Substance Use Disorders: Basic Overview for the Anesthesiologist.

Substance use disorders (SUDs) represent a current major public health concern in the United States and around the world. Social and economic stressors secondary to the coronavirus disease 2019 (COVID-19) pandemic have likely led to an increase in SUDs around the world. This chronic, debilitating disease is a prevalent health problem, and yet many clinicians do not have adequate training or clinical experience diagnosing and treating SUDs. Anesthesiologists and other perioperative medical staff frequently encounter patients with co-occurring SUDs. By such, through increased awareness and education, physicians and other health care providers have a unique opportunity to positively impact the lives and improve the perioperative outcomes of patients with SUDs. Understanding commonly used terms, potentially effective perioperative screening tools, diagnostic criteria, basics of treatment, and the perioperative implications of SUDs is essential to providing adequate care to patients experiencing this illness.

How, when and why to establish preoperative surgical risk in thoracic surgery.

PURPOSE OF REVIEW: Emphasizing a systems-based approach, we discuss the timing for referral for perioperative surgical consultation. This review then highlights several types of comorbidities that may complicate thoracic procedures, and references recent best practices for their management. RECENT FINDINGS: Patients requiring thoracic surgeries present some of the most challenging cases for both intraoperative and postoperative management. The recent SARS-CoV-2 pandemic has only exacerbated these concerns. Effective preoperative optimization, however, provides for identification of patient comorbidities, allowing for mitigation of surgical risks. This kind of planning is multidisciplinary by nature. We believe patients benefit from early engagement of a dedicated preoperative clinic experienced for caring for complex surgical patients. SUMMARY: Optimizing patients for thoracic surgery can be challenging for small and large health systems alike. Implementation of evidence-based guidelines can improve care and mitigate risk. As surgical techniques evolve, future research is needed to ensure that perioperative care continues to progress.

Comparing bupivacaine alone to liposomal bupivacaine plus bupivacaine in interscalene blocks for total shoulder arthroplasty: a randomized, non-inferiority trial.

INTRODUCTION: Interscalene brachial plexus blocks are a commonly performed procedure to reduce pain following total shoulder arthroplasty. Liposomal bupivacaine has been purported to prolong the duration of brachial plexus blocks for up to 72 hours; however, there has been controversy surrounding the analgesic benefits of this drug. Our hypothesis was that an interscalene block performed with bupivacaine alone would be non-inferior to a combination of liposomal bupivacaine and bupivacaine with respect to opioid consumption following total shoulder arthroplasty. METHODS: Subjects presenting for primary total shoulder arthroplasty were randomized in a 1:1 ratio to an ultrasound-guided, single-injection interscalene block with either a combination of liposomal bupivacaine and bupivacaine (LB group) or bupivacaine without additive (Bupi group). The primary outcome of this study was 72-hour postoperative cumulative opioid consumption (in oral morphine equivalents) with a non-inferiority margin of 22.5 mg. Secondary outcomes included pain scores, patient satisfaction with analgesia and patient reported duration of sensory block. RESULTS: Seventy-six subjects, 38 from the Bupi group and 38 from the LB group, completed the study. Analysis of the primary outcome showed a 72-hour cumulative geometric mean oral morphine equivalent consumption difference of 11.9 mg (95% CI -6.9 to 30.8) between groups (calculated on the log scale). This difference constitutes approximately 1.5 tablets of oxycodone over 3 days. No secondary outcomes showed meaningful differences between groups. DISCUSSION: Interscalene brachial plexus blocks performed with bupivacaine alone did not demonstrate non-inferiority compared to a mixture of liposomal bupivacaine plus bupivacaine with regards to 72-hour cumulative opioid consumption following total shoulder arthroplasty. However, the difference between groups did not appear to be clinically meaningful.

Pericapsular nerve group (PENG) block for hip arthroscopy: a randomized, double-blinded, placebo-controlled trial.

INTRODUCTION: Arthroscopic hip surgery is associated with significant postoperative pain. Femoral nerve blocks have been shown to improve postoperative analgesia at the expense of quadriceps weakness. The pericapsular nerve group (PENG) block could be an alternative that may improve postoperative analgesia while preserving quadriceps strength. Our hypothesis was that a PENG block would provide superior postoperative analgesia compared with a sham block following arthroscopic hip surgery. METHODS: Subjects presenting for arthroscopic hip surgery were randomized in a 1:1 ratio to either an ultrasound-guided unilateral, single-injection PENG block (PENG group) with 20 mL of 0.5% ropivacaine or a sham injection with 5 mL of 0.9% normal saline (Sham group) prior to receiving general anesthesia. The primary outcome of this study was worst pain score within 30 min of emergence from anesthesia. Secondary outcomes included opioid consumption, patient satisfaction with analgesia, opioid-related adverse events, and persistent opioid use at 1 week. RESULTS: Sixty-eight subjects, 34 from the PENG group and 34 from the Sham group, completed the study per protocol. Analysis of the primary outcome demonstrated a mean difference in pain scores of -0.79 (95% CI -1.96 to 0.37; p=0.17) between the PENG and Sham groups immediately following surgery. No secondary outcomes showed statistically significant differences between groups. DISCUSSION: This study demonstrates that a preoperative PENG block does not improve analgesia following arthroscopic hip surgery. TRIAL REIGSTRATION NUMBER: NCT04508504.

Implementation of a pharmacy automation system (robotics) to ensure medication safety at Norwalk hospital.

This article reports an intervention to improve the quality and safety of hospital patient care by introducing the use of pharmacy robotics into the medication distribution process. Medication safety is vitally important. The integration of pharmacy robotics with computerized practitioner order entry and bedside medication bar coding produces a significant reduction in medication errors. The creation of a safe medication-from initial ordering to bedside administration-provides enormous benefits to patients, to health care providers, and to the organization as well.

Medication administration: the implementation process of bar-coding for medication administration to enhance medication safety.

Approximately 1.5 million Americans are injured each year because of medication errors. In hospitals alone medication errors cost the health system well over $3.5 billion per year. Nurses are at the frontline of medication administration accountability. A Bar Code Medication Administration application was implemented at a 300-bed community hospital. The creation of the process was spearheaded by a taskforce consisting of staff nurses, nursing and pharmacy administrators, and an IT representative. This group planned the implementation process, which included changes to medication policies and procedures, downtime procedures, workflow designs, planning for nursing training, and changes to medication delivery. The results from the pilot indicated that the bar-cod technology reduced medication errors by 80%.

Reduction of plastid-localized carbonic anhydrase activity results in reduced Arabidopsis seedling survivorship.

Carbonic anhydrase (CA; EC 4.2.1.1) catalyzes the interconversion of CO2 and HCO3(-) and is a major protein constituent of the C3 higher plant chloroplast where it is presumed to play a role in photosynthetic carbon assimilation. In this study, we have used both RNA antisense and gene knockout lines to specifically reduce the activity of the chloroplast betaCA1 polypeptide (At3g01500) in the model plant Arabidopsis (Arabidopsis thaliana). Although able to germinate, seedling establishment of transgenic plants is significantly reduced relative to wild-type plants when grown at ambient levels of CO2. Growth at elevated (1,500 microL L(-1)) CO2 or on plates supplemented with sucrose restores seedling establishment rates to wild-type levels. Seed from wild-type and transgenic plants exhibited no significant differences in seed protein, lipid content, or reserve mobilization during seedling growth. betaCA1-deficient seedlings do, however, exhibit reduced capacity for light-dependent 14CO2 assimilation prior to the development of true leaves. The small number of surviving seedlings able to grow and develop are phenotypically similar to wild-type plants, even when subsequently grown at subambient levels of CO2. Microarray analysis of mature leaves of betaCA1-deficient plants shows some differences in transcript abundance, particularly with genes involved in ethylene signaling and response. The data suggest that reduced levels of seedling establishment by betaCA1-deficient plants could be the result of poor cotyledon photosynthetic performance at the onset of phototrophic growth and prior to the development of true leaves.

Short incision, short flap face-lift surgery versus deep plane face-lift surgery.

Face-lift surgery is becoming very common. The number of techniques and the expected results from those techniques vary greatly. Often it is confusing to patients and surgeons what is meant when the term FACE-LIFT is used. This article then analyzes two specific face-lift techniques, noting differences in patient selection, technique, result, and healing time.

Notch2 is required for formation of the placental circulatory system, but not for cell-type specification in the developing mouse placenta.

We have previously reported that a mutation in the ankyrin repeats of mouse Notch2 results in embryonic lethality by embryonic day 11.5 (E11.5), showing developmental retardation at E10.5. This indicated that Notch2 plays an essential role in postimplantation development in mice. Here, we demonstrate that whole embryo culture can circumvent developmental retardation of Notch2 mutant embryos for up to 1 day, suggesting that the lethality was primarily caused by extraembryonic defects. Histological examinations revealed delayed entry of maternal blood into the mutant placenta and poor blood sinus formation at later stages. Notch2-expressing cells appeared around maternal blood sinuses. Specification of trophoblast subtypes appeared not to be drastically disturbed and expression of presumptive downstream genes of Notch2 signaling was not altered by the Notch2 mutation. Thus, in the developing mouse placenta, Notch2 is unlikely to be involved in cell fate decisions, but rather participates in formation of maternal blood sinuses. In aggregation chimeras with wild-type tetraploid embryos, the mutant embryos developed normally until E12.5, but died before E13.5. The chimeric placentas showed a restored maternal blood sinus formation when compared with the mutant placentas, but not at the level of wild-type diploid placentas. Therefore, it was concluded that the mutant suffers from defects in maternal blood sinus formation. Thus, Notch2 is not cell autonomously required for the early cell fate determination of subtypes of trophoblast cells, but plays an indispensable role in the formation of maternal blood sinuses in the developing mouse placenta.

Trials and tribulations: a small pilot telehealth home care program for medicare patients.

This article describes a home care agency's experience initiating the technology of a telehealth program for a selected view of its home care patients. The goal of the telehealth program was to improve patient outcomes by augmenting patients' regularly scheduled in-home skilled nursing visits with video-conferencing encounters. Patient selection, costs, projected savings, patient satisfaction, and the technical, clinical, and patient problems with the telehealth system are discussed.

Developing a pilot telehealth program: one agency's experience.

This article explores one home care agency's experience launching a pilot telehealth program. Patient selection, costs, projected savings, and patient satisfaction with the telehealth program are discussed.

Complementation of the yeast deletion mutant DeltaNCE103 by members of the beta class of carbonic anhydrases is dependent on carbonic anhydrase activity rather than on antioxidant activity.

In recent years, members of the beta class of CAs (carbonic anhydrases) have been shown to complement Delta NCE103, a yeast strain unable to grow under aerobic conditions. The activity required for complementation of Delta NCE103 by tobacco chloroplast CA was studied by site-directed mutagenesis. E196A (Glu196-->Ala), a mutated tobacco CA with low levels of CA activity, complemented Delta NCE103. To determine whether restoration of Delta NCE103 was due to residual levels of CA activity or whether it was related to previously proposed antioxidant activity of CAs [Götz, Gnann and Zimmermann (1999) Yeast 15, 855-864], additional complementation analysis was performed using human CAII, an alpha CA structurally unrelated to the beta class of CAs to which the tobacco protein belongs. Human CAII complemented Delta NCE103, strongly arguing that CA activity is responsible for the complementation of Delta NCE103. Consistent with this conclusion, recombinant NCE103 synthesized in Escherichia coli shows CA activity, and Delta NCE103 expressing the tobacco chloroplast CA exhibits the same sensitivity to H2O2 as the wild-type strain.