Association of Intraoperative Opioid Administration With Postoperative Pain and Opioid Use.

Importance: Opioids administered to treat postsurgical pain are a major contributor to the opioid crisis, leading to chronic use in a considerable proportion of patients. Initiatives promoting opioid-free or opioid-sparing modalities of perioperative pain management have led to reduced opioid administration in the operating room, but this reduction could have unforeseen detrimental effects in terms of postoperative pain outcomes, as the relationship between intraoperative opioid usage and later opioid requirements is not well understood. Objective: To characterize the association between intraoperative opioid usage and postoperative pain and opioid requirements. Design, Setting, and Participants: This retrospective cohort study evaluated electronic health record data from a quaternary care academic medical center (Massachusetts General Hospital) for adult patients who underwent noncardiac surgery with general anesthesia from April 2016 to March 2020. Patients who underwent cesarean surgery, received regional anesthesia, received opioids other than fentanyl or hydromorphone, were admitted to the intensive care unit, or who died intraoperatively were excluded. Statistical models were fitted on the propensity weighted data set to characterize the effect of intraoperative opioid exposures on primary and secondary outcomes. Data were analyzed from December 2021 to October 2022. Exposures: Intraoperative fentanyl and intraoperative hydromorphone average effect site concentration estimated using pharmacokinetic/pharmacodynamic models. Main Outcomes and Measures: The primary study outcomes were the maximal pain score during the postanesthesia care unit (PACU) stay and the cumulative opioid dose, quantified in morphine milligram equivalents (MME), administered during the PACU stay. Medium- and long-term outcomes associated with pain and opioid dependence were also evaluated. Results: The study cohort included a total of 61 249 individuals undergoing surgery (mean [SD] age, 55.44 [17.08] years; 32 778 [53.5%] female). Increased intraoperative fentanyl and intraoperative hydromorphone were both associated with reduced maximum pain scores in the PACU. Both exposures were also associated with a reduced probability and reduced total dosage of opioid administration in the PACU. In particular, increased fentanyl administration was associated with lower frequency of uncontrolled pain; a decrease in new chronic pain diagnoses reported at 3 months; fewer opioid prescriptions at 30, 90, and 180 days; and decreased new persistent opioid use, without significant increases in adverse effects. Conclusions and Relevance: Contrary to prevailing trends, reduced opioid administration during surgery may have the unintended outcome of increasing postoperative pain and opioid consumption. Conversely, improvements in long-term outcomes might be achieved by optimizing opioid administration during surgery.

Individualized Electrode Subset Improves the Calibration Accuracy of an EEG P300-design Brain-Computer Interface for People with Severe Cerebral Palsy.

Objective: This study examined the effect of individualized electroencephalogram (EEG) electrode location selection for non-invasive P300-design brain-computer interfaces (BCIs) in people with varying severity of cerebral palsy (CP). Approach: A forward selection algorithm was used to select the best performing 8 electrodes (of an available 32) to construct an individualized electrode subset for each participant. BCI accuracy of the individualized subset was compared to accuracy of a widely used default subset. Main Results: Electrode selection significantly improved BCI calibration accuracy for the group with severe CP. Significant group effect was not found for the group of typically developing controls and the group with mild CP. However, several individuals with mild CP showed improved performance. Using the individualized electrode subsets, there was no significant difference in accuracy between calibration and evaluation data in the mild CP group, but there was a reduction in accuracy from calibration to evaluation in controls. Significance: The findings suggested that electrode selection can accommodate developmental neurological impairments in people with severe CP, while the default electrode locations are sufficient for many people with milder impairments from CP and typically developing individuals.

The effects of organic grass and grass-birdsfoot trefoil pastures on Jersey heifer development: Heifer growth, performance, and economic impact.

Dairy heifers developed in certified organic programs, especially those utilizing pasture-based management schemes, have lower rates of gain than heifers raised in nonorganic confinement production systems in temperate climates, such as in the Intermountain West region of the United States. This study investigates the effects that different forages in a rotational grazing system have on development of organically raised Jersey heifers. Over 3 years, 210 yearling Jersey heifers were randomly assigned to one of 9 treatments, including a conventional confinement control where animals were fed a total mixed ration or one of 8 pasture treatments: Cache Meadow bromegrass (Bromus riparius Rehmann), QuickDraw orchard grass (Dactylis glomerata L.), Amazon perennial ryegrass (Lolium perenne L.), or Fawn tall fescue (Schendonorus arundinaceus [Schreb.] Dumort) and each individual grass interseeded with birdsfoot trefoil (Lotus corniculatus L., BFT). Each treatment had 3 blocks/yr over the 3-yr period, with each block having a 0.4 ha pasture of each treatment. Every 35 d, over a 105-d period, heifers were weighed and measured for hip height, and blood samples were collected to determine serum insulin-like growth factor-1 and blood urea nitrogen concentrations. Fecal egg counts were also assessed. Heifer body weight (BW), blood urea nitrogen, and insulin-like growth factor-1 concentrations were affected by treatment when analyzed over time. Heifers on grass-BFT pastures had increased BW compared with heifers on monoculture grass pastures. Heifers receiving a total mixed ration or perennial ryegrass+BFT had increased BW gain over the 105-d period compared with heifers grazing tall fescue+BFT, orchard grass, perennial ryegrass, meadow bromegrass, or tall fescue. Individually for all grass species, heifers grazing +BFT pastures had greater ending BW and weight gain than heifers grazing the respective grass monocultures. Furthermore, weight gain for heifers on perennial ryegrass+BFT, meadow bromegrass+BFT, and orchard grass+BFT were not different from those on a total mixed ration. Heifers grazing grass-BFT pastures had increased blood urea nitrogen compared with heifers grazing monoculture grass pastures. Heifer hip height and fecal egg counts were not affected by treatment. These results show that the addition of BFT to organic pasture improves growth of grazing replacement heifers. Economic analyses also demonstrate that interseeding grass pastures with BFT results in an increased economic return compared with grazing monoculture grass pastures. Grass pastures interseeded with BFT may be a sustainable option to achieve adequate growth of Jersey heifers raised in an organic pasture scenario in a temperate climate.

Slik phosphorylation of Talin T152 is crucial for proper Talin recruitment and maintenance of muscle attachment in Drosophila.

Talin is the major scaffold protein linking integrin receptors with the actin cytoskeleton. In Drosophila, extended Talin generates a stable link between the sarcomeric cytoskeleton and the tendon matrix at muscle attachment sites. Here, we identify phosphorylation sites on Drosophila Talin by mass spectrometry. Talin is phosphorylated in late embryogenesis when muscles differentiate, especially on T152 in the exposed loop of the F1 domain of the Talin head. Localization of a mutated version of Talin (Talin-T150/T152A) is reduced at muscle attachment sites and can only partially rescue muscle attachment compared with wild-type Talin. We also identify Slik as the kinase phosphorylating Talin at T152. Slik localizes to muscle attachment sites, and the absence of Slik reduces the localization of Talin at muscle attachment sites causing phenotypes similar to Talin-T150/T152A. Thus, our results demonstrate that Talin phosphorylation by Slik plays an important role in fine-tuning Talin recruitment to integrin adhesion sites and maintaining muscle attachment.

Variation in seclusion rates across New Zealand's specialist mental health services: Are sociodemographic and clinical factors influencing this?

Rates of seclusion vary across New Zealand's publicly funded district health board (DHB) adult mental health inpatient services as indicated by national data. Anecdotally, this variation has been attributed to a range of factors directly relating to the people admitted to acute inpatient services. This study examined the extent to which variation in seclusion rates could be explained by the sociodemographic and clinical differences between populations admitted into adult mental health inpatient services. Retrospective data were obtained from the Programme for the Integration of Mental Health Data (PRIMHD). A logistic regression model was fitted to these data, with seclusion (yes/no) as the dependent variable and DHB groups as the independent variable. The DHBs were classified into four groups based on their seclusion rates. The model adjusted for ethnicity, age, number of bed nights, total Health of the Nation Outcome Scales (HoNOS) scores, and compulsory treatment status. Odds ratios remained virtually unchanged after adjustment for sociodemographic and clinical factors. People admitted to DHB Group 4 (highest secluding DHBs) were 11 times more likely to be secluded than people in Group 1 (lowest secluding DHBs), adjusted OR = 11.1, 95% CI [7.5,16.4], P < 0.001. Results indicate DHB variation in seclusion rates cannot be attributed to the sociodemographic and clinical factors of people admitted into DHB adult mental health inpatient services. Instead, this variation may be explained by differences in service delivery models and practice approaches. A model of system improvements aimed at reducing seclusion is discussed.

Stem cell approaches for vocal fold regeneration.

OBJECTIVES/HYPOTHESIS: Current interventions in the management of vocal fold (VF) dysfunction focus on conservative and surgical approaches. However, the complex structure and precise biomechanical properties of the human VF mean that these strategies have their limitations in clinical practice and in some cases offer inadequate levels of success. Regenerative medicine is an exciting development in this field and has the potential to further enhance VF recovery beyond conventional treatments. Our aim in this review is to discuss advances in the field of regenerative medicine; that is, advances in the process of replacing, engineering, or regenerating the VF through utilization of stem cells, with the intention of restoring normal VF structure and function. DATA SOURCES: English literature (1946-2015) review. METHODS: We conducted a systematic review of MEDLINE for cases and studies of VF tissue engineering utilizing stem cells. RESULTS: The three main approaches by which regenerative medicine is currently applied to VF regeneration include cell therapy, scaffold development, and utilization of growth factors. CONCLUSION: Exciting advances have been made in stem cell biology in recent years, including use of induced pluripotent stem cells. We expect such advances to be translated into the field in the forthcoming years. Laryngoscope, 126:1865-1870, 2016.

Talin autoinhibition is required for morphogenesis.

The establishment of a multicellular body plan requires coordinating changes in cell adhesion and the cytoskeleton to ensure proper cell shape and position within a tissue. Cell adhesion to the extracellular matrix (ECM) via integrins plays diverse, essential roles during animal embryogenesis and therefore must be precisely regulated. Talin, a FERM-domain containing protein, forms a direct link between integrin adhesion receptors and the actin cytoskeleton and is an important regulator of integrin function. Similar to other FERM proteins, talin makes an intramolecular interaction that could autoinhibit its activity. However, the functional consequence of such an interaction has not been previously explored in vivo. Here, we demonstrate that targeted disruption of talin autoinhibition gives rise to morphogenetic defects during fly development and specifically that dorsal closure (DC), a process that resembles wound healing, is delayed. Impairment of autoinhibition leads to reduced talin turnover at and increased talin and integrin recruitment to sites of integrin-ECM attachment. Finally, we present evidence that talin autoinhibition is regulated by Rap1-dependent signaling. Based on our data, we propose that talin autoinhibition provides a switch for modulating adhesion turnover and adhesion stability that is essential for morphogenesis.

Zasp regulates integrin activation.

Integrins are heterodimeric adhesion receptors that link the extracellular matrix (ECM) to the cytoskeleton. Binding of the scaffold protein, talin, to the cytoplasmic tail of ß-integrin causes a conformational change of the extracellular domains of the integrin heterodimer, thus allowing high-affinity binding of ECM ligands. This essential process is called integrin activation. Here we report that the Z-band alternatively spliced PDZ-motif-containing protein (Zasp) cooperates with talin to activate α5ß1 integrins in mammalian tissue culture and αPS2ßPS integrins in Drosophila. Zasp is a PDZ-LIM-domain-containing protein mutated in human cardiomyopathies previously thought to function primarily in assembly and maintenance of the muscle contractile machinery. Notably, Zasp is the first protein shown to co-activate α5ß1 integrins with talin and appears to do so in a manner distinct from known αIIbß3 integrin co-activators.

Heart team discussion in managing patients with coronary artery disease: outcome and reproducibility.

Recent ESC/EACTS revascularization guidelines advocate a 'Heart Team' (HT) approach in the decision-making process when managing patients with coronary disease. We prospectively assessed HT decision-making in 150 patients analysing personnel attendance, data presented, the 'actioning' of the HT decision and, if not completed, then the reasons why. Additionally, 50 patients were specifically re-discussed after 1 year in order to assess consistency in decision-making. We have two HT meetings each week. At least one surgeon, interventional cardiologist and non-interventional cardiologist were present at all meetings. Data presented included patient demographics, symptoms, co-morbidities, coronary angiography, left ventricular function and other relevant investigations, e.g. echocardiograms. HT decisions included continued medical treatment (22%), percutaneous coronary intervention (PCI; 22%), coronary-artery bypass grafting (CABG; 34%) or further investigations such as pressure wire studies, dobutamine stress echo or cardiac magnetic resonance imaging (22%). These decisions were fully undertaken in 86% of patients. Reasons for aberration in the remaining 21 patients included patient refusal (CABG 29%, PCI 10%) and further co-morbidities (28%). On re-discussion of the same patient data (n = 50) a year later, 24% of decisions differed from the original HT recommendations reflecting the fact that, for certain coronary artery disease pattern, either CABG or PCI could be appropriate.

Muscle type-specific expression of Zasp52 isoforms in Drosophila.

Zasp52 is a member of the PDZ-LIM domain protein family in Drosophila, which comprises Enigma, ENH, ZASP, Alp, CLP36, RIL, and Mystique in vertebrates. Drosophila Zasp52 colocalizes with integrins at myotendinous junctions and with α-actinin at Z-disks, and is required for muscle attachment as well as Z-disk assembly and maintenance. Here we document 13 Zasp52 splice variants giving rise to six different LIM domains. We demonstrate stage- and tissue-specific expression in different muscle types for Zasp52 isoforms encoding different LIM domains. In particular, LIM1b is expressed only in heart muscle and certain somatic muscles, implying muscle-specific functions in Z-disk assembly or maintenance.

Direct electrochemistry of horseradish peroxidase immobilized in a chitosan-[C4mim][BF4] film: determination of electrode kinetic parameters.

The direct electrochemistry of a HRP-chi-[C(4)mim][BF(4)] film (where HRP = horseradish peroxidase, chi = chitosan, and [C(4)mim][BF(4)] = the room temperature ionic liquid (RTIL) 1-butyl-3-methylimidazolium tetrafluoroborate) has been studied by cyclic voltammetry on a glassy carbon electrode. The mechanism for the electrochemical reaction of HRP is suggested to be EC for the reduction, and CE for the following re-oxidation, as the oxidative peak potential remained approximately unchanged across the scan rate range. The half wave potential of HRP reduction was found to be pH dependent, suggesting that a concomitant proton and electron transfer is occurring. Using theoretical simulations of the experimentally obtained peak positions, the standard electron transfer rate constant, k(0), was found to be 98 (+/-16) s(-1) at 295 K in pH 7 phosphate buffer solution, which is very close to the value reported in the absence of ionic liquid. This suggests that the ionic liquid used here in the HRP-chi-[C(4)mim][BF(4)]/GC electrode does not enhance the rate of electron transfer. k(0) was found to increase systematically with increasing temperature and followed a linear Arrhenius relation, giving an activation energy of 14.20 kJ mol(-1). The electrode kinetics and activation energies obtained are identical to those reported for HRP films in aqueous media. This leads us to question if the use of RTIL films provide any unique benefits for enzyme/protein voltammetry. Rather the films may likely contain aqueous zones in which the enzymes are located and undergo electron transfer.