The Efficacy and Safety of Transversus Abdominis Plane Blocks After Open Cholecystectomy in Low- and Middle-Income Countries.

BACKGROUND: Postoperative pain management is challenging in low- and middle-income countries (LMICs). This study assesses the safety and efficacy of transversus abdominis plane (TAP) blocks as an adjunct for postoperative pain control after an open cholecystectomy in LMICs during short-term surgical missions (STSMs). TAP block is a regional anesthesia technique that has been shown to be effective in providing supplementary analgesia to the anterolateral wall post abdominal surgery. METHODS: A retrospective chart review of patients undergoing open cholecystectomy during STSMs was performed. STSMs took place in Guatemala, the Philippines, and Peru from 2009 to 2019. Measured outcomes including pain scores, presence of postoperative nausea or vomiting, and opioid consumption were compared between TAP block and non-TAP block groups. RESULTS: Of the 48 patients analyzed, 28 underwent TAP block (58%). Non-TAP block patients received, on average, 8 mg of oral morphine equivalents more than the TAP patients (P = 0.035). No significant difference was noted in pain scores, which were taken immediately after surgery, 2 h after surgery, and at multiple times between these time points to calculate an average. Of the patients who received a TAP block, 11% reported nausea or vomiting compared with 45% in the standard group (P < 0.01). There were no reported procedure-related complications. CONCLUSIONS: TAP blocks are safe and effective adjuncts for postoperative pain management on STSMs to LMICs. Additional studies are needed to investigate the potential advantages and disadvantages of more widespread use of TAP blocks in LMICs.

Propofol-sparing effect of different concentrations of dexmedetomidine : Comparison of gender differences.

BACKGROUND: The pharmacodynamics of propofol are closely linked to gender. Dexmedetomidine can decrease propofol needs during propofol anesthesia. The aim of this study was to compare the gender differences on the calculated effect site median effective concentration (EC50) of propofol for loss of consciousness (LOC) after pretreatment with different concentrations of dexmedetomidine. METHODS: In this study 60 male and 60 female patients were randomly allocated to receive dexmedetomidine at target plasma concentrations of 0.0 ng/ml (0.0 group), 0.4 ng/ml (0.4 group), 0.6 ng/ml (0.6 group) and 0.8 ng/ml (0.8 group). Propofol was administered after dexmedetomidine had been intravenously infused for 15 min. The propofol infusion was targeted to provide an initial effect-site concentration of 1.0 µg/ml, followed by increments by 0.2 µg/ml when the effect-site concentration and target concentration of propofol were in equilibrium until LOC was established, where LOC was defined by the observer's assessment of alertness/sedation scale (OAA/S) score < 2. RESULTS: The calculated effect-site EC50 of propofol LOC was higher in males than in females in the 0.0, 0.4, 0.6, and 0.8 groups (2.43 vs. 2.17, 1.99 vs. 1.82, 1.72 vs. 1.56 and 1.50 vs. 1.32 µg/ml, respectively, all p < 0.05). The hypnotic interaction between dexmedetomidine and propofol could be described with an additive model of pharmacodynamic interaction. CONCLUSION: Gender significantly influenced the calculated effect-site EC50 of propofol for LOC after pretreatment with different concentrations of intravenous dexmedetomidine. It was concluded that an additive interaction could describe the results seen. Thus, gender has to be considered when these drugs are co-administered.

Pharmacological Manipulation of the Rostromedial Tegmental Nucleus Changes Voluntary and Operant Ethanol Self-Administration in Rats.

BACKGROUND: The aversive properties of ethanol (EtOH) that limit its intake are poorly understood. There is an increasing interest in the role of the rostromedial tegmental nucleus (RMTg), because it encodes aversion signals and inhibits motivated behaviors. It is also a major source of inhibitory GABAergic inputs to the midbrain dopamine neurons. Up to this time, the role of the RMTg in EtOH-drinking behaviors has not been well explored. METHODS: Male Long-Evans rats were trained either to drink EtOH under the intermittent 2-bottle-choice protocol or to self-administer EtOH in operant chambers under fixed-ratio-3 schedules. Changes in drinking behaviors induced by the bilateral infusion into the RMTg of α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA), an agonist of AMPA-type glutamate receptors, or muscimol, an agonist of GABAA receptors, were measured. RESULTS: Consumption and preference for EtOH, numbers of active lever pressing, and head entrance to the EtOH port were all significantly decreased upon activation of the RMTg by the infusion of AMPA, but were increased upon inhibition of the RMTg by the infusion of muscimol. By contrast, intra-RMTg infusion of these agents did not change sucrose consumption. CONCLUSIONS: These data show for the first time that EtOH-drinking and EtOH-seeking behaviors of rats changed inversely with RMTg function, supporting the idea that the RMTg plays a crucial role in EtOH-drinking behaviors.

The Risks and Benefits of Physician Practice Acquisition and Consolidation: A Narrative Review of Peer-Reviewed Publications Between 2009 and 2022 in the United States.

The objective of this narrative review was to assess current literature regarding acquisition and consolidation of physician practices in the United States (US). The acquisition and consolidation of physician practices is a trend affecting patient care, quality of services, healthcare economics and the daily practice of physicians. As practices are acquired by fellow physician groups, private equity investors and entities such as hospitals or large healthcare systems, it is important to better understand the underlying forces driving these transactions and their effects. This is a narrative review of peer-reviewed publications to determine what current literature has covered regarding the acquisition and consolidation of physician practices in the US regarding risks and benefits of this trend. Sources included the SCOPUS, Medline- PUBMED and Web of Science databases. Peer reviewed publications from 2009 to 2022 were included for initial review and curation for relevance using the search terms "physician" and "practice" with either "acquisition" or "consolidation". Synthesis conducted after narrowing down of relevant articles did not use quantitative measurements, but instead examined overall trends, as well as risk and benefits of ongoing acquisition and consolidation in a narrative format. Journal articles focused on physician consolidation in the US often reported increases in physician numbers with decreases in numbers of individual practices. Private equity quantitative analyses reported rapidly accelerating acquisitions driven by these investors, and vertical integration scholarly work reported frequent geographic consolidation of nearby practitioners. Risks associated with these transactions included such items as decreased physician autonomy and higher cost of care. Benefits included practice stability, improved negotiation with insurers and improved access to resources.

Should rocuronium and sugammadex replace succinylcholine for airway emergencies in class B ambulatory anesthesia settings?

INTRODUCTION: In class B surgical facilities, where only oral or intravenous (IV) sedation is employed without the administration of volatile anesthetics, laryngospasm is among the most common airway complications. However, these facilities generally do not stock succinylcholine to avoid the cost of storing dantrolene for the treatment of malignant hyperthermia (MH). High dose IV rocuronium with sugammadex reversal has been suggested as an alternative to succinylcholine for airway emergencies. The aim of this paper was to evaluate the clinical utility, patient safety, and financial implications of replacing succinylcholine with rocuronium and sugammadex in lieu of stocking dantrolene in class B facilities. EVIDENCE ACQUISITION: A systematic review of the literature concerning neuromuscular blockade for airway emergencies in class B settings in adult patients was conducted. The MEDLINE and EMBASE databases were searched for published studies from January 1, 1990, to October 1, 2021. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system was used to assess the certainty of evidence. EVIDENCE SYNTHESIS: The search strategy yielded 1124 articles. After review, 107 articles were included, with 49 graded as "strong" evidence to provide recommendations for the posed questions. CONCLUSIONS: The use of succinylcholine in isolation without volatile agents has a low incidence of triggering MH. Laryngospasm is a common airway emergency that requires immediate treatment to avoid morbidity and mortality. Both succinylcholine and rocuronium-sugammadex provide adequate treatment of airway emergencies and rapid return of spontaneous ventilation, but succinylcholine has a superior economic and clinical profile.

Anesthetic Implications of Previously Undiagnosed Temporomandibular Joint Ankylosis: A Case Report.

Temporomandibular joint (TMJ) ankylosis is characterized by bony fusion that limits TMJ mobility. We present the case of an elderly woman who was brought to the operating room for dental rehabilitation under general anesthesia. The patient had an undiagnosed TMJ ankylosis, which was discovered only after induction of anesthesia due to her nonverbal status and advanced dementia. The surgical team canceled the case due to limited access to the surgical field. We discuss the factors that suggest TMJ ankylosis and propose the perioperative management when TMJ ankylosis is suspected but unconfirmed.

Acupuncture for alcohol use disorder.

Alcohol use disorder (AUD) is a common medical and social problem, affecting about 240 million people in the world. To address this major health concern, the currently available treatments for AUD need to be improved. Acupuncture, a popular form of complementary and alternative therapy, is emerging as an effective treatment for AUD. This review summarizes how preclinical and clinical studies are related to the application of acupuncture for AUD. These studies suggest that if used correctly, acupuncture may effectively reduce alcohol intake, attenuate alcohol withdrawal syndrome, and rebalance AUD-induced maladaptation in neurotransmitters and hormones in related brain areas. The progress of research in this field is at an early stage. Future investigations with rigorous design and carefully constructed protocols are still needed.

Intraoperative Low-frequency Electroacupuncture under General Anesthesia Improves Postoperative Recovery in a Randomized Trial.

Neuronal stimulation improves physiological responses to infection and trauma, but the clinical potential of this strategy is unknown. We hypothesized that transdermal neural stimulation through low-frequency electroacupuncture might control the immune responses to surgical trauma and expedite the postoperative recovery. However, the efficiency of electroacupuncture is questioned due to the placebo effect. Here, electroacupuncture was performed on anesthetized patients to avoid any placebo. This is a prospective double-blinded pilot trial to determine whether intraoperative electroacupuncture on anesthetized patients improves postoperative recovery. Patients with electroacupuncture required 60% less postoperative analgesic, even they had pain scores similar to those in the control patients. Electroacupuncture prevented postoperative hyperglycemia and attenuated serum adrenocorticotropic hormone in the older and heavier group of patients. From an immunological perspective, electroacupuncture did not affect the protective immune responses to surgical trauma, including the induction of interleukin-6 and interleukin-10. The most significant immunological effect of electroacupuncture was enhancing transforming growth factor-ß1 production during surgery in the older and lighter group of patients. These results suggest that intraoperative electroacupuncture on anesthetized patients can reduce postoperative use of analgesics and improve immune and stress responses to surgery.