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Concise definitive review of how to read and critically appraise a systematic review.None.Current literature describing the conduct, reporting, and appraisal of systematic reviews and meta-analyses.Best practices for conducting, reporting, and appraising systematic review were summarized.A systematic review is a review of a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise relevant original research, and to collect and analyze data from the studies that are included in the review. Critical appraisal methods address both the credibility (quality of conduct) and rate the confidence in the quality of summarized evidence from a systematic review. The A Measurement Tool to Assess Systematic Reviews-2 tool is a widely used practical tool to appraise the conduct of a systematic review. Confidence in estimates of effect is determined by assessing for risk of bias, inconsistency of results, imprecision, indirectness of evidence, and publication bias.Systematic reviews are transparent and reproducible summaries of research and conclusions drawn from them are only as credible and reliable as their development process and the studies which form the systematic review. Applying evidence from a systematic review to patient care considers whether the results can be directly applied, whether all important outcomes have been considered, and if the benefits are worth potential harms and costs.

Background: Minimally invasive surgery for left ventricular assist device implantation may have advantages over conventional sternotomy (CS). Additionally, ultra-fast-track anesthesia has been linked to better outcomes after cardiac surgery. This study summarizes our early experience of combining minimally invasive surgery with ultra-fast-track anesthesia (MIFTA) in patients receiving HeartMate 3 devices and compares the outcomes between MIFTA and CS. Methods: From October 2015 to January 2019, 18 of 49 patients with Interagency Registry for Mechanically Assisted Circulatory Support profiles >1 underwent MIFTA for HeartMate 3 implantation. For bias reduction, propensity scores were calculated and used as a covariate in a regression model to analyze outcomes. Weighted parametric survival analysis was performed. Results: In the MIFTA group, intensive care unit stays were shorter (mean difference, 8 days [95% CI, 4–13]; P P =0.016, respectively). At 6 and 12 hours postoperatively, MIFTA patients had a better hemodynamic performance with lower pulmonary wedge pressure (mean difference, 2.23 mm Hg [95% CI, 0.41–4.06]; P =0.028) and a higher right ventricular stroke work index (mean difference, −1.49 g·m/m 2 per beat [95% CI, −2.95 to −0.02]; P =0.031). CS patients had a worse right heart failure–free survival rate (hazard ratio, 2.35 [95% CI, 0.96–5.72]; P Conclusions: Compared with CS, MIFTA is a beneficial approach for non–Interagency Registry for Mechanically Assisted Circulatory Support 1 HeartMate 3 patients with lower adverse event incidences, better hemodynamic performance, and preserved right heart function. Future large multicentric investigations are required to verify MIFTA’s effects on outcomes.

To determine the incidence of enteral feed intolerance, identify factors associated with enteral feed intolerance, and assess the relationship between enteral feed intolerance and key nutritional and clinical outcomes in critically ill patients.Analysis of International Nutrition Survey database collected prospectively from 2007 to 2014.Seven-hundred eighty-five ICUs from around the world.Mechanically ventilated adults with ICU stay greater than or equal to 72 hours and received enteral nutrition during the first 12 ICU days.None.We defined enteral feed intolerance as interrupted feeding due to one of the following reasons: high gastric residual volumes, increased abdominal girth, distension, subjective discomfort, emesis, or diarrhea. The current analysis included 15,918 patients. Of these, 4,036 (24%) had at least one episode of enteral feed intolerance. The enteral feed intolerance rate increased from 1% on day 1 to 6% on days 4 and 5 and declined daily thereafter. After controlling for site and patient covariates, burn (odds ratio 1.46; 95% CIs, 1.07-1.99), gastrointestinal (odds ratio 1.45; 95% CI, 1.27-1.66), and sepsis (odds ratio 1.34; 95% CI, 1.17-1.54) admission diagnoses were more likely to develop enteral feed intolerance, as compared to patients with respiratory-related admission diagnosis. enteral feed intolerance patients received about 10% less enteral nutrition intake, as compared to patients without enteral feed intolerance after controlling for important covariates including severity of illness. Enteral feed intolerance patients had fewer ventilator-free days and longer ICU length of stay time to discharge alive (all p0.0001). The daily mortality hazard rate increased by a factor of 1.5 (1.4-1.6; p0.0001) once enteral feed intolerance occurred.Enteral feed intolerance occurs frequently during enteral nutrition delivery in the critically ill. Burn and gastrointestinal patients had the highest risk of developing enteral feed intolerance. Enteral feed intolerance is associated with lower enteral nutrition delivery and worse clinical outcomes. Identification, prevention, and optimal management of enteral feed intolerance may improve nutrition delivery and clinical outcomes in important "at risk" populations.

Extracorporeal life support (ECLS) including venovenous and venoarterial extracorporeal membrane oxygenation (ECMO) and ventricular assist devices (VAD) provide mechanical pulmonary and circulatory support, respectively, in patients with acute pulmonary or cardiovascular failure. This review discusses recently published data regarding specific topics of nutritional support in patients with ECLS and VAD.ECLS may aggravate loss of endogenous and exogenous micronutrients and macronutrients. Observational studies have shown that enteral nutrition is feasible and most commonly used in patients with ECLS. Indirect calorimetry may be feasible for measuring energy expenditure during ECLS. Specific tools are available to assess malnutrition or nutrition risk in patients with VAD but require further validation in the perioperative setting. If parenteral nutrition is indicated, the use of intravenous lipid emulsions may be associated with membrane oxygenator dysfunction of the ECLS device or increased infectious risk in patients with VAD.Despite the exponential use of ECLS and VAD over the last decade, the role of nutrition on clinical outcome in this patient population remains an important but yet underinvestigated field.

Background Although macrophage migration inhibitory factor ( MIF ) has been demonstrated to mediate cardioprotection in ischemia/reperfusion injury and antagonize fibrotic effects through its receptor, CD 74, the function of the soluble CD 74 receptor ectodomain ( sCD 74) and its interaction with circulating MIF have not been explored in cardiac disease. Methods and Results Cardiac fibroblasts were isolated from hearts of neonatal mice and differentiated into myofibroblasts. Co‐treatment with recombinant MIF and sCD 74 induced cell death ( P RIP) 1/ RIP 3‐dependent necroptosis ( P =0.0376). This effect was specific for cardiac fibroblasts and did not affect cardiomyocytes. Gene expression analyses using microarray and RT ‐ qPCR technology revealed a 4‐fold upregulation of several interferon‐induced genes upon co‐treatment of myofibroblasts with sCD 74 and MIF (Ifi44: P =0.011; Irg1: P =0.022; Clec4e: P =0.011). Furthermore, Western blot analysis confirmed the role of sCD 74 as a modulator of MIF signaling by diminishing MIF ‐mediated protein kinase B ( AKT) activation ( P =0.0197) and triggering p38 activation ( P =0.0641). We obtained evidence that sCD 74 inhibits MIF ‐mediated survival pathway through the C‐X‐C chemokine receptor 4/ AKT axis, enabling the induction of CD 74‐dependent necroptotic processes in cardiac myofibroblasts. Preliminary clinical data revealed a lowered sCD 74/ MIF ratio in heart failure patients (17.47±10.09 versus 1.413±0.6244). Conclusions These findings suggest that treatment of cardiac myofibroblasts with sCD 74 and MIF induces necroptosis, offering new insights into the mechanism of myofibroblast depletion during scar maturation. Preliminary clinical data provided first evidence about a clinical relevance of the sCD 74/ MIF axis in heart failure, suggesting that these proteins may be a promising target to modulate cardiac remodeling and disease progression in heart failure.

Randomised controlled trials (RCTs) are the gold standard for measuring the efficacy of any medical intervention. The present study assesses the implementation of the CONSORT statement in the top 11 anaesthesiology journals in 2011.We designed this study in order to determine how well authors in the top 11 ranked anaesthesiology journals follow the CONSORT statement's criteria.A retrospective cross-sectional data analysis.The study was performed at the RWTH Aachen University Hospital.Journals included Pain, Anesthesiology, British Journal of Anaesthesia, Regional Anesthesia and Pain Medicine, European Journal of Pain, Anesthesia and Analgesia, Anaesthesia, Minerva Anestesiologica, Canadian Journal of Anesthesia, Journal of Neurosurgical Anesthesiology and the European Journal of Anaesthesiology.All articles in the online table of contents from the top 11 anaesthesiology journals according to the ISI Web of Knowledge were screened for RCTs published in 2011. The RCTs were assessed using the CONSORT checklist. We also analysed the correlation between the number of citations and the adherence to CONSORT items.We evaluated 319 RCTs and found that, more than ten years after the publication of the CONSORT statement, the RCTs satisfied a median of 60.0% of the CONSORT criteria. Only 72.1% of the articles presented clearly defined primary and secondary outcome parameters. The number of citations is only weakly associated with the fulfilment of the CONSORT statement (r = 0.023).Adherence to the CONSORT criteria remains low in top-ranked anaesthesiology journals. We found only a very weak correlation between the number of citations and fulfilment of the requirements of the CONSORT statement.

The trace elements selenium, copper, and zinc are essential for maintaining the oxidative balance. A depletion of antioxidative trace elements has been observed in critically ill patients and is associated with the development of multiorgan dysfunction and an increased mortality. Cardiac surgery using cardiopulmonary bypass provokes ischemia-reperfusion-mediated oxidative stress. We hypothesized that an intraoperative decrease of circulating trace elements may be involved in this response.Prospective observational clinical study.University hospital cardiothoracic operation theater and intensive care unit.Sixty patients (age 65 ± 14 yrs) undergoing cardiac surgery with the use of cardiopulmonary bypass.Whole blood concentrations of selenium, copper, and zinc were measured after induction of anesthesia and 1 hr after admission to the intensive care unit. All patients were separated in a priori defined subgroups according to the development of no organ failure, single organ failure, and ≥ 2 organ failures in the postoperative period.Fifty patients exhibited a significant selenium deficiency already before surgery, whereas copper and zinc concentrations were within the reference range. In all patients, blood levels of selenium, copper, and zinc were significantly reduced after end of surgery when compared to preoperative values (selenium: 89.05 ± 12.65 to 70.84 ± 10.46 μg/L; zinc: 5.15 ± 0.68 to 4.19 ± 0.73 mg/L; copper: 0.86 ± 0.15 to 0.65 ± 0.14 mg/L; p.001). During their intensive care unit stay, 17 patients were free from any organ failure, while 31 patients developed single-organ failure and 12 patients multiple organ failure. Multilogistic regression analysis showed that selenium concentrations at end of surgery were independently associated with the postoperative occurrence of multiorgan failure (p = .0026, odds ratio 0.8479, 95% confidence interval 0.7617 to 0.9440).Cardiac surgery using cardiopulmonary bypass resulted in a profound intraoperative decrease of whole blood levels of antioxidant trace elements. Low selenium concentrations at end of surgery were an independent predictor for the postoperative development of multiorgan failure.

Background: Cardiac surgery is increasingly been performed on an aging patient population with increased numbers of comorbid conditions. These patients are frequently exposed to myocardial ischemia/reperfusion with deleterious consequences and development of organ dysfunctions. The pleiotropic cytokine macrophage migration inhibitory factor (MIF) is an upstream regulator of the immune response and rapidly released from pre-formed cytoplasmatic pools in response to activating stimuli such as hypoxia, infection or inflammation. Yet, its interaction with related mediators such as its homolog, D-dopachrome tautomerase (MIF-2) is largely unknown. Therefore, we aimed to investigate the interaction and clinical significance of MIF and MIF-2 in patients undergoing cardiac surgery with myocardial ischemia/reperfusion. Methods and Results: Circulating levels of MIF and MIF-2 were measured peri-operatively in 100 patients that underwent elective cardiac surgery and showed a rapid increase upon myocardial ischemia. Intra-operative MIF levels reached maximum during myocardial reperfusion and were independently associated with a reduced risk for the development of AF in the post-operative period (odds ratio 0.99 (0.98-1.00); p=0.007), whereas circulating levels of MIF-2 were associated with an increased frequency of organ dysfunction and predicted the occurrence of atrial fibrillation (area under the curve (AUC)=0.663;p=0.041) and pneumonia (AUC=0.708;p=0.040). Known functional MIF allelic variants were analyzed and patients with high-expression MIF-genotype exhibited reduced incidence of organ dysfunction (3 vs. 25; p=0.042). Conclusion: Our findings present the first description of the kinetics and potential clinical relevance of the MIF, MIF-2 and MIF genotype in myocardial ischemia/reperfusion (I/R) in the setting of cardiac surgery. The present study demonstrated that increased intra-operative MIF levels may provide organoprotective effects, whereas elevated serum levels of MIF-2 were associated with the development of organ dysfunctions in patients after cardiac surgery. Patients with a high-expression MIF genotype experienced a significantly lower incidence of organ dysfunctions.