bluuebunny/crossref_metadata_2025_split huggingface dataset:
The opioid epidemic in pediatrics: a 2020 update
Authors: Yaster Myron , McNaull Peggy P. , Davis Peter J. 
Published: May 2020

Purpose of review
Over the last 3 years and for the first time in 60 years, life expectancy in the United States has declined across all racial groups primarily because of drug overdoses, alcohol abuse, and suicide. A public health response to the opioid crisis must expand its focus to more broadly include children, adolescents, and young adults while increasing efforts toward preventing new cases of opioid addiction, early identification of individuals with opioid-abuse disorder, and ensuring access to effective opioid addiction treatment, while simultaneously continuing to safely meet the needs of patients experiencing pain.

Recent findings
Although a multimodal approach to pain management is fundamental in current practice, opioids remain an essential building block in the management of acute and chronic pain and have been for over 5000 years as they work. Left over, unconsumed opioids that were appropriately prescribed for pain have become the gateway for the development of opioid use disorder, particularly in the vulnerable adolescents and young adult patient populations. How to reduce the amount of opioids dispensed, improve methods of disposal in an environmentally safe way, and proactively make naloxone, particularly nasal spray, readily available to patients (and their families) receiving prescription opioids or who are at risk of opioid use disorder are highlighted in this review.

Summary
We describe the historical use of opioids and the scope of the current opioid crisis, review the differences between dependence and addiction, and the private and public sectors response to pain management and highlight the issue of adolescent vulnerability. We conclude with a proposal for future directions that address both public and patient health needs.
Updates in periprocedural management of direct oral anticoagulants
Authors: Tao Jing , Oprea Adriana D. 
Published: May 2020

Purpose of review
As the prevalence of patients on antithrombotics is increasing, anesthesiologists must have a firm understanding of these medications and considerations for their periprocedural management. This review details up-to-date periprocedural management of direct oral anticoagulants (DOACs).

Recent findings
DOACs have favorable pharmacokinetics including quick onset of action and short half-lives. Periprocedural management of DOACs relies heavily on drug half-life as well as procedural risk of bleeding. Other than a few exceptions, the American College of Cardiologists generally recommends complete clearance of oral anticoagulants prior to high-risk bleeding procedures and partial clearance prior to low-risk bleeding procedures. Procedures with little to no clinical risk of bleeding can be performed without any drug interruption or during trough levels. Exceptions to periprocedural DOAC management pertain to electrophysiology procedures.

Summary
With the exception of no clinically relevant bleeding risk or certain electrophysiology procedures, DOACs should be discontinued periprocedurally in accordance with bleeding risks and drug's half-life. Bridging is generally not recommended for DOACs.
Perioperative management of antiplatelet therapy in noncardiac surgery
Authors: Filipescu Daniela C. , Stefan Mihai G. , Valeanu Liana , Popescu Wanda M. 
Published: May 2020

Purpose of review
Perioperative management of antiplatelet agents (APAs) in the setting of noncardiac surgery is a controversial topic of balancing bleeding versus thrombotic risks.

Recent findings
Recent data do not support a clear association between continuation or discontinuation of APAs and rates of ischemic events, bleeding complications, and mortality up to 6 months after surgery. Clinical factors, such as indication and urgency of the operation, time since stent placement, invasiveness of the procedure, preoperative cardiac optimization, underlying functional status, as well as perioperative control of supply–demand mismatch and bleeding may be more responsible for adverse outcome than antiplatelet management.

Summary
Perioperative management of antiplatelet therapy (APT) should be individually tailored based on consensus among the anesthesiologist, cardiologist, surgeon, and patient to minimize both ischemic/thrombotic and bleeding risks. Where possible, surgery should be delayed for a minimum of 1 month but ideally for 3–6 months from the index cardiac event. If bleeding risk is acceptable, dual APT (DAPT) should be continued perioperatively; otherwise P2Y12 inhibitor therapy should be discontinued for the minimum amount of time possible and aspirin monotherapy continued. If bleeding risk is prohibitive, both aspirin and P2Y12 inhibitor therapy should be interrupted and bridging therapy may be considered in patients with high thrombotic risk.
Lateral Brain Displacement and Cerebral Autoregulation in Acutely Comatose Patients
Authors: Adatia Krishma , Geocadin Romergryko G. , Healy Ryan , Ziai Wendy , Ponce-Mejia Luciano , Anderson-White Mirinda , Shah Dhaval , Radzik Batya R. , Palmisano Caitlin , Hogue Charles W. , Brown Charles , Suarez Jose I. , Rivera-Lara Lucia 
Published: May 2020

Objectives:
Lateral displacement and impaired cerebral autoregulation are associated with worse outcomes following acute brain injury, but their effect on long-term clinical outcomes remains unclear. We assessed the relationship between lateral displacement, disturbances to cerebral autoregulation, and clinical outcomes in acutely comatose patients.

Design:
Retrospective analysis of prospectively collected data.

Setting:
Neurocritical care unit of the Johns Hopkins Hospital.

Patients:
Acutely comatose patients (Glasgow Coma Score ≤ 8).

Interventions:
None.

Measurements and Main Results:
Cerebral oximetry index, derived from near-infrared spectroscopy multimodal monitoring, was used to evaluate cerebral autoregulation. Associations between lateral brain displacement, global cerebral autoregulation, and interhemispheric cerebral autoregulation asymmetry were assessed using mixed random effects models with random intercept. Patients were grouped by functional outcome, determined by the modified Rankin Scale. Associations between outcome group, lateral displacement, and cerebral oximetry index were assessed using multivariate linear regression. Increasing lateral brain displacement was associated with worsening global cerebral autoregulation (p = 0.01 septum; p = 0.05 pineal) and cerebral autoregulation asymmetry (both p < 0.001). Maximum lateral displacement during the first 3 days of coma was significantly different between functional outcome groups at hospital discharge (p = 0.019 pineal; p = 0.008 septum), 3 months (p = 0.026; p = 0.007), 6 months (p = 0.018; p = 0.010), and 12 months (p = 0.022; p = 0.012). Global cerebral oximetry index was associated with functional outcomes at 3 months (p = 0.019) and 6 months (p = 0.013).

Conclusions:
During the first 3 days of acute coma, increasing lateral brain displacement is associated with worsening global cerebral autoregulation and cerebral autoregulation asymmetry, and poor long-term clinical outcomes in acutely comatose patients. The impact of acute interventions on outcome needs to be explored.
Financial Toxicity After Acute Respiratory Distress Syndrome: A National Qualitative Cohort Study*
Authors: Hauschildt Katrina E. , Seigworth Claire , Kamphuis Lee A. , Hough Catherine L. , Moss Marc , McPeake Joanne M. , Iwashyna Theodore J. ,   for the National Heart, Lung, and Blood Institute (NHLBI) Prevention and Early Treatment of Acute Lung Injury (PETAL) Network
Published: May 2020

Objectives:
The financial burdens and subsequent related distress of medical care, referred to as financial toxicity, may limit access to beneficial treatments. However, financial toxicity after acute care is less described—and may be an important but underexplored mechanism preventing full recovery after critical illnesses such as acute respiratory distress syndrome. We sought to identify the mechanisms by which financial toxicity manifested in patients with acute respiratory distress syndrome, protective factors against such toxicity, and the consequences of financial toxicity to survivors’ lives following acute respiratory distress syndrome.

Design:
We conducted semistructured interviews following patients’ hospitalization and during recovery as an ancillary study to a multicenter randomized clinical trial in acute respiratory distress syndrome. Patients were 9–16 months post randomization at the time of interview.

Setting and Participants:
The Reevaluation Of Systemic Early Neuromuscular Blockade trial examined the use of early neuromuscular blockade in mechanically ventilated patients with moderate/severe acute respiratory distress syndrome. We recruited consecutive surviving patients who were English speaking, consented to follow-up, and were randomized between December 11, 2017, and May 4, 2018 (n = 79) from 29 U.S. sites.

Measurements and Main Results:
We asked about patients’ perceptions of financial burden(s) that they associated with their acute respiratory distress syndrome hospitalization. Forty-six of 79 eligible acute respiratory distress syndrome survivors (58%) participated (from 22 sites); their median age was 56 (interquartile range 47–62). Thirty-one of 46 reported at least one acute respiratory distress syndrome-related financial impact. Financial toxicity manifested via medical bills, changes in insurance coverage, and loss of employment income. Respondents reported not working prior to acute respiratory distress syndrome, using Medicaid or Medicare, or, conversely, generous work benefits as factors which may have limited financial burdens. Patients reported multiple consequences of acute respiratory distress syndrome–related financial toxicity, including harms to their mental and physical health, increased reliance on others, and specific material hardships.

Conclusions:
Financial toxicity related to critical illness is common and may limit patients’ emotional, physical, and social recovery after acute respiratory distress syndrome hospitalization for at least a year.
Effects of intra-operative positive end-expiratory pressure setting guided by oesophageal pressure measurement on oxygenation and respiratory mechanics during laparoscopic gynaecological surgery
Authors: Piriyapatsom Annop , Phetkampang Sanchai 
Published: May 2020

BACKGROUND
The creation of pneumoperitoneum during laparoscopic surgery can lead to adverse effects on the respiratory system. Positive end-expiratory pressure (PEEP) plays an important role in mechanical ventilation during laparoscopic surgery.

OBJECTIVE
To evaluate whether PEEP setting guided by oesophageal pressure (P
oeso) measurement would affect oxygenation and respiratory mechanics during laparoscopic gynaecological surgery.

DESIGN
A randomised controlled study.

SETTING
A single-centre trial from March 2018 to June 2018.

PATIENTS
Forty-four adult patients undergoing laparoscopic gynaecological surgery with anticipated duration of surgery more than 2 h.

INTERVENTION
PEEP set according to P
oeso measurement (intervention group) versus PEEP constantly set at 5 cmH2O (control group).

MAIN OUTCOME MEASURES
Gas exchange and respiratory mechanics after induction and intubation (T0) and at 15 and 60 min after initiation of pneumoperitoneum (T1 and T2, respectively).

RESULTS
PEEP during pneumoperitoneum was significantly higher in the intervention group than in the control group (T1, 12.5 ± 1.9 vs. 5.0 ± 0.0 cmH2O and T2, 12.4 ± 1.9 vs. 5.0 ± 0.0 cmH2O, both P < 0.001). Partial pressures of oxygen decreased significantly from baseline during pneumoperitoneum in the control group but not in the intervention group. Nevertheless, the changes in partial pressures of oxygen did not differ between groups. Compliance of the respiratory system (C
RS) significantly decreased and driving pressure significantly increased during pneumoperitoneum in both groups. However, the changes in C
RS and driving pressure were significantly less in the intervention group. Transpulmonary pressure during expiration was maintained in the intervention group while it decreased significantly in the control group.

CONCLUSION
PEEP setting guided by P
oeso measurement showed no beneficial effects in terms of oxygenation but respiratory mechanics were better during laparoscopic gynaecological surgery.

TRIAL REGISTRATION
ClinicalTrials.gov identifier: NCT03256396.
Very early changes in serum creatinine are associated with 30-day mortality after cardiac surgery
Authors: Bernardi Martin H. , Ristl Robin , Neugebauer Thomas , Hiesmayr Michael J. , Druml Wilfred , Lassnigg Andrea 
Published: May 2020

BACKGROUND
Acute kidney injury predicts adverse outcomes after cardiac surgery.

OBJECTIVES
To determine whether ultra-short-term changes (within 120 min) in serum creatinine (SCrea) levels after cardiac surgery predict clinical outcomes (30-day mortality).

DESIGN
Observational cohort study.

SETTING
Austrian tertiary referral centre.

PATIENTS
A total of 7651 patients scheduled to undergo elective cardiac surgery.

MAIN OUTCOME MEASURES
We analysed SCrea levels measured pre-operatively (baseline) and within 120 min after surgery. We also adjusted the postoperative SCrea levels for fluid balance. Patients were grouped according to the difference between the pre and postoperative SCrea levels (ΔSCreaAdmICU). We performed univariable and multivariable analyses to determine the association between changes in SCrea levels and 30-day mortality.

RESULTS
After cardiac surgery, the SCrea level decreased in 5923 patients and increased in 1728 patients. Increased SCrea levels were associated with a 21% increase in 30-day mortality. Even minimal increases in SCrea (0 to <26.5 μmol l−1) were significantly associated with 30-day mortality [hazard ratio (HR), 1.98; 95% confidence interval (CI), 1.54 to 2.55; P < 0.001]. Adjustments for fluid balance strengthened the above association (increases of 0 to <26.5 μmol l−1: HR, 1.78; 95% CI, 1.40 to 2.26; P < 0.001; increases of at least 26.5 μmol l−1: HR, 2.40; 95% CI, 1.68 to 3.42; P < 0.001).

CONCLUSION
Even minimal, ultra-short-term increases in SCrea levels after cardiac surgery are associated with increased 30-day mortality. Adjustment for fluid balance strengthens this association. The change in SCrea between baseline and after admission to the Intensive Care Unit (ΔSCreaAdmICU) can serve as a simple, cheap and widely available marker for very early risk stratification after cardiac surgery.
Erroneous neuraxial administration of neuromuscular blocking drugs
Authors: Patel Santosh 
Published: May 2020

BACKGROUND
Drug errors during neuraxial anaesthesia or analgesia are not well known.

OBJECTIVES
To review the clinical consequences associated with incorrect administration of neuromuscular blocking drugs (NMBDs) during spinal or epidural anaesthesia, and to investigate human factors and strategies available to help prevent such errors.

DESIGN
A review of reports of neuraxial administration of NMBDs in humans.

DATA SOURCES
Published reports of errors involving NMBDs. We searched the period between 1965 and 2019.

ELIGIBILITY CRITERIA
Error reports in any language. Nonneuraxial drug errors were excluded.

RESULTS
We identified 20 reports involving seven different NMBDs inadvertently administered via the epidural or intrathecal routes. All patients developed systemic neuromuscular junction blockade. Fourteen errors occurred while patients were awake. The onset of action was delayed following epidural rocuronium and suxamethonium. The duration of action was prolonged following epidural administration of vecuronium, pancuronium, cisatracrium and suxamethonium. Five patients required emergency airway interventions. Intrethecal gallamine caused convulsions and muscle spasms migrating up the body. Syringe swap was the primary cause for the majority of errors and perceptual errors were the most common. Implementation of recommendations could have prevented the errors.

CONCLUSION
Following the epidural injection of NMBDs the effects are delayed and prolonged. There was no serious morbidity reported following neuraxial administration of the NMBDs used in current practice. Perceptual errors resulting in incorrect syringe choice were the commonest cause. Four measures can be introduced to reduce such errors.
Effects of KCNMB2 gene polymorphisms on ritodrine therapy outcomes in women with preterm labor
Authors: Yoon Ha Young , Park Jin Young , Yee Jeong , Hwang Han Sung , Chung Jee Eun , Lee Kyung Eun , Kim Young Ju , Gwak Hye Sun 
Published: May 2020

Objective
The present prospective follow-up study aimed to evaluate the effects of KCNMB2 gene polymorphisms on ritodrine efficacy and adverse drug events (ADEs) in patients with preterm labor.

Methods
A total of 163 preterm labor patients were included in this single-center study. Nine single nucleotide polymorphisms (SNPs) in the KCNMB2 gene (rs10936979, rs7624046, rs7429015, rs7625907, rs6443559, rs9839376, rs9637454, rs11918114, and rs1382045) were assessed. The primary endpoint was time to delivery, and the secondary endpoint was ritodrine-induced ADEs.

Results
Patients with variant homozygotes of two SNPs (rs7624046 and rs9839376), which were in linkage disequilibrium, showed 2.06 [95% confidence interval (CI), 1.14–3.73] and 2.68 (95% CI, 1.16–6.20) times the hazard of time to delivery compared to wild-type allele carriers, respectively. Among demographic characteristics, gestational age at start of drug therapy and modified Bishop score were significant factors for time to delivery. Regarding safety outcomes, patients with variant homozygotes of rs7625907 had fewer ADEs compared to those with other genotypes (odds ratio, 0.32; 95% CI, 0.13–0.83).

Conclusion
This pharmacogenomic study suggests that ritodrine efficacy and ADEs are associated with KCNMB2 gene polymorphisms in patients with preterm labor.
Associations between carotid-femoral and heart-femoral pulse wave velocity in older adults: the Atherosclerosis Risk In Communities study
Authors: Stoner Lee , Meyer Michelle L. , Kucharska-Newton Anna , Stone Keeron , Zieff Gabriel , Dave Gaurav , Fryer Simon , Credeur Daniel , Faulkner James , Matsushita Kunihiro , Hughes Timothy M. , Tanaka Hirofumi 
Published: May 2020

Background:
Carotid-femoral pulse wave velocity (cfPWV) is widely used in epidemiological studies to assess central arterial stiffness. However, despite being superior to traditional risk factors in predicting cardiovascular outcomes, cfPWV is not routinely used in clinical practice. cfPWV assessments require applanation of the carotid artery, which can be cumbersome, and individual-level factors, including carotid artery plaque, may confound the measurements. Heart-femoral PWV (hfPWV) may be a suitable alternative measure of central arterial stiffness.

Objectives:
The aim of this study was to estimate the strength of the agreement between hfPWV and cfPWV.

Methods:
We evaluated 4133 older-aged [75.2 (5.0) years] African–American and white adults in the community-based Atherosclerosis Risk in Communities (ARIC) Study. cfPWV and hfPWV were measured using an automated cardiovascular screening device. Agreement between the two measurements was determined using Pearson's correlation coefficient (r), standard error of estimate (SEE) and Bland–Altman analysis.

Results:
There was a strong (r > 0.7) agreement between hfPWV and cfPWV (r = 0.83, 95% CI: 0.82–0.84). Although the mean cfPWV [11.5 m/s (SD: 3.0)] and hfPWV [11.5 m/s (SD: 2.3)] were comparable, the SEE was 1.7 m/s. Inspection of the Bland–Altman plot revealed greater variability and bias for higher PWV values, with higher PWV further away from the regression line.

Discussion:
Findings suggest good agreement between hfPWV and cfPWV. hfPWV is a simpler alternative to cfPWV that is less likely to be confounded by individual-level factors. Considering the greater variability for higher PWV values, further work is warranted to determine the importance of local artery mechanics to both measures.
Additional CTA-Subtraction Technique in Detection of Pulmonary Embolism—a Benefit for Patients or Only an Increase in Dose?
Authors: Nestler Kai , Becker Benjamin Valentin , Majewski Matthäus , Veit Daniel Anton , Krull Bastian Felix , Waldeck Stephan 
Published: May 2020

Abstract
Latest advantages in computed tomography (CT) come with enhanced diagnostic imaging and also sophisticated dose reduction techniques. However, overall exposure to ionizing radiation of patients in Germany rises slightly, which is mainly based on the growing number of performed CT scans. Furthermore, new possibilities in modern imaging, including 4D scans or perfusion protocols, offer new medical insights but require additional scans.
In this study, we reevaluated data sets from patients undergoing CT examinations because of suspected pulmonary embolism and compared doses and diagnostic results of the standard protocol to the additional modern CT subtraction technique. Two groups of single-blinded radiologists were provided with CT data sets from 50 patients. One group (G1) had access to full datasets including CT subtraction with perfusion map. The other group (G2) only evaluated conventional CT angiography. Results were compared to final clinical diagnosis. Dose length product (DLP) of CT angiography was compared to CT subtraction technique, which consists of an additional non-contrast-enhanced scan and perfusion map. Effective dose was calculated using a Monte Carlo simulation-based software tool (ImpactDose). Inter-rater agreement of both groups was strong in G1 with κ = .896 and minimal in G2 (κ = .307). Agreement to final diagnosis was strong in both groups (G1, κ = .848; G2, κ = .767). Doses applied using the CT subtraction technique were 34.8% higher than for CT angiography alone (G1 DLP 337.6 ± 171.3 mGy x cm; G2 DLP 220.2 ± 192.8 mGy x cm; p < .001). Calculated effective dose was therefore significantly higher for G1 (G1 4.82 ± 2.20 mSv; G2 3.04 ± 1.33 mSv; p < .001). Our results indicate a benefit of the CT subtraction technique for the detection of pulmonary embolisms in clinical routine, accompanied by an increase in the dose administered. Although CT protocols should always be applied carefully to specific clinical indications in order to maximize the potential for dose reduction and keep the administered dose as low as reasonably achievable, one should never lose sight of the diagnostic benefit, especially in vital clinical indications.