Anesthetic Management of Middle Aortic Syndrome in an Adult: A Case Report.

Middle aortic syndrome (MAS) is a rare disorder characterized by narrowing of the aorta. Depending on the location and extent of aortic narrowing, surgical management may be necessary to prevent long-term sequelae, such as stroke and congestive heart failure. We report a case of MAS and discuss the unique intraoperative anesthetic considerations including hemodynamic monitoring proximal and distal to the aortic narrowing, minimizing the risk of spinal cord ischemia, and utilization of intraoperative dobutamine stress testing to guide surgical management.

Recidivism after orthopaedic trauma has diminished over time.

PURPOSE: The purpose was to analyze our trauma population during two periods to assess for predictors of recidivism. METHODS: Prior (2007-2011, n = 879) and recent (2014-2019, n = 954) orthopaedic trauma patients were reviewed. Recidivists were those returning with an unrelated injury. Recidivism rates were compared, and factors associated with recidivism were identified. RESULTS: Recidivism decreased: 18.7% to 14.3% (p = 0.01). Mean age and sex of the two cohorts were not different. Recent recidivists were more likely to sustain gunshot wound (GSW) injuries (22.1% vs 18.9%, p = 0.09), and mental illness was more common (56.6% vs 28.1%, p < 0.0001). The recent recidivist population was less often married (12.9% vs 23.8%, p = 0.03), and both recidivist groups were often underinsured (Medicaid or uninsured: (60.6% vs 67.0%)). CONCLUSION: Recidivism diminished, although more GSW and mental illness were seen. Recidivists are likely to be underinsured. The changing profile of recidivists may be attributed to socioeconomic trends and new programs to improve outcomes after trauma.

Trauma recidivism is pervasive and is associated with mental and social health opportunities.

INTRODUCTION: Recidivism after orthopedic trauma results in greater morbidity and costs. Prior studies explored the effects of social and medical factors affecting the frequency of return to the hospital with new, unrelated injury. Identification of mental, social and other risk factors for trauma recidivism may provide opportunities for mitigation. The purposes of this study are to determine the rates of subsequent, unrelated injury noted among orthopedic trauma patients at a large urban trauma center and to evaluate what patient and injury features are associated with greater rates of trauma recidivism. We hypothesize higher rates of new injuries will be related to ballistic trauma and other forms of assault, alcohol and recreational drug use, unemployment, and unmarried status among our trauma patients. METHODS: A series of 954 skeletally mature patients at a level 1 trauma center over a 5 year period were included in the study. All were treated operatively for thoracolumbar, pelvic ring, acetabulum, and/or proximal or shaft femoral fractures from a high energy mechanism. Retrospective review of demographic, injury, medical, and social factors, and subsequent care was performed. Trauma recidivism was defined as returning to the emergency department for treatment of any new injury. A backward stepwise logistic regression statistical analysis was used to identify independent predictors of recidivism. RESULTS: Mean age of all patients was 41.2 years, and 73.2% were male. 136 patients (14.3%) returned with a new injury within a mean of 21 months. These trauma recidivists were more likely to sustain a GSW (22.1% vs 11.4%, p = 0.001). They had higher rates of substance use, including tobacco (57.4% vs 41.8%, p = 0.001) and recreational drugs (50.7% vs 34.4%, p = 0.001), and were less likely to be married (10% vs 25.9%, p<0.001). Mental illness was pervasive, noted in 56.6% of patients with new injury (vs 32.8%, p<0.001). Medicaid insurance was most common in the trauma recidivist population (58.1% vs 35.0%, p = 0.001), and 12.5% were uninsured. Completing high school or more education was protective (93% non-recidivist (vs 79%, p = 0.001). Sixty-nine patients (50.7%) were repeat trauma recidivists within the study period. Independent predictors of new injury included recreational drug use (OR 1.64, p = 0.05) and history of assault due to GSW or other means (OR 1.67, p = 0.05). History of pre-existing mental illness represented the greatest risk factor for trauma recidivism (OR 2.55, p<0.001). DISCUSSION: New injuries resulting in emergency department presentation after prior orthopedic trauma occurred in 14.3% and were associated with history of assault, lower education, Medicaid insurance, tobacco smoking and recreational drug use. Mental illness was the greatest risk factor. Over half of patients with these additional injuries were repeat trauma recidivists, returning for another new injury within less than 2 years. Awareness of risk factors may promote focused education and other interventions to mitigate this burden. LEVEL OF EVIDENCE: Level 3 retrospective, prognostic.

An Anatomic Study Examining Lumbar Pars Interarticularis Distance and Spinal Canal Width in Relation to Lumbar Decompressive Surgery.

BACKGROUND: Lumbar laminectomy is a surgical procedure allowing for decompression of neural structures. A wide laminectomy to adequately decompress neural elements without compromising the structural integrity of the spinal column is ideal. Pars interarticularis fractures with spinal instability after isolated laminectomy from overresection of the posterior elements have been reported. There are limited anatomical studies in the spine literature that measure the pars interarticularis distance (PID) and spinal canal width (SCW) in the lumbar spine. OBJECTIVE: The purpose of this study was to assess the differences in PID and SCW at each level of the lumbar spine and to determine their effects on the extent of laminectomy at each lumbar level. METHODS: We performed an anatomic study measuring PID and SCW in the lumbar spine from 93 skeletally matured osseous specimens. Groups were compared using an independent sample t test, 1-way analysis of variance, and Wilcoxon test, and significance was set at P < 0.05. RESULTS: Our study suggests that the distance between PID and SCW increases from L1 to L5 in African American and Caucasian women and men. However, the respective increase in SCW at each lumbar level is less than the respective increase in PID at the same levels. This trend suggests that there is a wider window available for decompression without compromising spinal stability in the lower lumbar spine compared with the upper lumbar spine. CONCLUSIONS: Our findings suggest that the upper lumbar spine has a narrower window for decompression; therefore, care should be taken to preserve as much of the pars at L1-L3. Understanding the variations in PID and SCW in the lumbar spine will help surgeons perform adequate decompression of a stenotic canal while avoiding postoperative spinal instability. CLINICAL RELEVANCE: Awareness of PID to SCW ratio may help spine surgeons avoid iatrogenic instability, postoperative intractable back pain, spondylolisthesis, or complications involving alterations of the lumbar spine biomechanics.

BRAIN UK: Accessing NHS tissue archives for neuroscience research.

The purpose of BRAIN UK (the UK BRain Archive Information Network) is to make the very extensive and comprehensive National Health Service (NHS) Neuropathology archives available to the national and international neuroscience research community. The archives comprise samples of tumours and a wide range of other neurological disorders, not only from the brain but also spinal cord, peripheral nerve, muscle, eye and other organs when relevant. BRAIN UK was founded after the recognition of the importance of this large tissue resource, which was not previously readily accessible for research use. BRAIN UK has successfully engaged the majority of the regional clinical neuroscience centres in the United Kingdom to produce a centralised database of the extensive autopsy and biopsy archive. Together with a simple application process and its broad ethical approval, BRAIN UK offers researchers easy access to most of the national archives of neurological tissues and tumours (http://www.brain-uk.org). The range of tissues available reflects the spectrum of disease in society, including many conditions not covered by disease-specific brain banks, and also allows relatively large numbers of cases of uncommon conditions to be studied. BRAIN UK has supported 141 studies (2010-2020) that have generated 70 publications employing methodology as diverse as morphometrics, genetics, proteomics and methylomics. Tissue samples that would otherwise have been unused have supported valuable neuroscience research. The importance of this unique resource will only increase as molecular techniques applicable to human tissues continue to develop and technical advances permit large-scale high-throughput studies.

Is There Value in Venous Thromboembolism Chemoprophylaxis After Pediatric Scoliosis Surgery? A 28-Year Single Center Study.

BACKGROUND: With a recognized increase in the incidence of venous thromboembolism (VTE) in children, especially in those with complex, chronic conditions, it is important for patient safety and risk management to identify subgroups that would benefit from prophylactic treatment. The aim of our study was to assess whether scoliosis surgery in children was associated with an increased incidence of VTE, including deep venous thrombosis (DVT) and pulmonary embolism, and if chemoprophylaxis is warranted. METHODS: We reviewed our institution's Pediatric Orthopaedic Spine Database (1992-2019) to identify patients who had a symptomatic VTE postoperatively. RESULTS: There were 1471 patients (1035 female, 436 male) with a mean age at surgery of 12.1±3.2 years (range, 1 to 18 y) underwent posterior spinal fusion and instrumentation (2131 procedures). No patients were given pharmacological VTE prophylaxis, and no routine screening for VTE was performed. Two patients had a lower extremity DVT (0.13%) within 6 months following surgery, (range, 55 to 161 d). Neither patient had a subsequent pulmonary embolism. They were 9 and 17 years of age with a diagnosis of neuromuscular scoliosis (1 each postpolio and myelodysplasia). One affected patient had a central venous line inserted perioperatively, a known risk factor for thromboembolism. All DVTs were treated with appropriately dosed anticoagulants. None had a family history of hypercoagulation. CONCLUSIONS: The risk of symptomatic VTE is extraordinarily low after pediatric spinal deformity surgery. Mechanical prophylaxis is sufficient in most cases. Further multi-center studies may help identify patient specific risk factors.

Cell Line-, Protein-, and Sialoglycosite-Specific Control of Flux-Based Sialylation in Human Breast Cells: Implications for Cancer Progression.

Sialylation, a post-translational modification that impacts the structure, activity, and longevity of glycoproteins has been thought to be controlled primarily by the expression of sialyltransferases (STs). In this report we explore the complementary impact of metabolic flux on sialylation using a glycoengineering approach. Specifically, we treated three human breast cell lines (MCF10A, T-47D, and MDA-MB-231) with 1,3,4-O-Bu3ManNAc, a "high flux" metabolic precursor for the sialic acid biosynthetic pathway. We then analyzed N-glycan sialylation using solid phase extraction of glycopeptides (SPEG) mass spectrometry-based proteomics under conditions that selectively captured sialic acid-containing glycopeptides, referred to as "sialoglycosites." Gene ontology (GO) analysis showed that flux-based changes to sialylation were broadly distributed across classes of proteins in 1,3,4-O-Bu3ManNAc-treated cells. Only three categories of proteins, however, were "highly responsive" to flux (defined as two or more sialylation changes of 10-fold or greater). Two of these categories were cell signaling and cell adhesion, which reflect well-known roles of sialic acid in oncogenesis. A third category-protein folding chaperones-was unexpected because little precedent exists for the role of glycosylation in the activity of these proteins. The highly flux-responsive proteins were all linked to cancer but sometimes as tumor suppressors, other times as proto-oncogenes, or sometimes both depending on sialylation status. A notable aspect of our analysis of metabolically glycoengineered breast cells was decreased sialylation of a subset of glycosites, which was unexpected because of the increased intracellular levels of sialometabolite "building blocks" in the 1,3,4-O-Bu3ManNAc-treated cells. Sites of decreased sialylation were minor in the MCF10A (<25% of all glycosites) and T-47D (<15%) cells but dominated in the MDA-MB-231 line (~60%) suggesting that excess sialic acid could be detrimental in advanced cancer and cancer cells can evolve mechanisms to guard against hypersialylation. In summary, flux-driven changes to sialylation offer an intriguing and novel mechanism to switch between context-dependent pro- or anti-cancer activities of the several oncoproteins identified in this study. These findings illustrate how metabolic glycoengineering can uncover novel roles of sialic acid in oncogenesis.

Integration of genetic and metabolic features related to sialic acid metabolism distinguishes human breast cell subtypes.

In this report we use 'high-flux' tributanoyl-modified N-acetylmannosamine (ManNAc) analogs with natural N-acetyl as well as non-natural azido- and alkyne N-acyl groups (specifically, 1,3,4-O-Bu3ManNAc, 1,3,4-O-Bu3ManNAz, and 1,3,4-O-Bu3ManNAl respectively) to probe intracellular sialic acid metabolism in the near-normal MCF10A human breast cell line in comparison with earlier stage T-47D and more advanced stage MDA-MB-231 breast cancer lines. An integrated view of sialic acid metabolism was gained by measuring intracellular sialic acid production in tandem with transcriptional profiling of genes linked to sialic acid metabolism. The transcriptional profiling showed several differences between the three lines in the absence of ManNAc analog supplementation that helps explain the different sialoglycan profiles naturally associated with cancer. Only minor changes in mRNA transcript levels occurred upon exposure to the compounds confirming that metabolic flux alone can be a key determinant of sialoglycoconjugate display in breast cancer cells; this result complements the well-established role of genetic control (e.g., the transcription of STs) of sialylation abnormalities ubiquitously associated with cancer. A notable result was that the different cell lines produced significantly different levels of sialic acid upon exogenous ManNAc supplementation, indicating that feedback inhibition of UDP-GlcNAc 2-epimerase/ManNAc kinase (GNE)-generally regarded as the 'gatekeeper' enzyme for titering flux into sialic acid biosynthesis-is not the only regulatory mechanism that limits production of this sugar. A notable aspect of our metabolic glycoengineering approach is its ability to discriminate cell subtype based on intracellular metabolism by illuminating otherwise hidden cell type-specific features. We believe that this strategy combined with multi-dimensional analysis of sialic acid metabolism will ultimately provide novel insights into breast cancer subtypes and provide a foundation for new methods of diagnosis.

Cross-Sector Partnerships for Systemic Change: Systematized Literature Review and Agenda for Further Research.

The literature on cross-sector partnerships has increasingly focused attention on broader systemic or system-level change. However, research to date has been partial and fragmented, and the very idea of systemic change remains conceptually underdeveloped. In this article, we seek to better understand what is meant by systemic change in the context of cross-sector partnerships and use this as a basis to discuss the contributions to the Thematic Symposium. We present evidence from a broad, multidisciplinary systematized review of the extant literature, develop an original definition of systemic change, and offer a framework for understanding the interactions between actors, partnerships, systemic change, and issues. We conclude with some suggestions for future research that we believe will enhance the literature in its next phase of development.

Comparing thought suppression and acceptance as coping techniques for food cravings.

Handling food cravings seems to play a major role in weight management. Many try to simply avoid cravings. However, avoidance based techniques like thought suppression can make attempts to deal with cravings more difficult. Recent research suggests that acceptance based techniques, such as defusion, may be a plausible alternative. The current study aimed to compare these two techniques. Participants were instructed in either a thought suppression or defusion technique at the beginning of a week-long period of attempted chocolate abstinence. A control group was given no instruction. It was predicted that the participants given the defusion intervention would eat less chocolate during six days and during a final taste test. It was found that participants in the defusion group ate significantly less chocolate during the taste test than other groups. However, no difference was found in the amount of chocolate eaten throughout the duration of the experiment. The results are discussed in terms of the possible utility of acceptance based techniques in promoting weight management.