Glial immune-related pathways mediate effects of closed head traumatic brain injury on behavior and lethality in Drosophila.

In traumatic brain injury (TBI), the initial injury phase is followed by a secondary phase that contributes to neurodegeneration, yet the mechanisms leading to neuropathology in vivo remain to be elucidated. To address this question, we developed a Drosophila head-specific model for TBI termed Drosophila Closed Head Injury (dCHI), where well-controlled, nonpenetrating strikes are delivered to the head of unanesthetized flies. This assay recapitulates many TBI phenotypes, including increased mortality, impaired motor control, fragmented sleep, and increased neuronal cell death. TBI results in significant changes in the transcriptome, including up-regulation of genes encoding antimicrobial peptides (AMPs). To test the in vivo functional role of these changes, we examined TBI-dependent behavior and lethality in mutants of the master immune regulator NF-κB, important for AMP induction, and found that while sleep and motor function effects were reduced, lethality effects were enhanced. Similarly, loss of most AMP classes also renders flies susceptible to lethal TBI effects. These studies validate a new Drosophila TBI model and identify immune pathways as in vivo mediators of TBI effects.

Pain Plan Implementation Effect: Analysis of Postoperative Opioid Use, Hospital Length of Stay, and Clinic Resource Utilization for Patients Undergoing Elective Spine Surgery.

INTRODUCTION: The Pain Plan was developed collaboratively and implemented a unique systematic approach to reduce opioid usage in elective spine surgery. METHODS: This was a retrospective cohort study comparing patients who underwent elective spine surgery before and after Pain Plan implementation. The Pain Plan was implemented on May 1, 2019. The experimental group comprised patients over the subsequent 1-year period with a Pain Plan (n = 319), and the control group comprised patients from the previous year without a Pain Plan (n = 385). Outcome variables include hospital length of stay (LOS), inpatient opioid use, outpatient opioid prescription quantities, number of clinic communication encounters, and communication encounter complexity. Patients were prospectively divided into three surgical invasiveness index subgroups representing small-magnitude, medium-magnitude, and large-magnitude spine surgeries. RESULTS: There was a statistically significant decrease in hospital LOS ( P = 0.028), inpatient opioid use ( P = 0.001), and the average number of steps per communication encounter ( P = 0.010) for Pain Plan patients and a trend toward decreased outpatient opioid prescription quantities ( P = 0.052). No difference was observed in patient-reported pain scores. Statistically significant decreases in inpatient opioid use were seen in large-magnitude (50% reduction, P < 0.001) and medium-magnitude surgeries (49% reduction, P < 0.001). For small-magnitude surgeries, there was no difference (1.7% reduction, P = 0.99). The median LOS for large-magnitude surgeries decreased by 38% (20.5-hour decrease, P < 0.001) and decreased by 34% for medium-magnitude surgeries (17-hour difference, P = 0.055). For small-magnitude surgeries, there was no significant difference ( P = 0.734). Outpatient opioid prescription quantities were markedly decreased in small-magnitude surgeries only. The total number of communication encounters was not statistically significant in any group. However, the number of steps within a communication encounter was significantly decreased ( P = 0.010), and staff survey respondents reported more efficient and effective postoperative pain management for Pain Plan patients. DISCUSSION: Pain Plan implementation markedly decreased hospital LOS, inpatient opioid use and outpatient opioid prescription quantities, and clinic resource utilization in elective spine surgery patients.

Utilizing previous patient opioid experiences for pain plan implementation: Role of opioid use categorization on inpatient and outpatient opioid use, length of stay, pain scores, and clinic resource utilization following elective spine surgery.

Background: A Pain Plan was formulated for all patients undergoing elective spine surgery at our institution. It was based on prior opioid experiences and developed collaboratively between the patient and the surgeon at a preoperative clinic visit. Category 1 patients had no previous opioid experience, Category 2 patients had remote previous opioid experience with acceptable pain control and no side effects, Category 3 patients had remote previous opioid experience with unacceptable pain control and/or side effects, and Category 4 patients had opioid use leading up to surgery. Methods: This is a retrospective cohort study comparing adult patients within four different pain plan categories over one year (n = 313) to determine if categorization is predictive. Demographic data collected included age, gender, ASA class, BMI, smoking status, insurance status, substance abuse, and comorbid psychiatric diagnoses. Demographic factors between categories were compared and controlled for as covariates within analyses. Outcomes measures comprised self-reported pain scores and functional measurements, including inpatient opioid use, outpatient opioid prescription quantities, and postoperative healthcare utilization. Results: Inpatient and outpatient opioid use were statistically significant amongst the categories, with prescription quantities greatest in Category 4, followed by Categories 2, 3, and 1, respectively. There was no difference in LOS or complexity of communication encounters amongst any of the groups. Patient-reported pain scores showed statistically significant differences and followed the same trend as opioid quantities, 4, 2, 3, and 1. The number of communication encounters was significant exclusively for Category 3 vs. 4. Conclusions: The use of categorization in Pain Plan formation has been a helpful tool for postoperative pain management at our institution. Categorization is predictive of pain scores and opioid use after surgery, allowing the surgical team to tailor their care and counseling towards individual patients. In addition, the plan's collaborative nature enables patients to be involved in their pain management decisions while also setting limits and expectations.