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The quest for a safe and effective anesthetic medication in the mid-20th century led to the discovery of CI-581, which was later named ketamine. Ketamine was labeled a "dissociative anesthetic" due to the state of sensory deprivation that it induces in the subjects receiving it. Although it enjoyed widespread use at the beginning of the Vietnam war, its use rapidly waned due to its psychedelic effect and it became more popular as a recreational drug, and in the field of veterinary medicine. However, as we gained more knowledge about its multiple sites of action, it has reemerged as a useful anesthetic/analgesic agent. In the last decade, the field of neurology has witnessed the growing use of ketamine for the treatment of several neurological conditions including migraine, status epilepticus, stroke, and traumatic brain injury (TBI). Ketamine acts primarily as a non-competitive N-methyl-D-aspartate (NMDA) receptor antagonist. The binding of ketamine to NMDA receptors leads to decreased frequency and duration of Ca

Microscopic polyangiitis (MPA) is a systemic small vessel vasculitis but it is rare to see life-threatening diffuse alveolar hemorrhage (DAH) in MPA as an initial presentation. MPA more commonly presents with renal involvement and develops pulmonary manifestations later in the disease course. Our patient is a 77-year-old female with a recent history of recovered COVID-19 infection who presented with sudden onset fever, dyspnea, and hemoptysis for three days. She was diagnosed with MPA because of the new-onset DAH, a strongly positive myeloperoxidase (MPO) antibody, and the low likelihood of another etiology. The patient was treated with pulse-dose steroids and plasmapheresis while being on mechanical ventilation. This case highlights the importance of the prompt recognition of DAH as an initial presentation of MPA and illustrates the possible role of COVID-19 in inciting autoimmune conditions.

Lung cancer is the most common cause of death in both men and women. The United States Preventive Services Task Force (USPSTF) recommends annual lung screening with low-dose computed tomography (LDCT) chest for individuals aged 55-80 who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. We reviewed the electronic medical records of patients visiting our outpatient clinic over a period of one year. We included all eligible individuals according to USPSTF guidelines for LDCT to identify screening rates at our institution. All primary care physicians, including residents and attendings, were given a prepared questionnaire to understand their beliefs and concerns with the implementation of this program. A total of 13,500 patients visited the outpatient clinic and 1178 were eligible for LDCT. Forty-five percent (45%) of patients received LDCT screening, which was higher than the national average of 2%-5%. A total of 50 primary care providers were included in the survey. The majority of the providers were aware of the USPSTF guidelines and believed that patients with multiple comorbidities and insurance issues were barriers in initiating LDCT screening. Lung cancer screening is an important component in cancer preventive strategies. Widespread awareness among the primary care providers and the public is extremely necessary for improving the use of LDCT.

Spine surgery at the wrong level is an undesirable event and unique pitfall in spine surgery. It is detrimental to the relationship between the patient and the surgeon and typically results in profound medical and legal consequences. It falls under the wrong-site surgery sentinel events reporting system. This error is most frequently observed in lumbosacral spine. Several risk factors are implicated; however, anatomical variations of the lumbosacral spine are a major risk factor. The aim of this article was to provide a detailed description of these high-risk anatomical variations, including transitional vertebrae, lumbar ribs, butterfly vertebrae, hemivertebra, block/fused vertebrae, and spinal dysraphism. A literature review was performed in the database PubMed to obtain all relative English-only articles concerning these anatomical variations and their implication in the development of lumbosacral spine surgery at the wrong level. We also described patient characteristics that can lead to lumbosacral surgery at the wrong level such as tumors, infection, previous lumbosacral surgery, obesity, and osteoporosis. Certain techniques to prevent such incorrect surgery were explained. Lumbosacral spine anatomical variations are surgically significant. Awareness of their existence may provide better pre-operative planning and surgical intervention, leading to avoidance of incorrect-level surgery and potentially better clinical outcomes. In addition, collaboration with radiologists and careful examination of patient’s anatomy and characteristics should be exercised, especially in difficult cases.

Spine surgery at the wrong level is a detrimental ordeal for both surgeon and patient, and it falls under the wrong-site surgery sentinel events reporting system. While there are several methods designed to limit the incidence of these events, they continue to occur and can result in significant morbidity for the patient and malpractice lawsuits for the surgeon. In thoracic spine, numerous risk factors influence the development of this misadventure. These include anatomical variations such as transitional vertebrae, rib variants, hemivertebra, and block/fused vertebrae as well as patient characteristics, such as tumors, infections, previous thoracic spine surgery, obesity, and osteoporosis. An extensive literature search of the PubMed database up to 2019 was completed on each of the anatomical entities and their influence on developing thoracic spine surgery at the wrong level, taking into consideration patient's individual factors. A reliable protocol and effective techniques were described to prevent this error. In addition, the surgeon should collaborate with radiologists, particularly in challenging cases. A thorough understanding of the surgical anatomy and its variants coupled with patients characteristic is crucial for maximal patient benefit and avoidance of thoracic spine surgery at the wrong level.

Spine surgery at the wrong level is an adversity that many spine surgeons will encounter in their career, and it falls under the wrong-site surgery sentinel events reporting system. The cervical spine is the second most common location in the spine at which surgery is performed at the wrong level. Anatomical variations of the cervical spine are one of the most important incriminating risk factors. These anomalies include craniocervical junction abnormalities, cervical ribs, hemivertebrae, and block/fused vertebrae. In addition, patient characteristics, such as tumors, infection, previous cervical spine surgery, obesity, and osteoporosis, play an important role in the development of cervical surgery at the wrong level. These were described, and several effective techniques to prevent this error were provided. A thorough review of the English-language literature was performed in the database PubMed between 1981 and 2019 to review and summarize these risk factors. Compulsive attention to these factors is essential to ensure patient safety. Therefore, the surgeon must carefully review the patient’s anatomy and characteristics through imaging and collaborate with radiologists to reduce the likelihood of performing cervical spine surgery at the wrong level.

Lumbar spinal stenosis is defined as narrowing of the lumbar spinal canal, which causes compression of the spinal cord and nerves. Spinal stenosis can cause leg pain and potentially back pain that can affect the quality of life. Ultimately, surgical decompression is required to alleviate the symptoms. In this review, we first utilize several important studies to compare lumbar laminectomy alone versus lumbar laminectomy and fusion. We also compare the effectiveness of more novel surgical approaches, stand-alone anterior lumbar interbody fusion (ALIF), and stand-alone lateral lumbar interbody fusion (LLIF). These techniques have their own advantages and disadvantages in which many factors must be taken into account before choosing a surgical approach. In addition, the patient's anatomy and pathology, lifestyle, and desires should be analyzed to help determine the ideal surgical strategy.

Background Marijuana is a widely used recreational substance. Few cases have been reported of acute myocardial infarction following marijuana use. To our knowledge, this is the first ever study analyzing the lifetime odds of acute myocardial infarction (AMI) with marijuana use and the outcomes in AMI patients with versus without marijuana use. Methods We queried the 2010-2014 National Inpatient Sample (NIS) database for 11-70-year-old AMI patients. Pearson Chi-square test for categorical variables and Student T-test for continuous variables were used to compare the baseline demographic and hospital characteristics between two groups (without vs. with marijuana) of AMI patients. The univariate and multivariate analyses were used to assess and compare the clinical outcomes between two groups. We used Cochran-Armitage test to measure the trends. All statistical analyses were executed by IBM SPSS Statistics 22.0 (IBM Corp., Armonk, NY). We used weighted data to produce national estimates in our study. Results Out of 2,451,933 weighted hospitalized AMI patients, 35,771 patients with a history of marijuana and 2,416,162 patients without a history of marijuana use were identified. The AMI-marijuana group consisted more of younger, male, African American patients. The length of stay and mortality rate were lower in the AMI-marijuana group with more patients being discharged against medical advice. Multivariable analysis showed that marijuana use was a significant risk factor for AMI development when adjusted for age, sex, race (adjusted OR 1.079, 95% CI 1.065-1.093, p

Cocaine is the third most common substance of abuse after cannabis and alcohol. The use of cocaine as an illicit substance is implicated as a causative factor for multisystem derangements ranging from an acute crisis to chronic complications. Vasospasm is the proposed mechanism behind adverse events resulting from cocaine abuse, acute ischemic strokes (AIS) being one of the few. Our study looked into in-hospital outcomes owing to cocaine use in the large population based study of AIS patients. Using the national inpatient sample (NIS) database from 2014 of United States of America, we identified AIS patients with cocaine use using International Classification of Disease, Ninth Revision (ICD-9) codes. We compared demographics, mortality, in-hospital outcomes and comorbidities between AIS with cocaine use cohort versus AIS without cocaine use cohort. Acute ischemic strokes (AIS) with cocaine group consisted of higher number of older patients (> 85 years) (25.6% versus 18.7%, p