Pub Date : 2024-05-01DOI: 10.1016/j.bjane.2023.07.013
Saullo Queiroz Silveira , Rafael Sousa Fava Nersessian , Arthur de Campos Vieira Abib , Leonardo Barbosa Santos , Fernando Nardy Bellicieri , Karen Kato Botelho , Helidea de Oliveira Lima , Renata Mazzoni de Queiroz , Gabriel Silva dos Anjos , Hermann dos Santos Fernandes , Glenio B. Mizubuti , Joaquim Edson Vieira , Leopoldo Muniz da Silva
Background
Alarms alert healthcare professionals of deviations from normal/physiologic status. However, alarm fatigue may occur when their high pitch and diversity overwhelm clinicians, possibly leading to alarms being disabled, paused, and/or ignored. We aimed to determine whether a staff educational program on customizing alarm settings of bedside monitors may decrease inconsistent alarms in the Post-Anesthesia Care Unit (PACU).
Methods
This is a prospective, analytic, quantitative, pragmatic, open-label, single-arm study. The outcome was evaluated on PACU admission before (P1) and after (P2) the implementation of the educational program. The heart rate, blood pressure, and oxygen saturation alarms were selected for clinical consistency.
Results
A total of 260 patients were included and 344 clinical alarms collected, with 270 (78.4%) before (P1), and 74 (21.6%) after (P2) the intervention. Among the 270 alarms in P1, 45.2% were inconsistent (i.e., false alarms), compared to 9.4% of the 74 in P2. Patients with consistent alarms occurred in 30% in the P1 and 27% in the P2 (p = 0.08). Patients with inconsistent alarms occurred in 25.4% in the P1 and in 3.8% in the P2. Ignored consistent alarms were reduced from 21.5% to 2.6% (p = 0.004) in the P2 group. The educational program was a protective factor for the inconsistent clinical alarm (OR = 0.11 [95% CI 0.04–0.3]; p < 0.001) after adjustments for age, gender, and ASA physical status.
Conclusion
Customizing alarm settings on PACU admission proved to be a protective factor against inconsistent alarm notifications of multiparametric monitors.
{"title":"Decreasing inconsistent alarms notifications: a pragmatic clinical trial in a post-anesthesia care unit","authors":"Saullo Queiroz Silveira , Rafael Sousa Fava Nersessian , Arthur de Campos Vieira Abib , Leonardo Barbosa Santos , Fernando Nardy Bellicieri , Karen Kato Botelho , Helidea de Oliveira Lima , Renata Mazzoni de Queiroz , Gabriel Silva dos Anjos , Hermann dos Santos Fernandes , Glenio B. Mizubuti , Joaquim Edson Vieira , Leopoldo Muniz da Silva","doi":"10.1016/j.bjane.2023.07.013","DOIUrl":"10.1016/j.bjane.2023.07.013","url":null,"abstract":"<div><h3>Background</h3><p>Alarms alert healthcare professionals of deviations from normal/physiologic status. However, alarm fatigue may occur when their high pitch and diversity overwhelm clinicians, possibly leading to alarms being disabled, paused, and/or ignored. We aimed to determine whether a staff educational program on customizing alarm settings of bedside monitors may decrease inconsistent alarms in the Post-Anesthesia Care Unit (PACU).</p></div><div><h3>Methods</h3><p>This is a prospective, analytic, quantitative, pragmatic, open-label, single-arm study. The outcome was evaluated on PACU admission before (P1) and after (P2) the implementation of the educational program. The heart rate, blood pressure, and oxygen saturation alarms were selected for clinical consistency.</p></div><div><h3>Results</h3><p>A total of 260 patients were included and 344 clinical alarms collected, with 270 (78.4%) before (P1), and 74 (21.6%) after (P2) the intervention. Among the 270 alarms in P1, 45.2% were inconsistent (i.e., false alarms), compared to 9.4% of the 74 in P2. Patients with consistent alarms occurred in 30% in the P1 and 27% in the P2 (<em>p</em> = 0.08). Patients with inconsistent alarms occurred in 25.4% in the P1 and in 3.8% in the P2. Ignored consistent alarms were reduced from 21.5% to 2.6% (<em>p</em> = 0.004) in the P2 group. The educational program was a protective factor for the inconsistent clinical alarm (OR = 0.11 [95% CI 0.04–0.3]; <em>p</em> < 0.001) after adjustments for age, gender, and ASA physical status.</p></div><div><h3>Conclusion</h3><p>Customizing alarm settings on PACU admission proved to be a protective factor against inconsistent alarm notifications of multiparametric monitors.</p></div>","PeriodicalId":32356,"journal":{"name":"Brazilian Journal of Anesthesiology","volume":null,"pages":null},"PeriodicalIF":1.3,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S0104001423000817/pdfft?md5=592beb01a2ecbd58d1a21aee9bac0c92&pid=1-s2.0-S0104001423000817-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10040586","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-01DOI: 10.1016/j.bjane.2023.07.010
Ilka D. Alp, Bengü G. Köksal, Keziban Bollucuoğlu, Gamze Küçükosman, Özcan Pişkin, Çağdaş Baytar, Rahşan D. Okyay, Hilal Ayoğlu
Background
Patients diagnosed with Obstructive Sleep Apnea (OSA) syndrome have a tendency towards hypoventilation, hypoxia, and hypercarbia in the perioperative period. This study hypothesized that the Oxygen Reserve Index (ORi) could predict possible hypoxia and determine difficult airways in patients at risk for OSA, as determined by the STOP-Bang questionnaire.
Methods
This prospective study included adult patients undergoing elective surgery under general anesthesia with endotracheal intubation, divided into two groups: low risk (0–2 points) and high risk (3–8 points) based on their STOP-Bang questionnaire results. The primary outcome measure was the highest ORi value reached during preoxygenation and the time to reach this value. Data were recorded at four time points: before preoxygenation (T1), end of preoxygenation (T2), end of mask ventilation (T3), and end of intubation (T4), as well as partial oxygen pressure values in T1, T2, and T4. The secondary outcome measures were the grading scale for mask ventilation, Cormack-Lehane score, tonsil dimensions, use of a stylet, and application of the burp maneuver during intubation.
Results
In the high-risk group, preoperative peripheral oxygen saturation values, the highest ORi value reached in preoxygenation, and ORi values at T3 and T4 times were lower, and the time to reach the highest ORi value was longer (p < 0.05).
Conclusion
Using ORi in patients with OSA may be useful in evaluating oxygenation, and since difficult airway is more common, ORi monitoring will better manage possible hypoxic conditions.
背景：被诊断为阻塞性睡眠呼吸暂停（OSA）综合征的患者在围手术期有通气不足、缺氧和高碳酸血症的倾向。本研究假设氧储备指数（ORi）可以预测可能出现的缺氧，并根据 STOP-Bang 问卷确定 OSA 高危患者的困难气道：这项前瞻性研究纳入了在全身麻醉下接受气管插管择期手术的成年患者，根据他们的 STOP-Bang 问卷调查结果分为两组：低风险组（0-2 分）和高风险组（3-8 分）。主要结果指标是预吸氧时达到的最高 ORi 值和达到该值的时间。记录了四个时间点的数据：预吸氧前（T1）、预吸氧结束（T2）、面罩通气结束（T3）和插管结束（T4），以及 T1、T2 和 T4 的氧分压值。次要结果指标包括面罩通气分级、Cormack-Lehane 评分、扁桃体尺寸、支架的使用以及插管时打嗝动作的应用：在高风险组中，术前外周血氧饱和度值、吸氧前达到的最高 ORi 值、T3 和 T4 时间的 ORi 值均较低，达到最高 ORi 值的时间较长（P < 0.05）：结论：在 OSA 患者中使用 ORi 可能有助于评估氧合情况，由于困难气道更为常见，ORi 监测将更好地处理可能出现的缺氧情况。
{"title":"Evaluation of the relationship between the STOP-Bang score with oxygen reserve index and difficult airway: a prospective observational study","authors":"Ilka D. Alp, Bengü G. Köksal, Keziban Bollucuoğlu, Gamze Küçükosman, Özcan Pişkin, Çağdaş Baytar, Rahşan D. Okyay, Hilal Ayoğlu","doi":"10.1016/j.bjane.2023.07.010","DOIUrl":"10.1016/j.bjane.2023.07.010","url":null,"abstract":"<div><h3>Background</h3><p>Patients diagnosed with Obstructive Sleep Apnea (OSA) syndrome have a tendency towards hypoventilation, hypoxia, and hypercarbia in the perioperative period. This study hypothesized that the Oxygen Reserve Index (ORi) could predict possible hypoxia and determine difficult airways in patients at risk for OSA, as determined by the STOP-Bang questionnaire.</p></div><div><h3>Methods</h3><p>This prospective study included adult patients undergoing elective surgery under general anesthesia with endotracheal intubation, divided into two groups: low risk (0–2 points) and high risk (3–8 points) based on their STOP-Bang questionnaire results. The primary outcome measure was the highest ORi value reached during preoxygenation and the time to reach this value. Data were recorded at four time points: before preoxygenation (T1), end of preoxygenation (T2), end of mask ventilation (T3), and end of intubation (T4), as well as partial oxygen pressure values in T1, T2, and T4. The secondary outcome measures were the grading scale for mask ventilation, Cormack-Lehane score, tonsil dimensions, use of a stylet, and application of the burp maneuver during intubation.</p></div><div><h3>Results</h3><p>In the high-risk group, preoperative peripheral oxygen saturation values, the highest ORi value reached in preoxygenation, and ORi values at T3 and T4 times were lower, and the time to reach the highest ORi value was longer (<em>p</em> < 0.05).</p></div><div><h3>Conclusion</h3><p>Using ORi in patients with OSA may be useful in evaluating oxygenation, and since difficult airway is more common, ORi monitoring will better manage possible hypoxic conditions.</p></div>","PeriodicalId":32356,"journal":{"name":"Brazilian Journal of Anesthesiology","volume":null,"pages":null},"PeriodicalIF":1.3,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S0104001423000799/pdfft?md5=b9494a017d29fff63e2632ac7fbcb6c1&pid=1-s2.0-S0104001423000799-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10357937","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-01DOI: 10.1016/j.bjane.2024.844504
Luiz Guilherme V. da Costa , Fabio V. Papa , Gregory M.T. Hare , Marcello F. Salgado-Filho , Eric B. Lineburger , André P. Schmidt
{"title":"Anemia and outcomes in cardiac surgery","authors":"Luiz Guilherme V. da Costa , Fabio V. Papa , Gregory M.T. Hare , Marcello F. Salgado-Filho , Eric B. Lineburger , André P. Schmidt","doi":"10.1016/j.bjane.2024.844504","DOIUrl":"10.1016/j.bjane.2024.844504","url":null,"abstract":"","PeriodicalId":32356,"journal":{"name":"Brazilian Journal of Anesthesiology","volume":null,"pages":null},"PeriodicalIF":1.3,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S0104001424000265/pdfft?md5=ddde89cbe271425e7069c8bfd4eeab4e&pid=1-s2.0-S0104001424000265-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140772636","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-01DOI: 10.1016/j.bjane.2023.03.003
Estevão Bassi , Bruno Martins Tomazini , Bárbara Vieira Carneiro , Amanda Rodrigues de Oliveira Siqueira , Sara Rodrigues de Oliveira Siqueira , Thais Guimarães , Fernando da Costa Ferreira Novo , Edivaldo Massazo Utiyama , Paolo Pelosi , Luiz Marcelo Sá Malbouisson
Background
Systemic inflammatory responses mimicking infectious complications are often present in surgical patients.
Methods
The objective was to assess the association between withholding early antimicrobial therapy while investigating alternative diagnoses and worse outcomes in nonseptic patients with suspected nosocomial infection in a retrospective cohort of critically ill surgical patients. The initiation of antibiotic therapy within 24 h of the suspicion of infection was defined as the Early Empirical Antibiotic strategy (EEA) group and the initiation after 24 h of suspicion or not prescribed was defined as the Conservative Antibiotic strategy (CA) group. Primary outcome was composite: death, sepsis, or septic shock within 14 days. Main exclusion criteria were sepsis or an evident source of infection at inclusion.
Results
Three hundred and forty patients were eligible for inclusion (74% trauma patients). Age, sex, reason for hospital admission, SAPS3 score, SOFA score, and use of vasopressors or mechanical ventilation were not different between the groups. Within 14 days of inclusion, 100% (130/130) of EEA patients received antibiotics compared to 57% (120/210) of CA patients. After adjusting for confounding variables, there was no association between primary outcome and the groups. In a post hoc subgroup analysis including only patients with a posteriori confirmed infection (by microbiological cultures), delay in initiation of adequate antimicrobial therapy was independently associated with the primary outcome (Odds Ratio = 1.19 per day of delay; 95% CI 1.05–1.37).
Conclusions
Withholding early empiric antibiotic therapy was not associated with progression of organ dysfunction within 14 days in nonseptic surgical patients with suspected nosocomial infection without an obvious source.
背景：模拟感染并发症的全身炎症反应经常出现在手术患者身上：手术患者经常出现模仿感染并发症的全身炎症反应：目的是在一个重症手术患者回顾性队列中，评估在调查其他诊断的同时暂停早期抗菌治疗与疑似鼻腔感染的无菌患者较差的预后之间的关系。怀疑感染后 24 小时内开始抗生素治疗的患者被定义为早期经验性抗生素策略（EEA）组，怀疑感染后 24 小时后开始抗生素治疗或未处方抗生素的患者被定义为保守抗生素策略（CA）组。主要结果为综合结果：14 天内死亡、败血症或脓毒性休克。主要排除标准是败血症或纳入时有明显的感染源：340名患者符合纳入条件（74%为创伤患者）。两组患者的年龄、性别、入院原因、SAPS3 评分、SOFA 评分以及使用血管加压剂或机械通气的情况均无差异。在入院后的14天内，100%（130/130）的EEA患者接受了抗生素治疗，而CA患者中只有57%（120/210）接受了抗生素治疗。在对混杂变量进行调整后，主要结果与各组之间没有关联。在一项仅包括后确诊感染（通过微生物培养）患者的事后亚组分析中，延迟开始适当的抗菌治疗与主要结果有独立关联（Odds Ratio = 1.19 per day of delay; 95% CI 1.05-1.37）：结论：对于无明显感染源的非化脓性外科疑似鼻腔感染患者，拒绝早期经验性抗生素治疗与14天内器官功能障碍的恶化无关。
{"title":"Impact of withholding early antibiotic therapy in nonseptic surgical patients with suspected nosocomial infection: a retrospective cohort analysis","authors":"Estevão Bassi , Bruno Martins Tomazini , Bárbara Vieira Carneiro , Amanda Rodrigues de Oliveira Siqueira , Sara Rodrigues de Oliveira Siqueira , Thais Guimarães , Fernando da Costa Ferreira Novo , Edivaldo Massazo Utiyama , Paolo Pelosi , Luiz Marcelo Sá Malbouisson","doi":"10.1016/j.bjane.2023.03.003","DOIUrl":"10.1016/j.bjane.2023.03.003","url":null,"abstract":"<div><h3>Background</h3><p>Systemic inflammatory responses mimicking infectious complications are often present in surgical patients.</p></div><div><h3>Methods</h3><p>The objective was to assess the association between withholding early antimicrobial therapy while investigating alternative diagnoses and worse outcomes in nonseptic patients with suspected nosocomial infection in a retrospective cohort of critically ill surgical patients. The initiation of antibiotic therapy within 24 h of the suspicion of infection was defined as the Early Empirical Antibiotic strategy (EEA) group and the initiation after 24 h of suspicion or not prescribed was defined as the Conservative Antibiotic strategy (CA) group. Primary outcome was composite: death, sepsis, or septic shock within 14 days. Main exclusion criteria were sepsis or an evident source of infection at inclusion.</p></div><div><h3>Results</h3><p>Three hundred and forty patients were eligible for inclusion (74% trauma patients). Age, sex, reason for hospital admission, SAPS3 score, SOFA score, and use of vasopressors or mechanical ventilation were not different between the groups. Within 14 days of inclusion, 100% (130/130) of EEA patients received antibiotics compared to 57% (120/210) of CA patients. After adjusting for confounding variables, there was no association between primary outcome and the groups. In a post hoc subgroup analysis including only patients with <em>a posteriori</em> confirmed infection (by microbiological cultures), delay in initiation of adequate antimicrobial therapy was independently associated with the primary outcome (Odds Ratio = 1.19 per day of delay; 95% CI 1.05–1.37).</p></div><div><h3>Conclusions</h3><p>Withholding early empiric antibiotic therapy was not associated with progression of organ dysfunction within 14 days in nonseptic surgical patients with suspected nosocomial infection without an obvious source.</p></div>","PeriodicalId":32356,"journal":{"name":"Brazilian Journal of Anesthesiology","volume":null,"pages":null},"PeriodicalIF":1.3,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S010400142300026X/pdfft?md5=cdb57ceabf129b0aeca8c3491765c88c&pid=1-s2.0-S010400142300026X-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9675432","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-01DOI: 10.1016/j.bjane.2023.11.001
Nicole Morem Pilau Moritz , José Eduardo Moritz , Gabriel Oscar Cremona Parma , Franklin Dexter , Jefferson Traebert
Background
The Iowa Satisfaction with Anesthesia Scale (ISAS) was developed to assess the satisfaction of patients undergoing sedation with monitored anesthesia care. This study aimed to cross-culturally adapt the ISAS instrument and evaluate the acceptability, validity, and reliability of the proposed Brazilian version (ISAS-Br).
Methods
The cross-cultural adaptation process involved translation, synthesis, back-translation, expert committee review, pre-testing, and final review of the ISAS-Br. A cross-sectional study was conducted, involving 127 adult individuals undergoing ambulatory surgeries with moderate/deep sedation. The acceptability, reliability, and construct validity of the scale were assessed.
Results
The cross-cultural adaptation process did not require significant changes to the final version of the scale. The ISAS-Br demonstrated excellent acceptability, with a completion rate of 99% and an average completion time of 4.6 minutes. Exploratory factor analysis revealed three factors: emotional well-being, physical comfort, and anxiety relief, with respective composite reliability coefficient values of 0.874, 0.580, and 0.428. The test-retest reliability of the ISAS-Br, measured by the intraclass correlation coefficient, was 0.67 (95% confidence interval [95% CI] 0.42 to 0.83), and the Bland-Altman plot showed satisfactory agreement between the measurements.
Conclusion
The proposed Brazilian version of the ISAS underwent successful cross-cultural adaptation according to international standards. It demonstrated good acceptability and reliability, regarding the assessment of temporal stability. However, the ISAS-Br exhibited low internal consistency for some factors, indicating that this instrument lacks sensitivity to assess the satisfaction of deeply sedated patients. Further studies are necessary to explore the hypotheses raised based on the knowledge of its psychometric properties.
{"title":"Cross-cultural adaptation and validation of the Iowa Satisfaction with Anesthesia Scale for use in Brazil: a cross-sectional study","authors":"Nicole Morem Pilau Moritz , José Eduardo Moritz , Gabriel Oscar Cremona Parma , Franklin Dexter , Jefferson Traebert","doi":"10.1016/j.bjane.2023.11.001","DOIUrl":"10.1016/j.bjane.2023.11.001","url":null,"abstract":"<div><h3>Background</h3><p>The Iowa Satisfaction with Anesthesia Scale (ISAS) was developed to assess the satisfaction of patients undergoing sedation with monitored anesthesia care. This study aimed to cross-culturally adapt the ISAS instrument and evaluate the acceptability, validity, and reliability of the proposed Brazilian version (ISAS-Br).</p></div><div><h3>Methods</h3><p>The cross-cultural adaptation process involved translation, synthesis, back-translation, expert committee review, pre-testing, and final review of the ISAS-Br. A cross-sectional study was conducted, involving 127 adult individuals undergoing ambulatory surgeries with moderate/deep sedation. The acceptability, reliability, and construct validity of the scale were assessed.</p></div><div><h3>Results</h3><p>The cross-cultural adaptation process did not require significant changes to the final version of the scale. The ISAS-Br demonstrated excellent acceptability, with a completion rate of 99% and an average completion time of 4.6 minutes. Exploratory factor analysis revealed three factors: emotional well-being, physical comfort, and anxiety relief, with respective composite reliability coefficient values of 0.874, 0.580, and 0.428. The test-retest reliability of the ISAS-Br, measured by the intraclass correlation coefficient, was 0.67 (95% confidence interval [95% CI] 0.42 to 0.83), and the Bland-Altman plot showed satisfactory agreement between the measurements.</p></div><div><h3>Conclusion</h3><p>The proposed Brazilian version of the ISAS underwent successful cross-cultural adaptation according to international standards. It demonstrated good acceptability and reliability, regarding the assessment of temporal stability. However, the ISAS-Br exhibited low internal consistency for some factors, indicating that this instrument lacks sensitivity to assess the satisfaction of deeply sedated patients. Further studies are necessary to explore the hypotheses raised based on the knowledge of its psychometric properties.</p></div>","PeriodicalId":32356,"journal":{"name":"Brazilian Journal of Anesthesiology","volume":null,"pages":null},"PeriodicalIF":1.3,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S0104001423001161/pdfft?md5=71a197d31a430d2ba88a7897944960f1&pid=1-s2.0-S0104001423001161-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89720920","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Acute Kidney Injury (AKI) is a common complication after cardiac surgery and has been associated with poor outcomes. Dexmedetomidine (DEX) has been shown to confer direct renoprotection based on some animal and clinical studies, but data from other trials came to the opposite conclusion following cardiac surgery. This meta-analysis was conducted to evaluate the effects of perioperative DEX administration on the occurrence of AKI and the outcomes after cardiac surgery.
Methods
We searched databases including EMBASE, PubMed, and Cochrane CENTRAL for Randomized Controlled Trials (RCTs) focused on DEX for AKI in adult patients after cardiac surgery. The primary outcome was incidence of AKI. Secondary outcomes were Mechanical Ventilation (MV) duration, Intensive Care Unit (ICU) Length Of Stay (LOS), hospital LOS and mortality.
Results
Fifteen trials enrolling 2907 study patients were collected in the meta-analyses. Compared with controls, DEX reduced the incidence of postoperative AKI (Odds Ratio [OR = 0.66]; 95% Confidence Interval [95% CI 0.48–0.91]; p = 0.01), and there was no significant difference between groups in postoperative mortality (OR = 0.63; 95% CI 0.32–1.26; p = 0.19), MV duration (Weighted Mean Difference [WMD = -0.44]; 95% CI -1.50–0.63; p = 0.42), ICU LOS (WMD = -1.19; 95% CI -2.89–0.51; p = 0.17), and hospital LOS (WMD = -0.31; 95% CI -0.76–0.15; p = 0.19).
Conclusions
Perioperative DEX reduced the incidence of postoperative AKI in adult patients undergoing cardiac surgery. No significant decrease existed in mortality, MV duration, ICU LOS and hospital LOS owing to DEX administration.
背景：急性肾损伤（AKI）是心脏手术后常见的并发症，与不良预后有关。根据一些动物和临床研究，右美托咪定（DEX）可直接保护肾脏，但其他试验的数据却得出了与心脏手术相反的结论。本荟萃分析旨在评估围手术期使用DEX对心脏手术后AKI发生率和预后的影响：我们在 EMBASE、PubMed 和 Cochrane CENTRAL 等数据库中检索了有关心脏手术后成人患者使用 DEX 治疗 AKI 的随机对照试验 (RCT)。主要结果是 AKI 发生率。次要结果是机械通气（MV）持续时间、重症监护室（ICU）住院时间、住院时间和死亡率：荟萃分析收集了 15 项试验，共 2907 名患者参与了研究。与对照组相比，DEX可降低术后AKI的发生率（Odds Ratio [OR = 0.66]; 95% Confidence Interval [95% CI 0.48-0.91]; p = 0.01），组间术后死亡率无显著差异（OR = 0.63; 95% CI 0.32-1.26; p = 0.19）、MV持续时间（加权平均差[WMD = -0.44]; 95% CI -1.50-0.63; p = 0.42）、ICU LOS（WMD = -1.19; 95% CI -2.89-0.51; p = 0.17）和住院LOS（WMD = -0.31; 95% CI -0.76-0.15; p = 0.19）：结论：围手术期DEX可降低接受心脏手术的成年患者术后AKI的发生率。结论：围手术期使用DEX可降低心脏手术成人患者术后AKI的发生率，但使用DEX后死亡率、MV持续时间、ICU LOS和住院时间均无明显下降。
{"title":"Does dexmedetomidine reduce the risk of acute kidney injury after cardiac surgery? A meta-analysis of randomized controlled trials","authors":"Chunxiao Zhao , Shuo Liu , Huiquan Zhang , Mengqi Gao","doi":"10.1016/j.bjane.2023.07.003","DOIUrl":"10.1016/j.bjane.2023.07.003","url":null,"abstract":"<div><h3>Background</h3><p>Acute Kidney Injury (AKI) is a common complication after cardiac surgery and has been associated with poor outcomes. Dexmedetomidine (DEX) has been shown to confer direct renoprotection based on some animal and clinical studies, but data from other trials came to the opposite conclusion following cardiac surgery. This meta-analysis was conducted to evaluate the effects of perioperative DEX administration on the occurrence of AKI and the outcomes after cardiac surgery.</p></div><div><h3>Methods</h3><p>We searched databases including EMBASE, PubMed, and Cochrane CENTRAL for Randomized Controlled Trials (RCTs) focused on DEX for AKI in adult patients after cardiac surgery. The primary outcome was incidence of AKI. Secondary outcomes were Mechanical Ventilation (MV) duration, Intensive Care Unit (ICU) Length Of Stay (LOS), hospital LOS and mortality.</p></div><div><h3>Results</h3><p>Fifteen trials enrolling 2907 study patients were collected in the meta-analyses. Compared with controls, DEX reduced the incidence of postoperative AKI (Odds Ratio [OR = 0.66]; 95% Confidence Interval [95% CI 0.48–0.91]; <em>p</em> = 0.01), and there was no significant difference between groups in postoperative mortality (OR = 0.63; 95% CI 0.32–1.26; <em>p</em> = 0.19), MV duration (Weighted Mean Difference [WMD = -0.44]; 95% CI -1.50–0.63; <em>p</em> = 0.42), ICU LOS (WMD = -1.19; 95% CI -2.89–0.51; <em>p</em> = 0.17), and hospital LOS (WMD = -0.31; 95% CI -0.76–0.15; <em>p</em> = 0.19).</p></div><div><h3>Conclusions</h3><p>Perioperative DEX reduced the incidence of postoperative AKI in adult patients undergoing cardiac surgery. No significant decrease existed in mortality, MV duration, ICU LOS and hospital LOS owing to DEX administration.</p></div>","PeriodicalId":32356,"journal":{"name":"Brazilian Journal of Anesthesiology","volume":null,"pages":null},"PeriodicalIF":1.3,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S0104001423000702/pdfft?md5=ef98eecea417b1784db31948f1487694&pid=1-s2.0-S0104001423000702-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9885898","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-01DOI: 10.1016/j.bjane.2023.02.003
Sinem Sari , Jack Brooker , Mateo Montalvo-Campana , Peter Shehata , Xuan Pu , Steven Insler , Kurt Ruetzler , Christopher A. Troianos , Alparslan Turan
Background
Most cardiac surgery patients experience postoperative anemia. Delirium and Atrial Fibrillation (AF) are common and independent predictors of morbidity and mortality. Few reports examine their association with postoperative anemia. This study aims to quantify the association between anemia and these outcomes in patients undergoing cardiac surgery.
Methods
This post-hoc analysis of the DECADE randomized controlled trial ran at six academic US hospitals. Patients aged 18–85 years with heart rate > 50 bpm undergoing cardiac surgery who had daily hemoglobin measurements in the first 5 Postoperative Days (POD) were included. Delirium was assessed twice daily with the Confusion Assessment Method for the ICU (CAM – ICU), preceded by the Richmond Agitation and Sedation Scale, with patients excluded from assessment if sedated. Patients had daily hemoglobin measurements, continuous cardiac monitoring plus twice-daily 12-lead electrocardiograms, up to POD4. AF was diagnosed by clinicians blinded to hemoglobin levels.
Results
Five hundred and eighty-five patients were included. Mean postoperative hemoglobin Hazard Ratio (HR): 0.99 (95% CI 0.83, 1.19; p = 0.94) per 1 g.dL−1 hemoglobin decrease. 197 (34%) developed AF, mainly on POD = 2.3. Estimated HR = 1.04 (95% CI 0.93, 1.17; p = 0.51) per 1 g.dL−1 hemoglobin decrease.
Conclusions
Most patients undergoing major cardiac surgery were anemic in the postoperative phase. AF and delirium occurred in 34% and 12% of patients, respectively, but neither were significantly correlated with postoperative hemoglobin.
{"title":"The association of hemoglobin with postoperative delirium and atrial fibrillation after cardiac surgery: a retrospective sub-study","authors":"Sinem Sari , Jack Brooker , Mateo Montalvo-Campana , Peter Shehata , Xuan Pu , Steven Insler , Kurt Ruetzler , Christopher A. Troianos , Alparslan Turan","doi":"10.1016/j.bjane.2023.02.003","DOIUrl":"10.1016/j.bjane.2023.02.003","url":null,"abstract":"<div><h3>Background</h3><p>Most cardiac surgery patients experience postoperative anemia. Delirium and Atrial Fibrillation (AF) are common and independent predictors of morbidity and mortality. Few reports examine their association with postoperative anemia. This study aims to quantify the association between anemia and these outcomes in patients undergoing cardiac surgery.</p></div><div><h3>Methods</h3><p>This post-hoc analysis of the DECADE randomized controlled trial ran at six academic US hospitals. Patients aged 18–85 years with heart rate > 50 bpm undergoing cardiac surgery who had daily hemoglobin measurements in the first 5 Postoperative Days (POD) were included. Delirium was assessed twice daily with the Confusion Assessment Method for the ICU (CAM – ICU), preceded by the Richmond Agitation and Sedation Scale, with patients excluded from assessment if sedated. Patients had daily hemoglobin measurements, continuous cardiac monitoring plus twice-daily 12-lead electrocardiograms, up to POD4. AF was diagnosed by clinicians blinded to hemoglobin levels.</p></div><div><h3>Results</h3><p>Five hundred and eighty-five patients were included. Mean postoperative hemoglobin Hazard Ratio (HR): 0.99 (95% CI 0.83, 1.19; <em>p</em> = 0.94) per 1 g.dL<sup>−1</sup> hemoglobin decrease. 197 (34%) developed AF, mainly on POD = 2.3. Estimated HR = 1.04 (95% CI 0.93, 1.17; <em>p</em> = 0.51) per 1 g.dL<sup>−1</sup> hemoglobin decrease.</p></div><div><h3>Conclusions</h3><p>Most patients undergoing major cardiac surgery were anemic in the postoperative phase. AF and delirium occurred in 34% and 12% of patients, respectively, but neither were significantly correlated with postoperative hemoglobin.</p></div>","PeriodicalId":32356,"journal":{"name":"Brazilian Journal of Anesthesiology","volume":null,"pages":null},"PeriodicalIF":1.3,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S0104001423000209/pdfft?md5=9d128d7a564713b20085c1344c5c1bff&pid=1-s2.0-S0104001423000209-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9173069","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-17DOI: 10.1016/j.bjane.2024.844503
Ana G.G. Vale , Catia S. Govêia , Gabriel M.N. Guimarães , Laíze R. Terra , Luís C.A. Ladeira , Guilherme A. Essado
Background
The incidence of arterial hypotension during induction of general anesthesia is influenced by the method of propofol administration, but there is a dearth of randomized clinical trials comparing bolus injection and target-controlled infusion in relation to arterial hypotension. This study seeks to compare the incidence of arterial hypotension between these two methods of propofol administration.
Methods
This prospective, randomized, single-center, non-blinded study included 60 patients (aged 35 to 55 years), classified as ASA physical status I or II, who were undergoing non-cardiac surgeries. They were randomly allocated using a computer to two groups based on the method of propofol administration during the induction of general anesthesia: the Target Group, receiving target-controlled infusion at 4 μg.mL−1, and the Bolus Group, receiving a bolus infusion of 2 mg.kg−1. Both groups also received midazolam 2 mg, fentanyl 3 μg.kg−1, and rocuronium 0.6 mg.kg−1. Over the first 10 minutes of anesthesia induction, Mean Arterial Pressure (MAP), Heart Rate (HR), level of Consciousness (qCON), and Suppression Rate (SR) were recorded every 2 minutes.
Results
Twenty-seven patients remained in the TCI group, while 28 were in the Bolus group. Repeated measure analysis using mixed-effects models could not reject the null hypothesis for the effect of group-time interactions in MAP (p = 0.85), HR (p = 0.49), SR (p = 0.44), or qCON (p = 0.72). The difference in means for qCON (60.2 for TCI, 50.5 for bolus, p < 0.001), MAP (90.3 for TCI, 86.2 for bolus, p < 0.006), HR (76.2 for TCI, 76.9 for bolus, p = 0.93), and SR (0.01 for TCI, 5.5 for bolus, p < 0.001), irrespective of time (whole period means), revealed some significant differences.
Conclusion
Patients who received propofol bolus injection exhibited a lower mean arterial pressure, a greater variation in the level of consciousness, and a higher suppression rate compared to those who received it as a target-controlled infusion. However, the interaction effect between groups and time remains inconclusive.
{"title":"Comparison of arterial hypotension incidence during general anesthesia induction – target-controlled infusion vs. bolus injection of propofol: a randomized clinical trial","authors":"Ana G.G. Vale , Catia S. Govêia , Gabriel M.N. Guimarães , Laíze R. Terra , Luís C.A. Ladeira , Guilherme A. Essado","doi":"10.1016/j.bjane.2024.844503","DOIUrl":"10.1016/j.bjane.2024.844503","url":null,"abstract":"<div><h3>Background</h3><p>The incidence of arterial hypotension during induction of general anesthesia is influenced by the method of propofol administration, but there is a dearth of randomized clinical trials comparing bolus injection and target-controlled infusion in relation to arterial hypotension. This study seeks to compare the incidence of arterial hypotension between these two methods of propofol administration.</p></div><div><h3>Methods</h3><p>This prospective, randomized, single-center, non-blinded study included 60 patients (aged 35 to 55 years), classified as ASA physical status I or II, who were undergoing non-cardiac surgeries. They were randomly allocated using a computer to two groups based on the method of propofol administration during the induction of general anesthesia: the Target Group, receiving target-controlled infusion at 4 μg.mL<sup>−1</sup>, and the Bolus Group, receiving a bolus infusion of 2 mg.kg<sup>−1</sup>. Both groups also received midazolam 2 mg, fentanyl 3 μg.kg<sup>−1</sup>, and rocuronium 0.6 mg.kg<sup>−1</sup>. Over the first 10 minutes of anesthesia induction, Mean Arterial Pressure (MAP), Heart Rate (HR), level of Consciousness (qCON), and Suppression Rate (SR) were recorded every 2 minutes.</p></div><div><h3>Results</h3><p>Twenty-seven patients remained in the TCI group, while 28 were in the Bolus group. Repeated measure analysis using mixed-effects models could not reject the null hypothesis for the effect of group-time interactions in MAP (<em>p</em> = 0.85), HR (<em>p</em> = 0.49), SR (<em>p</em> = 0.44), or qCON (<em>p</em> = 0.72). The difference in means for qCON (60.2 for TCI, 50.5 for bolus, <em>p</em> < 0.001), MAP (90.3 for TCI, 86.2 for bolus, <em>p</em> < 0.006), HR (76.2 for TCI, 76.9 for bolus, <em>p</em> = 0.93), and SR (0.01 for TCI, 5.5 for bolus, <em>p</em> < 0.001), irrespective of time (whole period means), revealed some significant differences.</p></div><div><h3>Conclusion</h3><p>Patients who received propofol bolus injection exhibited a lower mean arterial pressure, a greater variation in the level of consciousness, and a higher suppression rate compared to those who received it as a target-controlled infusion. However, the interaction effect between groups and time remains inconclusive.</p></div>","PeriodicalId":32356,"journal":{"name":"Brazilian Journal of Anesthesiology","volume":null,"pages":null},"PeriodicalIF":1.3,"publicationDate":"2024-04-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S0104001424000253/pdfft?md5=f5db07c12017ce725a202a262a6c0eb1&pid=1-s2.0-S0104001424000253-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140792555","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-09DOI: 10.1016/j.bjane.2024.844502
Eugênio dos Santos Neto , Pedro Paulo de Alcantara Pedro , Maria do Socorro de Sousa Cartágenes , José Osvaldo Barbosa Neto , João Batista Santos Garcia
Background
This study aimed to investigate the analgesic impact of S(+)-ketamine on pain behavior and synovial inflammation in an osteoarthritis (OA) model.
Methods
Animals were grouped as follows: OA-Saline (n = 24) and OA-Ketamine (n = 24), OA induced via intra-articular sodium monoiodoacetate (MIA); a Non-OA group (n = 24) served as the control. On the 7th day post OA induction, animals received either saline or S(+)-ketamine (0.5 mg.kg−1). Behavioral and histopathological assessments were conducted up to day 28.
Results
S(+)-ketamine reduced allodynia from day 7 to 28 and hyperalgesia from day 10 to 28. It notably alleviated weight distribution deficits from day 10 until the end of the study. Significant walking improvement was observed on day 14 in S(+)-ketamine-treated rats. Starting on day 14, OA groups showed grip force decline, which was countered by S(+)-ketamine on day 21. However, S(+)-ketamine did not diminish synovial inflammation.
Conclusion
Low Intra-articular (IA) doses of S(+)-ketamine reduced MIA-induced OA pain but did not reverse synovial histopathological changes.
{"title":"The effect of low dose intra-articular S(+) ketamine on osteoarthritis in rats: an experimental study","authors":"Eugênio dos Santos Neto , Pedro Paulo de Alcantara Pedro , Maria do Socorro de Sousa Cartágenes , José Osvaldo Barbosa Neto , João Batista Santos Garcia","doi":"10.1016/j.bjane.2024.844502","DOIUrl":"https://doi.org/10.1016/j.bjane.2024.844502","url":null,"abstract":"<div><h3>Background</h3><p>This study aimed to investigate the analgesic impact of S(+)-ketamine on pain behavior and synovial inflammation in an osteoarthritis (OA) model.</p></div><div><h3>Methods</h3><p>Animals were grouped as follows: OA-Saline (n = 24) and OA-Ketamine (n = 24), OA induced via intra-articular sodium monoiodoacetate (MIA); a Non-OA group (n = 24) served as the control. On the 7<sup>th</sup> day post OA induction, animals received either saline or S(+)-ketamine (0.5 mg.kg<sup>−1</sup>). Behavioral and histopathological assessments were conducted up to day 28.</p></div><div><h3>Results</h3><p>S(+)-ketamine reduced allodynia from day 7 to 28 and hyperalgesia from day 10 to 28. It notably alleviated weight distribution deficits from day 10 until the end of the study. Significant walking improvement was observed on day 14 in S(+)-ketamine-treated rats. Starting on day 14, OA groups showed grip force decline, which was countered by S(+)-ketamine on day 21. However, S(+)-ketamine did not diminish synovial inflammation.</p></div><div><h3>Conclusion</h3><p>Low Intra-articular (IA) doses of S(+)-ketamine reduced MIA-induced OA pain but did not reverse synovial histopathological changes.</p></div><div><h3>IRB approval number</h3><p>23115 012030/2009-05.</p></div>","PeriodicalId":32356,"journal":{"name":"Brazilian Journal of Anesthesiology","volume":null,"pages":null},"PeriodicalIF":1.3,"publicationDate":"2024-04-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S0104001424000241/pdfft?md5=8dd8de13116d6acf2227e97190a8eb7c&pid=1-s2.0-S0104001424000241-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140551496","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-05DOI: 10.1016/j.bjane.2024.844501
Xixi Cai , Le Liu , Fangfang Xia , Thomas J. Papadimos , Quanguang Wang
Introduction
Cardiac arrest or arrhythmia caused by bupivacaine may be refractory to treatment. Apelin has been reported to directly increase the frequency of spontaneous activation and the propagation of action potentials, ultimately promoting cardiac contractility. This study aimed to investigate the effects of apelin-13 in reversing cardiac suppression induced by bupivacaine in rats.
Methods
A rat model of cardiac suppression was established by a 3-min continuous intravenous infusion of bupivacaine at the rate of 5 mg.kg−1.min−1, and serial doses of apelin-13 (50, 150 and 450 μg.kg−1) were administered to rescue cardiac suppression to identify its dose-response relationship. We used F13A, an inhibitor of Angiotensin Receptor-Like 1 (APJ), and Protein Kinase C (PKC) inhibitor chelerythrine to reverse the effects of apelin-13. Moreover, the protein expressions of PKC, Nav1.5, and APJ in ventricular tissues were measured using Western blotting and immunofluorescence assay.
Results
Compared to the control rats, the rats subjected to continuous intravenous administration of bupivacaine had impaired hemodynamic stability. Administration of apelin-13, in a dose-dependent manner, significantly improved hemodynamic parameters in rats with bupivacaine-induced cardiac suppression (p < 0.05), and apelin-13 treatment also significantly upregulated the protein expressions of p-PKC and Nav1.5 (p < 0.05), these effects were abrogated by F13A or chelerythrine (p < 0.05).
Conclusion
Exogenous apelin-13, at least in part, activates the PKC signaling pathway through the apelin/APJ system to improve cardiac function in a rat model of bupivacaine-induced cardiac suppression.
{"title":"Apelin-13 reverses bupivacaine-induced cardiotoxicity: an experimental study","authors":"Xixi Cai , Le Liu , Fangfang Xia , Thomas J. Papadimos , Quanguang Wang","doi":"10.1016/j.bjane.2024.844501","DOIUrl":"https://doi.org/10.1016/j.bjane.2024.844501","url":null,"abstract":"<div><h3>Introduction</h3><p>Cardiac arrest or arrhythmia caused by bupivacaine may be refractory to treatment. Apelin has been reported to directly increase the frequency of spontaneous activation and the propagation of action potentials, ultimately promoting cardiac contractility. This study aimed to investigate the effects of apelin-13 in reversing cardiac suppression induced by bupivacaine in rats.</p></div><div><h3>Methods</h3><p>A rat model of cardiac suppression was established by a 3-min continuous intravenous infusion of bupivacaine at the rate of 5 mg.kg<sup>−1</sup>.min<sup>−1</sup>, and serial doses of apelin-13 (50, 150 and 450 μg.kg<sup>−1</sup>) were administered to rescue cardiac suppression to identify its dose-response relationship. We used F13A, an inhibitor of Angiotensin Receptor-Like 1 (APJ), and Protein Kinase C (PKC) inhibitor chelerythrine to reverse the effects of apelin-13. Moreover, the protein expressions of PKC, Nav1.5, and APJ in ventricular tissues were measured using Western blotting and immunofluorescence assay.</p></div><div><h3>Results</h3><p>Compared to the control rats, the rats subjected to continuous intravenous administration of bupivacaine had impaired hemodynamic stability. Administration of apelin-13, in a dose-dependent manner, significantly improved hemodynamic parameters in rats with bupivacaine-induced cardiac suppression (<em>p</em> < 0.05), and apelin-13 treatment also significantly upregulated the protein expressions of p-PKC and Nav1.5 (<em>p</em> < 0.05), these effects were abrogated by F13A or chelerythrine (<em>p</em> < 0.05).</p></div><div><h3>Conclusion</h3><p>Exogenous apelin-13, at least in part, activates the PKC signaling pathway through the apelin/APJ system to improve cardiac function in a rat model of bupivacaine-induced cardiac suppression.</p></div>","PeriodicalId":32356,"journal":{"name":"Brazilian Journal of Anesthesiology","volume":null,"pages":null},"PeriodicalIF":1.3,"publicationDate":"2024-04-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S010400142400023X/pdfft?md5=64b95cf8c618c291285d66448c72f6bc&pid=1-s2.0-S010400142400023X-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140542610","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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