Analgesic benefits of regional anesthesia in the perioperative management of transition-related surgery: a systematic review.

INTRODUCTION: Transition-related surgery is an effective treatment for gender dysphoria, but the perioperative analgesic management of transgender patients is nuanced and potentially complicated by higher rates of mood and substance use disorders. Regional anesthetic techniques are known to reduce pain severity and opioid requirements; however, little is known regarding the relative analgesic effectiveness of regional anesthesia for transgender patients undergoing transition-related surgery. METHODS: We performed a systematic review of the literature to evaluate original reports characterizing the analgesic effectiveness of regional anesthetic techniques for patients undergoing chest and/or genital transition-related surgery. Our primary outcomes were pain severity and opioid requirements on the first postoperative day. RESULTS: Of the 1863 records identified, 10 met criteria for inclusion and narrative synthesis. These included two randomized controlled trials, three cohort studies, and five case reports/series, comprising 293 patients. Four reports described 243 patients undergoing chest surgery, of whom 86% were transgender men undergoing mastectomy with pectoralis nerve blocks or local anesthetic instillation devices. The remaining six reports comprised 50 patients undergoing genital surgery, of whom 56% were transgender women undergoing vaginoplasty with erector spinae plane blocks or epidural anesthesia. Three studies directly compared regional techniques to parenteral analgesia alone. Two of these studies reported lower pain scores and opioid requirements on the first postoperative day with nerve blocks compared with none while the third study reported no difference between groups. Complications related to regional anesthetic techniques were rare among patients undergoing transition-related surgery. DISCUSSION: Despite the ever-growing demand for transition-related surgery, the relative analgesic effectiveness of regional anesthesia for transgender patients undergoing transition-related surgery is very understudied and insufficient to guide clinical practice. Our systematic review of the literature serves to underscore regional anesthesia for transition-related surgery as a priority area for future research.

The heart of anaesthesiology: revitalising humanism in the age of technology.

Technological innovation has greatly aided modern medicine, and anaesthesiology in particular, but also contributes to dehumanising influences that promote physician burnout and dissatisfaction among patients. Here we advocate for a profound reaffirmation of humanistic principles-empathy, compassion, and communication-in perioperative medicine. We propose adaptable strategies to bolster humanism in practice, such as curricular offerings, simulation training, role modelling, and recognition. As perioperative technologies continue to evolve, the threat of depersonalisation in anaesthetic care looms, making commitments to humanism a crucial precondition for healing in the communities in which we work and live.

A Meta-Analysis of Neurodevelopmental Outcomes following Intravitreal Bevacizumab for the Treatment of Retinopathy of Prematurity.

BACKGROUND: Retinopathy of prematurity (ROP) is the most common cause of preventable blindness in preterm infants. First-line treatments include intravitreal bevacizumab (IVB) or laser photocoagulation (LPC). OBJECTIVES: The aim of the study was to evaluate neurodevelopmental safety of IVB compared to LPC for ROP. METHODS: MEDLINE, Embase, and Cochrane library were searched up to September 2022. Studies were included with at least 12-month follow-up of primary outcomes such as severe neurodevelopmental impairment (sNDI), cerebral palsy (CP), and hearing impairment (HI). Secondary outcomes were moderate-to-severe neurodevelopmental impairment (msNDI), Bayley Scores of Infant Development (BSID-III), and visual impairment. RESULTS: 1,231 patients from 11 comparative studies were included. Quality of evidence was rated low for all outcomes. IVB was associated with a higher risk for sNDI (risk ratio [RR] = 1.25, 95% confidence interval [CI]: [1.01, 1.53], p = 0.04); and CP (RR = 1.40, CI: [1.08, 1.81], p = 0.01) compared to LPC. There was no significant difference between IVB and LPC for msNDI (RR = 1.15, CI: [0.98, 1.35], p = 0.08) and HI (RR = 1.43, CI: [0.86, 2.39], p = 0.17). BSID-III percentile scores were similar between IVB and LPC, with weighted mean differences of 1.51 [CI = -1.25, 4.27], 2.43 [CI = -1.36, 6.22], and 1.97 [CI = -1.06, 5.01] for cognitive, language, and motor domains, respectively (p > 0.05). CONCLUSION: To our knowledge, this is the largest meta-analysis on neurodevelopmental outcomes and the first to rigorously examine IVB monotherapy in ROP treatment. Compared to LPC, there was a marginally increased risk for sNDI and CP with IVB but little or no difference in the risk of msNDI and HI. Further randomized studies are needed to strengthen these findings.

Prevalence and predictors for being unscreened for diabetic retinopathy: a population-based study over a decade.

OBJECTIVE: To determine the population-level predictors for being unscreened for diabetic retinopathy (DR) among individuals with diabetes in a developed country. DESIGN: A retrospective population-based repeated-cross-sectional study. PARTICIPANTS: All individuals with diabetes (types 1 and 2) aged ≥20 years in the universal health care system in Ontario were identified in the 2011-2013 and 2017-2019 time periods. METHODS: The Mantel-Haenszel test was used for the relative risk (RR) comparison of subcategories stratified by the 2 cross-sectional time periods. RESULTS: A total of 1 145 645 and 1 346 578 individuals with diabetes were identified in 2011-2013 and 2017-2019, respectively. The proportion of patients unscreened for DR declined very slightly from 35% (n = 405 967) in 2011-2013 to 34% (n = 455 027) in 2017-2019 of the population with diabetes (RR = 0.967; 95% CI, 0.964-0.9693; p < 0.0001). Young adults aged 20-39 years of age had the highest proportion of unscreened patients (62% and 58% in 2011-2013 and 2017-2019, respectively). Additionally, those who had a lower income quintile (RR = 1.039; 95% CI, 1.036-1.044; p < 0.0001), were recent immigrants (RR = 1.286; 95% CI, 1.280-1.293; p < 0.0001), lived in urban areas (RR = 1.149; 95% CI, 1.145-1.154; p < 0.0001), had a mental health history (RR = 1.117; 95% CI, 1.112-1.122; p < 0.0001), or lacked a connection to a primary care provider (RR = 1.656; 95% CI, 1.644-1.668; p < 0.0001) had a higher risk of being unscreened. CONCLUSIONS: This population-based study suggests that over 1 decade, 33% of individuals with diabetes are unscreened for DR, and young age, low income, immigration, residing in a large city, mental health illness, and no primary care access are the main predictors.

Protocol for a systematic review and meta-analysis of the diagnostic accuracy of artificial intelligence for grading of ophthalmology imaging modalities.

BACKGROUND: With the rise of artificial intelligence (AI) in ophthalmology, the need to define its diagnostic accuracy is increasingly important. The review aims to elucidate the diagnostic accuracy of AI algorithms in screening for all ophthalmic conditions in patient care settings that involve digital imaging modalities, using the reference standard of human graders. METHODS: This is a systematic review and meta-analysis. A literature search will be conducted on Ovid MEDLINE, Ovid EMBASE, and Wiley Cochrane CENTRAL from January 1, 2000, to December 20, 2021. Studies will be selected via screening the titles and abstracts, followed by full-text screening. Articles that compare the results of AI-graded ophthalmic images with results from human graders as a reference standard will be included; articles that do not will be excluded. The systematic review software DistillerSR will be used to automate part of the screening process as an adjunct to human reviewers. After the full-text screening, data will be extracted from each study via the categories of study characteristics, patient information, AI methods, intervention, and outcomes. Risk of bias will be scored using Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) by two trained independent reviewers. Disagreements at any step will be addressed by a third adjudicator. The study results will include summary receiver operating characteristic (sROC) curve plots as well as pooled sensitivity and specificity of artificial intelligence for detection of any ophthalmic conditions based on imaging modalities compared to the reference standard. Statistics will be calculated in the R statistical software. DISCUSSION: This study will provide novel insights into the diagnostic accuracy of AI in new domains of ophthalmology that have not been previously studied. The protocol also outlines the use of an AI-based software to assist in article screening, which may serve as a reference for improving the efficiency and accuracy of future large systematic reviews. TRIAL REGISTRATION: PROSPERO, CRD42021274441.

Docosahexaenoic and eicosapentaenoic fatty acids differentially regulate glucose and fatty acid metabolism in L6 rat skeletal muscle cells.

The objective of this study was to investigate whether the n-3 polyunsaturated fatty acids (PUFAs) docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) can directly regulate glucose and fat metabolism in skeletal muscle besides exerting anti-inflammatory effects. To accomplish this, L6 skeletal muscle cells were treated with 50 µM of either DHA or EPA for 1, 3, and 5 days. Here, we report that basal and insulin-stimulated rates of glucose uptake, glycogen synthesis, protein kinase B (AKT), and glycogen synthase kinase 3 (GSK3) phosphorylation were not affected by DHA or EPA. However, glucose and palmitate oxidation were consistently elevated by DHA treatment, whereas EPA only increased this variable transiently. Similarly, only DHA caused significant and sustained increases in AMP-activated protein kinase (AMPK) phosphorylation and protein levels of carnitine-palmitoyl transferase-1b (CPT1b) and peroxisome proliferator-activated receptor gamma coactivator-1α (PGC-1α) in skeletal muscle cells. DHA also caused a larger anti-inflammatory effect than EPA in these cells. In conclusion, besides exerting anti-inflammatory effects, DHA and EPA directly regulated glucose and fat metabolism in skeletal muscle cells, although DHA was more effective in doing so than EPA. Thus, by directly enhancing glucose and fat oxidation, DHA may increase glucose disposal and reduce intramyocellular lipid accumulation.

Cold acclimation reduces hepatic protein Kinase B and AMP-activated protein kinase phosphorylation and increases gluconeogenesis in Rats.

This study investigated the molecular and metabolic responses of the liver to cold-induced thermogenesis. To accomplish that, male Wistar rats were exposed to cold (4°C) for 7 days. Livers were then extracted and used for the determination of glucose and fatty acid oxidation, glycogen content, the expression and content of proteins involved in insulin signaling, as well as in the regulation of gluconeogenesis and de novo lipid synthesis. Despite being hyperphagic, cold-acclimated rats displayed normoglycemia with reduced insulinemia, which suggests improved whole-body insulin sensitivity. However, liver protein kinase B (AKT) and glycogen synthase kinase 3 (GSK3) phosphorylations were markedly reduced along with the expressions of the insulin receptor (IR) and its substrates IRS1 and IRS2, whereas glycogen synthase (GS) phosphorylation increased. Thus, major signaling steps of the glycogen synthesis pathway in the liver were inhibited. Furthermore, glucagonemia and hepatic glucose and fatty acid oxidation were increased, whereas liver glycogen content was reduced by cold acclimation. This was accompanied by significantly elevated expressions of the gluconeogenic transcription regulators CRTC2, PGC-1α, and FoxO1, as well as of major gluconeogenic enzymes (G6Pase, FBP1, and PEPCK). Conversely, phosphorylation and contents of AMP-activated protein kinase (AMPK) and acetyl-CoA carboxylase (ACC) and fatty acid synthase (FAS) content were markedly downregulated in livers of cold-acclimated rats. In conclusion, cold acclimation suppressed hepatic glycogen synthesis and promoted profound metabolic changes in the liver so the organ could sustain its ability to regulate whole-body glucose and lipid metabolism under conditions of high-energy demand in thermogenic tissues.