The Reviewer Academy of the Society of Critical Care Medicine: Key Principles and Strategic Plan.

The Society of Critical Care Medicine (SCCM) Reviewer Academy seeks to train and establish a community of trusted, reliable, and skilled peer reviewers with diverse backgrounds and interests to promote high-quality reviews for each of the SCCM journals. Goals of the Academy include building accessible resources to highlight qualities of excellent manuscript reviews; educating and mentoring a diverse group of healthcare professionals; and establishing and upholding standards for insightful and informative reviews. This manuscript will map the mission of the Reviewer Academy with a succinct summary of the importance of peer review, process of reviewing a manuscript, and the expected ethical standards of reviewers. We will equip readers to target concise, thoughtful feedback as peer reviewers, advance their understanding of the editorial process and inspire readers to integrate medical journalism into diverse professional careers.

Post-operative Weaning of Opioids After Ambulatory Surgery: the Importance of Physician Stewardship.

PURPOSE OF REVIEW: We performed a systematic review to elucidate the current guidelines on weaning patients from opioids in the post-operative ambulatory surgery setting, and how pain management intraoperatively can impact this process. DESIGN: The review highlights the most up-to-date research from clinical trials, patient reports, and retrospective studies regarding both the current guidelines and weaning of opioid analgesia in ambulatory surgery setting. RECENT FINDINGS: A striking paucity of convincing evidence exists on ambulatory postoperative pain management discontinuation or weaning of pain medications. However, retrospective and patient-reported studies suggest our approach should be similar to acute pain management strategies. The first steps include identifying high-risk patients and devising an appropriate pain plan. This may be accomplished by implementing multimodal analgesia, anticipating opioid needs, and the proper use of regional anesthesia. The increasing roles for Transitional Pain Service (TPS), Perioperative Surgical Home (PSH), and Enhanced Recovery After Surgery (ERAS) may also guide us in this process. Patients discharged from same-day surgery may lack the additional infrastructure of a hospital or medical establishment to monitor postoperative recovery. As such, weaning of pain medications in ambulatory surgery settings requires teams that are adept at treating varied patient populations through a tailored, novel means that invoke multimodal analgesia. Given the growth of surgeries moving toward the ambulatory sector, more data and practice guidelines are needed to direct postoperative pain regimen titration for the patients.

Procedural sedation in the ICU and emergency department.

PURPOSE OF REVIEW: Procedures are increasingly being performed in the acute care setting, outside of the operating rooms (OR). This article aims to review the current literature on out-of-OR procedural sedation with a focus on the ICU and emergency department, highlighting the following topics: multidisciplinary team approach, choice of pharmacologic agent, sedation scales, current safety guidelines, anticipating complications, appropriate monitoring and necessary resources. RECENT FINDINGS: Subjective assessment of sedation using sedation scales is controversial. Addition of ketamine and dexmedetomidine to propofol for sedation improves patient and proceduralist satisfaction. The short-acting benzodiazepine remimazolam shows promise in initial phase 2 trials. Use of capnography for monitoring during sedation is being challenged by new literature from the emergency department setting. Hypoxia is the most common adverse event with procedural sedation, and the risk of pulmonary aspiration is low. SUMMARY: Multimodal/synergistic sedation under a multidisciplinary team provides the best patient satisfaction. Collection and analysis of physiological data and outcomes of patients undergoing procedural sedation is necessary to maintain compliance with regulatory bodies. There is a paucity of comprehensive guidelines for conducting research in procedural sedation; therefore, it is being currently addressed by the Sedation Consortium.

Ten-Year Outcome of Glaucoma Drainage Device Surgery After Penetrating Keratoplasty.

PRECIS: In eyes with intractable glaucoma, drainage devices provide long-term control of intraocular pressure also after penetrating keratoplasty (PK). There is a high incidence of corneal graft failure. PURPOSE: To compare very long-term results of eyes with glaucoma drainage device (GDD) after PK. METHODS: We retrospectively reviewed medical records of all patients who underwent GDD placement after PK at our institution between 2001 and 2017. Forty eyes of 40 patients were studied. Glaucoma outcome was assessed by postoperative intraocular pressure (IOP), number of medications, and need for further glaucoma surgery. Corneal outcome was assessed by graft rejection, failure, and visual acuity. Surgical procedures before and during the study period, and their complications were evaluated. RESULTS: The mean follow-up was 125.0±52.3 (median, 116.5) months. Twenty of 40 eyes had a follow-up of at least 10 years. The mean preoperative IOP was 34.0±8.3 (median, 32.0) mm Hg with 3.2±1.3 (median, 3.5) glaucoma medications. At last postoperative follow-up, the mean IOP decreased to 12.7±4.9 (median, 14.0) mm Hg with 1.0±1.2 (median, 0.0) glaucoma medications. GDD implantation successfully controlled glaucoma in 88%, 88%, 85%, 80%, 78%, 75%, and 70% of eyes, at 1, 2, 3, 4, 5, 7, and 10 years, respectively. At last follow-up 68% showed glaucoma success. The corneal grafts remained clear in 74%, 63%, 45%, 45%, 37%, 32%, and 26% of eyes at 1, 2, 3, 4, 5, 7, and 10 years, respectively. Only 7 corneal grafts (17.5%) remained clear at last follow-up. CONCLUSIONS: A GDD can successfully control intractable glaucoma even after a very long period of time also after PK. However, the survival of the corneal grafts is low.

Anterior chamber depth and iridocorneal angle in healthy White subjects: effects of age, gender and refraction.

PURPOSE: Prior to phakic intraocular lens implantation, it is important to obtain precise knowledge of the anterior chamber depth (ACD). Accurate topographic evaluation of the iridocorneal angle is helpful in estimating risk for angle-closure glaucoma. This study investigated the use of the Orbscan II system to measure ACD and the iridocorneal angle in healthy subjects and assessed the influences of age, gender and spherical equivalent on these parameters. METHODS: The Orbscan II system was used to determine the ACD and iridocorneal angle in eight different positions in 390 healthy White subjects with a mean age of 41± 16years (range 10-80 years). The sample included 242 male and 148 female subjects. The influences of age, gender and spherical equivalent were assessed using multiple regression analysis. RESULTS: Mean ACD was 2.87 ± 0.04 mm in male subjects and 2.81±0.37mm in female subjects. The explanatory variables relevant to the ACD were age (partial regression coefficient B = -0.0115, p < 0.0001), spherical equivalent (B = - 0.0562, p< 0.0001) and gender (B = 0.0996, p=0.0036). The mean iridocorneal angle (MIA) was 30.7 ± 2.0 ° in male and 31.6 ± 2.1° in female subjects. The variables relevant to the MIA were gender (B =- 0.865, p < 0.0001), age (B =- 0.017, p = 0.0007) and spherical equivalent (B = - 0.121, p = 0.001). The superior iridocorneal angle displayed the strongest negative correlation with age, whereas the temporal angle exhibited the least correlation with age. CONCLUSIONS: The decline in ACD appears to be linear with age, amounting to a mean of 0.58 mm over 50 years. This may become clinically relevant in the use of phakic intraocular lenses. In addition, the angle is more severely constricted in the superior quadrant than in the temporal quadrant.

Photodynamic therapy with intravitreal application of triamcinolone acetonide in age-related macular degeneration: functional results in 54 patients.

PURPOSE: This study aimed to investigate the functional results, efficacy and complications after photodynamic therapy (PDT) combined with intravitreal triamcinolone acetonide injection (IVTA) in patients with choroidal neovascularization (CNV) caused by age-related macular degeneration (AMD). METHODS: A retrospective analysis of clinical data for 54 patients with CNV resulting from AMD was carried out. All patients had a follow-up of 12 months. The patients were treated with standardized PDT and IVTA (4 mg) as a first-line treatment or following PDT failure. Visual acuity (VA), greatest linear diameter (GLD) of the CNV and foveal thickness were evaluated. RESULTS: Mean VA at baseline was 0.8 logMAR (0.4-1.4). After 12 months VA improved (> 2 lines) in 20.4% of patients and stabilized (+/- 2 lines) in 64.8%. There was no statistical significance in VA outcome between patients undergoing first-line treatment and patients with PDT failure; however, fewer PDT treatments were required to stop CNV activity in patients undergoing first-line treatment. At 12 months, a reduction in foveal thickness was seen in 67.7% of patients and a reduction in CNV GLD in 32.7%. Complications occurred in 22% of patients and included a transient rise in intraocular pressure, cataract and sterile hypopyon. CONCLUSIONS: Our analysis shows that fewer PDT treatments were required to stop CNV activity when triamcinolone was used as first-line treatment. We can thus conclude that PDT combines synergistically with IVTA and the combination may lead to a cost reduction compared with PDT therapy alone. The overall complication rate of 22% is high and must be compared with complication rates caused by new intravitreal anti-VEGF (vascular endothelial growth factor) drugs in combination with PDT.

Characterization of the thinnest point of the cornea compared with the central corneal thickness in normal subjects.

INTRODUCTION: For ongoing progress in refractive surgery, exact knowledge about the anatomical properties of the cornea is useful. Thus, the aim of the study was to characterize the thinnest point of the cornea compared with the central corneal thickness in normal subjects and to investigate with regard to influencing factors such as sex, age, refraction, and intraocular pressure. MATERIALS AND METHODS: The central corneal thickness and the thinnest point of the cornea were determined with the Orbscan II in 390 white normal subjects. Difference between the 2 eyes, influence of sex, and measuring repetition accuracy were tested for statistical significance with t tests, and the influence of age was tested with nonparametrical test methods. RESULTS: In the right eyes, the mean central corneal thickness was 548 +/- 37 microm and the thinnest point 537 +/- 37 microm. In the left eyes, the mean central corneal thickness was 547 +/- 37 microm and the thinnest point 535 +/- 39 microm. The difference between the central corneal thickness and the thinnest point was found to be significant in both eyes in paired t test (P > 0.001). No influence of sex, refraction, and intraocular pressure on the thickness of the thinnest point of the cornea could be observed. The difference between central corneal thickness and thickness at the thinnest point was not subject to a statistically significant influence of age. CONCLUSIONS: In the calculation of the residual corneal layer thickness in laser refractive surgery, the thinnest point of the cornea should form the basis.

Increase of expression and activation of chemokine CCL15 in chronic renal failure.

Chemokines are believed to be involved in the pathogenesis of chronic renal failure (CRF). In CRF, significantly increased CCL15-IR plasma concentrations were detected. Whereas in plasma of healthy individuals one predominant CCL15-IR molecule with a M(w) of 15kDa [high molecular weight (HMW-CCL15-IR)] was identified, CRF plasma contains increased concentrations of truncated CCL15-IR molecules [intermediate molecular weight (IMW-CCL15-IR)]. HMW-CCL15-IR isolated from hemofiltrate revealed an M(w) of 10141.3, corresponding to deglycosylated CCL15(1-92) carrying a N-terminal pyrrolidone carboxylic acid. CCL15(12-92) was identified as a major component of IMW-CCL15-IR in CRF plasma. Compared to CCL15(1-92), in monocytes CCL15(12-92) causes stronger induction of intracellular calcium flux, chemotactic activity, and adhesion to fibronectin. Intracellular calcium flux assays revealed that, in comparison to peripheral blood mononuclear cells (PBMC) of healthy donors, PBMCs of CRF patients demonstrated an increased sensitivity to CCL15. Our results point to an involvement of the CCL15-CCR1 axis in the pathophysiology of CRF.

Quantum proteolytic activation of chemokine CCL15 by neutrophil granulocytes modulates mononuclear cell adhesiveness.

Monocyte infiltration into inflammatory sites is generally preceded by neutrophils. We show here that neutrophils may support this process by activation of CCL15, a human chemokine circulating in blood plasma. Neutrophils were found to release CCL15 proteolytic activity in the course of hemofiltration of blood from renal insufficiency patients. Processing of CCL15 immunoreactivity (IR) in the pericellular space is suggested by a lack of proteolytic activity in blood and blood filtrate, but a shift of the retention time (t(R)) of CCL15-IR, detected by chromatographic separation of CCL15-IR in blood and hemofiltrate. CCL15 molecules with N-terminal deletions of 23 (delta23) and 26 (delta26) aa were identified as main proteolytic products in hemofiltrate. Neutrophil cathepsin G was identified as the principal protease to produce delta23 and delta26 CCL15. Also, elastase displays CCL15 proteolytic activity and produces a delta21 isoform. Compared with full-length CCL15, delta23 and delta26 isoforms displayed a significantly increased potency to induce calcium fluxes and chemotactic activity on monocytes and to induce adhesiveness of mononuclear cells to fibronectin. Thus, our findings indicate that activation of monocytes by neutrophils is at least in part induced by quantum proteolytic processing of circulating or endothelium-bound CCL15 by neutrophil cathepsin G.