Intraoperative Monitoring of Scoliosis Surgery in Young Patients.

SUMMARY: Intraoperative neurophysiologic monitoring has added substantially to the safety of spinal deformity surgery correction since its introduction over four decades ago. Monitoring routinely includes both somatosensory evoked potentials and motor evoked potentials. Either modality alone will detect almost all instances of spinal cord injury during deformity correction. The combined use of the two modalities provides complementary information, can permit more rapidly identification of problems, and enhances safety though parallel redundancy should one modality fail. Both techniques are well established and continue to be refined. Although there is room for provider preference, proper monitoring requires attention to technical detail, understanding of the underlying physiology, and familiarity with effects of commonly used anesthetic agents.

Perioperative Analgesia in Spine Surgery: A Review of Current Data Supporting Future Direction.

This Clinical Research discusses the diverse nature of spine surgery procedures and the use of multimodal analgesia within enhanced recovery after surgery (ERAS) protocols to improve patient outcomes. Spine surgeries range from minor decompressions to extensive tumor resections, performed by neurosurgeons or orthopedic spine surgeons on adults and children. To manage perioperative pain effectively, various methods have been employed, including multimodal analgesia within ERAS protocols. Incorporating ERAS protocols into spine surgery has shown benefits such as reduced pain scores, decreased opioid use, shorter hospital stays, and improved functionality. ERAS protocols help to enhance patient outcomes, focusing on deconstructing these protocols for surgeons and anesthesiologists.

A multidisciplinary opioid-reduction pathway for robotic prostatectomy: outcomes at year one.

BACKGROUND: Opioid use has come under increasing scrutiny, driven in part by the opioid crisis and growing concerns that up to 6% of opioid-naïve patients may become chronic opioid users. This has resulted in a revaluation of perioperative practice. For this reason, we implemented a multidisciplinary pathway to reduce perioperative opioid usage through education and standardization of practice. METHODS: A single-centre retrospective evaluation was performed after 1 year, comparing the outcomes to those of the 2 years prior to pathway implementation. Comparisons were made between pre- vs. post pathway change by 2:1 propensity matching between cohorts. Univariate linear regression models were created using demographic variables with those that were p < 0.15 included in the final model and using post-operative opioid use (in oral morphine equivalents, OME) as the primary outcome. RESULTS: We found that intraoperative opioid use was significantly decreased 38.2 mg (28.3) vs. 18.0 mg (40.4) oral morphine equivalents (OME), p < .001, as was post-operative opioid use for the duration of the hospitalization, 46.3 mg (49.5) vs. 35.49 mg (43.7) OME, p = 0.002. In subgroup analysis of those that received some intraoperative opioids (n = 152) and those that received no opioids (n = 34), we found that both groups required fewer opioids in the post-operative period 47.0 mg (47.7) vs. 32.4 mg (40.6) OME, p = 0.001, + intraoperative opioids, 62.4 mg (62.9) vs. 35.8 mg (27.7) OME, p = 0.13, - intraoperative opioids. Time to discharge from the PACU was reduced in both groups 215 min (199) vs. 167 min (122), p < 0.003, + intraoperative opioids and 253 min (270) vs. 167 min (105), p = 0.028, - intraoperative opioids. The duration of time until meeting discharge criteria from PACU was 221 min (205) vs. 170 min (120), p = 0.001. Hospital length of stay (LOS) was significantly reduced 1.4 days (1.3) vs. 1.2 days (0.8), p = 0.005. Both sub-groups demonstrated reduced hospital LOS 1.5 days (1.4) vs. 1.2 days (0.8), p = 0.0047, + intraoperative opioids and 1.7 days (1.6) vs. 1.3 days (0.9), p = 0.0583, - intraoperative opioids. Average pain scores during PACU admission and post-PACU until discharge were not statistically different between cohorts. CONCLUSIONS: These findings underscore the effectiveness of a multidisciplinary approach to reduce opioids. Furthermore, it demonstrates improved patient outcomes as measured by both shorter PACU and almost 50% reduction in perioperative opioid use whilst maintaining similar analgesia as indicated by patient-reported pain scores.

Digital technologies in the public-health response to COVID-19.

Digital technologies are being harnessed to support the public-health response to COVID-19 worldwide, including population surveillance, case identification, contact tracing and evaluation of interventions on the basis of mobility data and communication with the public. These rapid responses leverage billions of mobile phones, large online datasets, connected devices, relatively low-cost computing resources and advances in machine learning and natural language processing. This Review aims to capture the breadth of digital innovations for the public-health response to COVID-19 worldwide and their limitations, and barriers to their implementation, including legal, ethical and privacy barriers, as well as organizational and workforce barriers. The future of public health is likely to become increasingly digital, and we review the need for the alignment of international strategies for the regulation, evaluation and use of digital technologies to strengthen pandemic management, and future preparedness for COVID-19 and other infectious diseases.

THE EFFECTS OF PERIOPERATIVE DEXAMETHASONE ON GLYCEMIC CONTROL AND POSTOPERATIVE OUTCOMES.

Objective: Perioperative glucocorticoids are commonly given to reduce pain and nausea in patients undergoing surgery. However, the glycemic effects of steroids and the potential effects on morbidity and mortality have not been systematically evaluated. This study investigated the association between perioperative dexamethasone and postoperative blood glucose, hospital length of stay (LOS), readmission rates, and 90-day survival. Methods: Data from 4,800 consecutive orthopedic surgery patients who underwent surgery between 2000 and 2016 within a single health system were analyzed retrospectively. Results: Patients with and without diabetes mellitus (DM) who were given a single dose of dexamethasone had higher rates of hyperglycemia during the first 24 hours after surgery as compared to those who did not receive dexamethasone (hazard ratio [HR] was 1.81, and 95% confidence interval [CI] was [1.46, 2.24] for the DM cohort; HR 2.34, 95% CI [1.66, 3.29] for the nonDM cohort). LOS was nearly 1 day shorter in patients who received dexamethasone (geometric mean ratio [GMR] 0.79, 95% CI [0.75, 0.83] for patients with DM; GMR 0.75, 95% CI [0.72, 0.79] for patients without DM), and there was no difference in 90-day readmission rates. In patients without DM, dexamethasone was associated with a higher 90-day overall survival (99.07% versus 96.90%; P = .004). Conclusion: In patients with and without DM who undergo orthopedic surgery, perioperative dexamethasone was associated with a transiently higher risk of hyperglycemia. However, dexamethasone treatment was associated with a shorter LOS in patients with and without DM, and a higher overall 90-day survival rate in patients without DM, compared to patients who did not receive dexamethasone. Abbreviations: BMI = body mass index; CAD = coronary artery disease; CI = confidence interval; DM = diabetes mellitus; GMR = geometric mean ratio; HR = hazard ratio; IV = intravenous; LOS = length of stay; POD = postoperative day.

The rising tide of opioid use and abuse: the role of the anesthesiologist.

Opioid use has risen dramatically in the past three decades. In the USA, opioid overdose has become a leading cause of unintentional death, surpassing motor vehicle accidents. A patient's first exposure to opioids may be during the perioperative period, a time where anesthesiologists have a significant role in pain management. Almost all patients in the USA receive opioids during a surgical encounter. Opioids have many undesirable side effects, including potential for misuse, or opioid use disorder. Anesthesiologists and surgeons employ several methods to decrease unnecessary opioid use, opioid-related adverse events, and side effects in the perioperative period. Multimodal analgesia, enhanced recovery pathways, and regional anesthesia are key tools as we work towards optimal opioid stewardship and the ideal of effective analgesia without undesirable sequelae.

Imaging in Chronic Traumatic Encephalopathy and Traumatic Brain Injury.

CONTEXT: The diagnosis of chronic traumatic encephalopathy (CTE) can only be made pathologically, and there is no concordance of defined clinical criteria for premorbid diagnosis. The absence of established criteria and the insufficient imaging findings to detect this disease in a living athlete are of growing concern. EVIDENCE ACQUISITION: The article is a review of the current literature on CTE. Databases searched include Medline, PubMed, JAMA evidence, and evidence-based medicine guidelines Cochrane Library, Hospital for Special Surgery, and Cornell Library databases. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 4. RESULTS: Chronic traumatic encephalopathy cannot be diagnosed on imaging. Examples of imaging findings in common types of head trauma are discussed. CONCLUSION: Further study is necessary to correlate the clinical and imaging findings of repetitive head injuries with the pathologic diagnosis of CTE.

A Smartphone-based Decision Support Tool Improves Test Performance Concerning Application of the Guidelines for Managing Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy.

BACKGROUND: The American Society of Regional Anesthesia and Pain Medicine (ASRA) consensus statement on regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy is the standard for evaluation and management of these patients. The authors hypothesized that an electronic decision support tool (eDST) would improve test performance compared with native physician behavior concerning the application of this guideline. METHODS: Anesthesiology trainees and faculty at 8 institutions participated in a prospective, randomized trial in which they completed a 20-question test involving clinical scenarios related to the ASRA guidelines. The eDST group completed the test using an iOS app programmed to contain decision logic and content of the ASRA guidelines. The control group completed the test by using any resource in addition to the app. A generalized linear mixed-effects model was used to examine the effect of the intervention. RESULTS: After obtaining institutional review board's approval and informed consent, 259 participants were enrolled and randomized (eDST = 122; control = 137). The mean score was 92.4 ± 6.6% in the eDST group and 68.0 ± 15.8% in the control group (P < 0.001). eDST use increased the odds of selecting correct answers (7.8; 95% CI, 5.7 to 10.7). Most control group participants (63%) used some cognitive aid during the test, and they scored higher than those who tested from memory alone (76 ± 15% vs. 57 ± 18%, P < 0.001). There was no difference in time to completion of the test (P = 0.15) and no effect of training level (P = 0.56). CONCLUSIONS: eDST use improved application of the ASRA guidelines compared with the native clinician behavior in a testing environment.

Packed red blood cells suppress T-cell proliferation through a process involving cell-cell contact.

BACKGROUND: Packed red blood cell (PRBC) transfusion suppresses immunity and increases morbidity and mortality. Leukocyte reduction has failed to abrogate these effects, thus implicating red blood cells themselves or their components. PRBC impair proliferation of immortal (Jurkat) T cells by depleting arginine from the extracellular environment. The effect of PRBC on isolated ex vivo T-cell proliferation has not been reported. We hypothesize that PRBCs depress mitogen-stimulated proliferation in isolated human and mouse T cells. METHODS: Human peripheral T cells were isolated by Ficoll-Hypaque gradient, purified by magnetic separation, and stimulated with anti-CD3 or anti-CD28. DO11.10 transgenic mouse splenic T cells were stimulated with ovalbumin. Cells were cultured at 1 x 10(6)/mL in 96-well plates or in 24-transwell plates in the presence of PRBC (0.015-5% by volume, stored for 4-6 weeks). In culture media, arginine and citrulline were varied. Proliferation was measured at 72 hours by thymidine incorporation. T-cell viability, apoptosis, and receptor zeta chain were measured by flow cytometry. RESULTS: PRBC significantly depressed human peripheral and mouse splenic T-cell proliferation in a dose-dependent manner. PRBC arginase blockade by N-omega-hydroxy-nor-l-arginine only partly restored proliferation. Cell contact was required in both cell types for maximal effect. Depressed zeta chain in human peripheral T cells was partly restored by arginase blockade. Salvage by high-dose arginine and citrulline was unsuccessful. Decreased proliferation was not related to cell death. CONCLUSION: PRBC suppresses mitogen-stimulated human and antigen-stimulated mouse T-cell proliferation by mechanisms independent of arginine depletion. This is a novel mechanism for transfusion-associated immune suppression.

A C. elegans homolog of huntingtin-associated protein 1 is expressed in chemosensory neurons and in a number of other somatic cell types.

Huntingtin-associated protein 1 (HAP1) is a binding partner for huntingtin, the protein responsible for Huntington's disease. In mammals, HAP1 is mostly found in brain where it is expressed in neurons. Although several functions have been proposed for HAP1, its role has not yet been clearly established. In this paper, we report on the identification of a HAP1 Caenorhabditis elegans homolog called T27A3.1. T27A3.1 shows conservation with rat and human HAP1, as well as with Milton, a Drosophila HAP1 homolog. To determine the cellular expression of T27A3.1 (multiple isoforms; a-e), we generated several transgenic worm lines expressing a fluorescent reporter protein [green fluorescent protein (GFP) and DsRed2] under the control of the promoter for T27A3.1. We have found that T27A3.1 is expressed in many cell types including a subset of chemosensory neurons in the head and tail. These include the amphid chemosensory neurons ASKL and R, ASIL and R, ADFL and ASEL, the phasmid neurons PHBL and R, and the CAN neurons that are required for worm survival.

MRI analysis of the size and shape of the oropharynx in chronic whiplash.

OBJECTIVES: To quantify differences in the size/shape of the oropharynx between female subjects with whiplash and controls. DESIGN: Retrospective cohort. METHODS: A total of 113 subjects (79 whiplash, 34 controls) were included. T1-weighted MRI was used to measure 1) cross-sectional area (CSA [mm(2)]) and 2) shape ratios for the oropharynx. Reliability data were established. RESULTS: Whiplash subjects had significantly smaller oropharynx CSAs (P < 0.001) and shape ratios (P < 0.001) compared with healthy controls. Self-reported levels of pain and disability and duration of symptoms were not associated with size and shape of the oropharynx in whiplash subjects (P = 0.75 and P = 0.99, respectively). Age and BMI did influence the size (P = 0.01) and shape of the oropharynx (P < 0.001) in the whiplash subjects, but only 20 to 30 percent of the variance could be explained by these factors. CONCLUSION: Significant difference in the size and shape of the oropharynx was noted in subjects with chronic whiplash compared with controls. Future studies are required to investigate the relationships between oropharynx morphometry and symptoms in patients with chronic whiplash.

Red blood cell arginase suppresses Jurkat (T cell) proliferation by depleting arginine.

BACKGROUND: Transfusion of packed red blood cells (PRBC) suppresses immunity, but the mechanisms are incompletely understood. PRBCs contain arginase, an enzyme which converts arginine to ornithine and depletes arginine in vitro. Arginine depletion suppresses proliferation of Jurkat T cells in other models. We hypothesize that PRBC arginase-mediated arginine depletion will suppress proliferation of T cells. METHODS: A transfusion model was designed adding PRBC to culture RPMI media with or without an irreversible arginase blocker (nor-NOHA), incubating for 6-48 hours and then removing the PRBCs. Amino acid concentrations in the media were measured using liquid chromatography mass spectrometry. T cells were then added to the pre-conditioned media, cultured for 24 hours, and proliferation was measured. RESULTS: PRBC depleted arginine significantly and increased ornithine in media compared to baseline PRBC treated wells and significantly decreased T cell proliferation. These effects were enhanced with volume of PRBC exposure. Nor-NOHA inhibition of arginase restored T cell proliferation in PRBC treated cultures. CONCLUSIONS: Jurkat T cell proliferation was impaired by PRBC in clinically relevant volumes. The mechanism influencing T cell impairment appears to result from arginine depletion by arginase. Arginine depletion by PRBC arginase may be a novel mechanism for immunosuppression after transfusion.

Influences of inbreeding and genetics on telomere length in mice.

We measured telomere lengths of blood leukocytes in several inbred and outbred mammalian species, using a telomere-specific fluorescent probe and flow cytometry. Humans, non-human primates, and three outbred populations of Peromyscus mice ( Peromyscus leucopus, Peromyscus maniculatus, and Peromyscus polionotus) have short telomeres. Two common strains of laboratory mice, C57BL/6J and DBA/2J, have telomeres several times longer than most other mammals surveyed. Moreover, the two inbred laboratory mouse strains display significantly different telomere lengths, suggesting the existence of strain-specific genetic determinants. To further examine the effects of inbreeding, we studied three Peromyscus leucopus inbred lines (GS109, GS16A1, and GS16B), all derived from the outbred P. leucopus stock. Telomeres of all three inbred lines are significantly lengthened relative to outbred P. leucopus, and the three lines display strain-specific significantly different telomere lengths, much like the C57BL/6J and DBA/2J strains of M. musculus. To further characterize the genetic inheritance of telomere length, we carried out several crosses to obtain hybrid F(1) mice between parental strains displaying the phenotype of long and short telomeres. In all F(1) mice assayed, peripheral blood leukocyte telomere length was intermediate to that of the parents. Additionally, we generated F(2) mice from a cross of the ( P. leucopus outbred x GS16B)F(1). Based on the distribution of telomere length in the F(2) population, we determined that more than five loci contribute to telomere length regulation in Peromyscus. We concluded that inbreeding, through unknown mechanisms, results in the elongation of telomeres, and that telomere length for a given species and/or sub-strain is genetically determined by multiple segregating loci.