The epidemiology of postoperative dobutamine and phosphodiesterase inhibitors after adult elective cardiac surgery and its impact on the length of hospital stay: a post hoc analysis from the multicenter retrospective observational study.

The optimal administration of inotrope after cardiac surgery is unknown. This study aimed to investigate the impact of postoperative inotrope on clinical outcomes in adult elective cardiac surgery patients. Data from the Blood Pressure and Relative Optimal Target after Heart Surgery in Epidemiologic Registry study were analyzed, employing propensity score considering the hospital of admission. The primary outcome was the length of hospital stay evaluated using quantile regression. Secondary outcomes were kidney injury progression, renal replacement therapy, atrial fibrillation, mortality, mechanical ventilation duration, and length of intensive care unit (ICU) stay. Among 870 patients from 14 ICUs in Japan, 535 received inotropes within 24 h of ICU admission, with usage rates ranging from 40 to 100% among facilities. After propensity score matching, 218 patients were included in each group. The inotrope group had a significantly longer hospital stay compared to the control group (16 days vs. 14 days; median difference 1.78 [95% confidence interval [CI] 0.31-3.24]; p = 0.018). However, no significant differences were observed in the secondary outcomes, except for mechanical ventilation duration. The results of the sensitivity analysis using a mixed-effects quantile regression analysis considering the hospital of admission for length of hospital stay in the original cohort were consistent with the results of the propensity analyses (median difference in days, 2.35 [95% CI, 0.35-4.36]; p = 0.022). The use of inotropes within 24 h of ICU admission in adult elective cardiac surgery patients was associated with an extended hospitalization period of approximately 2 days, without offering any prognostic benefit. Clinical trial registration: UMIN-CTR, https://www.umin.ac.jp/ctr/index-j.htm , UMIN000037074.

Measurement accuracy of a microwave doppler sensor beneath the mattress as a continuous respiratory rate monitor: a method comparison study.

PURPOSE: Non-contact continuous respiratory rate monitoring is preferred for early detection of patient deterioration. However, this technique is under development; a gold standard respiratory monitor has not been established. Therefore, this prospective observational method comparison study aimed to compare the measurement accuracy of a non-contact continuous respiratory rate monitor, a microwave Doppler sensor positioned beneath the mattress, with that of other monitors. METHODS: The respiratory rate of intensive care unit patients was simultaneously measured using a microwave Doppler sensor, capnography, thoracic impedance pneumography, and a piezoelectric sensor beneath the mattress. Bias and 95% limits of agreement between the respiratory rate measured using capnography (standard reference) and that measured using the other three methods were calculated using Bland-Altman analysis for repeated measures. Clarke error grid (CEG) analysis evaluated the sensor's ability to assist in correct clinical decision-making. RESULTS: Eighteen participants were included, and 2,307 data points were analyzed. The bias values (95% limits of agreement) of the microwave Doppler sensor, thoracic impedance pneumography, and piezoelectric sensor were 0.2 (- 4.8 to 5.2), 1.5 (- 4.4 to 7.4), and 0.4 (- 4.0 to 4.8) breaths per minute, respectively. Clinical decisions evaluated using CEG analyses were correct 98.1% of the time for the microwave Doppler sensor, which was similar to the performance of the other devices. CONCLUSION: The microwave Doppler sensor had a small bias but relatively low precision, similar to other devices. In CEG analyses, the risk of each monitor leading to inadequate clinical decision-making was low. TRIAL REGISTRATION NUMBER: UMIN000038900, February 1, 2020.

Indirect laryngoscopy is more effective than direct laryngoscopy when tracheal intubation is performed by novice operators: a systematic review, meta-analysis, and trial sequential analysis.

PURPOSE: We sought to perform a systematic review and meta-analysis to determine whether indirect laryngoscopy has an advantage over direct laryngoscopy in terms of the tracheal intubation rate, glottic visualization, and intubation time when used by novice operators. METHODS: We extracted adult prospective randomized trials comparing tracheal intubation with indirect vs direct laryngoscopy in novice operators from electronic databases. We extracted the following data from the identified studies: success rate, glottic visualization, and intubation time. Data from each trial were combined via a random-effects model to calculate the pooled relative risk (RR) or weighted mean difference (WMD) with a 95% confidence interval (CI). We also performed a trial sequential analysis. RESULTS: We included 15 articles (17 trials) comprising 2,290 patients in the systematic review. Compared with the direct laryngoscopy, indirect laryngoscopy improved success rate (RR, 1.15; 95% CI, 1.07 to 1.24; P = 0.0002; I2 = 88%), glottic visualization (RR, 1.76; 95% CI, 1.36 to 2.28; P < 0.001; I2 = 85%), and intubation time (WMD, -9.06 sec; 95% CI, -16.4 to -1.76; P = 0.01; I2 = 98%) in tracheal intubation. Trial sequential analysis showed that the total sample size was sufficient to analyze the success rate and intubation time. CONCLUSION: In this systematic review, we found that the tracheal intubation success rate, glottic visualization, and intubation time were improved when novice operators used indirect laryngoscopy rather than direct laryngoscopy. Trial sequential analysis results indicated that the sample size was sufficient for examining the success rate and intubation time. STUDY REGISTRATION: PROSPERO (CRD42022309045); first registered 4 September 2022.

RéSUMé: OBJECTIF: Nous avons cherché à réaliser une revue systématique et une méta-analyse pour déterminer si la laryngoscopie indirecte présente un avantage par rapport à la laryngoscopie directe en termes de taux de succès d'intubation trachéale, de visualisation glottique et de temps d'intubation lorsqu'elle est utilisée par des opératrices et opérateurs novices. MéTHODE: Nous avons extrait des études randomisées prospectives chez l'adulte comparant l'intubation trachéale avec une laryngoscopie indirecte vs directe réalisée par des opérateurs et opératrices novices à partir de bases de données électroniques. Nous avons extrait les données suivantes des études identifiées : taux de succès, visualisation glottique et temps d'intubation. Les données de chaque étude ont été combinées au moyen d'un modèle à effets aléatoires pour le calcul du risque relatif (RR) groupé ou de la différence moyenne pondérée (DMP) avec un intervalle de confiance (IC) de 95 %. Nous avons également réalisé une analyse séquentielle des études. RéSULTATS: Nous avons inclus 15 articles (17 études) portant sur 2290 patient·es dans notre revue systématique. Par rapport à la laryngoscopie directe, la laryngoscopie indirecte a amélioré le taux de succès (RR, 1,15; IC 95 %, 1,07 à 1,24; P = 0,0002; I2 = 88 %), la visualisation glottique (RR, 1,76; IC 95 %, 1,36 à 2,28; P < 0,001; I2 = 85 %), et le temps d'intubation (DMP, −9,06 s; IC 95 %, −16,4 à −1,76; P = 0,01; I2 = 98 %) pour l'intubation trachéale. L'analyse séquentielle des études a montré que la taille totale de l'échantillon était suffisante pour analyser le taux de succès et le temps d'intubation. CONCLUSION: Dans cette revue systématique, nous avons constaté que le taux de succès de l'intubation trachéale, la visualisation glottique et le temps d'intubation étaient améliorés lorsque les opératrices et opérateurs novices utilisaient la laryngoscopie indirecte plutôt que la laryngoscopie directe. L'analyse séquentielle des études a montré que la taille totale de l'échantillon était suffisante pour analyser le taux de succès et le temps d'intubation. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42022309045); première inscription le 4 septembre 2022.

Inappropriate shock incidence in patients with subcutaneous implantable cardioverter-defibrillators with concomitant cardiac implantable electronic devices: A single-center cohort study.

BACKGROUND: Subcutaneous implantable cardioverter defibrillators (S-ICDs) are occasionally used in combination with other cardiac implantable electronic devices (CIEDs). However, whether the incidence of inappropriate shock increases in patients with S-ICDs and concomitant CIEDs remains unclear. This study aimed to investigate the association between the concomitant use of CIEDs and the incidence of inappropriate shock in patients with current-generation S-ICDs. METHODS: A total of 127 consecutive patients received an S-ICD. Patients were assigned to two groups depending on concomitant use of CIEDs at the time of S-ICD implantation: patients without other CIEDs (non-combined group, 106 patients) and patients with other CIEDs (combined group, 21 patients). CIEDs included pacemakers, implantable cardioverter defibrillators, cardiac resynchronization therapy pacemakers, and cardiac resynchronization therapy defibrillators. The primary outcome was inappropriate shock, defined as a shock other than ventricular arrhythmia. Hazard ratios and 95% confidence intervals were calculated using a time-varying Cox proportional hazards model which was adjusted for age because age differed between the groups and could be a confounder. RESULTS: During a median follow-up period of 2.2 years (interquartile range, 1.0-3.4 years), inappropriate shock events occurred in 17 (16%) and five (19%) patients of the non-combined and combined groups, respectively. While the age-adjusted hazard ratio for inappropriate shock was 24% higher in the combined than in the non-combined group (hazard ratio = 1.24, 95% confidence interval, 0.39-3.97), this difference was insignificant (p = .71). CONCLUSION: The incidence of inappropriate shock did not differ between patients with and without concomitant use of CIEDs, suggesting that S-ICDs could potentially be combined with other CIEDs without increasing the number of inappropriate shocks. Further studies are warranted to confirm the safety and feasibility of concomitant use of S-ICDs and CIEDs.

Incidence of long-term post-acute sequelae of SARS-CoV-2 infection related to pain and other symptoms: A systematic review and meta-analysis.

BACKGROUND: Persistent symptoms are reported in patients who survive the initial stage of COVID-19, often referred to as "long COVID" or "post-acute sequelae of SARS-CoV-2 infection" (PASC); however, evidence on their incidence is still lacking, and symptoms relevant to pain are yet to be assessed. METHODS: A literature search was performed using the electronic databases PubMed, EMBASE, Scopus, and CHINAL and preprint servers MedRχiv and BioRχiv through January 15, 2021. The primary outcome was pain-related symptoms such as headache or myalgia. Secondary outcomes were symptoms relevant to pain (depression or muscle weakness) and symptoms frequently reported (anosmia and dyspnea). Incidence rates of symptoms were pooled using inverse variance methods with a DerSimonian-Laird random-effects model. The source of heterogeneity was explored using meta-regression, with follow-up period, age and sex as covariates. RESULTS: In total, 38 studies including 19,460 patients were eligible. Eight pain-related symptoms and 26 other symptoms were identified. The highest pooled incidence among pain-related symptoms was chest pain (17%, 95% confidence interval [CI], 11%-24%), followed by headache (16%, 95% CI, 9%-27%), arthralgia (13%, 95% CI, 7%-24%), neuralgia (12%, 95% CI, 3%-38%) and abdominal pain (11%, 95% CI, 7%-16%). The highest pooled incidence among other symptoms was fatigue (44%, 95% CI, 32%-57%), followed by insomnia (27%, 95% CI, 10%-55%), dyspnea (26%, 95% CI, 17%-38%), weakness (25%, 95% CI, 8%-56%) and anosmia (19%, 95% CI, 13%-27%). Substantial heterogeneity was identified (I2, 50-100%). Meta-regression analyses partially accounted for the source of heterogeneity, and yet, 53% of the symptoms remained unexplained. CONCLUSIONS: The current meta-analysis may provide a complete picture of incidence in PASC. It remains unclear, however, whether post-COVID symptoms progress or regress over time or to what extent PASC are associated with age or sex.

Effect of remote ischemic preconditioning on lung function after surgery under general anesthesia: a systematic review and meta-analysis.

Remote ischemic preconditioning (RIPC) protects organs from ischemia-reperfusion injury. Recent trials showed that RIPC improved gas exchange in patients undergoing lung or cardiac surgery. We performed a systematic search to identify randomized controlled trials involving RIPC in surgery under general anesthesia. The primary outcome was the PaO2/FIO2 (P/F) ratio at 24 h after surgery. Secondary outcomes were A-a DO2, the respiratory index, duration of postoperative mechanical ventilation (MV), incidence of acute respiratory distress syndrome (ARDS), and serum cytokine levels. The analyses included 71 trials comprising 7854 patients. Patients with RIPC showed higher P/F ratio than controls (mean difference [MD] 36.6, 95% confidence interval (CI) 12.8 to 60.4, I2 = 69%). The cause of heterogeneity was not identified by the subgroup analysis. Similarly, A-a DO2 (MD 15.2, 95% CI - 29.7 to - 0.6, I2 = 87%) and respiratory index (MD - 0.17, 95% CI - 0.34 to - 0.01, I2 = 94%) were lower in the RIPC group. Additionally, the RIPC group was weaned from MV earlier (MD - 0.9 h, 95% CI - 1.4 to - 0.4, I2 = 78%). Furthermore, the incidence of ARDS was lower in the RIPC group (relative risk 0.73, 95% CI 0.60 to 0.89, I2 = 0%). Serum TNFα was lower in the RIPC group (SMD - 0.6, 95%CI - 1.0 to - 0.3 I2 = 87%). No significant difference was observed in interleukin-6, 8 and 10. Our meta-analysis suggested that RIPC improved oxygenation after surgery under general anesthesia.Clinical trial number: This study protocol was registered in the University Hospital Medical Information Network (registration number: UMIN000030918), https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000035305.

The Efficacy of Ramelteon to Prevent Postoperative Delirium After General Anesthesia in the Elderly: A Double-Blind, Randomized, Placebo-Controlled Trial.

OBJECTIVE: Postoperative delirium is common and serious in elderly patients. Several drugs have been proposed as potential prophylactic agents for postoperative delirium. Studies on melatonin receptor agonists showed heterogeneity in age, cognitive function, anesthesia, surgery, interventions, methodologies for assessing outcomes, and results. Our objective was to examine the effect of ramelteon to prevent postoperative delirium in elderly patients, including those with dementia. DESIGN: A stratified, double-blind, randomized, placebo-controlled trial (UMIN000028436, jRCTs031180054). SETTING: Tertiary medical center. PARTICIPANTS: Patients aged older than or equal to 65 years undergoing elective surgery under general anesthesia. INTERVENTION: Ramelteon (8 mg orally) or placebo (lactose) for six nights (the preoperative night and five consecutive nights from postoperative day 1 to 5) at around 9 P.M. MEASUREMENTS: Patients were screened for postoperative delirium using the Confusion Assessment Method for the Intensive Care Unit twice daily until the sixth postoperative day. Patients with positive results were referred to a consultant psychiatrist to establish the diagnosis of delirium. RESULTS: A total of 108 patients were randomly assigned to receive ramelteon (n = 55) or placebo (n = 53). Most of the patients' characteristics were reasonably well-balanced between the two groups. The stratified log-rank test showed no significant difference in preventing postoperative delirium between ramelteon and placebo (χ2 = 0.30, degrees of freedom = 1, p = 0.60). The Cox proportional hazard ratio for ramelteon compared to placebo was 1.40 (95% confidence interval: 0.40-4.85, χ2 for likelihood ratio test = 0.29, degrees of freedom = 1, p = 0.60). CONCLUSION: There was no significant difference in the incidence of postoperative delirium between ramelteon and placebo after general anesthesia in elderly patients.

Effectiveness of acupuncture therapy for the prevention of emergence agitation in children: A systematic review and meta-analysis with trial sequential analysis.

This study aimed to evaluate the effectiveness of acupuncture therapy in preventing emergence agitation (EA) in children. A systematic review and meta-analysis were conducted across multiple locations according to the articles searched. Seven databases, including trial registration sites, were searched. A total of six trials were included involving 489 patients; of them, 244 received acupuncture therapy. Randomized clinical trials (RCTs) evaluating the incidence of EA compared with placebo/sham or standard care in children were included. The primary outcome was the incidence of EA, as evaluated using a specific assessment tool. Data about the incidence rate of EA, heterogeneity, quality of trials and evidence, and adverse events were collected. Additionally, data about patient demographic characteristics, type of anesthesia, duration and onset of acupuncture therapy, EA and pain score, time taken for extubation, and post-anesthesia care unit length of stay were collected. The results indicated that the overall incidence of EA in the acupuncture therapy group and the control group was 23.4% and 39.5%, respectively, with no significant difference (risk ratio, 0.62; 95% confidence interval, 0.26-1.48; I2 = 63%). Subgroup analysis showed a significant difference in the overall incidence of EA in the acupuncture therapy and control groups according to surgery type (high-risk vs. low-risk surgery), suggesting that acupuncture therapy may be effective in reducing EA for patients undergoing high-risk surgery. The quality of evidence was downgraded to "very low" due to the study designs, inconsistency, and possible publication bias. In conclusion, this meta-analysis shows that the currently available RCTs are insufficient to determine the effectiveness of acupuncture therapy in preventing EA in children undergoing general anesthesia.

Predictive ability of pulse oximetry-derived indices for hypotension after spinal anaesthesia for caesarean section: protocol for a systematic review and meta-analysis.

INTRODUCTION: In general, caesarean sections are performed under spinal anaesthesia. Hypotension after spinal anaesthesia adversely affects both the mother and fetus. Although several studies have used pulse oximetry-derived indices, such as pulse perfusion index (PI) and Pleth variability index (PVI), to predict hypotension after spinal anaesthesia, the predictive ability of the PI and PVI remain controversial. METHODS AND ANALYSIS: We prepared this protocol following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. We will conduct searches of MEDLINE, Embase, Web of Science, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Clinicaltrial.gov, European Union Clinical Trials Register (EU-CTR), WHO International Clinical Trials Registry Platform (ICTRP) and University Hospital Medical Information Network Clinical Trials Registry (UMIN) from inception until 8 October 2022. We will include retrospective and prospective observational studies and randomised controlled trials that evaluated the predictive ability of PI and PVI for hypotension after spinal anaesthesia for caesarean section, published in any language. We will exclude case reports, case series and animal studies. Two authors will independently scan and select eligible studies and perform data extraction and assessment of risk of bias. We will estimate predictive ability of PI and PVI as indices of hypotension after spinal anaesthesia for caesarean section using the Reitsma-type bivariate random-effects synthesis model and the hierarchical summary receiver operating characteristic curve. We will assess the quality of evidence using the Grading of Recommendation Assessment, Development and Evaluation approach. ETHICS AND DISSEMINATION: Ethics approval is not required as the systematic review will use existing published data. The results will be submitted for publication in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER: CRD42022362596.

Stomach position evaluated using computed tomography is related to successful post-pyloric enteral feeding tube placement in critically ill patients: a retrospective observational study.

BACKGROUND: Post-pyloric enteral feeding reduces respiratory complications and shortens the duration of mechanical ventilation. Blind placement of post-pyloric enteral feeding tubes (EFT) in patients with critical illnesses is often the first-line method because endoscopy or fluoroscopy cannot be easily performed at bedside; however, difficult placements regularly occur. We reported an association between the stomach position caudal to spinal level L1-L2, evaluated by abdominal radiographs after placement, and difficult placement; however, this method could not indicate difficulty before EFT placement. The aim of our study was to evaluate the association between stomach position, estimated using computed tomography (CT) images taken before the blind placement of the post-pyloric EFT, and the difficulty of EFT placement. METHODS: Data from patients aged ≥ 20 years who underwent post-pyloric EFT in our intensive care unit were obtained retrospectively. Logistic regression analysis was used to evaluate the association between successful initial EFT placement and explanatory variables, including stomach position estimated by CT. Two cut-off values were used: caudal to L1-L2 based on a previous study and the best cut-off value calculated by the receiver operating characteristic curve. Variable selection was performed backward stepwise using Akaike's Information Criterion. RESULTS: Of the total of 453 patients who were enrolled, the success rate of the initial EFT placement was 43.5%. The adjusted odds ratio for successful initial EFT placement of the stomach position caudal to L1-L2 was 0.61 (95% confidence interval: 0.41-1.07). Logistic regression analysis, including the stomach position caudal to L2-L3, calculated as the best cut-off value, indicated that stomach position was an independent factor for failure of initial EFT placement (adjusted odds ratio, 0.55; 95% confidence interval: 0.33-0.91). CONCLUSIONS: Stomach position evaluated using CT images was associated with successful initial post-pyloric EFT placement. The best cut-off value of the greater curvature of the stomach to predict the success or failure of the first attempt was spinal level L2-L3. Trial registration University Hospital Medical Information Network Clinical Trials Registry (UMIN000046986; February 28, 2022). https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000052151.

Diagnostic accuracy of point-of-care ultrasound for shock: a systematic review and meta-analysis.

BACKGROUND: Circulatory failure is classified into four types of shock (obstructive, cardiogenic, distributive, and hypovolemic) that must be distinguished as each requires a different treatment. Point-of-care ultrasound (POCUS) is widely used in clinical practice for acute conditions, and several diagnostic protocols using POCUS for shock have been developed. This study aimed to evaluate the diagnostic accuracy of POCUS in identifying the etiology of shock. METHODS: We conducted a systematic literature search of MEDLINE, Cochrane Central Register of Controlled Trials, Embase, Web of Science, Clinicaltrial.gov, European Union Clinical Trials Register, WHO International Clinical Trials Registry Platform, and University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR) until June 15, 2022. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and assessed study quality using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Meta-analysis was conducted to pool the diagnostic accuracy of POCUS for each type of shock. The study protocol was prospectively registered in UMIN-CTR (UMIN 000048025). RESULTS: Of the 1553 studies identified, 36 studies were full-text reviewed, and 12 studies with 1132 patients were included in the meta-analysis. Pooled sensitivity and specificity were 0.82 [95% confidence interval (CI) 0.68-0.91] and 0.98 [95% CI 0.92-0.99] for obstructive shock, 0.78 [95% CI 0.56-0.91] and 0.96 [95% CI 0.92-0.98] for cardiogenic shock, 0.90 [95% CI 0.84-0.94] and 0.92 [95% CI 0.88-0.95] for hypovolemic shock, and 0.79 [95% CI 0.71-0.85] and 0.96 [95% CI 0.91-0.98] for distributive shock, respectively. The area under the receiver operating characteristic curve for each type of shock was approximately 0.95. The positive likelihood ratios for each type of shock were all greater than 10, especially 40 [95% CI 11-105] for obstructive shock. The negative likelihood ratio for each type of shock was approximately 0.2. CONCLUSIONS: The identification of the etiology for each type of shock using POCUS was characterized by high sensitivity and positive likelihood ratios, especially for obstructive shock.

Dynamics of AMPA receptors regulate epileptogenesis in patients with epilepsy.

The excitatory glutamate α-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid receptors (AMPARs) contribute to epileptogenesis. Thirty patients with epilepsy and 31 healthy controls are scanned using positron emission tomography with our recently developed radiotracer for AMPARs, [11C]K-2, which measures the density of cell-surface AMPARs. In patients with focal-onset seizures, an increase in AMPAR trafficking augments the amplitude of abnormal gamma activity detected by electroencephalography. In contrast, patients with generalized-onset seizures exhibit a decrease in AMPARs coupled with increased amplitude of abnormal gamma activity. Patients with epilepsy had reduced AMPAR levels compared with healthy controls, and AMPARs are reduced in larger areas of the cortex in patients with generalized-onset seizures compared with those with focal-onset seizures. Thus, epileptic brain function can be regulated by the enhanced trafficking of AMPAR due to Hebbian plasticity with increased simultaneous neuronal firing and compensational downregulation of cell-surface AMPARs by the synaptic scaling.

Association between the Depth of Sevoflurane or Propofol Anesthesia and the Incidence of Emergence Agitation in Children: A Single-Center Retrospective Study.

In the present study, we investigated the hypothesis that the depth of general anesthesia affects emergence agitation (EA) in children in the early postanesthetic period. We retrospectively examined male and female children (aged 1-9 years) who underwent ambulatory surgery that lasted < 2 h. Various parameters, including the modified Yale Preoperative Anxiety Score (mYPAS) before anesthesia induction, the Pediatric Anesthesia Emergence Delirium (PAED) score at recovery time, and the value of the patient state index (PSI), were extracted from our electronic anesthesia database. The relationships between the PAED score and the mean PSI values were examined with univariate analyses. We also investigated the associations among the mean PSI, propofol anesthesia, age, mYPAS, the type of surgery, and the total amount of fentanyl divided by body weight with the PAED score using multiple regression analysis with interaction terms. There were 32 and 34 patients in the sevoflurane and propofol groups, respectively. The PAED scores (all patients: r = -0.34, p = 0.0048; sevoflurane group: r = -0.37, p = 0.036) were negatively correlated with the mean PSI, whereas the PAED score in the propofol group [r = 0.31 (-0.03, 0.59), p = 0.073] did not show a significant positive correlation with the mean PSI in the univariate analysis. The multiple linear regression analysis outcomes revealed that the mean PSI value was an independent clinical factor associated with the PAED score. Intraoperative electroencephalogram monitoring may be proved as one of the useful tools for the assessment of EA risks in children.

Effects of melatonin on postoperative sleep quality: a systematic review, meta-analysis, and trial sequential analysis.

PURPOSE: Postoperative sleep disturbances are common. Although several studies have examined the effect of melatonin on postoperative sleep disturbances, the results have not reached any definitive conclusion. We sought to conduct a systematic review to compare the effects of melatonin and melatonin agonists on postoperative sleep quality with those of placebo or no treatment in adult patients who underwent surgery under general or regional anesthesia. METHODS: We searched MEDLINE, Cochrane Central Register of Controlled Trials, Embase, Web of Science, ClinicalTrials.gov, and the UMIN Clinical Trials Registry up to 18 April 2022. Randomized clinical trials examining the effects of melatonin or melatonin agonists in patients undergoing general or regional anesthesia with sedation for any surgery were eligible for inclusion. The primary outcome was sleep quality measured using a visual analog scale (VAS). The secondary outcomes were postoperative sleep duration, sleepiness, pain, opioid consumption, quality of recovery, and adverse events. A random-effects model was used to combine the results. We assessed study quality with the Cochrane Risk of Bias Tool version 2. We applied a trial sequential analysis to assess the precision of the combined results. RESULTS: Eight studies (516 participants) were analyzed for sleep quality. Of those, four studies used only a short duration of melatonin, either on the night before and the day of surgery or only on the day of surgery. A random-effects meta-analysis showed that melatonin did not improve sleep quality measured by VAS compared with placebo (mean difference, -0.75 mm; 95% confidence interval, -4.86 to 3.35), with low heterogeneity (I2, 5%). Trial sequential analysis revealed that the accrued information size (n = 516) reached the estimated required information size (n = 295). We downgraded the certainty of the evidence because of the high risk of bias. The effect on postoperative adverse events was comparable between the melatonin and control groups. CONCLUSION: Our results indicate that melatonin supplementation does not improve postoperative sleep quality measured with the VAS compared with placebo in adult patients (GRADE: moderate). STUDY REGISTRATION: PROSPERO (CRD42020180167); registered 27 October 2022.

RéSUMé: OBJECTIF: Les troubles du sommeil postopératoires sont fréquents. Bien que plusieurs études aient examiné l'effet de la mélatonine sur les troubles du sommeil postopératoires, les résultats n'ont abouti à aucune conclusion définitive. Nous avons tenté de réaliser une revue systématique afin de comparer les effets de la mélatonine et des agonistes de la mélatonine sur la qualité du sommeil postopératoire à ceux d'un placebo ou de l'absence de traitement chez des patients adultes ayant bénéficié d'une intervention chirurgicale sous anesthésie générale ou régionale. MéTHODE: Nous avons effectué des recherches dans les bases de données MEDLINE, le registre Cochrane des essais contrôlés, Embase, Web of Science, ClinicalTrials.gov et le registre des essais cliniques UMIN pour en tirer les manuscrits publiés jusqu'au 18 avril 2022. Les études cliniques randomisées examinant les effets de la mélatonine ou des agonistes de la mélatonine chez des patients bénéficiant d'une anesthésie générale ou régionale avec sédation pour toute intervention chirurgicale étaient éligibles pour l'inclusion. Le critère d'évaluation principal était la qualité du sommeil mesurée à l'aide d'une échelle visuelle analogique (EVA). Les critères d'évaluation secondaires étaient la durée du sommeil postopératoire, la somnolence, la douleur, la consommation d'opioïdes, la qualité de la récupération et les événements indésirables. Un modèle à effets aléatoires a été utilisé pour combiner les résultats. Nous avons évalué la qualité des études en utilisant l'outil de risque de biais de Cochrane version 2.0. Nous avons appliqué une analyse séquentielle des études pour évaluer la précision des résultats combinés. RéSULTATS: Huit études (516 participants) ont été analysées pour déterminer la qualité du sommeil. Parmi celles-ci, quatre études n'ont utilisé la mélatonine que pour une courte durée, c'est-à-dire soit la nuit précédant et le jour de la chirurgie, soit le jour de la chirurgie seulement. Une méta-analyse à effets aléatoires a montré que la mélatonine n'améliorait pas la qualité du sommeil mesurée par une EVA comparativement au placebo (différence moyenne, -0,75 mm; intervalle de confiance à 95 %, -4,86 à 3,35), avec une faible hétérogénéité (I2, 5 %). L'analyse séquentielle des études a révélé que la taille de l'information accumulée (n = 516) avait atteint la taille estimative de l'information requise (n = 295). Nous avons abaissé le niveau de confiance des données probantes en raison du risque élevé de biais. L'effet sur les événements indésirables postopératoires était comparable entre le groupe mélatonine et les groupes témoin. CONCLUSION: Nos résultats indiquent que la supplémentation en mélatonine n'améliore pas la qualité du sommeil postopératoire mesurée avec une EVA par rapport au placebo chez les patients adultes (GRADE : modérée). ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42020180167); enregistrée le 27 octobre 2020.

Hemodynamic response related to the Airway Scope versus the Macintosh laryngoscope: A systematic review and meta-analysis with trial sequential analysis.

BACKGROUND: It is important to reduce the hemodynamic response during tracheal intubation. We performed a systematic review and meta-analysis of the Airway Scope and Macintosh laryngoscope to determine whether they reduce the hemodynamic responses of heart rate (HR) and mean blood pressure (MBP) after tracheal intubation under general anesthesia. METHODS: We performed a comprehensive literature search of electronic databases for clinical trials comparing hemodynamic response to tracheal intubation. The primary aim of our meta-analyst is to determine if the Airway Scope reduces hemodynamic responses (HR and mean MBP) 60 seconds after tracheal intubation compared to the Macintosh laryngoscope. We expressed pooled differences in hemodynamic responses between the 2 devices as weighted mean differences with 95% confidence intervals. We conducted trial sequential analysis. Secondarily, we investigated the ability of the Airway Scope and Macintosh laryngoscope to reduce hemodynamic responses at 120 seconds, 180 seconds, and 300 seconds after tracheal intubation. RESULTS: We identified clinical trials comparing hemodynamic response via a comprehensive literature search. Of 185 articles found in the search, we selected 8. In comparison to the Macintosh laryngoscope, the Airway Scope significantly reduced HR and MBP at 60 seconds after tracheal intubation (HR; weighted mean difference = -7.29; 95% confidence interval, -10.9 to -3.62; P < .0001; I2 = 57%, MBP; weighted mean difference = -11.5; 95% confidence interval, -20.4 to -2.65; P = .01; I2 = 91%). At the secondary outcome, the Airway Scope significantly reduced the fluctuation of HR after 120 seconds and 180 seconds of tracheal intubation. However, the Airway Scope did not significantly reduce MBP 120 seconds, 180 seconds, and 300 seconds after tracheal intubation. Trial sequential analysis suggested that the total sample size reached the required information size for heart rate. CONCLUSIONS: Our finding suggested that the Airway Scope attenuated hemodynamic responses at 60 seconds after tracheal intubation in comparison with that of the Macintosh laryngoscope. However, the MBP sample size is small and further research is needed.

Early alveolar epithelial cell necrosis is a potential driver of COVID-19-induced acute respiratory distress syndrome.

Acute respiratory distress syndrome (ARDS) with COVID-19 is aggravated by hyperinflammatory responses even after the peak of the viral load has passed; however, its underlying mechanisms remain unclear. In the present study, analysis of the alveolar tissue injury markers and epithelial cell death markers in patients with COVID-19 revealed that COVID-19-induced ARDS was characterized by alveolar epithelial necrosis at an early disease stage. Serum levels of HMGB-1, one of the DAMPs released from necrotic cells, were also significantly elevated in these patients. Further analysis using a mouse model mimicking COVID-19-induced ARDS showed that the alveolar epithelial cell necrosis involved two forms of programmed necrosis, namely necroptosis, and pyroptosis. Finally, the neutralization of HMGB-1 attenuated alveolar tissue injury in the mouse model. Collectively, necrosis, including necroptosis and pyroptosis, is the predominant form of alveolar epithelial cell death at an early disease stage and subsequent release of DAMPs is a potential driver of COVID-19-induced ARDS.

Comparison of Indirect and Direct Laryngoscopes in Pediatric Patients with a Difficult Airway: A Systematic Review and Meta-Analysis.

This meta-analysis was performed to determine whether an indirect laryngoscope is more advantageous than a direct laryngoscope for tracheal intubation in the setting of a difficult pediatric airway. Data on the intubation failure and intubation time during tracheal intubation were extracted from prospective and retrospective studies identified through a comprehensive literature search. Data from 10 individual articles (11 trials) were combined, and a DerSimonian and Laird random-effects model was used to calculate either the pooled relative risk (RR) or the weighted mean difference (WMD) and the corresponding 95% confidence interval (CI). Meta-analysis of the 10 articles indicated that the intubation failure of tracheal intubation with an indirect laryngoscope was not significantly different from that of a direct laryngoscope in patients with a difficult airway (RR 0.86, 95% CI 0.51-1.46; p = 0.59; Cochrane's Q = 50.5; I2 = 82%). Intubation time with an indirect laryngoscope was also similar to that with a direct laryngoscope (WMD 4.06 s; 95% CI -1.18-9.30; p = 0.13; Cochrane's Q 39.8; I2 = 85%). In conclusion, indirect laryngoscopes had the same intubation failure and intubation time as direct laryngoscopes in pediatric patients with a difficult airway. Currently, the benefits of indirect laryngoscopes have not been observed in the setting of a difficult pediatric airway.

Add-on effects of oral tocopherol supplementation to surgical varicocelectomy on the outcome of assisted reproductive technology: a single-center pilot study report.

Introduction: Varicocelectomy is well known to improve the pregnancy outcome of patients with clinical varicoceles in assisted reproductive technologies as well as spontaneous conception. Therefore, this study aimed to evaluate the additional effects of oral antioxidant therapy after varicocelectomy on the pregnancy outcome in the assisted reproductive technology setting. Methods: This study was a retrospective cohort study. The subjects were couples among whom the male partner had undergone varicocelectomy and was scheduled for subsequent assisted reproductive technology. Pregnancy outcomes were followed retrospectively in 62 couples with male partners who received tocopherol (antioxidant group) and 37 couples who did not (control group). The tocopherol and control groups were assigned dependent on the decision of the physician in charge and the patient's request. The clinical pregnancy rates per couple and embryo transfer, time to pregnancy, and the number of cycles during transfer to pregnancy were evaluated. Results: No significant differences were observed in the pregnancy rate per couple (antioxidant group 70.9% vs. control group 64.9%, P = 0.55) and per embryo transfer (50.4% vs. 39.6%, P = 0.22). Regarding the time to event analyzed by adjusted restricted mean survival time, the mean time to pregnancy was significantly shorter in the antioxidant (tocopherol) group (14.2 vs. 17.4 months, P = 0.025). No significant difference was observed in the embryo transfer cycle to pregnancy (mean embryo transfer cycles: 2.6 vs. 3.0, P = 0.238). Conclusions: Additional oral tocopherol nicotinate as antioxidant therapy after varicocelectomy was shown to shorten the time to pregnancy. It is recommended that add-on effects be tested in more well-designed randomized controlled trials to examine whether it improves assisted reproductive outcomes.

Nasal protection strategy reduces the incidence of nasal pressure injuries during nasotracheal intubation: Meta-analysis with trial sequential analysis.

BACKGROUND: Nasal pressure injury is a serious problem during nasotracheal intubation. We performed this systematic review and meta-analysis to determine whether use of a nasal protection strategy (a protective dressing or a modified fixation method for the tracheal tube) reduces the incidence of nasal pressure injury during nasotracheal intubation. METHODS: Literature searches were performed using three electronic databases. Data from each of the eligible trials were combined, and calculations were made using DerSimonian and Laird random effects models. The pooled effect estimates for nasal pressure injury were evaluated using the relative risk and 95% confidence interval, the Cochrane Q statistic, and the I2 statistic. We also performed trial sequential analysis (TSA) to assess sensitivity to prevent type I error. We separated patients into subgroups to analyze the incidence of nasal pressure injury according to whether a protective dressing or a modified fixation method for the tracheal tube was used. RESULTS: The literature search yielded five eligible trials. Meta-analysis of these trials showed that a nasal protection strategy significantly reduced the incidence of nasal pressure injury during nasotracheal intubation (relative risk (RR) 0.34; 95% confidence interval (CI) 0.21-0.56; P < .0001; Cochrane's Q = 5.86, I2 = 32%). The TSA boundary for futility could not be calculated because of an insufficient sample size. In subgroup analysis, both methods significantly reduced the incidence of nasal pressure injury during nasotracheal intubation. CONCLUSIONS: The findings of this meta-analysis suggest that a nasal protection strategy significantly reduces the incidence of nasal pressure injury during nasotracheal intubation. During nasotracheal intubation, the use of a protective dressing or modified fixation method for the tracheal tube can prevent to the incidence of nasal pressure injuries. However, the number of samples in our meta-analysis was too small for TSA and further studies are required. TRIALS REGISTRATION: PROSPERO (International Prospective Register of Systematic Reviews; registration number 252091).