The analgesic effectiveness of perioperative lidocaine infusions for acute and chronic persistent postsurgical pain in patients undergoing breast cancer surgery: a systematic review and meta-analysis.

BACKGROUND: Breast cancer is the most common cancer among women and tumour resection carries a high prevalence of chronic persistent postsurgical pain (CPSP). Perioperative i.v. lidocaine infusion has been proposed as protective against CPSP; however, evidence of its benefits is conflicting. This review evaluates the effectiveness of perioperative lidocaine infusions for breast cancer surgery. METHODS: Randomised trials comparing perioperative lidocaine infusions with parenteral analgesia in breast cancer surgery patients were sought. The two co-primary outcomes were the odds of CPSP at 3 and 6 months after operation. Secondary outcomes included rest pain at 1, 6, 12, and 24 h; analgesic consumption at 0-24 and 25-48 h; quality of recovery; opioid-related side-effects; and lidocaine infusion side-effects. Hartung-Knapp-Sidik-Jonkman (HKSJ) random effects modelling was used. RESULTS: Thirteen trials (1039 patients; lidocaine: 518, control: 521) were included. Compared with control, perioperative lidocaine infusion did not decrease the odds of developing CPSP at 3 and 6 months. Lidocaine infusion improved postoperative pain at 1 h by a mean difference (95% confidence interval) of -0.65 cm (-0.73 to -0.57 cm) (P<0.0001); however, this difference was not clinically important (1.1 cm threshold). Similarly, lidocaine infusion reduced oral morphine consumption by 7.06 mg (-13.19 to -0.93) (P=0.029) over the first 24 h only; however, this difference was not clinically important (30 mg threshold). The groups were not different for any of the remaining outcomes. CONCLUSIONS: Our results provide moderate-quality evidence that perioperative lidocaine infusion does not reduce CPSP in patients undergoing breast cancer surgery. Routine use of lidocaine infusions for perioperative analgesia and CPSP prevention is not supported in this population. SYSTEMATIC REVIEW PROTOCOL: PROSPERO CRD42023420888.

The impact of omega-3 polyunsaturated fatty acid supplementation on singing training in vocal performers: A non-randomized double-blind placebo-controlled study.

INTRODUCTION: Vocal performers often seek natural treatments to improve their vocal capability. Omega-3 polyunsaturated fatty acid (PUFA) supplementation may reduce inflammation and cause changes in body composition, such as loss of fat mass. The purpose of this study was to determine if omega-3 PUFA supplementation in combination with a singer's training regimen enhances singing training and body composition. METHODS: This was a non-randomized, double-blind, placebo-controlled trial. Forty-three college-level students were recruited and volunteered to serve as study participants. 3.0 grams of omega-3 PUFA per day or 3.0 grams of placebo per day were provided over a 10-week intervention. Participants completed Singing Voice Handicap Index (SVHI), Reflux Symptom Index (RSI), Evaluation of Ability to Sing Easily (EASE), Voice Range Profile (VRP), food records and body composition measures at baseline and study end. RESULTS: Thirty-five participants completed the study. SVHI was significantly different between groups (p = 0.0152; ƞ2 = 0.153). A minor third was added to the bottom of the range in 50% of males in the supplement group (placebo = 0%). Body composition measures were not statistically significant, although those in the supplement group lost more fat mass than placebo, p = 0.101. DISCUSSION/CONCLUSION: Omega-3 PUFA supplementation may be beneficial to improve how active singers feel about their voice and could potentially improve voice range in conjunction with voice lessons, however more research is necessary to confirm the latter. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05141045.

Rare Case of Tongue Ischemia Following Cardiopulmonary Bypass.

Tongue ischemia is a devastatingly rare disease complication that is typically attributed to cranial arteritis, vasculitis, or prolonged oral intubation that manifests in a patient as a phenotypically black or discolored tongue. There have been less than 10 cases reported in the literature, however, documenting tongue ischemia secondary to shock states requiring high-dose vasopressor support. In these cases, the ischemia or necrosis has typically been limited to the tip of the tongue or has been associated with unilateral disease as bilateral tongue involvement is unlikely given the collateral blood supply of the tongue. To date, the use of imaging modalities to confirm lingual artery disease as the etiology for the presentation of tongue ischemia has been limited. We present a unique case of bilateral tongue ischemia following the use of cardiopulmonary bypass which was confirmed with radiographic evidence demonstrating bilateral lingual artery disease. The nature of case is presented, previous reports of similar cases are reviewed, and potential etiologies of this rare manifestation are discussed.

Harnessing Followership to Empower Graduate Medical Education Trainees.

Followership is the leadership practiced by individuals who are in positions of responsibility without authority, whereby they exert their influence to help execute the vision of their leaders. The central principle of followership is a commitment to actively support leaders and organizations. Without effective followers, organizations flounder, decision-making lies only at the top echelons, and plans are either incompletely executed or not executed at all. In this perspective, we introduce the concept of followership as an important part of leadership development. We explore pedagogical methods for teaching graduate medical education (GME) trainees the followership tenets of service, assuming responsibility, and challenging leadership as necessary skills to achieve partnership with their leaders. We argue that developing followership skills, specifically partnering skills, can help trainees excel as leaders and attendings. GME trainees who practice effective followership take initiative by co-managing their patients with their attendings. By displaying both willingness to serve and challenge their leaders, they add to the success of the whole unit. Followership is a skill that can be learned. Learners should reflect on their own followership style and identify areas for flexibility and growth. Those seeking to become partners should solicit explicit feedback, observe their role models, and seek opportunities to role play situations that highlight the difficulties of followership. Partnership allows for development of a space between leaders and followers to experience empathy, reward ownership, and grow leaders.

Building Individual and Organizational Wellness Through Effective Followership.

Burnout is widespread across the healthcare industry. Physician burnout has been linked to significant decrements in personal wellness, patient satisfaction, patient outcomes, and organizational financial losses. Appropriately, burnout has been identified as an important issue for leaders in the field as it can lead to physician turnover and loss of talent. In this article, we address how burnout is related to followership. We assert that physicians can utilize effective followership to increase wellness not only for themselves, but also for their leaders and organizations.

The Impact of Fish Oil Supplementation on Self-Perception of the Voice in Vocal Performers: A Randomized, Single-Blind, Placebo-Controlled Study.

PURPOSE: Physically active adults have experienced training benefits from fish oil-derived omega-3 fatty acid (FO n3), which may also be of benefit to singers. The purpose of this research study was to determine if self-reported vocal adaptations and body composition changes occur in singers following FO n3 supplementation in conjunction with a singer's normal training regimen. METHOD: Twenty college students, currently enrolled in vocal lessons at a university, were randomized to receive either 3.0 g of FO n3 or placebo, which they took during a 10-week study period. Participants were blinded to group assignment. Participants completed the Reflux Symptom Index (RSI), Singing Voice Handicap Index-10 (SVHI-10), and the Evaluation of Ability to Sing Easily (EASE) and submitted to body composition measures (weight, skeletal mass, and body fat mass) before and after the study period. RESULTS: Sixteen participants completed all parts of the study protocol. Mean compliance for the placebo group (83.9%) and the supplement group (75.2%) was similar. There were no significant differences in body composition measures, RSI scores, and EASE scores between groups. Scores on the SVHI-10 decreased significantly over time for all participants. CONCLUSIONS: Improvements seen in the SVHI-10 were not meaningfully different between the supplement and placebo group, pointing to the benefit of weekly lessons. The lack of changes in the questionnaire scores in the supplement group are partially attributed to the low compliance rate and low sample size, which is supported by the lack of change in the body composition measures.

Early Mitral Valve Repair Failure in the Setting of Endocarditis: When to Reoperate?

Surgery is recommended for endocarditis complicated by annular abscess or destruction of the native valve. Guidelines also recommend valvular repair over replacement for endocarditis when feasible. Guidance on management of early repair failure is not well described. (Level of Difficulty: Intermediate.).

Comparison of physiological demands in Warmblood show jumping horses over a standardized 1.10 m jumping course versus a standardized exercise test on a track.

BACKGROUND: A greater understanding of exercise physiology and biochemistry is required for the sport horse disciplines, including show jumping. Conditioning of horses for show jumping is empirical because they are primarily trained on flat ground, however the equivalent workload between jumping and flat work is currently unknown. The objectives of the study were therefore to compare the physiological demands of Warmblood show jumpers over a standardized 1.10 m course vs a 600 m standardized incremental exercise test on flat ground, and to report reference field test values for competitive show jumping horses. In this prospective field study, 21 healthy, actively competing Warmblood show jumping horses were assessed to determine physiological variables after a standardized jumping course at 6.4 m/s (average speed) and track standardized incremental exercise test at 5 m/s, 8 m/s and 11 m/s. Heart rate, velocity, blood lactate, blood pH, pCO2, bicarbonate, PCV and TP concentrations were recorded. V200, V170 and VLa4 were calculated. Parametric statistics were performed on analysis of all 21 horses' variables. RESULTS: Contrary to exercise at 5 m/s and 11 m/s, cantering at 8 m/s did not induce any significant difference in blood lactate, mean heart rate or mean venous blood pH compared to after completion of the jumping course. CONCLUSIONS: Jumping a 1.10 m course demands a statistically similar workload to cantering around a flat track at 8 m/s. This study will help to test fitness and design conditioning programs for Warmblood show jumping horses.

Doing What Is Right.

Junior officers have an obligation to "lead up." They help senior officers successfully complete missions while maintaining accountability to core values and taking care of those they lead. The following case highlights one junior officer's challenge "leading up" in a very ambiguous situation.

Vitamin D levels are associated with epistaxis severity and bleeding duration in hereditary hemorrhagic telangiectasia.

AIM: To explore the association between vitamin D levels and mild versus severe epistaxis, as well as the overall epistaxis severity score (ESS) in patients with hereditary hemorrhagic telangiectasia. PATIENTS & METHODS: A retrospective chart review of 198 patients was performed to explore the relationship between vitamin D levels and the ESS. Vitamin D levels were also compared with those with mild epistaxis to those with severe epistaxis. RESULTS: A significant difference was found between patient's vitamin D levels and their associated ESS and duration of epistaxis. Patients with mild epistaxis had higher levels of vitamin D than patients with severe epistaxis. CONCLUSION: Vitamin D is associated with features of hereditary hemorrhagic telangiectasia including ESS, bleeding time and epistaxis severity.

Preoperative right ventricle voltage mapping in Ebstein's anomaly: can we make the late arrhythmogenic mortality following the cone procedure zero?

A young woman with Epstein's anomaly had a large endocardial scar in the atrialised ventricular myocardium. In patients with significant preoperative ventricular scarring, more information is needed to help appropriately manage the risk of ventricular arrhythmias and sudden death.

Ataxia telangiectasia mutated (ATM) interacts with p400 ATPase for an efficient DNA damage response.

BACKGROUND: Ataxia telangiectasia mutated (ATM) and TRRAP proteins belong to the phosphatidylinositol 3-kinase-related kinase family and are involved in DNA damage repair and chromatin remodeling. ATM is a checkpoint kinase that is recruited to sites of DNA double-strand breaks where it phosphorylates a diverse range of proteins that are part of the chromatin and DNA repair machinery. As an integral subunit of the TRRAP-TIP60 complexes, p400 ATPase is a chromatin remodeler that is also targeted to DNA double-strand break sites. While it is understood that DNA binding transcriptional activators recruit p400 ATPase into a regulatory region of the promoter, how p400 recognises and moves to DNA double-strand break sites is far less clear. Here we investigate a possibility whether ATM serves as a shuttle to deliver p400 to break sites. RESULTS: Our data indicate that p400 co-immunoprecipitates with ATM independently of DNA damage state and that the N-terminal domain of p400 is vital for this interaction. Heterologous expression studies using Sf9 cells revealed that the ATM-p400 complex can be reconstituted without other mammalian bridging proteins. Overexpression of ATM-interacting p400 regions in U2OS cells induced dominant negative effects including the inhibition of both DNA damage repair and cell proliferation. Consistent with the dominant negative effect, the stable expression of an N-terminal p400 fragment showed a decrease in the association of p400 with ATM, but did not alter the association of p400 with TRRAP. CONCLUSION: Taken together, our findings suggest that a protein-protein interaction between ATM and p400 ATPase occurs independently of DNA damage and contributes to efficient DNA damage response and repair.

Ectromelia Virus Disease Characterization in the BALB/c Mouse: A Surrogate Model for Assessment of Smallpox Medical Countermeasures.

In 2007, the United States- Food and Drug Administration (FDA) issued guidance concerning animal models for testing the efficacy of medical countermeasures against variola virus (VARV), the etiologic agent for smallpox. Ectromelia virus (ECTV) is naturally-occurring and responsible for severe mortality and morbidity as a result of mousepox disease in the murine model, displaying similarities to variola infection in humans. Due to the increased need of acceptable surrogate animal models for poxvirus disease, we have characterized ECTV infection in the BALB/c mouse. Mice were inoculated intranasally with a high lethal dose (125 PFU) of ECTV, resulting in complete mortality 10 days after infection. Decreases in weight and temperature from baseline were observed eight to nine days following infection. Viral titers via quantitative polymerase chain reaction (qPCR) and plaque assay were first observed in the blood at 4.5 days post-infection and in tissue (spleen and liver) at 3.5 days post-infection. Adverse clinical signs of disease were first observed four and five days post-infection, with severe signs occurring on day 7. Pathological changes consistent with ECTV infection were first observed five days after infection. Examination of data obtained from these parameters suggests the ECTV BALB/c model is suitable for potential use in medical countermeasures (MCMs) development and efficacy testing.

Cardiovascular Imaging for the Primary Prevention of Atherosclerotic Cardiovascular Disease Events.

Traditional cardiovascular risk factors have well-known limitations for the accurate assessment of individual cardiovascular risk. Unlike risk factor-based scores which rely on probabilistic calculations derived from population-based studies, coronary artery calcium (CAC) scoring, and carotid ultrasound allow for the direct visualization and quantification of subclinical atherosclerosis with the potential for a more accurate, personalized risk assessment and treatment approach. Among strategies used to guide preventive management, CAC scoring has consistently and convincingly outperformed traditional risk factors for the prediction of adverse cardiovascular events. Moreover, several studies have demonstrated the potential of CAC testing to improve precision for the use of more intensive pharmacologic therapies, such as aspirin and statins, in patients most likely to derive benefit, as compared to atherosclerotic cardiovascular disease risk calculators. By comparison to CAC, the role of carotid ultrasound for the measurement of carotid intima-media thickness (CIMT) remains less well-elucidated but may be significantly improved with the inclusion of plaque screening and novel three-dimensional measurements of plaque volume and morphology. Despite significant evidence supporting the ability of non-invasive atherosclerosis imaging (particularly CAC) to guide preventive management, imaging remains an under-utilized strategy among current guidelines and clinical practice. Herein, we review evidence regarding CAC and carotid ultrasound for patient risk classification, with a comparison of these techniques to currently advocated traditional risk factor-based scores.

The role of the prostaglandin E2 receptors in vulnerability of oligodendrocyte precursor cells to death.

BACKGROUND: Activity of cyclooxygenase 2 (COX-2) in mouse oligodendrocyte precursor cells (OPCs) modulates vulnerability to excitotoxic challenge. The mechanism by which COX-2 renders OPCs more sensitive to excitotoxicity is not known. In the present study, we examined the hypothesis that OPC excitotoxic death is augmented by COX-2-generated prostaglandin E2 (PGE2) acting on specific prostanoid receptors which could contribute to OPC death. METHODS: Dispersed OPC cultures prepared from mice brains were examined for expression of PGE2 receptors and the ability to generate PGE2 following activation of glutamate receptors with kainic acid (KA). OPC death in cultures was induced by either KA, 3'-O-(Benzoyl) benzoyl ATP (BzATP) (which stimulates the purinergic receptor P2X7), or TNFα, and the effects of EP3 receptor agonists and antagonists on OPC viability were examined. RESULTS: Stimulation of OPC cultures with KA resulted in nearly a twofold increase in PGE2. OPCs expressed all four PGE receptors (EP1-EP4) as indicated by immunofluorescence and Western blot analyses; however, EP3 was the most abundantly expressed. The EP3 receptor was identified as a candidate contributing to OPC excitotoxic death based on pharmacological evidence. Treatment of OPCs with an EP1/EP3 agonist 17 phenyl-trinor PGE2 reversed protection from a COX-2 inhibitor while inhibition of EP3 receptor protected OPCs from excitotoxicity. Inhibition with an EP1 antagonist had no effect on OPC excitotoxic death. Moreover, inhibition of EP3 was protective against toxic stimulation with KA, BzATP, or TNFα. CONCLUSION: Therefore, inhibitors of the EP3 receptor appear to enhance survival of OPCs following toxic challenge and may help facilitate remyelination.

Update: A Review of Women's Health Fellowships, Their Role in Interdisciplinary Health Care, and the Need for Accreditation.

While Women's Health (WH) Fellowships have been in existence since 1990, knowledge of their existence seems limited. Specialized training in WH is crucial to educate leaders who can appropriately integrate this multidisciplinary field into academic centers, especially as the demand for providers confident in the areas of contraception, perimenopause/menopause, hormone therapy, osteoporosis, hypoactive sexual desire disorder, medical management of abnormal uterine bleeding, office based care of stress/urge incontinence, and gender-based medicine are increasing popular and highly sought after. WH fellowship programs would benefit from accreditation from the American Board of Medical Subspecialties and from the American College of Graduate Medical Education, as this may allow for greater recruitment, selection, and training of future leaders in WH. This article provides a current review of what WH trained physicians can offer patients, and also highlights the added value that accreditation would offer the field. Ultimately, accrediting WH fellowships will improve women's health medical education by creating specialists that can serve as academic leaders to help infuse gender specific education in primary residencies, as well as serve as consultants and leaders, and promote visibility and prestige of the field.