Quality of conscious sedation using dexmedetomidine during full-endoscopic transforaminal discectomy for sciatica: a prospective case series.

INTRODUCTION: Percutaneous transforaminal endoscopic discectomy (PTED) is increasing in popularity as a minimally invasive procedure to treat sciatica caused by lumbar disc herniation. The objective of the current study is to evaluate safety of and satisfaction with the use of local anesthesia and conscious sedation during PTED. METHODS: During a 12-month inclusion period, patients were prospectively included in this single center case series. Inclusion criteria consisted of sciatica lasting for at least 6 weeks, which was not responsive to conservative treatment. PTED was performed using dexmedetomidine as sedative and lidocaine as local anesthesia. Measurements included the numeric rating scale (NRS, from 0 to 10) for leg pain, back pain, COMI-back, and NRS for anxiety of anesthesia and perioperative continuously monitored hemodynamics. Furthermore, satisfaction with the sedation was scored by patients, surgeons, and anesthesiologists. RESULTS: Ninety-two consecutive patients were enrolled. Of all patients, 18.5% had anxiety for undergoing surgery under local anesthesia. All but one patient underwent PTED successfully. There was one case of conversion due to severe, uncontrollable back pain during surgery. Throughout the procedure, hemodynamic parameters showed no clinically relevant change compared to baseline. Anesthesiologic complications were three cases (3.4%) of self-limiting hypoxia and five cases (8.6%) of nausea and/or vomiting. Surgeons and anesthesiologists had a high satisfaction rate (> 87%) with the conscious sedation during the procedure, while satisfaction with sedation was scored 8.4 ± 2.2 by patients. CONCLUSIONS: PTED performed under local anesthesia and conscious sedation is safe and effective to treat sciatica and yields high satisfaction rates from surgeons, anesthesiologists, and patients.

Honorary authorship in high-impact journals in anaesthesia and pain medicine.

Enlisting an author on a published paper, whose input was insufficient, is called honorary authorship. The aim of this study is to assess the proportion of honorary authorship in the field of pain medicine. Data were collected from seven high-impact journals. Corresponding authors were sent a survey regarding their awareness on authorship guidelines, the decision-making in authorship and specific contributions made to the surveyed article. We identified two types of honorary authorship: (1) self-perceived honorary authorship, which is measured by asking the corresponding author if honorary authorship was present according to their opinion and (2) International Committee of Medical Journal Editors (ICMJE)-defined honorary authorship, which is honorary authorship based on the guidelines. In total, 1051 mails were sent and 231 responded, leading to a response rate of 22.0%. 81.3% of the respondents were familiar with the ICMJE authorship guidelines, while 59.6% were aware of the issue of honorary authorship. 13.3% of the respondents were employed at a department in which the senior member is automatically included on all manuscripts. The ICMJE-defined honorary authorship was 40%, while self-perceived honorary authorship was 13.5%. There seems to be a high awareness of the ICMJE guidelines among corresponding authors in the field of Pain Medicine. Despite this high awareness, a high proportion of journal articles had honorary authorship, suggesting that authorship guidelines fail to be applied in a significant proportion of the literature.

SIZE study: study protocol of a multicentre, randomised controlled trial to compare the effectiveness of an interarcuair decompression versus extended decompression in patients with intermittent neurogenic claudication caused by lumbar spinal stenosis.

INTRODUCTION: Intermittent neurogenic claudication (INC) is often caused by lumbar spinal stenosis (LSS). Laminectomy is considered a frequently used surgical technique for LSS. Previous studies have shown that laminectomy can potentially cause lumbar instability. Less invasive techniques, preserving midline structures including the bilateral small size interarcuair decompression, are currently applied. Due to lack of evidence and consensus, surgeons have to rely on their training and own experiences to choose the best surgical techniques for their patients. Hence, an observer and patient blinded multicentre, randomised controlled trial was designed to determine the effectiveness and cost-effectiveness of bilateral interarcuair decompression versus laminectomy for LSS. METHODS AND ANALYSIS: 174 patients above 40 years with at least 12 weeks of INC will be recruited. Patients are eligible for inclusion if they have a clinical indication for surgery for INC with an MRI showing signs of LSS. Patients will be randomised to laminectomy or bilateral interarcuair decompression. The primary outcome is functional status measured with the Roland-Morris Disability Questionnaire at 12 months. Secondary outcomes consist of pain intensity, self-perceived recovery, functional status measured with the Oswestry Disability Index and a physical examination. Outcome measurement moments will be scheduled at 3 and 6 weeks, and at 3, 6, 12, 18, 24, 36 and 48 months after surgery. Physical examination will be performed at 6 weeks, and 12, 24 and 48 months. An economic evaluation will be performed and questionnaires will be used to collect cost data. ETHICS AND DISSEMINATION: The Medical Ethical Committee of the Erasmus Medical Centre Rotterdam approved this study (NL.65826.078.18). The results will be published in an international peer-reviewed journal. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov (NCT03480893). IRB APPROVAL STATUS: MEC-2018-093.

SARS-CoV-2 Infection of Pluripotent Stem Cell-derived Human Lung Alveolar Type 2 Cells Elicits a Rapid Epithelial-Intrinsic Inflammatory Response

The most severe and fatal infections with SARS-CoV-2 result in the acute respiratory distress syndrome, a clinical phenotype of coronavirus disease 2019 (COVID-19) that is associated with virions targeting the epithelium of the distal lung, particularly the facultative progenitors of this tissue, alveolar epithelial type 2 cells (AT2s). Little is known about the initial responses of human lung alveoli to SARS-CoV-2 infection due in part to inability to access these cells from patients, particularly at early stages of disease. Here we present an in vitro human model that simulates the initial apical infection of the distal lung epithelium with SARS-CoV-2, using AT2s that have been adapted to air-liquid interface culture after their derivation from induced pluripotent stem cells (iAT2s). We find that SARS-CoV-2 induces a rapid global transcriptomic change in infected iAT2s characterized by a shift to an inflammatory phenotype predominated by the secretion of cytokines encoded by NF-kB target genes, delayed epithelial interferon responses, and rapid loss of the mature lung alveolar epithelial program. Over time, infected iAT2s exhibit cellular toxicity that can result in the death of these key alveolar facultative progenitors, as is observed in vivo in COVID-19 lung autopsies. Importantly, drug testing using iAT2s confirmed an antiviral dose-response to remdesivir and demonstrated the efficacy of TMPRSS2 protease inhibition, validating a putative mechanism used for viral entry in human alveolar cells. Our model system reveals the cell-intrinsic responses of a key lung target cell to infection, providing a physiologically relevant platform for further drug development and facilitating a deeper understanding of COVID-19 pathogenesis.