Emerging Trends in Information-Seeking Behavior for Alpha-Gal Syndrome: Infodemiology Study Using Time Series and Content Analysis.

BACKGROUND: Alpha-gal syndrome is an emerging allergy characterized by an immune reaction to the carbohydrate molecule alpha-gal found in red meat. This unique food allergy is likely triggered by a tick bite. Cases of the allergy are on the rise, but prevalence estimates do not currently exist. Furthermore, varying symptoms and limited awareness of the allergy among health care providers contribute to delayed diagnosis, leading individuals to seek out their own information and potentially self-diagnose. OBJECTIVE: The study aimed to (1) describe the volume and patterns of information-seeking related to alpha-gal, (2) explore correlations between alpha-gal and lone star ticks, and (3) identify specific areas of interest that individuals are searching for in relation to alpha-gal. METHODS: Google Trends Supercharged-Glimpse, a new extension of Google Trends, provides estimates of the absolute volume of searches and related search queries. This extension was used to assess trends in searches for alpha-gal and lone star ticks (lone star tick, alpha gal, and meat allergy, as well as food allergy for comparison) in the United States. Time series analyses were used to examine search volume trends over time, and Spearman correlation matrices and choropleth maps were used to explore geographic and temporal correlations between alpha-gal and lone star tick searches. Content analysis was performed on related search queries to identify themes and subcategories that are of interest to information seekers. RESULTS: Time series analysis revealed a rapidly increasing trend in search volumes for alpha-gal beginning in 2015. After adjusting for long-term trends, seasonal trends, and media coverage, from 2015 to 2022, the predicted adjusted average annual percent change in search volume for alpha-gal was 33.78%. The estimated overall change in average search volume was 627%. In comparison, the average annual percent change was 9.23% for lone star tick, 7.34% for meat allergy, and 2.45% for food allergy during this time. Geographic analysis showed strong significant correlations between alpha-gal and lone star tick searches especially in recent years (ρ=0.80; P<.001), with primary overlap and highest search rates found in the southeastern region of the United States. Content analysis identified 10 themes of primary interest: diet, diagnosis or testing, treatment, medications or contraindications of medications, symptoms, tick related, specific sources of information and locations, general education information, alternative words for alpha-gal, and unrelated or other. CONCLUSIONS: The study provides insights into the changing information-seeking patterns for alpha-gal, indicating growing awareness and interest. Alpha-gal search volume is increasing at a rapid rate. Understanding specific questions and concerns can help health care providers and public health educators to tailor communication strategies. The Google Trends Supercharged-Glimpse tool offers enhanced features for analyzing information-seeking behavior and can be valuable for infodemiology research. Further research is needed to explore the evolving prevalence and impact of alpha-gal syndrome.

A quality assurance initiative on improving cefazolin perioperative redose compliance.

OBJECTIVE: Compliance with perioperative antibiotic prophylaxis is crucial for preventing surgical site infection. Anesthesiologists can play a significant role in reducing surgical site infections by following clinical practice guidelines for antibiotic prophylaxis and redosing during surgery. A quality assurance initiative was implemented at a tertiary hospital with the goal of improving cefazolin perioperative antibiotic compliance. DESIGN: This was a retrospective observational study. SETTING: Main operating room of a tertiary care teaching hospital in New York, USA. Our main operating room includes 22 operating rooms that incorporates surgeries from general surgery, vascular surgery, neurology, gynecology, urology, orthopedics, ear, nose and throat (ENT) etc. PARTICIPANTS: All cases in the main operating room from March 1, 2018 to March 31, 2021 that received first dose of Cefazolin and in which the duration of surgery was more than 4 hrs. INTERVENTION: A multifaceted intervention was initiated to address low compliance with cefazolin redosing. Multifaceted interventions included the development of a perioperative antibiotic guide for anesthesia providers, automated reminders in anesthesia electronic medical records, grand rounds education, survey and email communications, and regular feedback reports to the anesthesia department. MAIN OUTCOME MEASURES: Cefazolin perioperative redose compliance rate. RESULTS: Rates of redose compliance were examined in three time periods: preintervention, intervention and postintervention. Cefazolin redosing compliance was 58% in the preintervention period and 90% in the postintervention period. There was a significant positive change in the trend of compliance during the intervention period, indicating that the odds of compliance increased by 13% per month in the intervention period compared to the preintervention period (odds ratio = 1.13, P < 0.001). Redose compliance improvements were sustained a year after the postintervention period (an average of 91%). Surgical site infection rates for colon, coronary artery bypass graft and hip surgeries did not show any significant trend during these time periods. CONCLUSION: Multifaceted interventions led to significant and sustained improvements in cefazolin redosing compliance in the main operating room of a tertiary hospital.

Severe Acute Respiratory Syndrome Coronavirus 2 Convalescent Plasma Versus Standard Plasma in Coronavirus Disease 2019 Infected Hospitalized Patients in New York: A Double-Blind Randomized Trial.

OBJECTIVES: Four peer-reviewed publications have reported results from randomized controlled trials of convalescent plasma for coronavirus disease 2019 infection; none were conducted in the United States nor used standard plasma as a comparator. To determine if administration of convalescent plasma to patients with coronavirus disease 2019 increases antibodies to severe acute respiratory syndrome coronavirus 2 and improves outcome. DESIGN: Double-blind randomized controlled trial. SETTING: Hospital in New York. PATIENTS: Patients with polymerase chain reaction documented coronavirus disease 2019 infection. INTERVENTIONS: Patients were randomized (4:1) to receive 2 U of convalescent plasma versus standard plasma. Antibodies to severe acute respiratory syndrome coronavirus 2 were measured in plasma units and in trial recipients. MEASUREMENTS AND MAIN RESULTS: Enrollment was terminated after emergency use authorization was granted for convalescent plasma. Seventy-four patients were randomized. At baseline, mean (sd) Acute Physiology and Chronic Health Evaluation II score (23.4 [5.6] and 22.5 [6.6]), percent of patients intubated (19% and 20%), and median (interquartile range) days from symptom onset to randomization of 9 (6-18) and 9 (6-15), were similar in the convalescent plasma versus standard plasma arms, respectively. Convalescent plasma had high neutralizing activity (median [interquartile range] titer 1:526 [1:359-1:786]) and its administration increased antibodies to severe acute respiratory syndrome coronavirus 2 by 14.4%, whereas standard plasma administration led to an 8.6% decrease (p = 0.005). No difference was observed for ventilator-free days through 28 days (primary study endpoint): median (interquartile range) of 28 (2-28) versus 28 (0-28; p = 0.86) for the convalescent plasma and standard plasma groups, respectively. A greater than or equal to 2 point improvement in the World Health Organization scale was achieved by 20% of subjects in both arms (p = 0.99). All-cause mortality through 90 days was numerically lower in the convalescent plasma versus standard plasma groups (27% vs 33%; p = 0.63) but did not achieve statistical significance. A key prespecified subgroup analysis of time to death in patients who were intubated at baseline was statistically significant; however, sample size numbers were small. CONCLUSIONS: Administration of convalescent plasma to hospitalized patients with coronavirus disease 2019 infection increased antibodies to severe acute respiratory syndrome coronavirus disease 2 but was not associated with improved outcome.

Randomized controlled trial of 7, 28, vs 42 day stored red blood cell transfusion on oxygen delivery (VO2 max) and exercise duration.

BACKGROUND: Few studies have rigorously assessed the impact of red blood cell (RBC) transfusion on oxygen delivery. Several large trials demonstrated no clinical outcome differences between transfusion of shorter-storage vs prolonged-storage RBCs. These trials did not directly assess functional measures of oxygen delivery. Therefore, it is not clear if 42-day stored RBCs deliver oxygen as effectively as 7-day stored RBCs. STUDY DESIGN AND METHODS: Leukocyte-reduced RBCs were collected by apheresis in AS-3. Thirty subjects were randomized (1:1:1) to receive 2 units of autologous RBCs at either 7, 28, or 42 days following donation. VO2 max testing, using a standardized protocol to exhaustion, was performed 2 days before (Monday) and 2 days after (Friday) the transfusion visit (Wednesday). The primary endpoint was the percent increase in VO2 max between Monday and Friday. The secondary endpoint was the percent change in duration of exercise for the same time points. RESULTS: Hemoglobin levels decreased by 2.8 ± 1.4 g/dL after donation and increased by 2.1 ± 0.6 g/dL after transfusion. This change in hemoglobin was associated with expected decreases (then increases after transfusion) in VO2 max and exercise duration. No differences were observed between 7-day and 42-day RBC transfusion for percent increase in median [IQR] VO2 max (10.5 [0.2-17.3] vs 10.9 [5.7-16.8], P = .41) or for percent increase in exercise duration (5.4 [4.1-6.9] vs 4.9 [2.0-7.2], P = .91), respectively. Results were similar for 28-day RBCs and were consistent across the ITT and per-protocol analysis populations. CONCLUSION: These data indicate that 42-day, 28-day, and 7-day RBCs have similar ability to deliver oxygen.

Neutralizing activity to SARS-CoV-2 of convalescent and control plasma used in a randomized controlled trial.

BACKGROUND: There are limited data on the neutralizing activity of convalescent plasma (CP) administered in randomized controlled trials (RCT) of COVID-19 infection. STUDY DESIGN AND METHODS: As part of an RCT, CP was collected per FDA guidelines from individuals recovered from COVID-19 infection. CP donors had to have ≥145 optical density (OD) units (ideal target ≥300) using a semiquantitative, immunochromatographic test for IgG antibody to the nucleocapsid protein (NP) of SARS-CoV-2 (typical range 0-500 OD units). A random subset of samples [14 control plasma, 12 CP "medium-anti-NP" (145-299 OD units), and 13 CP "high" anti-NP (≥300 OD units)] were tested for neutralizing antibodies using an established viral luciferase antibody inhibition assay to detect the infection of SARS-CoV-2 pseudovirus that encoded spike protein (SARS2-Strunc ) on a human immunodeficiency virus 1 vector (NL43dEnvNanoLuc), using ACE2-expressing 293 T cells. The titer needed to neutralize 50% of viral activity (NT50) was calculated. RESULTS: The uptake of SARS-CoV-2 pseudovirus by 293TACE2 cells was inhibited by pretreatment with CP compared to control CP (p < .001) with control plasma having a median (IQR) 50% neutralization titer (NT50) of 1:28 (1:16,1:36) compared to 1:334 (1:130,1:1295) and 1:324 (1:244,1:578), for medium anti-NP and high anti-NP CP units, respectively. The neutralizing activity of CP met minimum FDA criteria with neutralizing antibody titers >1:80 in 100% of randomly selected samples, using a conservative approach that excluded non-specific binding. DISCUSSION: Plasma from donors screened using an immunochromatographic test for IgG antibody to SARS-CoV-2 NP exhibited neutralizing activity meeting FDA's minimum standard in all randomly selected COVID-19 CP units.

Impact of serological and PCR testing requirements on the selection of COVID-19 convalescent plasma donors.

BACKGROUND: Convalescent plasma is undergoing randomized trials as a potential therapeutic option for COVID-19 infection. Little empirical evidence exists regarding the determination of donor eligibility and experiences with donor selection. STUDY DESIGN AND METHODS: This prospective study was conducted at a tertiary care hospital in New York to select plasma donors for a randomized, double-blind, controlled convalescent plasma trial. Clearance for donation required successful completion of an online questionnaire and an in-person screening visit, which included (a) completion of a Donor Health Questionnaire (DHQ), (b) Immunoglobulin G (IgG) antibody testing using an immunochromatographic anti- severe acute respiratory coronavirus 2 (SARS-CoV-2) test, (c) Polymerase chain reaction (PCR) testing if <28 days from symptom resolution, and (d) routine blood bank testing. RESULTS: After receiving 3093 online questionnaires, 521 individuals presented for in-person screening visits, with 40.1% (n = 209) fully qualifying. Subjects (n = 312) failed to progress due to the following reasons: disqualifying answer from DHQ (n = 30, 9.6%), insufficient antibodies (n = 198, 63.5%), persistent positive PCR tests (n = 14, 4.5%), and blood donation testing labs (n = 70, 22.4%). Importantly, 24.6% and 11.1% of potential donors who reported having PCR-diagnosed infection had low or undetectable SARS-CoV-2 antibody levels, respectively. Surprisingly, 62.9% (56/89) of subjects had positive PCR tests 14-27 days after symptom resolution, with 13 individuals continuing to be PCR positive after 27 days. CONCLUSION: It is feasible for a single site to fully qualify a large number of convalescent plasma donors in a short period of time. Among otherwise qualified convalescent plasma donors, we found high rates of low or undetectable antibody levels and many individuals with persistently positive PCR tests.

A randomized-controlled trial of sugammadex versus neostigmine: impact on early postoperative strength.

BACKGROUND: Residual neuromuscular blockade after surgery is associated with airway obstruction, hypoxia, and respiratory complications. Compared with neostigmine, sugammadex reverses neuromuscular blockade to a train-of-four ratio > 0.9 more rapidly. It is unknown, however, whether the superior reversal profile of sugammadex improves clinically relevant measures of strength in the early postoperative period. METHODS: Patients undergoing general, gynecological, or urologic surgery were randomized to receive either neostigmine (70 µg·kg-1, maximum 5 mg) or sugammadex (2 or 4 mg·kg-1) to reverse neuromuscular blockade. The primary outcome was the ability to breathe deeply measured by incentive spirometry at 30, 60, and 120 min after reversal. RESULTS: We randomized 62 patients to either a neostigmine (n = 31) or sugammadex (n = 31) group. The incentive spirometry volume recovery trajectory was not different between the two groups (P = 0.35). Median spirometry volumes at baseline, 30, 60, and 120 min postoperatively were 2650 vs 2500 mL, 1775 vs 1750 mL, 1375 vs 2000 mL, and 1800 vs 1950 mL for the sugammadex and neostigmine groups, respectively. Postoperative incentive spirometry decrease from baseline was not different between the two groups. Hand grip strength, the ability to sit unaided, train-of-four ratio on postanesthesia care unit (PACU) admission, time to extubation, time to PACU discharge readiness, and Quality of Recovery-15 scores were also not different between the groups. CONCLUSIONS: Measures of postoperative strength, such as incentive spirometry, hand group strength, and the ability to sit up in the early postoperative period were not different in patients who received neostigmine or sugammadex for the reversal of neuromuscular blockade. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT02909439); registered: 21 September, 2016.

RéSUMé: CONTEXTE: Les blocs neuromusculaires résiduels après une chirurgie sont associés à l'obstruction des voies aériennes, à l'hypoxie et à des complications respiratoires. Par rapport à la néostigmine, le sugammadex neutralise le bloc neuromusculaire à un ratio de train-de-quatre (TOF) > 0,9 plus rapidement. Nous ne savons toutefois pas si le profil de neutralisation supérieur du sugammadex améliore les mesures pertinentes d'un point de vue clinique de la force en période postopératoire initiale. MéTHODE: Nous avons randomisé des patients subissant une chirurgie générale, gynécologique ou urologique à recevoir de la néostigmine (70 µg·kg-1, maximum 5 mg) ou du sugammadex (2 ou 4 mg·kg-1) pour neutraliser le bloc neuromusculaire. Le critère d'évaluation principal était la capacité des patients à respirer profondément telle que mesurée par spirométrie incitative à 30, 60 et 120 min après la neutralisation. RéSULTATS: Au total, 62 patients ont été randomisés dans les groupes néostigmine (n = 31) ou sugammadex (n = 31). Aucune différence dans la trajectoire de récupération de volume de spirométrie incitative n'a été observée entre les deux groupes (P = 0,35). Les volumes médians de spirométrie préopératoire et à 30, 60 et 120 min postopératoires étaient de 2650 vs 2500 mL, 1775 vs 1750 mL, 1375 vs 2000 mL, et 1800 vs 1950 mL pour les groupes sugammadex et néostigmine, respectivement. La diminution postopératoire de la spirométrie incitative par rapport aux valeurs de base était similaire dans les deux groupes. La force de préhension, la capacité à s'asseoir sans assistance, le ratio de train-de-quatre à l'admission à la salle de réveil, le délai jusqu'à l'extubation, le délai jusqu'à l'obtention des critères de congé de la salle de réveil et les scores de QoR-15 (mesurant la qualité de récupération) ne différaient pas non plus entre les groupes. CONCLUSION: Les mesures de la force postopératoire, telles que la spirométrie incitative, la force de préhension et la capacité de s'asseoir en période postopératoire initiale, ne différaient pas entre les patients ayant reçu de la néostigmine ou du sugammadex pour neutraliser le bloc neuromusculaire. ENREGISTREMENT DE L'éTUDE: www.clinicaltrials.gov (NCT02909439); enregistrée le 21 septembre 2016.

Laparoscopic versus open surgery: a systematic review evaluating Cochrane systematic reviews.

BACKGROUND: Laparoscopic surgical procedures (LSP) have grown in popularity due to their purported benefits of improved effectiveness and efficiency. This study summarizes the Cochrane systematic reviews' (CSRs') evidence comparing the use of LSP versus open procedures used for surgical patient management and comparing the CSRs' quality and consistency of LSP evidence reported across time and different surgical specialties. METHODS: The Cochrane Database was searched to identify CSRs comparing LSP versus open procedures; 36 CSRs and 15 CSR protocols were found as of February 16, 2016. Each CSR's clinical outcomes and major conclusions were evaluated; CSR's quality and completeness were assessed using PRISMA and AMSTAR criteria. Overall, CSRs' reporting variations across specialties and trends over time were summarized. RESULTS: A weighted analysis across all 36 CSRs found improved outcomes with LSP (odds ratio 0.90; 95% confidence interval 0.88, 0.92). Substantial CSR variation was found in the patient inclusion/exclusion criteria and clinical endpoints used. Individually, most CSR analyses showed no significant difference (65.4%) between LSP versus open procedures; 25.8% showed a LSP benefit versus 8.9% an open benefit. As a major conclusion, a positive LSP impact was documented by 8/36 (22.2%) CSRs; but only half of these CSRs decisively concluded that there was a LSP advantage. Undeclared conflicts of interest were identified in 9/36 CSRs (25.0%), raising the potential for a reporting bias. Both CSR variabilities (i.e., missing population, intervention, comparison, outcome, study design statements) and PRISMA-related deficiencies were documented. CONCLUSIONS: Overall, CSR evidence supports a LSP advantage; however, clinical decisions must be driven by CSR procedure-specific evidence. Variations and inconsistencies in CSR design and reporting identified future opportunities to improve CSR quality by increasing the methodological transparency, standardizing CSR reporting, and documenting comprehensively any non-financial conflicts of interest (i.e., ongoing research and historical publications) for all CSR team members.

Trainability of Cricoid Pressure Force Application: A Simulation-Based Study.

BACKGROUND: Aspiration of gastric contents is a leading cause of airway management-related mortality during anesthesia practice. Cricoid pressure (CP) is widely used during rapid sequence induction to prevent aspiration. National guidelines for CP suggest a target force of 10 N before and 30 N after loss of consciousness. However, few studies have rigorously assessed whether clinicians can be trained to consistently achieve these levels of force. We hypothesized that clinicians can be trained effectively to deliver 10-30 N during application of CP. METHODS: Clinicians (attending anesthesiologist, anesthesiology residents, certified registered nurse anesthetists, or operating room nurses) applied CP on a Vernier force plate simulator with measurements taken at 4 time points over 60 seconds, 2 measurements before and 2 measurements after loss of consciousness. A successful cycle required all 4 time points to be within the target range (10 ± 5 and 30 ± 5 N, respectively). After baseline assessment (n = 100 clinicians), a subset of 40 participants volunteered for education on recommended force targets, underwent self-regulated practice, and then performed 30 1-minute cycles of high-frequency simulation analyzed by cumulative sum analysis to assess their change in performance. RESULTS: At baseline, 5 cycles (1.3% [confidence interval {CI}, 0.3%-2.50%]) out of 400 were successful. Performance improved after education and self-regulated practice (16% successful cycles [CI, 7.8%-25%]), and performance during the last 4 of 30 cycles was 45% (CI, 33%-58%). The odds of success increased over time (odds ratio, 1.1; P < .001). By cumulative sum analysis, however, no subject crossed the h0 line, indicating that no one achieved proficiency of the predefined target forces. CONCLUSIONS: At baseline, performance was poor at achieving target forces specified by national guidelines. Simulation-based training improved the success rate, but no participant achieved the predefined threshold for proficiency.

A ten-year retrospective study of post-dural puncture headache in 32,655 obstetric patients.

PURPOSE: Accidental dural puncture and post-dural puncture headache are well-known complications of neuraxial anesthesia in parturients. The primary goal of this study was to identify the rate of post-dural puncture headache and epidural blood patch in all parturients who received a neuraxial anesthetic during a ten-year period at an academic tertiary-care medical centre. A secondary goal was to identify any delay in hospital discharge due to a post-dural puncture headache. METHODS: We conducted a retrospective analysis of all patients who received a neuraxial anesthetic on the labour and delivery unit at Stony Brook Medical Center from 1 January, 2006 to 31 December, 2015. Standardized neuraxial anesthesia equipment was used throughout this period. Chart reviews were conducted on all patients who received a neuraxial anesthetic and had an accidental dural puncture and/or developed a post-dural puncture headache. RESULTS: Of the 32,655 neuraxial anesthetics performed, 298 (0.9%) patients experienced a post- dural puncture headache. Analysis of all patients who developed a post-dural puncture headache showed that 150 (50.3%) patients received one or more epidural blood patches. Overall, 19 (0.06%) patients had a delay in hospital discharge due to a post-dural puncture headache. CONCLUSIONS: We showed a relatively low incidence (< 1%) of post-dural puncture headache following neuraxial anesthesia in parturients at an academic tertiary-care medical centre. Patients that rated their post-dural puncture headache as very severe were more likely to undergo at least one epidural blood patch procedure. Post-dural puncture headache is a well-known complication of neuraxial anesthesia, and may lead to a delay in hospital discharge.

Efficacy of acupressure on quality of recovery after surgery: Randomised controlled trial.

BACKGROUND: Acupressure therapy is associated with favourable efficacies on postoperative nausea, pain and sleep disturbance, although the quality of the evidence is generally low. No randomised clinical trial has yet assessed the effect of acupressure on postoperative quality of recovery (QoR). OBJECTIVE: The objective was to study acupressure efficacy on patient-reported postoperative recovery. DESIGN: We conducted a single centre, three-group, blind, randomised controlled, pragmatic trial assessing acupressure therapy on the PC6, LI4 and HT7 acupoints. PATIENTS: Postoperative patients expected to stay in hospital at least 2 days after surgery. INTERVENTIONS: In the acupressure group, pressure was applied for 6 min (2 min per acupoint), three times a day after surgery for a maximum of 2 postoperative days during the hospital stay. In the sham group, extremely light touch was applied to the acupoints. The third group did not receive any touch. MAIN OUTCOME MEASURES: The primary outcome was the change in the QoR, using the QoR-15 questionnaire, between postoperative days 1 and 3. Key secondary outcomes included patients' satisfaction, postoperative nausea and vomiting, pain score and opioid (morphine equivalent) consumption. Assessors for the primary and secondary endpoints were blind to the group allocation. RESULTS: Overall, 163 patients were randomised (acupressure n=55, sham n=53, no intervention n=55). The mean (SD) postoperative change in QoR-15 did not differ statistically (P = 0.27) between the acupressure, sham and no intervention groups: 15.2 (17.8), 14.2 (21.9), 9.2 (21.7), respectively. Patient satisfaction (on a 0 to 10 scale) was statistically different (P = 0.01) among these three groups: 9.1 (1.5), 8.4 (1.6) and 8.2 (2.2), respectively. Changes in pain score and morphine equivalent consumption were not significantly different between the groups. CONCLUSION: Two days of postoperative acupressure therapy (up to six treatments) did not significantly improve patient QoR, postoperative nausea and vomiting, pain score or opioid consumption. Acupressure, however, was associated with improved patient satisfaction. TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT02762435.

Intrathecal morphine administration reduces postoperative pain and peripheral endocannabinoid levels in total knee arthroplasty patients: a randomized clinical trial.

BACKGROUND: The primary goal of this study was to determine whether administration of intrathecal morphine reduces postoperative pain. The secondary goal was to determine the effect of intrathecal morphine upon circulating levels of the weakly analgesic endocannabinoids, anandamide (AEA) and 2-arachidonoylglycerol (2-AG), and the related lipids palmitoylethanolamide (PEA) and oleoylethanolamide (OEA). METHODS: Forty two total knee arthroplasty (TKA) patients were enrolled in a prospective, double-blinded, randomized study. The intervention consisted of intrathecal morphine (200 µg) or placebo administered at the time of the spinal anesthesia. Postoperative pain was measured during the first 4 h after surgery while serum levels of AEA, 2-AG, PEA, OEA, and cortisol were measured at baseline and 4 h after surgery. RESULTS: Administration of intrathecal morphine reduced postoperative pain 4 h after TKA surgery compared to placebo (p = 0.005) and reduced postoperative systemic opioid consumption (p = 0.001). At baseline, intrathecal morphine led to a significant reduction in AEA, 2-AG, and OEA levels but did not affect PEA or cortisol levels. In patients administered intrathecal placebo, 2-AG levels were elevated 4 h after surgery; whereas patients receiving intrathecal morphine showed reductions in AEA, PEA, and OEA when compared to placebo. At 4 h after TKA surgery cortisol levels were significantly elevated in the placebo group and reduced in those receiving morphine. CONCLUSIONS: These results indicate that intrathecal morphine reduces postoperative pain in TKA patients. Furthermore, activation of central opioid receptors negatively modulates the endocannabinoid tone, suggesting that potent analgesics may reduce the stimulus for production of peripheral endocannabinoids. This study is the first to document the existence of rapid communication between the central opioid and peripheral endocannabinoid systems in humans. TRIAL REGISTRATION: This trial was registered retrospectively. TRIAL REGISTRY: NCT02620631 . Study to Examine Pain Relief With Supplemental Intrathecal Morphine in TKA Patients, NCT02620631 , 12/03/2015.

Effect of perioperative goal-directed hemodynamic therapy on postoperative recovery following major abdominal surgery-a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Goal-directed hemodynamic therapy (GDHT) has been used in the clinical setting for years. However, the evidence for the beneficial effect of GDHT on postoperative recovery remains inconsistent. The aim of this systematic review and meta-analysis was to evaluate the effect of perioperative GDHT in comparison with conventional fluid therapy on postoperative recovery in adults undergoing major abdominal surgery. METHODS: Randomized controlled trials (RCTs) in which researchers evaluated the effect of perioperative use of GDHT on postoperative recovery in comparison with conventional fluid therapy following abdominal surgery in adults (i.e., >16 years) were considered. The effect sizes with 95% CIs were calculated. RESULTS: Forty-five eligible RCTs were included. Perioperative GDHT was associated with a significant reduction in short-term mortality (risk ratio [RR] 0.75, 95% CI 0.61-0.91, p = 0.004, I 2 = 0), long-term mortality (RR 0.80, 95% CI 0.64-0.99, p = 0.04, I 2 = 4%), and overall complication rates (RR 0.76, 95% CI 0.68-0.85, p < 0.0001, I 2 = 38%). GDHT also facilitated gastrointestinal function recovery, as demonstrated by shortening the time to first flatus by 0.4 days (95% CI -0.72 to -0.08, p = 0.01, I 2 = 74%) and the time to toleration of oral diet by 0.74 days (95% CI -1.44 to -0.03, p < 0.0001, I 2 = 92%). CONCLUSIONS: This systematic review of available evidence suggests that the use of perioperative GDHT may facilitate recovery in patients undergoing major abdominal surgery.

Long-Term Post-CABG Survival: Performance of Clinical Risk Models Versus Actuarial Predictions.

BACKGROUND/AIM: Clinical risk models are commonly used to predict short-term coronary artery bypass grafting (CABG) mortality but are less commonly used to predict long-term mortality. The added value of long-term mortality clinical risk models over traditional actuarial models has not been evaluated. To address this, the predictive performance of a long-term clinical risk model was compared with that of an actuarial model to identify the clinical variable(s) most responsible for any differences observed. METHODS: Long-term mortality for 1028 CABG patients was estimated using the Hannan New York State clinical risk model and an actuarial model (based on age, gender, and race/ethnicity). Vital status was assessed using the Social Security Death Index. Observed/expected (O/E) ratios were calculated, and the models' predictive performances were compared using a nested c-index approach. Linear regression analyses identified the subgroup of risk factors driving the differences observed. RESULTS: Mortality rates were 3%, 9%, and 17% at one-, three-, and five years, respectively (median follow-up: five years). The clinical risk model provided more accurate predictions. Greater divergence between model estimates occurred with increasing long-term mortality risk, with baseline renal dysfunction identified as a particularly important driver of these differences. CONCLUSIONS: Long-term mortality clinical risk models provide enhanced predictive power compared to actuarial models. Using the Hannan risk model, a patient's long-term mortality risk can be accurately assessed and subgroups of higher-risk patients can be identified for enhanced follow-up care. More research appears warranted to refine long-term CABG clinical risk models.

COVID-19 Booster Vaccination Status and Long COVID in the United States: A Nationally Representative Cross-Sectional Study.

Early studies have found that the initial COVID-19 vaccination series was protective against severe symptoms and long COVID. However, few studies have explored the association of booster doses on severe disease outcomes and long COVID. This cross-sectional analysis used data from the 2022 US National Health Interview Survey data to investigate how vaccination status correlates with COVID-19 infection severity and long COVID among previously infected individuals. Participants were categorized into three groups: those who had received at least one booster, those with only the initial complete vaccination series, and those with either an incomplete series or no vaccinations. Out of 9521 survey respondents who reported a past positive COVID-19 test, 51.2% experienced moderate/severe infections, and 17.6% experienced long COVID. Multivariable regression models revealed that receiving at least one booster shot was associated with lower odds of experiencing moderate/severe symptoms (aOR = 0.78, p < 0.001) compared to those unvaccinated or with an incomplete series. Additionally, having at least one booster reduced long COVID odds by 24% (aOR = 0.76, p = 0.003). Completing only the primary vaccine series did not significantly decrease the likelihood of severe illness or long COVID. These findings support the continued promotion of booster vaccinations to mitigate long COVID risks in vulnerable populations.

The Acute Effect of Chamomile Intake on Blood Coagulation Tests in Healthy Volunteers: A Randomized Trial.

BACKGROUND: Chamomile administration may have desirable effects in the perioperative setting. Current practice, however, discourages perioperative chamomile use due to a theoretical increase in bleeding. Therefore, we evaluated if chamomile acutely (within 4 h of ingestion) prolongs coagulation assays. METHODS: Eight healthy volunteers were randomized to receive 2 interventions in a crossover design: (a) single dose of chamomile extract capsule (500 mg) and (b) single dose of chamomile tea (3 g in 150 mL water). Interventions were separated at least 3 days apart from each other. Blood was sampled pre-ingestion, 2 h post-ingestion, and 4 h post-ingestion for each intervention. The primary outcome was the maximal change in prothrombin time (PT) before vs after each intervention. Secondary outcomes included changes in international normalized ratio, activated partial thromboplastin time, thrombin time, reptilase time, and fibrinogen levels. RESULTS: All 8 subjects completed the study. The average pre-ingestion PT values for tea and capsules were 11.9 (1.1) s and 12.0 (0.9) s, respectively. Tea significantly increased the average maximum PT by 0.7 (0.2) s (P = 0.0078). Extract capsules increased the maximum PT by 0.3 (0.2) s (P = 0.06). Neither PT prolongation met the predefined 10% threshold for clinical significance. No significant changes in secondary outcomes were observed. CONCLUSIONS: Chamomile tea ingestion prolongs PT. However, the clinical significance of this is unclear at this time and warrants further investigation. ClinicalTrials.gov Registration Number: NCT05272475.

Report from a quality assurance program on patients undergoing the MILD procedure.

OBJECTIVES: To characterize trends in pain and functional outcomes and identify risk factors in patients with lumbar spinal stenosis (LSS) and neurogenic claudication undergoing the "Minimally Invasive Lumbar Decompression" (MILD) procedure. DESIGN: Retrospective observational cohort study. SETTING: Academic multidisciplinary pain center at Stony Brook Medicine. SUBJECTS: Patients undergoing the MILD procedure from October 2010 to November 2012. METHODS: De-identified perioperative, pain and function related data for 50 patients undergoing MILD were extracted from the Center for Pain Management's quality assessment database. Data included numerical rating scale (NRS), symptom severity and physical function (Zurich Claudication Questionnaire), functional status (Oswestry Disability Index [ODI]), pain interference scores (National Institutes of Health Patient-Reported Outcomes Measurement Information System [PROMIS]), and patients' self-reported low back and lower extremity pain distribution. RESULTS: No MILD patient incurred procedure-related complications. Average NRS scores decreased postoperatively and 64.3% of patients reported less pain at 3 months. Clinically meaningful functional ODI improvements of at least 20% from baseline were present in 25% of the patients at 6 months. Preliminary analysis of changes in PROMIS scores at 3 months revealed that pre-MILD "severe" lumbar canal stenosis may be associated with high risk of "no improvement." No such impact was observed for NRS or ODI outcomes. CONCLUSION: Overall, pain is reduced and functional status improved in LSS patients following the MILD procedure at 3 and 6 months. Given the small sample size, it is not yet possible to identify patient subgroups at risk for "no improvement." Continued follow-up of longer-term outcomes appears warranted to develop evidence-based patient selection criteria.

COVID-19 symptom load as a risk factor for chronic pain: A national cross-sectional study.

INTRODUCTION: Emerging evidence suggests that a COVID-19 infection with a high initial severity may be associated with development of long-COVID conditions such as chronic pain. At the population level, it is unknown if severity of a COVID-19 infection might be a new risk factor for chronic pain above and beyond the traditional slate of pre-established risk factors. The purpose of this study is to examine whether COVID-19 severity of infection may be a new risk factor for chronic pain. METHODS: Using data from the 2021 National Health Interview Survey (n = 15,335), this study examined the adjusted odds of experiencing high frequency levels of pain in the past 3 months for those who reported no/mild symptoms from a COVID-19 infection, and those reporting moderate/severe symptoms from COVID-19, compared to those never infected. A 1:1:1 propensity score matched analysis was also performed to examine the odds of pain. RESULTS: Prevalence of pain was higher in the moderate/severe symptom group compared to the no infection group (25.48% vs 19.44%, p <0.001). Both the adjusted model (odds ratio [OR] = 1.28, 95% confidence interval [CI] = 1.09, 1.51) and matched model (OR = 1.45, CI = 1.14, 1.83) revealed higher odds of pain for those with moderate/high COVID-19 symptoms compared to no infection. CONCLUSIONS: A moderate/highly symptomatic COVID-19 infection may be a new risk factor for chronic pain. As the absolute number of severe COVID-19 infections continues to rise, overall prevalence of chronic pain may also increase. While knowledge continues to unfold on long-haul symptoms, prevention of severe infections remains essential.

Ability of the integrated pulmonary index to predict impending respiratory events in the early postoperative period.

BACKGROUND: In the early postoperative period, respiratory compromise is a significant problem. Standard-of-care monitoring includes respiratory rate (RR) and pulse oximetry, which are helpful; however, low SpO2 is often a late sign during decompensation. The FDA-approved Capnostream-20p monitor records four variables (SpO2, RR, End-tidal CO2, heart rate), which are combined by fuzzy logic into a single, unit-less value (range 1-10) called the integrated pulmonary index (IPI). No published studies have assessed the performance of a low IPI to predict impending respiratory events. METHODS: In this investigator-initiated study, adult patients undergoing general anesthesia were monitored with the Capnostream-20p monitor for up to 2 h during their recovery room stay. The study coordinator, who along with clinicians, was blinded to IPI values, recorded the time of any respiratory event, defined a priori as any one of eight respiratory-related interventions/conditions. The primary sensitivity endpoint (early detection success) was defined as at least 80% of events predicted by at least 2 consecutive low IPI (≤ 7) values within 2-15 min before an event occurred. Late detection was defined as low IPI values occurring with 2 min prior to or 2 min after the event occurred. DISCUSSION: Of 358 patients, ≥ 1 respiratory event occurred in 183 (51.1%) patients. Of 802 total events, 606 were detected early (within 2-15 min prior to the event), and 653 were detected either early or late. Therefore, the sensitivity for early detection was 75.6% (95% confidence interval [CI]: 72.6-78.5%), which differed significantly from the 80% sensitivity goal by 4.4% (p = 0.0016). Sensitivity for total success (early or late) was 81.4% (95% CI: 78.7-84.1%), which was significantly different from the 90% on time sensitivity goal by 8.6% (p < 0.0001). CONCLUSIONS: A low IPI was 75.6% sensitive for early detection (within 2-15 min) prior to respiratory events but did not achieve our preset threshold of 80% for success.