Cost of sterility: probe covers should not be mandated for single-shot peripheral nerve blocks.

Ultrasound guidance has become ubiquitous with regional anesthesia, but little consistency exists on necessary ultrasound probe hygiene and sterility barriers. Fear of possible infection has led to calls for universal use of sterile ultrasound probe covers. Available data seems to suggest that single-shot peripheral nerve blocks have a low infectious risk. The widespread use of single-use disposable probe covers would carry an associated cost, increased environmental impact, and little evidence to suggest that they are effective at preventing infection if proper technique is used. While various parties have labeled single-shot nerve blocks as a sterile procedure, in practice, it is a clean technique. In this article, we argue that mandating the use of probe covers is unnecessary and that it should be left to the anesthesiologist to determine what type of anti-infection equipment is necessary for single-shot nerve blocks based on their practice situation and expertize.

Anesthesia start time documentation accuracy where peripheral nerve block is the primary anesthetic.

INTRODUCTION: When used as the primary anesthetic, nerve blocks are not billed as separate procedures. In this scenario, the anesthesia start (AStart) time should include the block procedural time. We measured how often AStart time was documented before the nerve block was placed in the preoperative area, and compared cases where a block team performed the nerve block and cases where the intraoperative anesthesia attending supervised the nerve block. We hypothesized that the involvement of a regional anesthesia team would lead to more accurate documentation of AStart. We also estimated the lost revenue due to inaccurate start time documentation. METHODS: The study population were patients undergoing surgery with a peripheral nerve block as the primary anesthetic. For this analysis, AStart occurring less than 10 min before the in-operating room time was defined as potentially inaccurate. Lost potential revenue was estimated by taking the difference between the documented time of local anesthetic administration and the documented AStart time. RESULTS: A total of 745 cases were analyzed. Overall, 439 cases (58%) cases were identified as having potentially inaccurate start times. There were higher rates of inaccurate AStart documentation by the block team (316/482, 65.5%) compared with blocks supervised by the in-room anesthesia attendings (123/263, 46.7%, p<0.001). Overall, the estimated loss in billable revenue during the study period was a total of $70 265. CONCLUSIONS: The performance of primary regional anesthesia procedure by a block team increased the incidence of inaccurate documentation and uncaptured potential revenue. There is need for education about accurate nerve block documentation for anesthesiologists, especially when separate teams are used.

Substrate binding and inhibition of the anion exchanger 1 transporter.

Anion exchanger 1 (AE1), a member of the solute carrier (SLC) family, is the primary bicarbonate transporter in erythrocytes, regulating pH levels and CO2 transport between lungs and tissues. Previous studies characterized its role in erythrocyte structure and provided insight into transport regulation. However, key questions remain regarding substrate binding and transport, mechanisms of drug inhibition and modulation by membrane components. Here we present seven cryo-EM structures in apo, bicarbonate-bound and inhibitor-bound states. These, combined with uptake and computational studies, reveal important molecular features of substrate recognition and transport, and illuminate sterol binding sites, to elucidate distinct inhibitory mechanisms of research chemicals and prescription drugs. We further probe the substrate binding site via structure-based ligand screening, identifying an AE1 inhibitor. Together, our findings provide insight into mechanisms of solute carrier transport and inhibition.

Chronic post amputation pain: pathophysiology and prevention options for a heterogenous phenomenon.

PURPOSE OF REVIEW: Chronic postamputation pain (cPAP) remains a clinical challenge, and current understanding places a high emphasis on prevention strategies. Unfortunately, there is still no evidence-based regimen to reliably prevent chronic pain after amputation. RECENT FINDINGS: Risk factors for the development of phantom limb pain have been proposed. Analgesic preventive interventions are numerous and no silver bullet has been found. Novel techniques such as neuromodulation and cryoablation have been proposed. Surgical techniques focusing on reimplantation of the injured nerve might reduce the incidence of phantom limb pain after surgery. SUMMARY: Phantom limb pain is a multifactorial process involving profound functional and structural changes in the peripheral and central nervous system. These changes interact with individual medical, psychosocial and genetic patient risk factors. The patient collective of amputees is very heterogeneous. Available evidence suggests that efforts should focus on prevention of phantom limb pain, since treatment is notoriously difficult. Questions as yet unanswered include the evidence-base of specific analgesic interventions, their optimal "window of opportunity" where they may be most effective, and whether patient stratification according to biopsychosocial risk factors can help guide preventive therapy.

Transgender and Nonbinary Patients and Perioperative Scoring Systems: It Is Time for Inclusion.

This Viewpoint advocates for inclusion of nonbinary and transgender reporting in medical research and practice.