A not so sweet scenario: impact of perioperative glucose control on regional anesthetic techniques for orthopedic surgery.

PURPOSE OF REVIEW: Diabetes and hyperglycemia are well established risk factors for complications associated with common orthopedic surgeries. In some practice settings, these conditions are also viewed as contraindications to regional nerve catheters. In this article, we aim to present our approach to offering the benefits of this modality in a safe manner for patients with diabetes and even some with preexisting, localized infections. RECENT FINDINGS: Evidence suggests that reduction in opioids and avoidance of general anesthesia can be particularly beneficial for patients with diabetes and high blood sugar, who often suffer from comorbid conditions such as obesity and obstructive sleep apnea. On our high volume, high acuity acute pain service, we take a selective approach to nerve catheter placement in this population and even some who already have localized infections. In our experience, with careful monitoring and risk mitigation strategies these patients have improved pain control and an exceedingly low rate of complications associated with nerve catheter use. SUMMARY: Based on our experience and reading of the literature, we advocate for a liberalized approach to use of continuous regional anesthesia for diabetic patients having for orthopedic surgery. A set of consensus guidelines tailored to institutions' resources and monitoring capabilities can be a useful tool for standardizing care. It may also increase access to the clinical benefits of this modality in a population particularly vulnerable to opioid related adverse effects.

Ketamine: a versatile tool for anesthesia and analgesia.

PURPOSE OF REVIEW: Ketamine has been used for decades for a variety of indications. Beyond the historical benefits and effects of ketamine, newer developments have occurred worthy of an update. This review will discuss common uses and indications for ketamine in the perioperative setting, as well as highlight newer indications in recent years. RECENT FINDINGS: Multiple studies have examined the use of ketamine in a variety of environments, as ketamine has become more popular in emergency rooms and ICUs. Ketamine may be particularly beneficial in management of burn patients, who often require multiple procedures over the course of their treatment. Ketamine's role in the ongoing opioid crisis has been of particular interest, with multiple studies evaluating its potential role in managing both acute and chronic pain conditions. Ongoing studies examining the role of ketamine in treatment of depressions show promise as well. SUMMARY: Ketamine is regaining popularity in the field of anesthesia and beyond. New studies provide insight on the many indications and use that anesthesia providers may encounter during their perioperative care of patients. Ongoing research is needed to further elucidate ketamine's effects on the management of psychiatric conditions and potential indications for ketamine metabolites.

Steroid-Mediated Decrease in Blood Mesenchymal Stem Cells in Liver Transplant could Impact Long-Term Recovery.

Orthotopic liver transplant (OLT) remains the standard of care for end stage liver disease. To circumvent allo-rejection, OLT subjects receive gluococorticoids (GC). We investigated the effects of GC on endogenous mesenchymal stem (stromal) cells (MSCs) in OLT. This question is relevant because MSCs have regenerative potential and immune suppressor function. Phenotypic analyses of blood samples from 12 OLT recipients, at pre-anhepatic, anhepatic and post-transplant (2 h, Days 1 and 5) indicated a significant decrease in MSCs after GC injection. The MSCs showed better recovery in the blood from subjects who started with relatively low MSCs as compared to those with high levels at the prehepatic phase. This drop in MSCs appeared to be linked to GC since similar change was not observed in liver resection subjects. In order to understand the effects of GC on decrease MSC migration, in vitro studies were performed in transwell cultures. Untreated MSCs could not migrate towards the GC-exposed liver tissue, despite CXCR4 expression and the production of inflammatory cytokines from the liver cells. GC-treated MSCs were inefficient with respect to migration towards CXCL12, and this correlated with retracted cytoskeleton and motility. These dysfunctions were partly explained by decreases in the CXCL12/receptor axis. GC-associated decrease in MSCs in OLT recipients recovered post-transplant, despite poor migratory ability towards GC-exposed liver. In total, the study indicated that GC usage in transplant needs to be examined to determine if this could be reduced or avoided with adjuvant cell therapy.

Regulation of the proliferation of colon cancer cells by compounds that affect glycolysis, including 3-bromopyruvate, 2-deoxyglucose and biguanides.

In previous studies performed by our group, we observed that 2-deoxyglucose blocked the acidification of the medium used for culture of colon cancer cells caused by incubation with biguanides and it had an additive inhibitory effect on growth. In the present work, we found that 3-bromopyruvate can also prevent the lowering of pH caused by biguanide treatment. 3-Bromopyruvate inhibited colonic cancer cell proliferation, but the effect was not always additive to that of biguanides and an additive effect was more notable in combined treatment with 3-bromopyruvate and 2-deoxyglucose. The induction of alkaline phosphatase activity by butyrate was not consistently affected by combination with other agents that modified glucose metabolism. The drug combinations that were examined inhibited proliferation of wild-type and p53-null cells and affected colonic cancer lines with different growth rates.