Deep brain stimulation of the nucleus accumbens/ventral capsule for severe and intractable opioid and benzodiazepine use disorder.

Given high relapse rates and the prevalence of overdose deaths, novel treatments for substance use disorder (SUD) are desperately needed for those who are treatment refractory. The objective of this study was to evaluate the safety of deep brain stimulation (DBS) for SUD and the effects of DBS on substance use, substance craving, emotional symptoms, and frontal/executive functions. DBS electrodes were implanted bilaterally within the Nucleus Accumbens/Ventral anterior internal capsule (NAc/VC) of a man in his early 30s with >10-year history of severe treatment refractory opioid and benzodiazepine use disorders. DBS of the NAc/VC was found to be safe with no serious adverse events noted and the participant remained abstinent and engaged in comprehensive treatment at the 12-week endpoint (and 12-month extended follow-up). Using a 0-100 visual analog scale, substance cravings decreased post-DBS implantation; most substantially in benzodiazepine craving following the final DBS titration (1.0 ± 2.2) compared to baseline (53.4 ± 29.5; p < .001). A trend toward improvement in frontal/executive function was observed on the balloon analog risk task performance following the final titration (217.7 ± 76.2) compared to baseline (131.3 ± 28.1, p = .066). FDG PET demonstrated an increase in glucose metabolism in the dorsolateral prefrontal and medial premotor cortices at the 12-week endpoint compared to post-surgery/pre-DBS titration. Heart Rate Variability (HRV) improved following the final titration (rMSSD = 56.0 ± 11.7) compared to baseline (19.2 ± 8.2; p < .001). In a participant with severe, treatment refractory opioid and benzodiazepine use disorder, DBS of the NAc/VC was safe, reduced substance use and craving, and improved frontal and executive functions. Confirmation of these findings with future studies is needed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Prospective Evaluation of Cognitive Outcomes After Anesthesia for Patients in the Beach Chair Position.

The beach chair position has been popularized for shoulder surgeries, particularly those involving arthroscopy. Several published case reports and studies have raised concerns for neurologic complications related to anesthesia for surgery performed with patients in the beach chair position. The question has been raised whether cerebral perfusion monitoring should be used routinely to minimize these potential complications. This prospective study evaluated cognitive outcomes in patients who underwent anesthesia in the beach chair position. Patients were randomized to 2 groups. In group 1, the anesthesiologist was blinded to the cerebral monitoring and could treat based only on mean arterial pressure (MAP). In group 2, the anesthesiologist was aware of the results of the cerebral monitoring and could treat any desaturation events. All patients were evaluated pre- and postoperatively with a cognitive assessment tool. A total of 80 patients were enrolled in the study, with 40 patients in each group. There were no significant differences regarding age, body mass index, or American Society of Anesthesiologists score. Only 3 desaturation events occurred with no significant change in cognitive function. The findings indicate no advantage to cerebral perfusion monitoring during anesthesia for surgery performed with patients in the beach chair position as long as MAP is maintained within strict limits. Although little is known about the level of cerebral desaturation that will result in cognitive dysfunction, it may likely be related to MAP and cerebral perfusion. The findings of this study reinforce the need for careful monitoring of MAP during surgery and dispute the need for additional expensive monitoring devices. [Orthopedics. 2020; 43(1):e27-e30.].