1.  A JR is an academic session where we go through some articles previously codified/labelled, for 45 -60min.
2.  It takes place every day, except Sundays and the very last day of the month.
3. Its purpose is to understand and discuss relevant content elements applying systematized note-taking methodologies.

4.  We generate discussion and recall pivotal concepts about different topics, all pertinent  to our clinical practice.
5.  We write down the key -points of every session and publish them on our website
6. In the following session we apply the 'reinforcing rule' by recalling the key-points from previous JRs.

7.  The articles for the week are posted in advance in the jr-info-ⓘ channel of the Journal Reviews (JR) category of our DISCORD server.

February, 2023

2023 NEJM - Early Restrictive or Liberal Fluid mm for Sepsis-Induced Hypotension (Shapiro) [R].pdf

VP: vasopressors; AE: adverse events
1. CLOVERS ➩ 2023, NEJM, USA ➖ mc_unB_RCT ✚ >1.5k (±780 vs ±780) ✚ 24h protocol ➖ PICO:
     - P = septic COPD
     - I = restrictive fluid strategy
     - C = liberal fluid strategy
     - O = acMM90 before discharge home ➩ same (14% vs 14.9%, p=0.61)
2. Restrictive ➩ prioritizing VP + lower volumes
3. Liberal ➩ prioritizing ↑ vol of 💉 fluids BEFORE VP use
4. Volumes
    -  Restrictive -2318
    -  Liberal -1949
5. sOC = safety ➩ serious AE = SIMILAR
6. Early recognition of S• + ↓TA ± SØ ➩ need of prompt action
7. Large VOL is common practice but is_low-quality evidence
8. OBS (2016 ICM, CLASSIC – 2011 NEJM, MM in African children – 2015 CC, preload dependence SS•)
9. FIG 1 ➩ pictures the study protocol
10. The data and safety monitoring board recommended the halting of the trial for futility at the second interim analysis


⏳ TIME MANAGEMENT.

41:26:87
Round: 3  12:24:35  comments

Round: 2  18:10:99  urgART

Round: 1  10:51:51  Refresh

Wednesday, Feb 1, 2023 at 18h30 BO

GMC, GSQA, MIMC, MKFA, RBCB, ±JCAS, AAQC


❗️REFRESH: last Wednesday JR

  • ICME 2022 - Pathophysiology of fluid administration in critically ill patients (Messina) [r]
  • 2022 MEDPAGE - Did My Strong COVID Vax Reaction Give Me Better Immunity (Fiore) [r].pdf

2022 CC - Ten rules for optimizing ventilatory settings + targets in post-cardiac arrest pxs (Battaglini) [r].pdf

  1. MP: mechanical power; LPVS: lung protective ventilation strategies; C: compliance
    CA ➩ ↑ MB + MM (↔ neuro & systemic)
  2. Last decade for CA pxs ➩ implemented: ventilation, HD, Tº strategies
  3. Lung-protective ventilator strategy ↗️ MM, VENTI_freeD, others ➩ Vt 6-8, Pplat <20, ∆P <13, PEEP <7 + SAFETY MEASURES for w_risk brainINJ
  4. Protective + personalized in pxs wo_ARDS post-CA is MORE EVIDENT
  5. MP + O2 & CO2 targets ➩ debatable
  6. HD + Tº are CRITICAL STEPS
  7. ALL to limit VILI
  8. MV aims to avoid ‘↑ ↓ O2 and ↑ ↓ CO2’ (possible causes of secondary BRAIN & REPERFUSION damage + poor SS)
  9. MP proposed as IMP for MV settings ➩ ↑ MP = worse OC in nonARDS
  10. Rule 1 ➩ protective Vt
       - No DIFF ‘VENTIfreeD + LOS ICU&H + MM28&90’: Vt 6-8 VS   intermediate Vt
       - PRoVENT-iMiC ▶︎ no DIFF ‘Vt’: ↑ VS ↓ lungINJ prediction score (Vt 8) BUT lower Vt (Vt 7) were applied in ARDS
       - MA ▶︎ 20 trials wo_ARDS ➩ lower Vt = ↓ pulmINF + atelectasis + MM
       - ESICM & ERC GL ▶︎ Vt 6-8 in brainINJ + post-CA ➩ small evidence and other population
       - In CA pxs:
                  . Few studies
                  . OBS ▶︎ median ‘Vt 8.9 + PEEP 3.5’ ➩ Vt > 10 ≈ ICU-acquPNEUM
       - Beitler study ▶︎ lower Vt ≈ ‘fav_NEUROcog_OC + MVfreeD’ (256 post-CA)
       - TTM1 subanalysis ▶︎ ‘M Vt 7.7 (most <8)’ ≠ MM
       - Study of 3 years ▶︎ 2004, 2010, 2016 implementing LPVS in NEUROdis
       - TTM2 substudy ▶︎ 1848 postCA = M ‘Vt 7 + PEEP 7’ = noDIFF SS vs nonSS ➩ “increasingly application of lung-protective ven- tilator strategies in patients with CA”
       - |≈ of lower Vt & OC is not consistent|
       - |NO RCT in postCA|
       - |PSV is increasingly used a_CA|
       - THEY SUGGEST “post-CA patients the VT should be set between 6 and 8 mL/kg PBW, in volume- or pressure-controlled ventilation but keeping in mind the interplay between VT and other parameters of MV (i.e., PPLAT, ΔP, PEEP, MP) as well as hemodynamics”
  11. Rule 2 ➩ Pplat personalized
       - It is the relation ↔ VOL & C ➩ in the absence of FLOW
       - Pplat < 20 recommended in pxs wo_ARDS ➩ ↓ MM
       - PREVENT ▶︎ CIpxs wo_ARDS ➩ lower (18) VS intermediate (21) Pplat = WO_sigDIFF in “MVfreeD + LOS + complic + MM”
       - RELAX ▶︎ similar Pplat “PEEP 5 VS 8” ➩ ’19,9 VS 20’ ➩ ∑ lower PEEP better for pxs wo_ARDS
       - Post-CA study ▶︎ Pplat ≠ in 3 cohorts:
               . Highest 1998 (22.7)
               . Lowest 2010 (19.5)
               . Pplat > 17 ≈ ARDS development
       - Recent study (TTM2 sec analy. Robba et al) ▶︎ SUGGESTS postCA = Pplat <20 ➩ Pplat ≈ MM6m
       - MAIN AIM is to ↓ VILI
       - Careful in chest wall elastance ALTs ➩ obesity
                . ‘Obese’ OR ‘↑IAP_w_Pplat>27’ ➩ simplified formula MAY HELP
                . PPLAT: PPLAT target+(intra-abdominal pressure-13 cmH2O)/2 (CC 2021, Pelosi et al)
        - Non obese, MV pxs ➩ average IAP = 13 ➩ 1/2 of the IAP is transmitted to the thoracic cavity
        - THEY SUGGEST ”in post-CA patients the PPLAT should be kept equal or lower than 20 cmH2O and corrected for intra-abdominal pressure when clinically indicated.”
  12. Rule 5 ➩ RR targeted pHa + PaCO2
       - Contribution + harm of RR has been UNDERESTIMATED
       - RR per se + RR insensitivity ➩ provoke: VILI + dynamic hyperINFLA + respALKAL
       - RR is a MAJOR DRIVE of chemical feedback (PaO2, PaCO2, pHa)
       - ∑ modulates CBF + vascTONE ➩ ↑ PCO2 = CBV vasodilation + 🧠 edema
       - HERING-BREUER reflex ➩ if VOL or PRESS ↑ = RR ↓
       - Challenging in postCA
       - Harmon et al ▶︎ RR ≈ independently to MM28
       - Robba et al ▶︎ M RR 17 ≈ poorNEURO_OC + MM6m
       - RR should be adapted to ∆P + total MP
       - THEY SUGGEST ”in post-CA patients, the respiratory rate should be kept in a range between 8 and 16 breaths/min”

⏳ TIME MANAGEMENT.

01:00:08
Round: 4   02:53:68   Comments
Round: 3   47:55:53   urgART

Round: 2   01:15:40   Comment

Round: 1   08:03:43   Refresh

Thursday, Feb 2, 2023 at 18h30 BO

GMC, ±SGQA, MKFA, AAQC


❗️REFRESH: last Thursday JR

  • 2022 HEALIO - Non-nutritive sweeteners alter microbiome composition, glycemia in healthy adults (Cell) [r].pdf
August, 2023

Thursday, Aug 17, 2023 at 23h15 BE (18h30 BO)
±CLMT, AAQC

2023 HEALIO - High daily intake of sugar-sweetened beverages linked to 85% greater r for liver CA (JAMA) [blt].

CLD = chronic liver disease, Y, J, C ➖ T + N + t ➖ PICO2023,

1. 2023, JAMA, USA ➖ OBS ➕ >9.5k ➕21y ➖ PICO:

   P⃣ postMenop ♀

   I⃣ sugar-sweetened drinks (ssd) DAILY                   

   C⃣ ssd 3x MONTHLY

   O⃣ pOC = liver CA ➩ 85% ↗️ 🫃🏽 ➖ sOC = liverMM ➩ 68% ↗️

2. New dietary factors identified (etiology + primPreven)

3. Food frequency questionnaire (ffq) was used

4. 207 liver CA + 148 MM from CLD

5. Risk for liver cancer (11.8 vs. 10.2 per 100,000 per years; aHR = 1.17; 95% CI, 0.7-1.94) 6. Risk of chronic liver disease mortality (7.1 vs. 5.3 per 100,000 person-years; aHR = 0.9 95% CI, 0.49-1.84).


⏳ TIME MANAGEMENT.

40:58:38
Round: 4      03:23:42 Conclusions

Round: 3      21:56:74 Notes & analysis

Round: 2      10:31:12 HEALIO sugar-sweetened beverages

Round: 1      05:07:08 Intro, refresh

2023 HEALIO - FDA panel recommends USG renal denervation device for uncontrolled HTA (FDA).pdf

1. Renal denervation works for uncontrolled HTA   

2. There are concerns about their durability (long-term effects)
3. Beneficial for SHORT-TERM
4. 3 STUDIES: RADIANCE SOLO + TRIO + RADIANCE II
5. Panelists were interviewed:
          - Heterogeneity
          - Small effect size
          - Novel mechanism
          - Wording not clearly defined
          - Safe
          - Low risk
6. Fisher (ReCor) ➩ works for pxs who cannot take pills  (tolerance) + supple-ment to medical therapy
7. ADVICE of panelists:
          - Mention pxs antiHTA meds before + after
          - Age
          - Race
          - ABPM ambulatory…
         - UNDERREPRESENTED GROUPS (include them!!!)

⏳ TIME MANAGEMENT.

32:35:14

Round: 3 07:58:27 continue
Round: 2 00:22:44 pause

Round: 1 24:14:41 NEJMjw - HEALIO

Thursday, Aug 31, 2023 at 23h15 BE (18h30 BO)
JMCM, AAQC

Monday, Sep 18, 2023 at 23h15 BE (18h15 BO)

AAQC

2023 HEALIO - Global lead exposure greater CVD risk factor than smoking, cholesterol (Lancet)

LE: lead exposure, IQ = intelligence quotient, Rf = risk factor, LIC = low-income countries, MIC = middle-income countries
1. LE provoke 5.5M deaths indirectly through CVD (World Bank 2019)
2. In kids <5yo ➩ ↓ IQ points in 765M ➩ less work force entry (IQ limitations)
3. Published in The Lancet Planetary Health
4. Top of the list of environmental health rf
5. Equivalent loss of 6.9% of the global gross domestic product:           

   a. 77% due to MM           

   b. 23% due to future IQ-related income losses       

6. Sources are not understood in LIC & MIC ➩ include: lead acid battery recycling, metal mining, food, soil and dust, water, leaded paint, cookware from recycled materials, lead-glazed pottery and ceramics, spices, toys, cosmetics, electronic waste, fertilizers and cultured fish feed.

2023 ICUmmp - Triage Procedures for CC Resources (JAMA)1. 2023, JAMA, USA (Columbia + Puerto Rico) ➖ retros + 32                 w_detailed triage procedures + till June 2023 ➖ PICO: 

        a. all triage procedures (pandemic plans)
        b. network revision
        c. no
        d. pOC: prevalence comorbidities + their function in triage (duration of      

        postSS discharge) ➩ most plans RESTRICTED access to ‘scarce critical

        care resources’
2. 20/32 lists of coMORB, 11/32 excluding or deprioritizing pxs ➩ 21/32 took predSS beyond H+ discharge.
3. Concerns about HC access ↗️ specially d_health emergency,           affected situations:
       a. Chronic diseases
       b. Disabilities    

       c. Marginalized racial and ethnic communities


⏳ TIME MANAGEMENT. 

37:21:87

Round: 6 09:31:90 JR wrap-up database
Round: 5 11:21:39 Wrap-up

Round: 4 07:39:53 Triage procedures in CC

Round: 3 07:28:61 wrap-up

Round: 2 00:03:58 test

Round: 1 01:16:85 + 26min ➩ Double check in Medscape

2023 NEJMjw - Perioperative Glycemic Control in pxs with Diabetes (CDSR)

CoE = Certainty of Evidence

1. 2023, Cochrane DB sr, C (-) ➖ srMA + 20 RCT = >2500 pxs + t (-) ➖ PICO:

  - P: DM while surgery

  - I: tight control

  - C: not tight control  - O: pOC = MM OR INF complic OR H+LOS
  ➩ same pOC
  ➩ ↗️ hypoGLU ↗️ severe hypoGLU in “I”
2. R = Intensive control MIGHT NOT BE NECESSARY in DM d_major Qx
3. IN = major (non)🫀 Qx + GLU interventions + ≠ algorithms
4. OC ➩ MM = 10 🆚 9% ➖ INF compl = 13 🆚 18% ➖ H+LOS =

5. Intensive ➩ ↘️ advCV events (11 🆚 13%) ➖ ↗️ hypoGLU (12 🆚 3%)↗️ severe hypoGLU in “I” (4 🆚 0.6%)

6. MM ➩ only w_highCoE

7. Dressler: “seems reasonable to permit higher GLU levels wo_adverseOC affection”

8. CAVEAT: varying DEF ➕ varying DUR


⏳ TIME MANAGEMENT:
45:14:66
Round: 6 03:08:78 Main database filling
Round: 5 13:10:21 Wrap-up
Round: 4 00:00:04 mistake
Round: 3 06:07:92 Perioperative GLU control

Round: 2 13:58:13 Wrap-up

Round: 1 08:49:55 Pyuria & INF

2023 NEJMjw - Pyuria Doesn't Necessarily Indicate Infection (CID)

WBC: white blood cells; UTI: urinary tract infections

1. 2023, Clin Infect Dis, NL ➖ case control + 63 🆚 101 + t (–) ➖ PICO:
   - P: UTI older women.
   - I: observation
   - C: asymptomatic older women
   - O: pOC = urinary WBC, sOC =
2. NONE catheterized or w_cognitive impairment
3. Older women = ≥65yo
4. Spun urine sediment in UTI = 900 cell/uL5. Spun urine sediment in CONTROLS = 300 cell/uL ➩ pyuria among CONTROLS was considerably HIGHER than anticipated6. New “normal” values might be needed for OLDER women

Thursday,  Sep 21, 2023 at 23h15 BE (18h30 BO)
AAQC

September, 2023
October, 2023

2023 CC - Monotherapy or combination ATB therapy in the TTO of Pseudomonas aeruginosa VAP (Shen) [let]
PA-VAP = Pseudomona aeruginos ventilator associated pneumonia, PDR-PA = pan drug-resistant PA, DRT-PA = difficult-to-treat resistance PA.
1. Comments on Foucrier’s paper ‘Association between com- bination antibiotic therapy as opposed as monotherapy and outcomes of ICU patients with Pseudomonas aeruginosa ventilator-associated pneu- monia: an ancillary study of the iDIAPASON trial. Crit Care. 2023;27(1):211.’
2. Previous = Combination 🆚 mono therapy for ICU VAP P. aeruginosa in 169 pxs ➩ similar OC p=0.18
3. It is a SECONDARY ANALYSIS of a previous RCT
   -  Sample size was calculated based on COMPARISON long 🆚 short-term  ATB in PA-VAP pxs.
   -  Unclear if the curren sample size is sufficient
   -  Current study shows an ↗️ trend of MM in the ‘combination’ group
   -  Non-significance due to UNDERPOWERED sample size?
4. Other studies have seen the same and found the same. e.g. Garnacho-Montero J. Optimal management therapy for Pseudomonas aeruginosa ventilator-associated pneumonia: an obser- vational, multicenter study comparing monotherapy with combination antibiotic therapy. Crit Care Med. 2007;35(8):1888–95.
   -  183 pxs same P
   -  MM was similar in both groups
   -  Initial ATB was used as GROUPING METHOD (mono OR combination)
   -  All inappropriate TTO were adjusted to bacteria ID or suceptibility.
   -  Current study took the grouping AFTER the susceptibility tests’ adaptation
   -  Is the result truly similar to others???
5. In the MULTIVARIABLE analysis PDR-PA or DTR-PA should be considered.

2023 CC - Effect of corticosteroids on MM in pxs with CAP (Chen) [let]
1. Different opinions on ‘1. Wu JY, Tsai YW, Hsu WH, Liu TH, Huang PY, Chuang MH, Liu MY, Lai CC. Efficacy and safety of adjunctive corticosteroids in the treatment of severe community-acquired pneumonia: a systematic review and meta- analysis of randomized controlled trials. Crit Care. 2023;27(1):274.’
2. Previous = srMA of severe CAP of > 1500 pxs ➩ corticoids ↗️ clinical OC wo_↑ advEvents
3. Sensitivity analysis (SA) used LEAVE-ONE-OUT analyses (removing one trial at every MA)
   -  Could be a bias (inadequate study inclusion)
   -  They identified 2 other trials. After them the SA became unstable
   -  Became NON-SIGNIFICANT after excluding Dequin et al’s trial
4. Two RCTs reported the OPPOSITE ➩ efficacy of CORTIC in sevCAP may be HETEROGENEOUS
5. In Sabry’s study:
   -  All trial included H+ or 30MM
   -  Less than the reported median ‘time to death’ ➩ half of deaths were not observed..
   -  Current paper recommends EXCLUDING this paper so avoid instability
   -  They show a pooled analysis w_ and wo_ Sabry’s and RESULTS remain non-significant


⏳ TIME MANAGEMENT. 

Not registered

Monday 09.10.23 at 23h15 BE (18h15 BO)

AAQC

Journal Reviews