Correction: Synthesis and antimicrobial photodynamic effect of methylene blue conjugated carbon nanotubes on E. coli and S. aureus.

Correction for 'Synthesis and antimicrobial photodynamic effect of methylene blue conjugated carbon nanotubes on E. coli and S. aureus' by Paramanantham Parasuraman et al., Photochem. Photobiol. Sci., 2019, DOI: 10.1039/c8pp00369f.

Synthesis and antimicrobial photodynamic effect of methylene blue conjugated carbon nanotubes on E. coli and S. aureus.

Catheter-related bloodstream infections (CRBSIs) are one of the leading causes of high morbidity and mortality in hospitalized patients. The proper management, prevention and treatment of CRBSIs rely on the understanding of these highly resistant bacterial infections. The emergence of such a challenge to public health has resulted in the development of an alternative antimicrobial strategy called antimicrobial photodynamic therapy (aPDT). In the presence of a photosensitizer (PS), light of the appropriate wavelength, and molecular oxygen, aPDT generates reactive oxygen species (ROS) which lead to microbial cell death and cell damage. We investigated the enhanced antibacterial and antibiofilm activities of methylene blue conjugated carbon nanotubes (MBCNTs) on biofilms of E. coli and S. aureus using a laser light source at 670 nm with radiant exposure of 58.49 J cm-2. Photodynamic inactivation in test cultures showed 4.86 and 5.55 log10 reductions in E. coli and S. aureus, respectively. Biofilm inhibition assays, cell viability assays and EPS reduction assays showed higher inhibition in S. aureus than in E. coli, suggesting that pronounced ROS generation occurred due to photodynamic therapy in S. aureus. Results from a study into the mechanism of action proved that the cell membrane is the main target for photodynamic inactivation. Comparatively higher photodynamic inactivation was observed in Gram positive bacteria due to the increased production of free radicals inside these cells. From this study, we conclude that MBCNT can be used as a promising nanocomposite for the eradication of dangerous pathogens on medical devices.

Antimicrobial photodynamic activity of toluidine blue encapsulated in mesoporous silica nanoparticles against Pseudomonas aeruginosa and Staphylococcus aureus.

In the present study, the antimicrobial and antibiofilm efficacy of toluidine blue (TB) encapsulated in mesoporous silica nanoparticles (MSN) was investigated against Pseudomonas aeruginosa and Staphylococcus aureus treated with antimicrobial photodynamic therapy (aPDT) using a red diode laser 670 nm wavelength, 97.65 J cm-2 radiant exposure, 5 min). Physico-chemical techniques (UV-visible (UV-vis) absorption, photoluminescence emission, excitation, and FTIR) and high-resolution transmission electron microscopy (HR-TEM) were employed to characterize the conjugate of TB encapsulated in MSN (TB MSN). TB MSN showed maximum antimicrobial activities corresponding to 5.03 and 5.56 log CFU ml-1 reductions against P. aeruginosa and S. aureus, respectively, whereas samples treated with TB alone showed 2.36 and 2.66 log CFU ml-1 reductions. Anti-biofilm studies confirmed that TB MSN effectively inhibits biofilm formation and production of extracellular polymeric substances by P. aeruginosa and S. aureus.

Redesigning Health Care Organizations: The Influence of Government Policy and Methods of Payment.

Over the last 5 years, there has been a growing trend toward consolidation in the health care field. As reimbursement moves from a fee-for-service model to a value-based model, there will be continued pressure on physicians to either be a hospital employee or to be in a large multidisciplinary practice. This is largely due to the Accountable Care Act, which directs payers to utilize population-based cost analyses, rather than an individual patient-based analysis. To succeed in this environment, practices will have to break down traditional organizational barriers to create evidence-based algorithms for the treatment of individual diagnoses from the initial onset of symptoms until the resolution of symptoms.

Understanding a Value Chain in Health Care.

As the US health care system transitions toward a value-based system, providers and health care organizations will have to closely scrutinize their current processes of care. To do this, a value chain analysis can be performed to ensure that only the most efficient steps are followed in patient care. Ultimately this will produce a higher quality or equal quality product for less cost by eliminating wasteful steps along the way.

The Role of Strategy in Health Care.

Significant changes are occurring in the health care field, and spine surgeons must have an understanding of business strategy if they are going to adapt to the new health care environment. Spine surgeons will be required to demonstrate how their service provides a unique value to their patients or else the patients will obtain care from competitors. Classic methods for demonstrating value such as academic prestige and superior clinical outcomes may no longer be sufficient in the evolving health care field, and surgeons will need to demonstrate a comprehensive and cost-effective treatment algorithm for a diagnosis. This article will discuss the basics of business strategy for the spine surgeon, and ways in which the surgeon may demonstrate value to their patients.

Managing the Delivery of Health Care: What Can Health Care Learn From the Business Community?

The passage of the Patient Protection and Affordable Care Act in March 2010 has resulted in dramatic changes to the delivery of health care in the United States toward a value-based system. While this is a significant change from the previous model, it presents an opportunity for high-quality health care providers to improve patient outcomes while also increasing revenue. However, those that lack a clear strategy to effectively implement change and communicate the increased value to the patients likely will suffer, regardless of how successful or prestigious they seem today.

Advances in the understanding of cervical spine deformity.

Cervical spine deformities pose substantial challenges for spine surgeons. The anatomy and biomechanics of the cervical spine play an important role in the decision-making process regarding treatment. The etiology of cervical deformities can be congenital, developmental, iatrogenic, degenerative, or inflammatory. Dropped head syndrome has been recently described but is poorly understood. Patients have variable presentations ranging from neck pain to an inability to maintain head position and neural compromise. Radiographic angles are important to monitor the deformity and plan the surgical correction. Treatment is focused on relieving pain, preventing and improving neurologic compromise, and improving overall spinal alignment and balance. The surgical approach and the level of fusion should be individualized on a case-by-case basis. The surgeon can greatly improve a patient's quality of life by understanding the nature of the patient's deformity and fully considering all treatment options.

The integration of radiosurgery for the treatment of patients with metastatic spine diseases.

Significant evidence emerging in the spinal oncology literature recommends radiosurgery as a primary modality of treatment of spinal metastasis. Improvements in the methods of delivering radiation have increased the ability to provide a higher and more exacting dose of radiation to a tumor bed than previously. Using treatment-planning software, radiation is contoured around a specific lesion with the intent of administering a tumoricidal dose. Combined with a minimally invasive, tumor-load reducing surgery, this advanced form of radiation therapy can provide better local control of the tumor compared with conventional external beam radiation.

Patient Positioning in Spine Surgery: What Spine Surgeons Should Know?

Spine surgery has advanced tremendously over the last decade. The number of spine surgeries performed each year has also been increasing constantly. Unfortunately, the reporting of position-related complications in spine surgery has also been steadily increasing. These complications not only result in significant morbidity for the patient but also raises the risk of litigation for the surgical and anesthetic teams. Fortunately, most position-related complications are avoidable with basic positioning knowledge. Hence, it is critical to be cautious and take all necessary precautions to avoid position-related complications. We discuss the various position-related complications associated with the prone position, which is the most commonly used position in spine surgery, in this narrative review. We also discuss the various methods for avoiding complications. Furthermore, we briefly discuss less commonly used positions in spine surgery, like the lateral and sitting positions.

Dropped head syndrome: etiology and management.

Dropped head syndrome (DHS) is characterized by severe weakness of the cervical paraspinal muscles that results in the passively correctable chin-on-chest deformity. DHS is most commonly associated with neuromuscular disorders. However, it is not always accompanied by electromyographic findings or noticeable changes on muscle biopsy. In such cases, the term isolated neck extensory myopathy (INEM) is used instead. The literature on the management of INEM is limited. Most reports suggest that nonsurgical interventions help to stabilize the deformity. The literature on surgical management of INEM is limited and mixed, with outcomes ranging from poor to excellent. The prevalence of DHS likely will increase as life expectancy increases. Recent advances in our understanding of sagittal malalignment and surgical techniques have improved our ability to provide better quality of life for patients with cervical deformity.

Regional Anesthesia for Spine Surgery.

Current advancements in spine surgery have led to a recent interest in regional anesthesia for spine surgery. Spinal anesthesia, epidural anesthesia, and their combination are commonly used modalities for regional anesthesia in spine surgeries. The successful use of regional anesthesia has led to the emergence of several new concepts such as awake spinal fusion and outpatient spinal surgery. Regarding analgesic techniques, several new modalities have been described recently such as erector spinae and thoracolumbar interfascial plane blocks. These regional analgesic modalities are aimed at decreasing perioperative pain and enhancing early recovery in patients undergoing spine surgery. This narrative review focuses on the techniques, indications and contraindications, benefits, and complications of regional anesthesia in the context of spine surgery.

Enhanced recovery after surgery (ERAS) protocol in spine surgery.

Enhanced recovery after surgery (ERAS) protocols are a set of interventions which are carried out in the preoperative and perioperative period. They are aimed to decrease the harmful effects of surgery on the body and help the patient recover better post-surgery. The effectiveness of ERAS has been well established in various other surgical specialities. Earlier spine surgery was thought to be very complex for application of ERAS protocols. However, this has changed over the last decade with (ERAS) protocols gaining widespread popularity in spine surgery. Initial studies involving ERAS in spine surgery were limited to lumbar spine. However, over the years the horizon of ERAS has expanded to include anterior cervical surgeries, spine deformity, spinal tumors and spine surgery in the elderly. ERAS has been shown to reduce the length of hospital stay, overall hospital costs, opioid consumption in perioperative and postoperative period and to lower complication rates in spine surgery. In this narrative review, we discuss various aspects of ERAS in spine surgery including the benefits of ERAS in spine surgery, the various components of preoperative, intraoperative and postoperative measures of ERAS protocol.

Perioperative outcomes of general versus spinal anesthesia in the lumbar spine surgery population: A systematic review and meta-analysis of data from 2005 through 2021.

Study design: Meta-analysis. Objectives: Perform a systematic review and meta-analysis to determine the perioperative utility of general versus spinal anesthesia in the lumbar spine surgery population. Methods: PubMed and Embase were queried for manuscripts reporting perioperative outcomes for patients undergoing one to three-level lumbar spine surgery (including decompression, fusion, and decompression with fusion) using either general or spinal anesthesia. Inclusion criteria included studies published from 2005 to 2021, in English, involving primary data from human subjects. Studies were further screened for data on total operative time, blood loss, intraoperative hypotension, pain scores, postoperative nausea and vomiting, time required in post-anesthesia care unit (PACU), PACU pain anesthetic requirement, and length of stay. Risk of bias for each study was assessed using standardized tools (i.e., RoB 2, ROBINS-I, NOS, as appropriate). Potential predictors of outcome were compared using univariate analysis, and variables potentially associated with outcome were subjected to meta-analysis using Cochran-Mantel-Haenszel testing to produce standard mean differences (SMD) or odds ratios (OR) and 95% confidence intervals (CI). Results: In total, 12 studies totaling 2796 patients met inclusion criteria. 1414 (50.6%) and 1382 (49.4%) patients underwent lumbar spine surgery with general anesthesia and spinal anesthesia, respectively. Patients undergoing spinal anesthesia were statistically more likely to have coronary artery disease and respiratory dysfunction. Total operative time (SMD: 12.62 min, 95% CI -18.65 to -6.59), estimated blood loss (SMD: 0.57 mL, 95% CI -0.68 to -0.46), postoperative nausea and vomiting (OR = 0.20, 95% CI 0.15 to 0.26), time required in PACU (SMD = -0.20 min, 95% CI -0.32 to -0.08), and length of stay (SMD = -0.14 day, 95% CI -0.18 to -0.10), all statistically significantly favored spinal anesthesia over general anesthesia (p < 0.05). Conclusion: In one to three-level lumbar spine surgery, current literature supports spinal anesthesia as a viable alternative to general anesthesia. As this was a heterogeneous patient population, prospective randomized trials are needed to corroborate findings.

How to start an awake spine program: Protocol and illustrative cases.

Surgical techniques and technology are steadily improving, thereby expanding the pool of patients amenable for spine surgery. The growing and aging population in the United States further contributes to the increase in spine surgery cases. Traditionally, spine surgery is performed under general anesthesia. However, awake spinal surgery has recently gained traction due to evidence of decreased perioperative risks, postoperative opioid consumption, and costs, specifically in lumbar spine procedures. Despite the potential for improving outcomes, awake spine surgery has received resistance and has yet to become adopted at many healthcare systems. We aim to provide the fundamental steps in facilitating the initiation of awake spine surgery programs. We also present case reports of two patients who underwent awake spine surgery and reported improved clinical outcomes.

Awake Spinal Fusion.

¼: Awake spinal fusion (ASF) integrates advancements in surgical techniques and anesthetic modalities with the aim to maximize benefits and improve outcomes from the surgical and anesthetic standpoints. ¼: ASF employs minimally invasive or endoscopic surgical techniques that are complemented by regional modalities of anesthesia and analgesia. ¼: The current evidence, albeit limited, has shown better results with ASF in terms of postoperative pain scores, a patient's need for opioids, postoperative hospital length of stay, and rehabilitation compared with the conventional technique of open spinal fusion with the patient under general anesthesia.

Regional Anesthesia for Spine Surgery.

Recent advancements in spine surgery anesthesia techniques and pain management has led to a paradigm shift from conventional open spinal procedures to minimally invasive spine surgeries performed on an outpatient basis. Spinal anesthesia and epidural anesthesia alone or in combination with spinal are common regional anesthesia modalities used in spine surgeries. New modalities of regional analgesia have emerged recently including erector spinae and thoracolumbar interfascial plane block, aimed at decreasing perioperative pain and enhancing early recovery in patients undergoing spine surgery. In this narrative review we discuss the characteristics of regional anesthesia including its types, indications, contraindications, benefits, and potential complications along with new modalities of regional analgesia.

Comparative outcome analysis of spinal anesthesia versus general anesthesia in lumbar fusion surgery.

INTRODUCTION: Spinal anesthesia (SA) has been shown in several studies to be a viable alternative to general anesthesia (GA) in laminectomies, discectomies, and microdiscectomies. However, the use of SA in spinal fusion surgery has been very scarcely documented in the current literature. Here we present a comparison of SA to GA in lumbar fusion surgery in terms of perioperative outcomes and cost. METHODS: The authors retrospectively reviewed the charts of all patients who underwent 1- or 2-level minimally invasive transforaminal lumbar interbody fusion (TLIF) surgery by a single surgeon, at a single institution, from 2015 to 2018. Data collected included demographics, operative and recovery times, nausea/vomiting, postoperative pain, and opioid requirement. Costs were included in the analysis if they were: 1) non-fixed; 2) incurred in the operating room (OR); and 3) directly related to patient care. All cost data represents net costs and was obtained from the hospital revenue cycle team. Patients were grouped for statistical analysis based on anesthetic modality. RESULTS: A total of 29 patients received SA and 46 received GA. Both groups were similar in terms of age, gender, BMI, number of levels operated upon, preoperative diagnosis, and medical comorbidities. The SA group spent less time in the OR (163.86 ± 9.02 vs. 195.63 ± 11.27 min, p < 0.05), PACU (82.00 ± 7.17 vs. 102.98 ± 8.46 min, p < 0.05), and under anesthesia (175.03 ± 9.31 vs. 204.98 ± 10.15 min, p < 0.05) than the GA group. Post-surgery OR time was significantly less with SA than with GA (6.00 ± 1.09 vs. 17.26 ± 3.05 min, p < 0.05); however, pre-surgery OR time was similar between groups (50.17 ± 3.08 vs. 56.17 ± 5.34 min, p = 0.061). The SA group also experienced less maximum postoperative pain (3.31 ± 1.41 out of 10 vs. 5.96 ± 0.84/10, p < 0.05) and required less opioid analgesics (2.38 ± 1.37 vs. 5.39 ± 0.84 doses, p < 0.05). Both groups experienced similar nausea or vomiting rates and adverse events postoperatively. Net operative cost was found to be $812.31 (5.6%) less with SA than with GA, although this difference was not significant (p = 0.225). DISCUSSION/CONCLUSION: To our knowledge, SA is almost never used in lumbar fusion, and a cost-effectiveness comparison with GA has not been recorded. In this retrospective study, we demonstrate that the use of SA in lumbar fusion surgery leads to significantly shorter operative and recovery times, less postoperative pain and opioid usage, and slight cost savings over GA. Thus, we conclude that this anesthetic modality represents a safe and cost-effective alternative to GA in lumbar fusion.

Awake spinal fusion.

'Awake spinal fusion' is a novel approach to spine surgery that combines modern anaesthetic and surgical technique resulting in improved patient satisfaction and overall outcomes. Along with techniques of regional anaesthesia, minimally invasive or endoscopic surgical techniques are used to minimize surgical dissection and blood loss. Although, it is a relatively new concept with limited supporting evidence till date, it may prove to be highly effective in reducing post-operative hospital stays, in-hospital complications and cost of surgery while at the same time expediting recovery and rehabilitation. The current review focuses on techniques, advantages, limitations and the available evidence on awake spinal fusion.

Biogenic Silver Nanoparticles Decorated with Methylene Blue Potentiated the Photodynamic Inactivation of Pseudomonas aeruginosa and Staphylococcus aureus.

The persistence of multidrug resistance among microorganisms has directed a mandate towards a hunt for the development of alternative therapeutic modalities. In this context, antimicrobial photodynamic therapy (aPDT) is sprouted as a novel strategy to mitigate biofilms and planktonic cells of pathogens. Nanoparticles (NPs) are reported with unique intrinsic and antimicrobial properties. Therefore, silver NPs (AgNPs) were investigated in this study to determine their ability to potentiate the aPDT of photosensitizer against Staphylococcus aureus and Pseudomonas aeruginosa. Biologically synthesized AgNPs were surface coated with methylene blue (MB) and studied for their aPDT against planktonic cells and biofilms of bacteria. The nano-conjugates (MB-AgNPs) were characterized for their size, shape and coated materials. MB-AgNPs showed significant phototoxicity against both forms of test bacteria and no toxicity was observed in the dark. Moreover, activity of MB-AgNPs was comparatively higher than that of the free MB, which concludes that MB-AgNPs could be an excellent alternative to combat antibiotic resistant bacteria.