Daily ReportOct 10, 2026
Anesthesiology, October 10 edition
We read 3 papers and selected 3.
Summary
Today's three papers address perioperative sedation, medication safety, and the diagnostic recognition of rare systemic amyloidosis. The highest-ranked study is a registered randomized trial protocol comparing dexmedetomidine with remimazolam during lower-limb nerve block, while the observational veterinary study identifies decision-making as the principal stage associated with medication errors and the case report highlights unilateral vitreous amyloidosis as a possible first manifestation of hereditary transthyretin amyloidosis.
Research Themes
- Protocolized perioperative sedation and stress-response control
- Medication-error epidemiology and patient safety
- Early recognition of hereditary transthyretin amyloidosis
Selected Articles
1. Effects of dexmedetomidine versus remimazolam protocolized sedation during lower limb nerve block on early stress response and quality of recovery in patients undergoing diabetic foot ulcer repair: a randomized controlled trial protocol.
This registered prospective randomized single-center single-blind superiority trial protocol will enroll 160 patients undergoing elective diabetic foot ulcer repair. It compares dexmedetomidine and remimazolam as adjunctive procedural sedation during lower-limb nerve block, with the change in serum cortisol from baseline to 2 hours postoperatively as the primary outcome.
Impact: The protocol directly addresses an unresolved comparative question in regional anesthesia and procedural sedation using a biologically relevant stress-response endpoint together with patient-centered recovery outcomes. Its prospective randomization and trial registration provide a strong framework for generating clinically useful evidence, although results are not yet available.
Clinical Implications: If completed as designed, the trial could inform selection of adjunctive sedation for diabetic foot surgery under nerve block, particularly regarding perioperative stress attenuation, hemodynamic safety, pain control, and early recovery. It should not yet change practice because comparative outcome data are pending.
Key Findings
- The study plans to randomize 160 adults aged 18 to 75 years undergoing elective diabetic foot ulcer repair.
- Dexmedetomidine will be compared with remimazolam during lower-limb nerve block in a prospective, single-center, single-blind superiority design.
- The primary endpoint is the change in serum cortisol from preoperative baseline to 2 hours postoperatively, with pain, vital signs, recovery quality, and satisfaction as secondary outcomes.
Methodological Strengths
- Prospective randomized allocation with a prespecified superiority framework and registration in the Chinese Clinical Trial Registry.
- Combines an objective endocrine stress biomarker with clinically meaningful recovery, pain, safety, and satisfaction outcomes.
Limitations
- The single-center and single-blind design may limit external validity and leave room for performance or assessment bias.
- The abstract does not define the full follow-up schedule, and the protocol provides no outcome data or evidence of long-term recovery.
Future Directions: Completion should include transparent reporting according to CONSORT, prespecified handling of missing data, assessment of sedation-related adverse events, and longer-term patient-reported recovery. Multicenter trials should test generalizability across different diabetic foot procedures and patient-risk profiles.
BACKGROUND: For patients undergoing diabetic foot ulcer (DFU) repair, lower limb nerve block is the preferred anesthetic regimen. However, the block alone often fails to fully eliminate intraoperative anxiety and stress responses. Adjunctive procedural sedation and analgesia (PSA), using agents such as dexmedetomidine or remimazolam, is a key strategy to enhance surgical comfort. Nevertheless, the comparative effects of these two agents on early stress response and quality of recovery remain unclear. METHODS: This is a prospective, randomized, single-center, single-blind superiority controlled trial. A total of 160 patients aged 18 to 75 years undergoing elective DFU repair will be enrolled and randomized into Group A (dexmedetomidine) and Group B (remimazolam).
2. When good intentions go wrong: medication errors associated with adverse events in veterinary practice.
This retrospective quantitative document analysis examined 256 Finnish veterinary malpractice claims from 2014 to 2023, identifying 148 medication errors in 87 eligible cases. Omission of medication administration was the most common error, while 21.8% of cases were fatal and another 21.8% involved severe adverse events; 57.4% of errors occurred during decision-making.
Impact: The study quantifies the severity and process location of veterinary medication errors using real-world adverse-event claims data. Its identification of decision-making as the dominant error stage provides a concrete target for medication-safety interventions, including prescribing support, protocols, and team-based verification.
Clinical Implications: Veterinary clinics and hospitals should strengthen prescribing and medication-decision safeguards, especially for systemic antibacterials, anti-inflammatory drugs, sedatives, and anesthetics. Structured checklists, dose and indication verification, documentation, and review of omitted administrations may reduce preventable harm.
Key Findings
- Among 256 malpractice claims, 87 eligible cases contained 148 medication errors.
- Dogs accounted for 65.5% of errors, omission of medication administration was the most frequent error type at 16.9%, and systemic antibacterials, anti-inflammatory drugs, and anesthetics were the most commonly involved medication groups.
- Fatal outcomes occurred in 21.8% of cases, severe adverse events in another 21.8%, and 57.4% of errors occurred during the decision-making phase.
Methodological Strengths
- Uses a decade of systematically reviewed national-level malpractice-claim records rather than isolated case reports.
- Separates error types, medication classes, animal species, clinical settings, and process stages, enabling targeted safety interventions.
Limitations
- Claim-based data capture reported and litigated events rather than all medication errors, creating potential underascertainment and reporting-selection bias.
- The retrospective Finnish dataset may not represent routine veterinary practice in other countries or non-claim clinical settings.
Future Directions: Prospective multicenter surveillance should estimate denominator-based error rates and evaluate whether decision-support systems, standardized medication reconciliation, independent double checks, and incident-learning programs reduce severe outcomes. Comparative studies should examine species-specific and clinic-level risk factors.
BACKGROUND: Medication safety is a central component of patient safety. Although some studies on medication errors have been conducted in veterinary medicine, data on the prevalence and severity of errors remain scarce. This study investigated veterinary medication errors using Finnish authorative adverse event data about claimed medical malpractice. The study comprised a retrospective quantitative document analysis of 256 claims cases reviewed by the Assessment Board for Damages in Veterinary Practice between 2014 and 2023. RESULTS: A total of 87 cases met the inclusion criteria, in which 148 medication errors were identified. Medication errors occurred most frequently in dogs (n = 57/148, 65.5%) and horses (n = 12/148, 13.8%). The most common error type was omission of medication administration (n = 25/148, 16.9%).
3. Unilateral vitreous amyloidosis as the presenting feature of hereditary transthyretin amyloidosis (TTR p.Val50Met): a case report and focused literature review.
This case describes a 67-year-old man with unilateral vitreous amyloidosis caused by a heterozygous TTR p.Val50Met variant, despite no systemic symptoms or family history. Diagnostic vitrectomy demonstrated Congo red-positive amyloid, and vision improved postoperatively; the report emphasizes that unilateral or markedly asymmetric ocular disease can be an initial manifestation of hereditary transthyretin amyloidosis.
Impact: The report expands the recognized phenotypic spectrum of hereditary transthyretin amyloidosis by documenting isolated unilateral vitreous involvement. It provides a practical diagnostic warning for ophthalmologists and supports early genetic testing and multidisciplinary surveillance even when systemic manifestations are absent.
Clinical Implications: Unexplained unilateral vitreous opacity should prompt consideration of ocular amyloidosis after infectious and neoplastic causes are assessed. Congo red histology, TTR genetic testing, systemic evaluation for polyneuropathy and cardiomyopathy, and long-term multidisciplinary follow-up may be appropriate in selected patients.
Key Findings
- A 67-year-old man presented with progressive unilateral visual loss and dense left vitreous opacities without systemic symptoms or family history.
- Vitrectomy specimens showed Congo red-positive amyloid with apple-green birefringence, and genetic testing identified the heterozygous pathogenic TTR p.Val50Met variant.
- Visual acuity improved from counting fingers to 0.4 at 1 week and 0.5 or better at the last follow-up; systemic surveillance was recommended because late-onset carriers remain at risk for polyneuropathy and cardiomyopathy.
Methodological Strengths
- Combines clinical examination, exclusion of infectious and neoplastic mimics, histopathology, and molecular genetic confirmation.
- Places the unusual unilateral presentation in the context of a focused literature review and identifies implications for systemic surveillance.
Limitations
- A single case cannot establish the frequency, prognostic significance, or causal relationship between unilateral vitreous disease and later systemic involvement.
- The focused literature review may be subject to publication and selection bias, and the reported follow-up duration is not quantified in the abstract.
Future Directions: International registries and prospective ophthalmic-genetic cohorts should determine how often unilateral vitreous amyloidosis precedes systemic disease and which TTR variants confer the greatest risk. Longitudinal neurologic and cardiac surveillance studies may clarify optimal screening intervals and disease-modifying treatment timing.
BACKGROUND: Hereditary transthyretin amyloidosis (ATTRv) is an autosomal dominant systemic disorder characterized by extracellular amyloid deposition. Ocular manifestations typically present bilaterally, and unilateral vitreous amyloidosis without systemic symptoms or family history is rare. Few reports have documented the laterality pattern of vitreous amyloidosis or its role as an early indicator of systemic disease. CASE PRESENTATION: We present a 67-year-old Chinese man who experienced progressive left eye vision loss over 1 year. Dense vitreous opacities in the left eye initially mimicked vitreous hemorrhage or primary intraocular lymphoma. The right eye showed only age-related posterior vitreous detachment and foveal drusen, without clinically apparent vitreous amyloid; its isolated intraocular pressure elevation was not accompanied by optic disc or visual field damage.