less involved breast surgeries. We concluded that routine use of preoperative regional anesthesia is not beneficial for these specific patients. Future studies should focus on identifying patients that would directly benefit from regional interventions.
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12
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Weller M, Ellingson B, Alexander B, Wen P, Sulman E, Colman H, Berry D, Tanner K, Khasraw M, Lim M, Perry J, Lassman A, Cloughesy T, Yung WKA, Lee EQ, Mellinghoff I, Gordon G, de Groot J, Mikkelsen T, Cavenee W, Nelli A, Buxton M, Li W. P11.65.B GBM AGILE: A global, phase 2/3 adaptive platform trial to evaluate multiple treatment regimens in newly diagnosed and recurrent glioblastoma. Neuro Oncol 2022. [DOI: 10.1093/neuonc/noac174.254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
GBM AGILE (Glioblastoma Adaptive, Global, Innovative Learning Environment) is a biomarker based, multi-arm, international, seamless Phase 2/3 Response Adaptive Randomization platform trial designed to rapidly identify experimental therapies that improve overall survival and confirm efficacious experimental therapies and associated biomarker signatures to support new drug approvals and registration. It is a collaboration between academic investigators, patient organizations and industry, under the sponsorship of the non-profit organization, Global Coalition for Adaptive Research, to support new drug applications for newly diagnosed and recurrent GBM.
Material and Methods
The primary objective of GBM AGILE is to identify therapies that effectively improve overall survival in patients with newly diagnosed or recurrent GBM. Bayesian response adaptive randomization is used within subtypes of the disease to assign participants to investigational arms based on their performance. Operating under a master protocol, GBM AGILE allows multiple drugs from different pharmaceutical companies to be evaluated simultaneously and/or over time against a common control arm. Based on performance, a drug may graduate and move to a Stage 2 (Phase 3) within the trial, and the totality of the data can be used for a new drug application and registration process. New experimental therapies are added as information about promising new drugs is identified while other therapies are removed as they complete their evaluation. The master protocol/ trial infrastructure includes efficiencies through an adaptive trial design, shared control arm and operational processes such as risk-based monitoring and enhanced remote activities. With its adaptable structure, GBM AGILE has continued trial activation, inclusion of new investigational therapies, and enrollment globally through the challenges of a global pandemic.GBM AGILE provides an efficient mechanism to screen and develop robust information regarding the efficacy of proposed novel therapeutics and associated biomarkers for GBM and to quickly move therapies and biomarkers into clinic. GBM AGILE received initial approval from the United States FDA in April 2019, and in Europe through the Voluntary Harmonization Procedure (VHP) in April, 2021. As of 2022, AGILE has screened over 1000 patients studying multiple investigational treatments. Enrollment rates are 3 to 4 times greater than traditional GBM trials, with active sites averaging 0.75 to 1 patients/site/month.
Currently, there are 41 sites activated in the US, 4 in Canada and 2 in Switzerland and an estimated 24 sites yet to open in Germany, France, Switzerland, Italy and Austria. In addition to the continued expansion in Europe, effort is undergoing to extend the trial to China and Australia as well. Clinical trial information: NCT03970447
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Affiliation(s)
- M Weller
- Universitätsspital Zürich , Klinik für Neurologie, Zürich , Switzerland
| | - B Ellingson
- University of California , Los Angeles, CA , United States
| | - B Alexander
- Dana Farber Cancer Institute, Harvard University , Boston, MA , United States
| | - P Wen
- Dana Farber Cancer Institute , Boston, MA , United States
| | - E Sulman
- NYU Grossman School of Medicine , New York, NY , United States
| | - H Colman
- University of Utah, Salt Lake City, UT , United States
| | - D Berry
- Berry Consultants , Austin, TX , United States
| | - K Tanner
- National Brain Tumor Society , Newton, MA , United States
| | - M Khasraw
- Duke Cancer Institute, Duke University , Durham, NC , United States
| | - M Lim
- Stanford University , Stanford, CA , United States
| | - J Perry
- University of Toronto, Toronto , ON , Canada
| | - A Lassman
- Columbia University, New York City, NY , United States
| | - T Cloughesy
- University of California Los Angeles , Los Angeles, CA , United States
| | - W K A Yung
- UT MD Anderson Cancer Center , Houston, TX , United States
| | - E Q Lee
- Dana Farber Cancer Institute , Boston, MA , United States
| | - I Mellinghoff
- Memorial Sloan Kettering, New York City, NY , United States
| | - G Gordon
- Global Coalition for Adaptive Research , Larkspur, CA , United States
| | - J de Groot
- University of California, San Francisco , San Francisco, CA , United States
| | - T Mikkelsen
- Henry Ford Health , Detroit, MI , United States
| | - W Cavenee
- University of California San Diego , La Jolla, CA , United States
| | - A Nelli
- Global Coalition for Adaptive Research , Larkspur, CA , United States
| | - M Buxton
- Global Coalition for Adaptive Research , Larkspur, CA , United States
| | - W Li
- Beijing Tiantan Hospital, Capital Medical University , Beijing , China
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13
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Desebbe O, Anas C, Alexander B, Kouz K, Knebel JF, Schoettker P, Creteur J, Vincent JL, Joosten A. Evaluation of a novel optical smartphone blood pressure application: a method comparison study against invasive arterial blood pressure monitoring in intensive care unit patients. BMC Anesthesiol 2022; 22:259. [PMID: 35971072 PMCID: PMC9376576 DOI: 10.1186/s12871-022-01797-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 08/02/2022] [Indexed: 11/18/2022] Open
Abstract
Background Arterial hypertension is a worldwide public health problem. While it is currently diagnosed and monitored non-invasively using the oscillometric method, having the ability to measure blood pressure (BP) using a smartphone application could provide more widespread access to hypertension screening and monitoring. In this observational study in intensive care unit patients, we compared blood pressure values obtained using a new optical smartphone application (OptiBP™; test method) with arterial BP values obtained using a radial artery catheter (reference method) in order to help validate the technology. Methods We simultaneously measured three BP values every hour for five consecutive hours on two consecutive days using both the smartphone and arterial methods. Bland–Altman and error grid analyses were used for agreement analysis between both approaches. The performance of the smartphone application was investigated using the Association for the Advancement of Medical Instrumentation (AAMI) and the International Organization for Standardization (ISO) definitions, which require the bias ± SD between two technologies to be below 5 ± 8 mmHg. Results Among the 30 recruited patients, 22 patients had adequate OptiBP™ values and were thus analyzed. In the other 8 patients, no BP could be measured due to inadequate signals. The Bland–Altman analysis revealed a mean of the differences ± SD between both methods of 0.9 ± 7 mmHg for mean arterial pressure (MAP), 0.2 ± 14 mmHg for systolic arterial pressure (SAP), and 1.1 ± 6 mmHg for diastolic arterial pressure (DAP). Error grid analysis demonstrated that the proportions of measurement pairs in risk zones A to E were 88.8% (no risk), 10% (low risk), 1% (moderate risk), 0% (significant risk), and 0% (dangerous risk) for MAP and 88.4%, 8.6%, 3%, 0%, 0%, respectively, for SAP. Conclusions This method comparison study revealed good agreement between BP values obtained using the OptiBP™ and those done invasively. The OptiBP™ fulfills the AAMI/ISO universal standards for MAP and DAP (but not SAP). Error grid showed that the most measurements (≥ 97%) were in risk zones A and B. Trial registration ClinicalTrials.gov registration: NCT04728477
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Affiliation(s)
- Olivier Desebbe
- Department of Anesthesiology and Intensive Care, Clinique de La Sauvegarde, 80 Avenue Ben Gourion, 69009, Lyon, France
| | - Chbabou Anas
- Department of Anesthesiology, CUB Erasme University Hospital, Université Libre de Bruxelles, 808 Route de Lennik, 1070, Brussels, Belgium
| | - Brenton Alexander
- Department of Anesthesiology and Perioperative Care, University of California San Diego, San Diego, CA, USA
| | - Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | | | - Patrick Schoettker
- Biospectal SA, 1003, Lausanne, Switzerland.,Department of Anesthesiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jacques Creteur
- Department of Intensive Care, CUB Erasme University Hospital, Université Libre de Bruxelles, 808 Route de Lennik, 1070, Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, CUB Erasme University Hospital, Université Libre de Bruxelles, 808 Route de Lennik, 1070, Brussels, Belgium
| | - Alexandre Joosten
- Department of Anesthesiology, CUB Erasme University Hospital, Université Libre de Bruxelles, 808 Route de Lennik, 1070, Brussels, Belgium. .,Department of Anesthesiology, Paul Brousse Hospital, Université Paris-Sud, Villejuif, France.
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Karam L, Desebbe O, Coeckelenbergh S, Alexander B, Colombo N, Laukaityte E, Pham H, Lanteri Minet M, Toubal L, Moussa M, Naili S, Duranteau J, Vincent JL, Van der Linden P, Joosten A. Assessing the discriminative ability of the respiratory exchange ratio to detect hyperlactatemia during intermediate-to-high risk abdominal surgery. BMC Anesthesiol 2022; 22:211. [PMID: 35804321 PMCID: PMC9264511 DOI: 10.1186/s12871-022-01757-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 06/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A mismatch between oxygen delivery (DO2) and consumption (VO2) is associated with increased perioperative morbidity and mortality. Hyperlactatemia is often used as an early screening tool, but this non-continuous measurement requires intermittent arterial line sampling. Having a non-invasive tool to rapidly detect inadequate DO2 is of great clinical relevance. The respiratory exchange ratio (RER) can be easily measured in all intubated patients and has been shown to predict postoperative complications. We therefore aimed to assess the discriminative ability of the RER to detect an inadequate DO2 as reflected by hyperlactatemia in patients having intermediate-to-high risk abdominal surgery. METHODS This historical cohort study included all consecutive patients who underwent intermediate-to-high risk surgery from January 1st, 2014, to April 30th, 2019 except those who did not have RER and/or arterial lactate measured. Blood lactate levels were measured routinely at the beginning and end of surgery and RER was calculated at the same moment as the blood gas sampling. The present study tested the hypothesis that RER measured at the end of surgery could detect hyperlactatemia at that time. A receiver operating characteristic (ROC) curve was constructed to assess if RER calculated at the end of the surgery could detect hyperlactatemia. The chosen RER threshold corresponded to the highest value of the sum of the specificity and the sensitivity (Youden Index). RESULTS Among the 996 patients available in our study cohort, 941 were included and analyzed. The area under the ROC curve was 0.73 (95% CI: 0.70 to 0.76; p < 0.001), with a RER threshold of 0.75, allowing to discriminate a lactate > 1.5 mmol/L with a sensitivity of 87.5% and a specificity of 49.5%. CONCLUSION In mechanically ventilated patients undergoing intermediate to high-risk abdominal surgery, the RER had moderate discriminative abilities to detect hyperlactatemia. Increased values should prompt clinicians to investigate for the presence of hyperlactatemia and treat any potential causes of DO2/VO2 mismatch as suggested by the subsequent presence of hyperlactatemia.
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Affiliation(s)
- Lydia Karam
- Department of Anesthesiology and Intensive Care, Université Paris-Saclay, Paul Brousse Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Villejuif, France
| | - Olivier Desebbe
- Department of Anesthesiology and Perioperative Medicine Sauvegarde Clinic, Ramsay Santé, Lyon, France
| | - Sean Coeckelenbergh
- Department of Anesthesiology and Intensive Care, Université Paris-Saclay, Paul Brousse Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Villejuif, France.,Department of Anesthesiology, Paul Brousse Hospital, 12 Avenue Paul Vaillant Couturier, 94800, Villejuif, France
| | - Brenton Alexander
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Nicolas Colombo
- Department of Anesthesiology, Paul Brousse Hospital, 12 Avenue Paul Vaillant Couturier, 94800, Villejuif, France
| | - Edita Laukaityte
- Department of Anesthesiology and Intensive Care, Université Paris-Saclay, Paul Brousse Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Villejuif, France
| | - Hung Pham
- Department of Anesthesiology and Intensive Care, Université Paris-Saclay, Paul Brousse Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Villejuif, France
| | - Marc Lanteri Minet
- Department of Anesthesiology and Intensive Care, Université Paris-Saclay, Paul Brousse Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Villejuif, France
| | - Leila Toubal
- Department of Anesthesiology and Intensive Care, Université Paris-Saclay, Paul Brousse Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Villejuif, France
| | - Maya Moussa
- Department of Anesthesiology and Intensive Care, Université Paris-Saclay, Paul Brousse Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Villejuif, France
| | - Salima Naili
- Department of Anesthesiology and Intensive Care, Université Paris-Saclay, Paul Brousse Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Villejuif, France
| | - Jacques Duranteau
- Department of Anesthesiology and Intensive Care, Université Paris-Saclay, Paul Brousse Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Villejuif, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Philippe Van der Linden
- Department of Anesthesiology, Brugmann Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexandre Joosten
- Department of Anesthesiology and Intensive Care, Université Paris-Saclay, Paul Brousse Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Villejuif, France. .,Department of Anesthesiology, Paul Brousse Hospital, 12 Avenue Paul Vaillant Couturier, 94800, Villejuif, France.
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15
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Desebbe O, Tighenifi A, Jacobs A, Toubal L, Zekhini Y, Chirnoaga D, Collange V, Alexander B, Knebel JF, Schoettker P, Joosten A. Evaluation of a novel mobile phone application for blood pressure monitoring: a proof of concept study. J Clin Monit Comput 2021; 36:1147-1153. [PMID: 34409513 DOI: 10.1007/s10877-021-00749-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 08/12/2021] [Indexed: 10/20/2022]
Abstract
To provide information about the clinical relevance of blood pressure (BP) measurement differences between a new smartphone application (OptiBP™) and the reference method (automated oscillometric technique) using a noninvasive brachial cuff in patients admitted to the emergency department. We simultaneously recorded three BP measurements using both the reference method and the novel OptiBP™ (test method), except when the inter-arm difference was > 10 mmHg BP. Each OptiBP™ measurement required 1-min and the subsequent reference method values were compared to the values obtained with OptiBP™ using a Bland-Altman analysis and error grid analysis. Among the 110 patients recruited, OptiBP™ BP values could be collected on 61 patients (55%) and were included in the statistical analysis. The mean of differences (95% limits of agreement) between the reference method and the test method were - 0.1(- 22.5 to 22.4 mmHg) for systolic arterial pressure (SAP), - 0.1(- 12.9 to 12.7 mmHg) for diastolic arterial pressure (DAP) and - 0.3(- 18.1 to 17.4 mmHg) for mean arterial pressure (MAP). The proportions of measurements in risk zones A-E were 86.9%, 13.1%, 0%, 0%, and 0% for MAP and 89.3%, 10.7%, 0%, 0%, and 0% for SAP. In this pilot study conducted in stable and awake patients admitted to the emergency department, the absolute agreement between the OptiBP™ and the reference method was moderate. However, when BP measurements were made immediately after an initial calibration, error grid analysis showed that 100% of measurement differences between the OptiBP™ and reference method were categorized as no- or low-risk treatment decisions for all patients.Trial Registration: ClinicalTrials.gov Identifier: NCT04121624.
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Affiliation(s)
- Olivier Desebbe
- Department of Anesthesiology and Perioperative Medicine Sauvegarde Clinic, Ramsay Santé, Lyon, France
| | | | - Alexandra Jacobs
- Department of Anesthesiology, Erasme Hospital, Université Libre de Bruxelles, 808 route de lennik, 1070, Brussels, Belgium
| | - Leila Toubal
- Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), Villejuif, France
| | - Yassine Zekhini
- Department of Anesthesiology, Erasme Hospital, Université Libre de Bruxelles, 808 route de lennik, 1070, Brussels, Belgium
| | - Dragos Chirnoaga
- Department of Anesthesiology, Erasme Hospital, Université Libre de Bruxelles, 808 route de lennik, 1070, Brussels, Belgium
| | - Vincent Collange
- Department of Anesthesiology, Médipole Lyon Villeurbanne, Léon Blum, France
| | - Brenton Alexander
- Department of Anesthesiology, University of California San Diego, La Jolla, San Diego, CA, USA
| | | | - Patrick Schoettker
- Department of Anesthesiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Alexandre Joosten
- Department of Anesthesiology, Erasme Hospital, Université Libre de Bruxelles, 808 route de lennik, 1070, Brussels, Belgium. .,Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), Villejuif, France.
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16
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Joosten A, Rinehart J, Van der Linden P, Alexander B, Penna C, De Montblanc J, Cannesson M, Vincent JL, Vicaut E, Duranteau J. Computer-assisted Individualized Hemodynamic Management Reduces Intraoperative Hypotension in Intermediate- and High-risk Surgery: A Randomized Controlled Trial. Anesthesiology 2021; 135:258-272. [PMID: 33951140 PMCID: PMC8277754 DOI: 10.1097/aln.0000000000003807] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Individualized hemodynamic management during surgery relies on accurate titration of vasopressors and fluids. In this context, computer systems have been developed to assist anesthesia providers in delivering these interventions. This study tested the hypothesis that computer-assisted individualized hemodynamic management could reduce intraoperative hypotension in patients undergoing intermediate- to high-risk surgery. METHODS This single-center, parallel, two-arm, prospective randomized controlled single blinded superiority study included 38 patients undergoing abdominal or orthopedic surgery. All included patients had a radial arterial catheter inserted after anesthesia induction and connected to an uncalibrated pulse contour monitoring device. In the manually adjusted goal-directed therapy group (N = 19), the individualized hemodynamic management consisted of manual titration of norepinephrine infusion to maintain mean arterial pressure within 10% of the patient's baseline value, and mini-fluid challenges to maximize the stroke volume index. In the computer-assisted group (N = 19), the same approach was applied using a closed-loop system for norepinephrine adjustments and a decision-support system for the infusion of mini-fluid challenges (100 ml). The primary outcome was intraoperative hypotension defined as the percentage of intraoperative case time patients spent with a mean arterial pressure of less than 90% of the patient's baseline value, measured during the preoperative screening. Secondary outcome was the incidence of minor postoperative complications. RESULTS All patients were included in the analysis. Intraoperative hypotension was 1.2% [0.4 to 2.0%] (median [25th to 75th] percentiles) in the computer-assisted group compared to 21.5% [14.5 to 31.8%] in the manually adjusted goal-directed therapy group (difference, -21.1 [95% CI, -15.9 to -27.6%]; P < 0.001). The incidence of minor postoperative complications was not different between groups (42 vs. 58%; P = 0.330). Mean stroke volume index and cardiac index were both significantly higher in the computer-assisted group than in the manually adjusted goal-directed therapy group (P < 0.001). CONCLUSIONS In patients having intermediate- to high-risk surgery, computer-assisted individualized hemodynamic management significantly reduces intraoperative hypotension compared to a manually controlled goal-directed approach. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Alexandre Joosten
- Department of Anesthesiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
- Department of Anesthesiology and Intensive Care, Paris-Saclay University, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
| | - Joseph Rinehart
- Department of Anesthesiology & Perioperative Care, University of California Irvine, California, USA
| | - Philippe Van der Linden
- Department of Anesthesiology, Brugmann Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Brenton Alexander
- Department of Anesthesiology, University of California San Diego, California, USA
| | - Christophe Penna
- Department of Gastro-intestinal Surgery, Paris-Saclay University, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
| | - Jacques De Montblanc
- Department of Anesthesiology and Intensive Care, Paris-Saclay University, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
| | - Maxime Cannesson
- Department of Anesthesiology & Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, California, USA
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Eric Vicaut
- Unité de Recherche Clinique, Lariboisière, Paris 7 Diderot University, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Jacques Duranteau
- Department of Anesthesiology and Intensive Care, Paris-Saclay University, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
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Necchi A, Grivas P, Spiess P, Jacob J, Schrock A, Madison R, Pavlick D, Sokol E, Danziger N, Ramkissoon S, Severson E, Huang R, Lin D, Mata D, Decker B, Gjoerup O, Mcgregor K, Venstrom J, Alexander B, Ross J, Bratslavsky G. Methylthioadenosine Phosphorylase (MTAP) deletion is more common in Sarcomatoid (srcRCC) than in clear cell Renal Cell Carcinoma (ccRCC). Eur Urol 2021. [DOI: 10.1016/s0302-2838(21)01008-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Joosten A, Ickx B, Mokthari Z, Van Obbergh L, Lucidi V, Collange V, Naili S, Ichai P, Samuel D, Sa Cunha A, Alexander B, Legrand M, Taccone FS, Harrois A, Duranteau J, Vincent JL, Rinehart J, Van der Linden P. Mild increases in plasma creatinine after intermediate to high-risk abdominal surgery are associated with long-term renal injury. BMC Anesthesiol 2021; 21:135. [PMID: 33931017 PMCID: PMC8086102 DOI: 10.1186/s12871-021-01353-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 04/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The potential relationship between a mild acute kidney injury (AKI) observed in the immediate postoperative period after major surgery and its effect on long term renal function remains poorly defined. According to the "Kidney Disease: Improving Global Outcomes" (KDIGO) classification, a mild injury corresponds to a KIDIGO stage 1, characterized by an increase in creatinine of at least 0.3 mg/dl within a 48-h window or 1.5 to 1.9 times the baseline level within the first week post-surgery. We tested the hypothesis that patients who underwent intermediate-to high-risk abdominal surgery and developed mild AKI in the following days would be at an increased risk of long-term renal injury compared to patients with no postoperative AKI. METHODS All consecutive adult patients with a plasma creatinine value ≤1.5 mg/dl who underwent intermediate-to high-risk abdominal surgery between 2014 and 2019 and who had at least three recorded creatinine measurements (before surgery, during the first seven postoperative days, and at long-term follow up [6 months-2 years]) were included. AKI was defined using a "modified" (without urine output criteria) KDIGO classification as mild (stage 1 characterised by an increase in creatinine of > 0.3 mg/dl within 48-h or 1.5-1.9 times baseline) or moderate-to-severe (stage 2-3 characterised by increase in creatinine 2 to 3 times baseline or to ≥4.0 mg/dl). The exposure (postoperative kidney injury) and outcome (long-term renal injury) were defined and staged according to the same KDIGO initiative criteria. Development of long-term renal injury was compared in patients with and without postoperative AKI. RESULTS Among the 815 patients included, 109 (13%) had postoperative AKI (81 mild and 28 moderate-to-severe). The median long-term follow-up was 360, 354 and 353 days for the three groups respectively (P = 0.2). Patients who developed mild AKI had a higher risk of long-term renal injury than those who did not (odds ratio 3.1 [95%CI 1.7-5.5]; p < 0.001). In multivariable analysis, mild postoperative AKI was independently associated with an increased risk of developing long-term renal injury (adjusted odds ratio 4.5 [95%CI 1.8-11.4]; p = 0.002). CONCLUSIONS Mild AKI after intermediate-to high-risk abdominal surgery is associated with a higher risk of long-term renal injury 1 y after surgery.
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Affiliation(s)
- Alexandre Joosten
- Department of Anesthesiology, CUB Erasme, Université Libre de Bruxelles, 808 route de Lennik, 1070, Bruxelles, Belgium. .,Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), Université Paris-Saclay, 12 Avenue Paul Vaillant Couturier, 94800, Villejuif, France.
| | - Brigitte Ickx
- Department of Anesthesiology, CUB Erasme, Université Libre de Bruxelles, 808 route de Lennik, 1070, Bruxelles, Belgium
| | - Zakaria Mokthari
- Department of Anesthesiology, CUB Erasme, Université Libre de Bruxelles, 808 route de Lennik, 1070, Bruxelles, Belgium
| | - Luc Van Obbergh
- Department of Anesthesiology, CUB Erasme, Université Libre de Bruxelles, 808 route de Lennik, 1070, Bruxelles, Belgium
| | - Valerio Lucidi
- Department of Hepato-biliary Surgery, CUB Erasme, Université Libre de Bruxelles, 808 route de Lennik, 1070, Bruxelles, Belgium
| | - Vincent Collange
- Department of Anesthesiology, Médipole, Lyon Villeurbanne, France
| | - Salima Naili
- Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), Université Paris-Saclay, 12 Avenue Paul Vaillant Couturier, 94800, Villejuif, France
| | - Philippe Ichai
- Department of Liver Intensive Care Unit, AP-HP, Assistance Publique Hôpitaux de Paris, Paul-Brousse Hospital, Centre Hépato-Biliaire, 12 Avenue Paul Vaillant Couturier, 94800, Villejuif, France
| | - Didier Samuel
- Department of Liver Intensive Care Unit, AP-HP, Assistance Publique Hôpitaux de Paris, Paul-Brousse Hospital, Centre Hépato-Biliaire, 12 Avenue Paul Vaillant Couturier, 94800, Villejuif, France
| | - Antonio Sa Cunha
- Department of Hepato-biliary and Pancreatic Surgery, Assistance Publique Hôpitaux de Paris, Paul-Brousse Hospital, Centre Hépato-Biliaire, 12 Avenue Paul Vaillant Couturier, 94800, Villejuif, France
| | - Brenton Alexander
- Department of Anesthesiology, University of California San Diego, 9500 Gilman Dr, La Jolla, CA, 92093, USA
| | - Matthieu Legrand
- Department of Anesthesia and Perioperative care, University of California, San Francisco, 500 Parnassus Avenue, San Francisco, USA.,UMR INSERM 942, Institut National de la Santé et de la Recherche Médicale (INSERM), INI-CRCT network, Paris, France
| | - Fabio Silvio Taccone
- Department of Intensive Care, CUB Erasme, Université Libre de Bruxelles, 808 route de Lennik, 1070, Bruxelles, Belgium
| | - Anatole Harrois
- Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Bicetre Hospital, Assistance Publique Hôpitaux de Paris (APHP), Université Paris-Saclay, 78 rue du General Leclerc, 94270, Le Kremlin Bicetre, France
| | - Jacques Duranteau
- Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Bicetre Hospital, Assistance Publique Hôpitaux de Paris (APHP), Université Paris-Saclay, 78 rue du General Leclerc, 94270, Le Kremlin Bicetre, France
| | - Jean-Louis Vincent
- Department of Intensive Care, CUB Erasme, Université Libre de Bruxelles, 808 route de Lennik, 1070, Bruxelles, Belgium
| | - Joseph Rinehart
- Department of Anesthesiology and Perioperative Care, University of California Irvine, 101, the City Drive South, Orange, California, USA
| | - Philippe Van der Linden
- Department of Anesthesiology, Brugmann Hospital, Université Libre de Bruxelles, 4, Place A. Van Gehuchten, 1020 Bruxelles, Bruxelles, Belgium
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Joosten A, Lucidi V, Ickx B, Van Obbergh L, Germanova D, Berna A, Alexander B, Desebbe O, Carrier FM, Cherqui D, Adam R, Duranteau J, Saugel B, Vincent JL, Rinehart J, Van der Linden P. Intraoperative hypotension during liver transplant surgery is associated with postoperative acute kidney injury: a historical cohort study. BMC Anesthesiol 2021; 21:12. [PMID: 33430770 PMCID: PMC7798188 DOI: 10.1186/s12871-020-01228-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 12/27/2020] [Indexed: 12/12/2022] Open
Abstract
Background Acute kidney injury (AKI) occurs frequently after liver transplant surgery and is associated with significant morbidity and mortality. While the impact of intraoperative hypotension (IOH) on postoperative AKI has been well demonstrated in patients undergoing a wide variety of non-cardiac surgeries, it remains poorly studied in liver transplant surgery. We tested the hypothesis that IOH is associated with AKI following liver transplant surgery. Methods This historical cohort study included all patients who underwent liver transplant surgery between 2014 and 2019 except those with a preoperative creatinine > 1.5 mg/dl and/or who had combined transplantation surgery. IOH was defined as any mean arterial pressure (MAP) < 65 mmHg and was classified according to the percentage of case time during which the MAP was < 65 mmHg into three groups, based on the interquartile range of the study cohort: “short” (Quartile 1, < 8.6% of case time), “intermediate” (Quartiles 2–3, 8.6–39.5%) and “long” (Quartile 4, > 39.5%) duration. AKI stages were classified according to a “modified” “Kidney Disease: Improving Global Outcomes” (KDIGO) criteria. Logistic regression modelling was conducted to assess the association between IOH and postoperative AKI. The model was run both as a univariate and with multiple perioperative covariates to test for robustness to confounders. Results Of the 205 patients who met our inclusion criteria, 117 (57.1%) developed AKI. Fifty-two (25%), 102 (50%) and 51 (25%) patients had short, intermediate and long duration of IOH respectively. In multivariate analysis, IOH was independently associated with an increased risk of AKI (adjusted odds ratio [OR] 1.05; 95%CI 1.02–1.09; P < 0.001). Compared to “short duration” of IOH, “intermediate duration” was associated with a 10-fold increased risk of developing AKI (OR 9.7; 95%CI 4.1–22.7; P < 0.001). “Long duration” was associated with an even greater risk of AKI compared to “short duration” (OR 34.6; 95%CI 11.5-108.6; P < 0.001). Conclusions Intraoperative hypotension is independently associated with the development of AKI after liver transplant surgery. The longer the MAP is < 65 mmHg, the higher the risk the patient will develop AKI in the immediate postoperative period, and the greater the likely severity. Anesthesiologists and surgeons must therefore make every effort to avoid IOH during surgery.
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Affiliation(s)
- Alexandre Joosten
- Department of Anesthesiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium. .,Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), 12 Avenue Paul Vaillant Couturier, 94800, Villejuif, France.
| | - Valerio Lucidi
- Department of Digestive Surgery, Unit of Hepatobiliary Surgery and Liver Transplantation, Erasme hospital, Cliniques Universitaires de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Brigitte Ickx
- Department of Anesthesiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Luc Van Obbergh
- Department of Anesthesiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Desislava Germanova
- Department of Digestive Surgery, Unit of Hepatobiliary Surgery and Liver Transplantation, Erasme hospital, Cliniques Universitaires de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Antoine Berna
- Department of Anesthesiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Brenton Alexander
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Olivier Desebbe
- Department of Anesthesiology and Perioperative Medicine, Sauvegarde Clinic, Ramsay Santé, Lyon, France
| | - Francois-Martin Carrier
- Department of Anesthesiology, Centre hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Daniel Cherqui
- Department of Hepatobiliary Surgery, Paul Brousse Hospital, Villejuif, France
| | - Rene Adam
- Department of Hepatobiliary Surgery, Paul Brousse Hospital, Villejuif, France
| | - Jacques Duranteau
- Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), 12 Avenue Paul Vaillant Couturier, 94800, Villejuif, France
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Outcomes Research Consortium, Cleveland, Ohio, USA
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Joseph Rinehart
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, California, USA
| | - Philippe Van der Linden
- Department of Anesthesiology, Brugmann Hospital, Université Libre de Bruxelles, Bruxelles, Belgium
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Joosten A, Chirnoaga D, Van der Linden P, Barvais L, Alexander B, Duranteau J, Vincent JL, Cannesson M, Rinehart J. Automated closed-loop versus manually controlled norepinephrine infusion in patients undergoing intermediate- to high-risk abdominal surgery: a randomised controlled trial. Br J Anaesth 2021; 126:210-218. [PMID: 33041014 PMCID: PMC8489152 DOI: 10.1016/j.bja.2020.08.051] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/07/2020] [Accepted: 08/05/2020] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Hypotension occurs frequently during surgery and may be associated with adverse complications. Vasopressor titration is frequently used to correct hypotension, but requires considerable time and attention, potentially reducing the time available for other clinical duties. To overcome this issue, we have developed a closed-loop vasopressor (CLV) controller to help correct hypotension more efficiently. The aim of this randomised controlled study was to evaluate whether the CLV controller was superior to traditional vasopressor management at minimising hypotension in patients undergoing abdominal surgery. METHODS Thirty patients scheduled for elective intermediate-to high-risk abdominal surgery were randomised into two groups. In the CLV group, hypotension was corrected automatically via the CLV controller system, which adjusted the rate of a norepinephrine infusion according to MAP values recorded using an advanced haemodynamic device. In the control group, management of hypotension consisted of standard, manual adjustment of the norepinephrine infusion. The primary outcome was the percentage of time that a patient was hypotensive, defined as MAP <90% of their baseline value, during surgery. RESULTS The percentage of time patients were hypotensive during surgery was 10 times less in the CVL group than in the control group (1.6 [0.9-2.3]% vs 15.4 [9.9-24.3]%; difference: 13 [95% confidence interval: 9-19]; P<0.0001). The CVL group also spent much less time with MAP <65 mm Hg (0.2 [0.0-0.4]% vs 4.5 [1.1-7.9]%; P<0.0001). CONCLUSIONS In patients undergoing intermediate- to high-risk surgery under general anaesthesia, computer-assisted adjustment of norepinephrine infusion significantly decreases the incidence of hypotension compared with manual control. CLINICAL TRIAL REGISTRATION NCT04089644.
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Affiliation(s)
- Alexandre Joosten
- Department of Anaesthesiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium,Department of Anaesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Hôpital De Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France,Corresponding author.
| | - Dragos Chirnoaga
- Department of Anaesthesiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Philippe Van der Linden
- Department of Anaesthesiology, Brugmann Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Luc Barvais
- Department of Anaesthesiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Brenton Alexander
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Jacques Duranteau
- Department of Anaesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Hôpital De Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Joseph Rinehart
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA, USA
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Lee J, Chung J, Venstrom J, Alexander B, Schrock A, Ou SH. 99P Pan-tumor characterization of KRAS mutations (KRASm) detected in circulating tumor DNA (ctDNA) and concordance with paired tissue. Ann Oncol 2020. [DOI: 10.1016/j.annonc.2020.08.220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Elvin J, Danziger N, Corines J, Vergilio JA, Killian J, Lin D, Williams E, Tse J, Ramkissoon S, Severson E, Hemmerich A, Edgerly C, Duncan D, Huang R, Schrock A, Alexander B, Venstrom J, Reddy P, McGregor K, Ross J. 2001P Adenoid cystic carcinomas (ACC) of the trachea, salivary gland, breast: A comparative comprehensive genomic profiling (CGP) study. Ann Oncol 2020. [DOI: 10.1016/j.annonc.2020.08.1307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Alexander B, Sokol E, Danziger N, Pavlick D, Elvin J, Killian J, Lin D, Williams E, Ramkissoon S, Severson E, Hemmerich A, Duncan D, Edgerly C, Huang R, Hiemenz M, Reddy P, McGregor K, Venstrom J, Schrock A, Ross J. 107P Immune Checkpoint Inhibitor (ICPI) resistance genes STK11 and KEAP1: A comparative Comprehensive Genomic Profiling (CGP) study. Ann Oncol 2020. [DOI: 10.1016/j.annonc.2020.08.228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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McGregor K, Ross J, Danziger N, Sokol E, Venstrom J, Chung J, Lee J, Alexander B, Schrock A, Tukachinsky H. 305P Patterns of acquired mutations in estrogen receptor-positive metastatic breast cancer (MBC) patients identified by comprehensive genomic profiling (CGP). Ann Oncol 2020. [DOI: 10.1016/j.annonc.2020.08.407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Reddy P, Danziger N, Elvin J, Vergilio JA, Killian J, Lin D, Williams E, Ramkissoon S, Severson E, Hemmerich A, Duncan D, Edgerly C, Huang R, Hiemenz M, Chung J, McGregor K, Venstrom J, Schrock A, Alexander B, Ross J. 957P Ameloblastoma of the head and neck (HNAMB): A comprehensive profiling (CGP) study. Ann Oncol 2020. [DOI: 10.1016/j.annonc.2020.08.1072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Joosten A, Coeckelenbergh S, Alexander B, Delaporte A, Cannesson M, Duranteau J, Saugel B, Vincent JL, Van der Linden P. Hydroxyethyl starch for perioperative goal-directed fluid therapy in 2020: a narrative review. BMC Anesthesiol 2020; 20:209. [PMID: 32819296 PMCID: PMC7441629 DOI: 10.1186/s12871-020-01128-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 08/12/2020] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Perioperative fluid management - including the type, dose, and timing of administration -directly affects patient outcome after major surgery. The objective of fluid administration is to optimize intravascular fluid status to maintain adequate tissue perfusion. There is continuing controversy around the perioperative use of crystalloid versus colloid fluids. Unfortunately, the importance of fluid volume, which significantly influences the benefit-to-risk ratio of each chosen solution, has often been overlooked in this debate. MAIN TEXT The volume of fluid administered during the perioperative period can influence the incidence and severity of postoperative complications. Regrettably, there is still huge variability in fluid administration practices, both intra-and inter-individual, among clinicians. Goal-directed fluid therapy (GDFT), aimed at optimizing flow-related variables, has been demonstrated to have some clinical benefit and has been recommended by multiple professional societies. However, this approach has failed to achieve widespread adoption. A closed-loop fluid administration system designed to assist anesthesia providers in consistently applying GDFT strategies has recently been developed and tested. Such an approach may change the crystalloid versus colloid debate. Because colloid solutions have a more profound effect on intravascular volume and longer plasma persistence, their use in this more "controlled" context could be associated with a lower fluid balance, and potentially improved patient outcome. Additionally, most studies that have assessed the impact of a GDFT strategy on the outcome of high-risk surgical patients have used hydroxyethyl starch (HES) solutions in their protocols. Some of these studies have demonstrated beneficial effects, while none of them has reported severe complications. CONCLUSIONS The type and volume of fluid used for perioperative management need to be individualized according to the patient's hemodynamic status and clinical condition. The amount of fluid given should be guided by well-defined physiologic targets. Compliance with a predefined hemodynamic protocol may be optimized by using a computerized system. The type of fluid should also be individualized, as should any drug therapy, with careful consideration of timing and dose. It is our perspective that HES solutions remain a valid option for fluid therapy in the perioperative context because of their effects on blood volume and their reasonable benefit/risk profile.
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Affiliation(s)
- Alexandre Joosten
- Department of Anesthesiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
- Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Hôpital De Bicêtre, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
- Department of Anesthesiology & Perioperative Medicine, Bicêtre Hospital, 78, Rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - Sean Coeckelenbergh
- Department of Anesthesiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Brenton Alexander
- Department of Anesthesiology & Perioperative Care, University of California San Diego, San Diego, USA
| | - Amélie Delaporte
- Department of Anesthesiology & Intensive Care, Marie Lannelongue Hospital, Paris, France
| | - Maxime Cannesson
- Department of Anesthesiology & Perioperative Medicine, University of California Los Angeles, Los Angeles, USA
| | - Jacques Duranteau
- Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Hôpital De Bicêtre, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
| | - 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
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Philippe Van der Linden
- Department of Anesthesiology, Brugmann Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Finneran Iv JJ, Alexander B, Bechis SK, Sur RL, Ilfeld BM. Continuous erector spinae plane blocks with automated boluses for analgesia following percutaneous nephrolithotomy. Korean J Anesthesiol 2020; 74:178-180. [PMID: 32773726 PMCID: PMC8024201 DOI: 10.4097/kja.20398] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 08/06/2020] [Indexed: 11/18/2022] Open
Affiliation(s)
- John J Finneran Iv
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Brenton Alexander
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Seth K Bechis
- Department of Urology, University of California San Diego, San Diego, CA, USA
| | - Roger L Sur
- Department of Urology, University of California San Diego, San Diego, CA, USA
| | - Brian M Ilfeld
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
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Chaturvedi R, Alexander B, A'Court AM, Waterman RS, Burton BN, Urman RD, Gabriel RA. Genomics testing and personalized medicine in the preoperative setting: Can it change outcomes in postoperative pain management? Best Pract Res Clin Anaesthesiol 2020; 34:283-295. [PMID: 32711834 DOI: 10.1016/j.bpa.2020.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 10/24/2022]
Abstract
Postoperative pain and opioid use are major challenges in perioperative medicine. Pain perception and its response to opioid use are multi-faceted and include pharmacological, psychological, and genetic components. Precision medicine is a unique approach to individualized health care in which decisions in management are based on genetics, lifestyle, and environment of each person. Genetic variations can have an impact on the perception of pain and response to treatment. This can have an effect on pain management in both acute and chronic settings. Although there is currently not enough evidence for making recommendations about genetic testing to guide pain management in the acute care setting, there are some known polymorphisms that play a role in surgical pain and opioid-related postoperative adverse outcomes. In this review, we describe the potential use of pharmacogenomics (PGx) for improving perioperative pain management. We first review a number of genotypes that have shown correlations with pain and opioid use and then describe the importance of PGx-guided analgesic protocols and implementation of screening in a preoperative evaluation clinical setting.
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Affiliation(s)
- Rahul Chaturvedi
- School of Medicine, University of California, San Diego, La Jolla, CA, USA.
| | - Brenton Alexander
- Department of Anesthesiology, University of California, San Diego, La Jolla, CA, USA.
| | - Alison M A'Court
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, USA.
| | - Ruth S Waterman
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, USA.
| | - Brittany N Burton
- Department of Anesthesiology, University of California, Los Angeles, Los Angeles, CA, USA.
| | - Richard D Urman
- Department of Anesthesiology, Perioperative, and Pain Medicine, Harvard Medical School/Brigham and Women's Hospital, Boston, MA, USA.
| | - Rodney A Gabriel
- Department of Anesthesiology and Division of Biomedical Informatics, University of California, San Diego, La Jolla, CA, USA.
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Joosten A, Coeckelenbergh S, Alexander B, Cannesson M, Rinehart J. Feasibility of computer-assisted vasopressor infusion using continuous non-invasive blood pressure monitoring in high-risk patients undergoing renal transplant surgery. Anaesth Crit Care Pain Med 2020; 39:623-624. [PMID: 32268211 DOI: 10.1016/j.accpm.2019.12.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 12/03/2019] [Accepted: 12/15/2019] [Indexed: 01/24/2023]
Affiliation(s)
- Alexandre Joosten
- Department of Anaesthesiology and Intensive Care, hôpitaux universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, hôpital de Bicêtre, assistance publique hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France; Department of Anaesthesiology, Erasme University Hospital, Université Libre de Bruxelles, 808, route de Lennik, Brussels, Belgium.
| | - Sean Coeckelenbergh
- Department of Anaesthesiology, Erasme University Hospital, Université Libre de Bruxelles, 808, route de Lennik, Brussels, Belgium
| | - Brenton Alexander
- Department of Anaesthesiology, University of California San Diego, 9500, Gilman Dr, La Jolla, CA 92093 USA
| | - Maxime Cannesson
- Department of Anaesthesiology & Perioperative Medicine, David-Geffen School of Medicine, University of California Los Angeles, California 90095 USA
| | - Joseph Rinehart
- Department of Anaesthesiology & Perioperative Care, University of California Irvine, 101, The City Drive South, California 92868 USA
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Joosten A, Rinehart J, Bardaji A, Van der Linden P, Jame V, Van Obbergh L, Alexander B, Cannesson M, Vacas S, Liu N, Slama H, Barvais L. Anesthetic Management Using Multiple Closed-loop Systems and Delayed Neurocognitive Recovery: A Randomized Controlled Trial. Anesthesiology 2020; 132:253-266. [PMID: 31939839 PMCID: PMC7517610 DOI: 10.1097/aln.0000000000003014] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cognitive changes after anesthesia and surgery represent a significant public health concern. We tested the hypothesis that, in patients 60 yr or older scheduled for noncardiac surgery, automated management of anesthetic depth, cardiac blood flow, and protective lung ventilation using three independent controllers would outperform manual control of these variables. Additionally, as a result of the improved management, patients in the automated group would experience less postoperative neurocognitive impairment compared to patients having standard, manually adjusted anesthesia. METHODS In this single-center, patient-and-evaluator-blinded, two-arm, parallel, randomized controlled, superiority study, 90 patients having noncardiac surgery under general anesthesia were randomly assigned to one of two groups. In the control group, anesthesia management was performed manually while in the closed-loop group, the titration of anesthesia, analgesia, fluids, and ventilation was performed by three independent controllers. The primary outcome was a change in a cognition score (the 30-item Montreal Cognitive Assessment) from preoperative values to those measures 1 week postsurgery. Secondary outcomes included a battery of neurocognitive tests completed at both 1 week and 3 months postsurgery as well as 30-day postsurgical outcomes. RESULTS Forty-three controls and 44 closed-loop patients were assessed for the primary outcome. There was a difference in the cognition score compared to baseline in the control group versus the closed-loop group 1 week postsurgery (-1 [-2 to 0] vs. 0 [-1 to 1]; difference 1 [95% CI, 0 to 3], P = 0.033). Patients in the closed-loop group spent less time during surgery with a Bispectral Index less than 40, had less end-tidal hypocapnia, and had a lower fluid balance compared to the control group. CONCLUSIONS Automated anesthetic management using the combination of three controllers outperforms manual control and may have an impact on delayed neurocognitive recovery. However, given the study design, it is not possible to determine the relative contribution of each controller on the cognition score.
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Affiliation(s)
- Alexandre Joosten
- From the Department of Anesthesiology (A.J., A.B., V.J., L.V.O, L.B.) Department of Clinical and Cognitive Neuropsychology (H.S.) Erasme Hospital, and Department of Anesthesiology, Brugmann Hospital (P.V.d.L.), Université Libre de Bruxelles, Brussels, Belgium Department of Anesthesiology and Intensive Care, University of Paris-Saclay, Bicetre Hospital, Le Kremlin-Bicêtre, Paris, France (A.J.) Department of Anesthesiology and Perioperative Care, University of California, Irvine, Irvine, California (J.R.) Department of Anesthesiology, University of California, San Diego, San Diego, California (B.A.) Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California (M.C., S.V.) Department of Anesthesiology, Foch Hospital, Suresnes, Paris, France (N.L.) Outcome Research Consortium, Cleveland Clinic, Cleveland, Ohio (N.L.)
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Menon S, Ellis C, Poudel S, Johnson J, Szabo A, George B, Kevin Kelly W, Grant S, McPherson J, Cristofanilli M, Hoimes C, Gutierrez M, Doudement J, Chan L, Singal G, Alexander B, Miller V, Sohal D. B08 Impact of Concurrent STK11 Loss and c-MYC Amplification in Metastatic Non-Small Cell Lung Cancer (NSCLC). J Thorac Oncol 2020. [DOI: 10.1016/j.jtho.2019.12.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Feller J, Lund BC, Perencevich EN, Alexander B, Heintz B, Beck B, Nair R, Goto M, Livorsi DJ. Post-discharge oral antimicrobial use among hospitalized patients across an integrated national healthcare network. Clin Microbiol Infect 2019; 26:327-332. [PMID: 31600582 DOI: 10.1016/j.cmi.2019.09.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 09/04/2019] [Accepted: 09/15/2019] [Indexed: 01/12/2023]
Abstract
OBJECTIVES Antimicrobial stewardship programmes have focused on reducing inappropriate inpatient antimicrobial prescribing, but several small studies have found a large portion of antimicrobial exposure occurs immediately after hospital discharge. In this study, we describe the prescribing of oral antimicrobials at hospital discharge across an integrated national healthcare system. At the hospital level, we also compare total inpatient antimicrobial use and post-discharge oral antimicrobial use. METHODS This retrospective cross-sectional study used national administrative data to identify all acute-care admissions during 2014-2016 within the Veterans Health Administration (VHA). We evaluated inpatient days of therapy (DOT) and post-discharge DOT, defined as oral outpatient antimicrobials dispensed at the time of hospital discharge. At the hospital level, inpatient DOT/100 admissions were compared with post-discharge DOT/100 admissions using Spearman's rank-order correlation. RESULTS There were 1 681 701 acute-care admissions across 122 hospitals, and 335 369 (19.9%) were prescribed an oral antimicrobial at discharge. Fluoroquinolones (38.3%) were the most common post-discharge antimicrobial. At the hospital level, median inpatient antimicrobial use was 331.3 (interquartile range (IQR) 284.9-367.9) DOT/100 admissions and median post-discharge use was 209.5 (IQR 181.5-239.6) DOT/100 admissions. Thirty-nine per cent of the total duration of antimicrobial exposure occurred after discharge. At the hospital-level, the metrics of inpatient DOT/100 admissions and post-discharge DOT/100 admissions were weakly positively correlated with rho=0.44 (p < 0.001). CONCLUSIONS A large proportion of antimicrobial exposure among hospitalized patients occurred immediately following discharge. Antimicrobial-prescribing at hospital discharge provides an opportunity for antimicrobial stewardship. Hospital-level stewardship metrics need to include both inpatient and post-discharge antimicrobial-prescribing to provide a comprehensive assessment of hospital-associated antimicrobial use.
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Affiliation(s)
- J Feller
- Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
| | - B C Lund
- Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
| | - E N Perencevich
- Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA; Division of General Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - B Alexander
- Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
| | - B Heintz
- Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
| | - B Beck
- Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
| | - R Nair
- Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA; Division of General Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - M Goto
- Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA; Division of Infectious Diseases, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - D J Livorsi
- Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA; Division of Infectious Diseases, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
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Madison R, Schrock A, Gregg J, Carson K, Castellanos E, Singal G, Miller V, Ali S, Alexander B, Chung J. P1.01-23 Retrospective Analysis of Real-World Clinico-Genomic Data for Clinical Impact of Genomic Profiling of ctDNA in NSCLC. J Thorac Oncol 2019. [DOI: 10.1016/j.jtho.2019.08.738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Ou S, Schrock A, Bocharov E, Lee J, Madison R, Gay L, Miller V, Alexander B, Husain H, Riess J, Ali S, Velcheti V. P1.01-86 Occurrence of de Novo Dual HER2/HER3 or HER2/EGFR TMD Mutations: Extending the Spectrum of Targetable Mono-HER2 TMD in NSCLC? J Thorac Oncol 2019. [DOI: 10.1016/j.jtho.2019.08.801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Negrao M, Skoulidis F, Montesion M, Schulze K, Bara I, Shen V, Hu S, Elamin Y, Le X, Goldberg M, Wu C, Zhang J, Barreto D, Rinsurongkawong W, Simon G, Roth J, Swisher S, Lee J, Tsao A, Papadimitrakopoulou V, Gibbons D, Glisson B, Miller V, Alexander B, Frampton G, Albacker L, Shames D, Zhang J, Heymach J. MA03.05 BRAF Mutations Are Associated with Increased Benefit from PD1/PDL1 Blockade Compared with Other Oncogenic Drivers in Non-Small Cell Lung Cancer. J Thorac Oncol 2019. [DOI: 10.1016/j.jtho.2019.08.514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Tabrizi S, Rahman R, Cagney D, Aizer A, Tanguturi S, Arvold N, Reardon D, Lee E, Nayak L, Rinne M, Ligon K, Wen P, Alexander B. Impact of Delay in Initiation of Radiation Therapy in Newly Diagnosed Glioblastoma Patients after Gross Total Resection. Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/j.ijrobp.2019.06.2314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hemmerich A, Madison R, Klempner S, Sokol E, Severson E, Miller V, Lee J, Ou S, Alexander B, Schrock A, Ross J, Ali S. Genomic profiling of diffuse gastric carcinoma (DGC). Ann Oncol 2019. [DOI: 10.1093/annonc/mdz154.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Myer P, Lee J, Madison R, Newberg J, Ross J, Chung J, Albacker L, Alexander B, Miller V, Schrock A, Mitchell E, Frampton G, Ali S. Comprehensive genomic profiling (CGP) defines the genomic landscape of colorectal cancer (CRC) in individuals of African ancestry. Ann Oncol 2019. [DOI: 10.1093/annonc/mdz154.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Joosten A, Alexander B, Duranteau J, Taccone FS, Creteur J, Vincent JL, Cannesson M, Rinehart J. Feasibility of closed-loop titration of norepinephrine infusion in patients undergoing moderate- and high-risk surgery. Br J Anaesth 2019; 123:430-438. [PMID: 31255290 DOI: 10.1016/j.bja.2019.04.064] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 04/09/2019] [Accepted: 05/08/2019] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Vasopressor agents are used to prevent intraoperative hypotension and ensure adequate perfusion. Vasopressors are usually administered as intermittent boluses or manually adjusted infusions, but this practice requires considerable time and attention. We have developed a closed-loop vasopressor (CLV) controller to correct hypotension more efficiently. Here, we conducted a proof-of-concept study to assess the feasibility and performance of CLV control in surgical patients. METHODS Twenty patients scheduled for elective surgical procedures were included in this study. The goal of the CLV system was to maintain MAP within 5 mm Hg of the target MAP by automatically adjusting the rate of a norepinephrine infusion using MAP values recorded continuously from an arterial catheter. The primary outcome was the percentage of time that patients were hypotensive, as defined by a MAP of 5 mm Hg below the chosen target. Secondary outcomes included the total dose of norepinephrine, percentage of time with hypertension (MAP>5 mm Hg of the chosen target), raw percentage "time in target" and Varvel performance criteria. RESULTS The 20 subjects (median age: 64 years [52-71]; male (35%)) underwent elective surgery lasting 154 min [124-233]. CLV control maintained MAP within ±5 mm Hg of the target for 91.6% (85.6-93.3) of the intraoperative period. Subjects were hypotensive for 2.6% of the intraoperative period (range, 0-8.4%). Additional performance criteria for the controller included mean absolute performance error of 2.9 (0.8) and mean predictive error of 0.5 (1.0). No subjects experienced major complications. CONCLUSIONS In this proof of concept study, CLV control minimised perioperative hypotension in subjects undergoing moderate- or high-risk surgery. Further studies to demonstrate efficacy are warranted. TRIAL REGISTRY NUMBER NCT03515161 (ClinicalTrials.gov).
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Affiliation(s)
- Alexandre Joosten
- Department of Anesthesiology and Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium; Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Hôpital De Bicêtre, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France.
| | - Brenton Alexander
- Department of Anesthesiology, University of California-San Diego, San Diego, CA, USA
| | - Jacques Duranteau
- Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Hôpital De Bicêtre, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Maxime Cannesson
- Department of Anesthesiology & Perioperative Medicine, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, CA, USA
| | - Joseph Rinehart
- Department of Anesthesiology & Perioperative Care, University of California-Irvine, Irvine, CA, USA
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Joosten A, Jame V, Alexander B, Chazot T, Liu N, Cannesson M, Rinehart J, Barvais L. Feasibility of Fully Automated Hypnosis, Analgesia, and Fluid Management Using 2 Independent Closed-Loop Systems During Major Vascular Surgery: A Pilot Study. Anesth Analg 2019; 128:e88-e92. [PMID: 31094779 DOI: 10.1213/ane.0000000000003433] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Automated titration of intravenous anesthesia and analgesia using processed electroencephalography monitoring is no longer a novel concept. Closed-loop control of fluid administration to provide goal-directed fluid therapy has also been increasingly described. However, simultaneously combining 2 independent closed-loop systems together in patients undergoing major vascular surgery has not been previously detailed. The aim of this pilot study was to evaluate the clinical performance of fully automated hypnosis, analgesia, and fluid management using 2 independent closed-loop controllers in patients undergoing major vascular surgery before implementation within a larger study evaluating true patient outcomes.
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Affiliation(s)
- Alexandre Joosten
- From the Department of Anesthesiology, Cliniques Universitaires de Bruxelles Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Vincent Jame
- Department of Anesthesiology, Centre hospitalo-Universitaire Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Brenton Alexander
- Department of Anesthesiology, University of California San Diego, San Diego, California
| | - Thierry Chazot
- Department of Anesthesiology, Hopital Foch, Suresnes, France
| | - Ngai Liu
- Department of Anesthesiology, Hopital Foch, Suresnes, France
- Outcomes Research Consortium, Cleveland, Ohio
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, California
| | - Joseph Rinehart
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Orange, California
| | - Luc Barvais
- From the Department of Anesthesiology, Cliniques Universitaires de Bruxelles Erasme, Université Libre de Bruxelles, Brussels, Belgium
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Joosten A, Alexander B, Duranteau J. Clinical decision support system clears the way for perioperative goal directed therapy protocol adherence improvement. Minerva Anestesiol 2019; 85:691-692. [PMID: 30735021 DOI: 10.23736/s0375-9393.19.13417-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Alexandre Joosten
- Department of Anesthesiology and Intensive Care, University Hospital of Paris-Sud, University of Paris-Sud, Orsay, France - .,Hospital of Bicêtre, University of Paris-Saclay, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France -
| | - Brenton Alexander
- Department of Anesthesiology and Perioperative Medicine, University of California San Diego, San Diego, CA, USA
| | - Jacques Duranteau
- Department of Anesthesiology and Intensive Care, University Hospital of Paris-Sud, University of Paris-Sud, Orsay, France.,Hospital of Bicêtre, University of Paris-Saclay, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
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Al Hammad N, Alexander B, Baranchuk A, Haseeb S, Ibrahim O, Hopman W, Çinier G, Hetu MF, Li T, Johri A. PO356 Interatrial Block Predicts Atrial Fibrillation in Patients with Coronary and Carotid Artery Disease. Glob Heart 2018. [DOI: 10.1016/j.gheart.2018.09.281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Lopez Santi R, Haseeb S, Alexander B, Dovidio A, Gimenez S, Secotaro C, Martinez Demaría D, Pupi L, Costantini S, Piskorz D, Amarilla A, Lorenzatti A, Gutierrez N, Hopman W, Baranchuk A. PO524 Attitudes and Recommendations of Physicians Towards Alcohol Consumption and Cardiovascular Health: A Perspective From Argentina. Glob Heart 2018. [DOI: 10.1016/j.gheart.2018.09.401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Lamba N, Cagney D, Alexander B, Aizer A. Outcomes following Stereotactic Radiation (SRS/SRT) plus Surgery versus SRS/SRT Alone for Single or Solitary Metastasis in Patients with Controlled Systemic Disease: A Single-Institution Study. Int J Radiat Oncol Biol Phys 2018. [DOI: 10.1016/j.ijrobp.2018.07.1007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Hwang W, Lamba N, Kim D, Marciscano A, Stemmer-Rachamimov A, Curry W, Barker F, Martuza R, Santagata S, Dunn I, Claus E, Bi W, Aizer A, Alexander B, Oh K, Loeffler J, Shih H. Atypical Histopathological Features and the Risk of Progression/Recurrence in WHO Grade I-II Meningiomas. Int J Radiat Oncol Biol Phys 2018. [DOI: 10.1016/j.ijrobp.2018.07.773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pike L, Bang A, Taylor A, Krishnan M, Spektor A, Cagney D, Aizer A, Alexander B, Rahma O, Balboni T, Ott P, Hodi F, Schoenfeld J. Impact of Palliative Radiation on Lymphocyte Count and Neutrophil-to-Lymphocyte Ratio in Patients Receiving PD-1 Inhibitors. Int J Radiat Oncol Biol Phys 2018. [DOI: 10.1016/j.ijrobp.2018.07.630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Numan T, Derks J, de Witt Hamer PC, Gerstner ER, Stufflebeam SM, Alexander B, van Dijk KRA, Cagney DN, Reijneveld JC, Douw L. OS6.1 Glioma anatomic location and clinical phenotype relate to regional healthy brain network signature. Neuro Oncol 2018. [DOI: 10.1093/neuonc/noy139.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- T Numan
- Department of Anatomy and Neurosciences, VU University Medical Center, Amsterdam, Netherlands
- VUmc CCA Brain Tumor Center Amsterdam, Amsterdam, Netherlands
| | - J Derks
- Department of Anatomy and Neurosciences, VU University Medical Center, Amsterdam, Netherlands
- VUmc CCA Brain Tumor Center Amsterdam, Amsterdam, Netherlands
| | - P C de Witt Hamer
- VUmc CCA Brain Tumor Center Amsterdam, Amsterdam, Netherlands
- Department of Neurosurgery, Neuroscience Campus Amsterdam, Amsterdam, Netherlands
| | - E R Gerstner
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - S M Stufflebeam
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, United States
| | - B Alexander
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States
| | - K R A van Dijk
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, United States
| | - D N Cagney
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States
| | - J C Reijneveld
- VUmc CCA Brain Tumor Center Amsterdam, Amsterdam, Netherlands
- Department of Neurology, Neuroscience Campus Amsterdam, VU University Medical Center, Amsterdam, Netherlands
| | - L Douw
- VUmc CCA Brain Tumor Center Amsterdam, Amsterdam, Netherlands
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, United States
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Weiss S, Churilla T, Chowdhury I, Handorf E, Collette L, Collette S, Alexander B, Kocher M, Soffietti R, Claus E. P05.89 Comparison of local control of brain metastases with stereotactic radiosurgery versus surgical resection: A secondary analysis of EORTC 22952–26001. Neuro Oncol 2018. [DOI: 10.1093/neuonc/noy139.415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- S Weiss
- Fox Chase Cancer Center, Philadelphia, PA, United States
| | - T Churilla
- Fox Chase Cancer Center, Philadelphia, PA, United States
| | - I Chowdhury
- The Christ Hospital, Cincinnati, OH, United States
| | - E Handorf
- Fox Chase Cancer Center, Philadelphia, PA, United States
| | | | | | - B Alexander
- Dana-Farber/Brigham and Women’s Cancer Center, Boston, MA, United States
| | - M Kocher
- University Hospital of Cologne, Cologne, Germany
| | - R Soffietti
- University of Turin and City of Health and Science Hospital, Torino, Italy
| | - E Claus
- Brigham and Women’s Hospital, Boston, MA, United States
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Cinier G, Tekkesin AI, Celik T, Mercan O, Tanboga HI, Gunay B, Turkkan C, Hayiroglu MI, Alexander B, Baranchuk A. 1356Value of interatrial block for the prediction of silent ischemic brain lesions. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.1356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- G Cinier
- Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Center, cardiology, Istanbul, Turkey
| | - A I Tekkesin
- Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Center, cardiology, Istanbul, Turkey
| | - T Celik
- Haydarpasa Numune University Hospital, Neurology, Istanbul, Turkey
| | - O Mercan
- Haydarpasa Numune University Hospital, Neurology, Istanbul, Turkey
| | - H I Tanboga
- Hisar Intercontinental Hospital, Cardiology, Istanbul, Turkey
| | - B Gunay
- Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Center, cardiology, Istanbul, Turkey
| | - C Turkkan
- Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Center, cardiology, Istanbul, Turkey
| | - M I Hayiroglu
- Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Center, cardiology, Istanbul, Turkey
| | - B Alexander
- Queen's University, Cardiology, Kingston, Canada
| | - A Baranchuk
- Queen's University, Cardiology, Kingston, Canada
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