Sergio Daniel Bergese

Traumatic brain injury (TBI) is characterized by a “translational paradox”, where robust preclinical successes rarely achieve clinical efficacy. This review provides a critical appraisal of emerging therapeutics, moving beyond traditional silos to propose a unified, stage-dependent roadmap for neurorestoration. Reflecting on translational insights from past trials, specifically the limitations of standardized timing and phenotypic heterogeneity, we introduce the “Temporal Precision Medicine” framework. Central to this synthesis is the Dual-Axis Theory, which posits that successful emerging modalities, including repurposed agents such as glibenclamide, amantadine, and statins, alongside cell-free biologics and neuromodulation, converge on two shared pathological targets: the Inflammatory Axis (M1-to-M2 microglial polarization) and the Metabolic Axis (restoration of mitochondrial bioenergetics). We operationalize these biological insights into a Triple-Axis Framework, a dynamic clinical roadmap that aligns stage-dependent interventions with phase-specific biomarkers and pathological mechanisms. By integrating these biological signals with bioengineered delivery systems and artificial intelligence (AI)-driven precision phenotyping, the field can transition from acute neuroprotection toward genuine circuit-level regeneration. We conclude with a blueprint for the next generation of TBI trials, emphasizing biomarker-based stratification and multidimensional endpoints to bridge the translational gap.

Patients with heart failure require special considerations in the perioperative setting given the challenges caused by heart failure pathophysiology. This pathophysiology is complex and involves several mechanisms that contribute to both disease progression and the clinical syndrome, including cardiac remodeling, neurohormonal activation, and resultant hemodynamic derangements. Anesthetic management of these patients requires diligence at all stages of care. Preoperative assessment includes risk stratification, management of comorbid conditions, and heart failure medication management. Anesthetic agents have differing effects on hemodynamics and selection of these agents must be aimed at preventing hemodynamic collapse in patients with heart failure. In addition, the increased risk of intraoperative complications among these patients often necessitates means of invasive hemodynamic monitoring and use of vasopressor or inotropic support. Finally, the postoperative care of heart failure patients requires attention to the volume status of these patients, as well as considerations for pain management and modulation of the surgical stress response. In this review article, we aim to review how the pathophysiologic mechanisms and changes that occur with heart failure impact anesthetic management and patient-centered perioperative care.

Perioperative myocardial ischemia and myocardial injury after noncardiac surgery (MINS) remain prevalent contributors to postoperative morbidity and mortality. Recent advances, including high-sensitivity biomarkers and updated 2024 American Heart Association/American College of Cardiology (AHA/ACC) guidelines, have modified the clinical approach to preoperative ischemic evaluation. This review intends to synthesize contemporary evidence and provide a framework for perioperative ischemic workup. A narrative review of the current literature and major society guidelines was conducted, focusing on perioperative risk stratification, functional capacity assessment, biomarker utilization, noninvasive and invasive diagnostic modalities, and perioperative medical optimization strategies. Contemporary perioperative evaluation favors a stepwise, risk-based approach that uses clinical risk indices, functional capacity, and selective diagnostic testing. Biomarkers such as natriuretic peptides and cardiac troponins enhance risk prediction and enable the detection of MINS, which is strongly associated with increased mortality. Evidence does not support routine preoperative stress testing or prophylactic coronary revascularization in stable patients. Guideline-directed medical therapy, including sustained statin use and attentive management of antiplatelet and beta-blocker therapy, remains central to risk mitigation. Modern perioperative ischemic workup prioritizes individualized, evidence-based evaluation over routine testing. Integration of biomarkers, structured risk assessment, and multidisciplinary management may improve outcomes, though additional research is needed to define optimal strategies for detecting and treating MINS.

New study does not support use of dexmedetomidine-remifentanil to change neurodevelopmental outcomes of sevoflurane

Background: Preterm birth is a leading cause of neonatal mortality and long-term disability worldwide. Injury in premature infants is demonstrated by disrupted organ development from inflammation, oxidative stress, hypoxia, and impaired vascular maturation. Current therapies largely provide supportive care and do not directly promote tissue regeneration. Mesenchymal stem cell (MSC)-based therapies have emerged as a potential strategy to enhance endogenous repair across organ systems commonly affected by prematurity. Results: Evidence indicates that MSCs exert therapeutic effects primarily through transient paracrine signaling rather than long-term engraftment. Following administration, MSCs release cytokines, growth factors, and extracellular vesicles that reduce inflammation, promote angiogenesis, and support tissue repair. In preclinical models of neonatal brain injury, MSC therapy has been associated with improved oligodendrocyte maturation and reduced white matter injury. Early clinical trials in neonatal encephalopathy demonstrate feasibility and short-term safety of both autologous and allogeneic cell products. However, studies remain limited by small sample sizes and short follow-up. Cell-free approaches using MSC-derived extracellular vesicles may offer similar biological benefits with potentially lower safety and regulatory concerns. Conclusions: MSC-based therapies represent a promising regenerative approach for complications of prematurity. Rigorous, large-scale trials with standardized protocols and long-term follow-up are necessary to clarify efficacy, optimize delivery strategies, and define safety in this vulnerable population.

Stroke continues to impose an enormous morbidity and mortality burden worldwide. Stroke survivors often incur debilitating consequences that impair motor function, independence in activities of daily living and quality of life. Rehabilitation is a pivotal intervention to minimize disability and promote functional recovery following a stroke. The Internet of Medical Things, a network of connected medical devices, software and health systems that collect, store and analyze health data over the internet, is an emerging resource in neurorehabilitation for stroke survivors. Technologies such as asynchronous transmission to handle intermittent connectivity, edge computing to conserve bandwidth and lengthen device life, functional interoperability across platforms, security mechanisms scalable to resource constraints, and hybrid architectures that combine local processing with cloud synchronization help bridge the digital divide and infrastructure limitations in low-resource environments. This manuscript reviews emerging rehabilitation technologies such as robotic devices, virtual reality, brain–computer interfaces and telerehabilitation in the setting of neurorehabilitation for stroke patients.

Stroke continues to carry an enormous morbidity and mortality burden worldwide. Stroke survivors often incur debilitating consequences that impair motor function, independence in activities of daily living and quality of life. Rehabilitation is a pivotal intervention to minimize disability and promote functional recovery following a stroke. The Internet of Medical Things, a network of connected medical devices, software and health systems that collect, store and analyze health data over the internet is an emerging resource in neurorehabilitation for stroke survivors. This manuscript reviews emerging rehabilitation technologies such as robotic devices, virtual reality, brain-computer interfaces and telerehabilitation in the setting of neurorehabilitation for stroke patients.

Fast-track extubation has emerged as a vital component of Enhanced Recovery After Surgery pathways, designed to optimize recovery and resource utilization after cardiac surgery, contrasting with traditional prolonged ventilation. This review explores the evidence supporting fast-track extubation, detailing patient selection criteria based on preoperative risk factors and functional status and outlining perioperative management strategies. It synthesizes findings from various studies, including randomized controlled trials, retrospective studies, and meta-analyses, focusing on intraoperative techniques such as low-dose opioids, neuromuscular blockade reversal, controlled cardiopulmonary bypass duration, judicious inotrope use, and minimal transfusion, alongside structured postoperative protocols emphasizing early sedative weaning and spontaneous breathing trials. Results demonstrate that fast-track extubation decreases intensive care unit stay, reduces costs and ventilator-associated complications, with a safety comparable to conventional care. Prolonged cardiopulmonary bypass time, dependency on inotropes, and intraoperative blood transfusions are identified as critical predictors of fast-track extubation failure. In conclusion, the successful implementation of fast-track extubation protocols requires a collaborative, multidisciplinary approach, proving essential for improving patient outcomes, minimizing complications such as postoperative delirium, and enhancing hospital efficiency in cardiac surgery. Further research should aim to refine patient selection and standardize protocols across healthcare systems.

Mechanical ventilation is a critical intervention in patients who cannot spontaneously maintain adequate oxygenation and remove carbon dioxide. However, it can also lead to severe lung injury via volutrauma, barotrauma, atelectrauma and biotrauma, and it can worsen existing lung disease such as acute respiratory distress syndrome. Ventilator-associated lung injury, the clinical manifestations of lung damage associated with mechanical ventilation, can trigger systemic inflammatory cascades that contribute to multi-organ failure. The utilization of lung-protective ventilation strategies helps to minimize further injury to the lungs during mechanical ventilation and improve survival rates. This review discusses the pathophysiology of ventilator-associated lung injury, including cellular and molecular responses, its systemic effects, risk factors, clinical presentation and diagnosis, protective strategies, and emerging therapies. It incorporates interdisciplinary advances, from novel pharmacologic and stem-cell therapies coupled with artificial intelligence and machine learning systems to provide a framework for the prevention of ventilator-associated lung injury that moves beyond purely mechanical considerations.

Acute kidney injury (AKI) is a common and serious perioperative complication with several diverse etiologies. Elderly surgical patients are particularly vulnerable, experiencing higher rates of AKI and suffering worse outcomes, including multiorgan dysfunction, elevated mortality rates, and a heightened risk of developing chronic kidney disease (CKD) or end-stage renal disease (ESRD). AKI also imposes a significant economic burden, increasing healthcare costs due to prolonged hospitalizations and increased resource utilization. Given the limited treatment options for AKI, prevention is paramount. This involves identifying and optimizing modifiable patient, surgical, and anesthetic risk factors, implementing evidence-based care bundles in high-risk patients, avoiding potential causes of kidney insult, and employing novel preventive strategies such as remote-ischemic preconditioning. Early diagnosis is crucial when prevention fails, allowing timely intervention before irreversible kidney damage occurs. Novel diagnostic tools show promise in improving the accuracy and timeliness of AKI detection, facilitating prompt management. While renal-replacement therapy (RRT) remains the only definitive treatment for AKI, more refined criteria for its initiation are needed to enhance its delivery and improve patient outcomes.