Diabetes Mellitus is an Independent Predictor of Spinal Cord Injury After Descending Thoracic and Thoracoabdominal Aneurysm Repair: Maximum Likelihood Conditional Regression in a Propensity-Score Matched Cohort.

OBJECTIVE: To discern the impact of diabetes mellitus (DM) on spinal cord injury (SCI) after open descending thoracic and thoracoabdominal aneurysm repair (DTAAAR). BACKGROUND: Compared with euglycemia, hyperglycemia, and ketosis make neurons respectively more vulnerable and more resilient to ischemia. METHODS: During the study period (1997-2021), patient who underwent DTAAAR were dichotomized according to the presence/absence of DM. The latter was investigated as predictor of our primary (SCI) and secondary [operative mortality (OM), myocardial infarction, stroke, need for tracheostomy, de novo dialysis, and survival] endpoints. Two-level risk-adjustment employed maximum likelihood conditional regression after 1:2 propensity-score matching. RESULTS: DTAAAR was performed in 934 patients. Ninety-two diabetics were matched to 184 nondiabetics. All preoperative variables had a standardized mean difference <0.1 between the matched groups. Patients with DM had higher SCI (6.5% vs. 1.6%, P 0.03) and OM (14.1% vs. 6.0%, P =0.01), while the other secondary endpoints were similar between groups in the matched sample. DM was an independent predictor for SCI in the matched sample (odds ratio: 5.05, 95% confidence interval: 1.17-21.71). Matched patients with DM presented decreased survival at 1 (70.2% vs. 86.2%), 5 (50.4% vas 67.5%), 10 years (31.7% vs. 36.7%) ( P =0.03). The results are summarized in the graphical abstract. CONCLUSION: DM is associated to increased OM and decreased survival, and it is an independent predictor of SCI after open DTAAAR. Strict perioperative glycemic control should be implemented, and exogenous ketones should be investigated as neuroprotective agents to reduce such adverse events.

Global health education in United States anesthesiology residency programs: a survey of resident opportunities and program director attitudes.

BACKGROUND: Interest in global health during postgraduate residency training is increasing across medical specialties, and multiple disciplines have categorized global health training opportunities in their arena. No such cataloging exists for anesthesiology residency programs. The aim of this study was to assess and characterize global health opportunities and the attitudes of program directors (PDs) in U.S. anesthesiology residency programs towards this training. METHODS: A cross-sectional 20-question survey on global health opportunities was distributed to 128 ACGME accredited anesthesiology residency program directors via email between October 2015 and January 2016. Descriptive statistics and exploratory inferential analyses were applied. Maximal nonresponse selection bias was estimated. RESULTS: The overall response rate was 44%. Of those who responded, 61% reported that their residency program had a global health elective, with a maximal bias estimate of 6.5%. 45% of program directors with no global health elective reported wanting to offer one. 77% of electives have articulated educational goals, but there is substantial heterogeneity in curricula offered. Program director attitudes regarding the value of global health programs differed significantly between those with and without existing programs. CONCLUSIONS: The proportion of U.S. anesthesiology residency programs offering global health electives is similar to that in other medical specialties. There is inconsistency in program structure, goals, curriculum, and funding. Attitudes of program directors differ between programs with and without electives, which may reflect bidirectional influence to be investigated further. Further studies are needed to codify curricula, assess effectiveness, and validate methodologies.

Viscoelastic testing inside and beyond the operating room.

Hemorrhage is a major contributor to morbidity and mortality during the perioperative period. Current methods of diagnosing coagulopathy have various limitations including long laboratory runtimes, lack of information on specific abnormalities of the coagulation cascade, lack of in vivo applicability, and lack of ability to guide the transfusion of blood products. Viscoelastic testing offers a promising solution to many of these problems. The two most-studied systems, thromboelastography (TEG) and rotational thromboelastometry (ROTEM), offer similar graphical and numerical representations of the initiation, formation, and lysis of clot. In systematic reviews on the clinical efficacy of viscoelastic tests, the majority of trials analyzed were in cardiac surgery patients. Reviews of the literature suggest that transfusions of packed red blood cells (pRBC), plasma, and platelets are all decreased in patients whose transfusions were guided by viscoelastic tests rather than by clinical judgement or conventional laboratory tests. Mortality appears to be lower in the viscoelastic testing groups, despite no difference in surgical re-intervention rates and massive transfusion rates. Cost-effectiveness studies also seem to favor viscoelastic testing. Viscoelastic testing has also been investigated in small studies in other clinical contexts, such as sepsis, obstetric hemorrhage, inherited bleeding disorders, perioperative thromboembolism risk assessment, and management of anticoagulation for patients on mechanical circulatory support systems or direct oral anticoagulants (DOACs). While the results are intriguing, no systematic, larger trials have taken place to date. Viscoelastic testing remains a relatively novel method to assess coagulation status, and evidence for its use appears favorable in reducing blood product transfusions, especially in cardiac surgery patients.