Association of conflicts of interest with the results and conclusions of goal-directed hemodynamic therapy research: a systematic review with meta-analysis

Addressing Conflicts of Interest and Conflicts of Commitment in Public Advocacy and Policy Making on CRISPR/Cas-Based Human Genome Editing

Leading experts on CRISPR/Cas-based genome editing-such as 2020 Nobel laureates Jennifer Doudna and Emmanuelle Charpentier-are not only renowned specialists in their fields, but also public advocates for upcoming regulatory frameworks on CRISPR/Cas. These frameworks will affect large portions of biomedical research on human genome editing. In advocating for particular ways of handling the risks and prospects of this technology, high-profile scientists not only serve as scientific experts, but also as moral advisers. The majority of them currently intend to bring about a "responsible pathway" toward human genome interventions in clinical therapy. Engaging in advocacy for such a pathway, they issue moral judgments on the risks and benefits of this new technology. They declare that there actually is a responsible pathway, they draft resolutions on temporary moratoria, they make judgments on which groups and individuals are credible and should participate in public and semi-public debates, so they also set the standards for deciding who counts as well-informed, as well as the standards of evidence for adopting or rejecting research policies. This degree of influence on public debates and policy making is, at the very least, noteworthy. This contribution sounds a note of caution with regard to the endeavor of a responsible pathway to human genome editing and in particular scrutinizes the legitimacy of expert-driven research policies given commercial conflicts of interest and conflicts of commitment among first-rank scholars.

Classification and differential effectiveness of goal-directed hemodynamic therapies in surgical patients: A network meta-analysis of randomized controlled trials

PURPOSE

To investigate the most effective goal-directed hemodynamic therapy (GDHT) in surgical patients.

METHODS

GDHTs were classified as methods for intravascular volume, preload, stroke volume, cardiac output, oxygen delivery, systemic oxygenation, or tissue oxygenation optimization, alone or in combination. Their relative effectiveness and ranking were assessed using network meta-analysis and the surface under the cumulative ranking curve (SUCRA), respectively.

RESULTS

101 randomized controlled trials investigating GDHT effectiveness in surgical patients were eligible. The most commonly reported outcomes were 30-day mortality, acute kidney injury (AKI), and arrhythmia. Mortality was significantly reduced by GDHTs aimed at intravascular volume and cardiac output optimization (OR 0.40; 95% CrI 0.14-0.997; low quality). AKI was significantly reduced by GDHT aimed at intravascular volume optimization (OR 0.26; 95% CrI 0.08-0.71; moderate quality). No GDHT significantly reduced arrhythmia. GDHT aimed at intravascular volume and stroke volume optimization was likely most effective for mortality reduction (SUCRA = 78.8%) while that aimed at intravascular volume, stroke volume, and cardiac output optimization was likely most effective for AKI reduction (SUCRA = 85.4%).

CONCLUSIONS

Different GDHTs likely have different and outcome-dependent effectiveness in surgical patients. GDHTs aimed at intravascular volume, stroke volume, and cardiac output optimization are likely most effective as per the overall evidence.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42020159978.

Calcium Channel Blockers in Acute Care: The Links and Missing Links Between Hemodynamic Effects and Outcome Evidence

Calcium channel blockers (CCBs) exert profound hemodynamic effects via blockage of calcium flux through voltage-gated calcium channels. CCBs are widely used in acute care to treat concerning, debilitating, or life-threatening hemodynamic changes in many patients. The overall literature suggests that, for systemic hemodynamics, although CCBs decrease blood pressure, they normally increase cardiac output; for regional hemodynamics, although they impair pressure autoregulation, they normally increase organ blood flow and tissue oxygenation. In acute care, CCBs exert therapeutic efficacy or improve outcomes in patients with aneurysmal subarachnoid hemorrhage, acute myocardial infarction and unstable angina, hypertensive crisis, perioperative hypertension, and atrial tachyarrhythmia. However, despite the clear links, there are missing links between the known hemodynamic effects and the reported outcome evidence, suggesting that further studies are needed for clarification. In this narrative review, we aim to discuss the hemodynamic effects and outcome evidence for CCBs, the links and missing links between these two domains, and the directions that merit future investigations.

Intraoperative physiological ranges associated with improved outcomes after major spine surgery: an observational study

OBJECTIVE

There is inadequate information about the values of many intraoperative physiological measurements that are associated with improved outcomes after surgery. The purpose of this observational study is to investigate the optimal physiological ranges during major spine surgery.

SETTING

A teaching hospital in the USA.

PARTICIPANTS

A convenience sample of 102 patients receiving major posterior spine surgery with multilevel spinal fusion in a prone position.

METHODS

Physiological variables, including but not limited to mean arterial pressure (MAP) and cerebral and somatic tissue oxygen saturation (SctO₂/SstO₂), were recorded. The results of these measurements were associated with length of hospital stay and composite complication data and were analysed based on thresholds (ie, a cut-off value for optimal and suboptimal physiology) and the area under the curve (AUC) values. The AUC values were measured as the area enclosed by the actual tracing and the threshold. The outcomes were dichotomised into above-average and below-average (ie, improved) categories.

RESULTS

Analyses based on thresholds identified the following variables associated with above-average outcomes: MAP <60 mm Hg, temperature <35°C, heart rate >90 beats per minute (bpm), SctO₂ <60% and SstO₂ >80%. Analyses based on AUC values identified the following as associated with above-average outcomes: MAP <70 and >100 mm Hg, temperature <36°C, heart rate >90 bpm, tidal volume (based on ideal body weight)<6 mL/kg, tidal volume (based on actual body weight) >10 mL/kg and peak airway pressure <15 cmH₂O.

CONCLUSION

The following physiological ranges are associated with improved outcomes (ie, shorter hospitalisation and fewer complications) during major spine surgery: MAP of 70-100 mm Hg, temperature ≥36°C, heart rate <90 bpm, tidal volume based on ideal body weight >6 mL/kg, SctO₂ >60% and SstO₂ <80%.