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JungHyun Park, Jueun Kwak, Sukyung Chung, Hyo Ju Hong, Jin Young Chon, Ho Sik Moon Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of KoreaCorrespondence: Ho Sik MoonDepartment of Anesthesiology and Pain Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 1021, Tongil-ro, Eunpyeong-gu, Seoul 03312, Republic of KoreaTel +822-2030-3864Fax +822-2030-3861Email mhsjshgma@gmail.comPurpose: Endocrinological complications of an epidural steroid injection (ESI) are rare but dangerous. Nevertheless, despite the associated risks, repeated long-term ESIs are indispensable in some clinical situations. However, only a few reports to date have assessed the safety of this procedure. In this study, we evaluate the incidence of adrenal insufficiency (AI) and Cushing’s syndrome after long-term ESIs.Methods: This clinical observational study enrolled herniated nucleus pulposus or spinal stenosis patients who had received ESIs over a period of six months or longer. The adrenocorticotropic hormone (ACTH) stimulation test was performed to confirm AI and the late-night salivary cortisol (LNSC) test was performed to diagnose Cushing’s syndrome. To evaluate the hypothalamus pituitary adrenal axis suppression, salivary cortisol (SC) levels were measured on days 0, 1, 7, 21, 28, 35, and 42.Results: This study included 17 patients. Among these, two patients (11.8%) developed AI, but no cases of Cushing’s syndrome were reported. There was no predictor for the development of AI. The SC levels tended to increase with time after an ESI (β = 0.003). The slope of the mixed effect model between the AI and non-AI groups showed a significant difference (p value = 0.015). However, the differences in mean SC levels at each time point between the two groups were not significant (adjusted p value = 0.053).Conclusion: Long-term ESI use may be associated with AI development. An unexpected adrenal crisis due to AI could be life threatening. Therefore, regular monitoring of adrenal function in patients who have received long-term ESIs may be prudent.Keywords: epidural, glucocorticoid, salivary cortisol, adrenal insufficiency, long-term

Background: Although pharmacokinetic and pharmacodynamic models of remimazolam have been developed, their clinical application remains limited. This study aimed to administer a target-controlled infusion (TCI) of remimazolam at the effect-site concentration (Ce) in patients undergoing general anesthesia and to investigate the relationship of the remimazolam Ce with sedative effects and with recovery from general anesthesia., Methods: Fifty patients aged 20-75 years, scheduled for minimally invasive surgery under general anesthesia for less than 2 h, were enrolled. Anesthesia was induced and maintained using Schüttler's model for effect-site TCI of remimazolam. During induction, the remimazolam Ce was increased stepwise, and sedation levels were assessed using the Modified Observer's Assessment of Alertness/Sedation (MOAA/S) scale and bispectral index (BIS). Following attainment of MOAA/S scale 1, continuous infusion of remifentanil was commenced, and rocuronium (0.6 mg/kg) was administered for endotracheal intubation. The target Ce of remimazolam and the remifentanil infusion rate were adjusted to maintain a BIS between 40 and 70 and a heart rate within 20% of the baseline value. Approximately 5 min before surgery completion, the target Ce of remimazolam was reduced by 20-30%, and anesthetic infusion ceased at the end of surgery. Nonlinear mixed-effects modeling was employed to develop pharmacodynamic models for each sedation level as well as emergence from anesthesia., Results: The remimazolam Ces associated with 50% probability (Ce 50 ) of reaching MOAA/S scale ≤4, 3, 2, and 1 were 0.302, 0.397, 0.483, and 0.654 μg/mL, respectively. The Ce 50 values for recovery of responsiveness (ROR) and endotracheal extubation were 0.368 and 0.345 μg/mL, respectively. The prediction probabilities of Ce and BIS for detecting changes in sedation level were 0.797 and 0.756, respectively. The sedation scale significantly correlated with remimazolam Ce ( r = -0.793, P < 0.0001) and BIS ( r = 0.914, P < 0.0001). Age significantly correlated with Ce at MOAA/S1 and ROR., Conclusion: Effect-site TCI of remimazolam was successfully performed in patients undergoing general anesthesia. The remimazolam Ce significantly correlated with sedation depth. The Ce 50 for MOAA/S scale ≤1 and ROR were determined to be 0.654 and 0.368 μg/mL, respectively., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Chon, Seo, Lee and Lee.)

Background: Propofol-based total intravenous anesthesia (TIVA) improves long-term outcomes after cancer surgery compared with inhalation anesthesia. However, its effect on patients undergoing non-small cell lung cancer (NSCLC) surgery remains unclear. We aimed to compare the oncological outcomes of TIVA and inhalation anesthesia after curative resection of early-stage NSCLC., Methods: We analyzed the medical records of patients diagnosed with stage I or II NSCLC who underwent curative resection at a tertiary university hospital between January 2010 and December 2017. The primary outcomes were recurrence-free survival (RFS) and overall survival (OS) according to anesthesia type., Results: We included 1,508 patients with stage I/II NSCLC. The patients were divided into the TIVA (n = 980) and Inhalation (n = 528) groups. The two groups were well-balanced in terms of baseline clinical characteristics. The TIVA group demonstrated significantly improved RFS (7.7 years, 95% CI [7.37, 8.02]) compared with the Inhalation group (6.8 years, 95% CI [6.30, 7.22], P = 0.003). Similarly, TIVA was superior to inhalation agents with respect to OS (median OS; 8.4 years, 95% CI [8.08, 8.69] vs. 7.3 years, 95% CI [6.81, 7.71]; P < 0.001). Multivariable Cox regression analysis revealed that TIVA was an independent prognostic factor related to recurrence (hazard ratio [HR]: 1.24, 95% CI [1.04, 1.47], P = 0.014) and OS (HR: 1.39, 95% CI [1.12, 1.72], P = 0.002)., Conclusions: Propofol-based TIVA was associated with better RFS and OS than inhalation anesthesia in patients with stage I/II NSCLC who underwent curative resection.

Rationale: Hepatectomy is a treatment to increase survival and curability of patients with intrahepatic lesions or malignant tumors. However, posthepatectomy liver failure (PHLF) can occur. This case is a patient showing acute mental change in postanesthetic care unit (PACU) as an uncommon symptom of PHLF after extended right hepatectomy., Patient Concerns: A 68-year-old male patient was admitted for surgery of Klatskin tumor. He had hypertension and atrial fibrillation. His model for end-stage liver disease score was 16 pts. His serum bilirubin and ammonia levels were 4.75 mg/dL and 132.8 mcg/dL, respectively. Other laboratory data were nonspecific. He underwent extended right hepatic lobectomy including segments IV-VIII for 9 hours. Weight of liver specimen was 1028 g which was about 58% of total liver volume based on computed tomographic volumetry. The patient was extubated and moved to the PACU with stable vital sign and regular self-breathing. He could obey verbal commands. Fifteen minutes after admission to the PACU, the patient showed abruptly decreasing mental status and self-breathing., Diagnoses: Brain computed tomography, blood culture, and sputum culture were performed to diagnose brain lesions and sepsis for evaluating the sudden onset comatous mental status. Results showed nonspecific finding., Interventions: He was intubated for securing airway and applying ventilatory care. The patient was moved to the intensive care unit. He received intensive conservative therapy including continuous renal replacement therapy and broad-spectrum antibiotics., Outcomes: The patient's condition was worsened. He expired on postoperative day 3., Lessons: Acute mental change is uncommon and rare as initial symptoms of PHLF. Therefore, clinician may overlook the diagnosis of PHLF in patients with acute mental change after hepatectomy. Thus, clinician should plan an aggressive treatment for PHLF including liver transplantation by recognizing any suspicious symptom, although such symptom is rare.

Recipient's immune responses are an important factor in allograft survival in transplantation. Cytokines are reflected with immune responses. In the present study, we aimed to evaluate potential affecting factors of liver allograft survival and their possible correlation with seroum cytokine levels in living donor liver transplantation (LDLT). One hundred and seventy-one adult patients' data were collected retrospectively. Five cytokines were collected: interferon (IFN)-γ, interleukin (IL)-2, IL-10, IL-6, and IL-17. Ischemic time of liver grafts was divided into two periods: cold and warm ischemic times (CIT and WIT, respectively). CIT had no statically significant correlation, but WIT showed a significant correlation with IFN-γ, IL-2, and IL-17 serum levels (r = 0.0252, 0.282, 0.178, respectively; P < 0.05). WIT was dichotomized as T1 (<22 min), T2 (22-70 min), and T3 (>70 min). IFN-γ was significantly increased in T2 and T3 as compared to T1. IL-6 was in T3 compared to T1 and T2. IL-17 was in T3 compared to T1. For the Th1-to-Th2 ratio, IFN-γ/IL-10, IFN-γ/IL-6, and IL-2/IL-10 were significantly different in T2 and T3 as compared to T1, and also in T3 as compared to T2. Th1 cell activities were enhanced with increased WIT. In conclusion, the longer WIT (>70 min) in LDLT is more likely to induce immunological reactions of recipients by leading to a deleterious cytokine balances in favor of an reinforced production of Th1 cytokines.

Study Design: A single-centre retrospective study of prospectively collected data., Objective: Analyse factors associated with the patient-reported outcome after far lateral decompression surgery (FLDS) for lumbar nerve root compression using the far-lateral approach., Summary of Background Data: To date, no studies have investigated the influence of vertebral level, coronal segmental Cobb angle, and the nature of the compressive tissue (hard or soft) on the patient-reported outcome following FLDS., Patients and Methods: Patients who had undergone FLDS between 2005 and 2020 were included. Coronal segmental angle (CSCA) was measured on preoperative, posteroanterior radiographs. The primary outcome measure was the core outcome measures index (COMI) score at two years' follow-up (2Y-FU). Patients who had undergone microsurgical decompression using a midline approach served as a comparator group., Results: There were 148 FLDS and 463 midline approach patients. In both groups, there was a significant improvement in the COMI score from preoperative to 2Y-FU ( P <0.0001), with greater improvement in patients treated at higher vertebral levels than in those treated at L5/S1 ( P =0.014). Baseline COMI, American Society of Anesthesiologists grade, body mass index, and low back pain as the "chief complaint" all had a significant association with the two-year COMI score. The nature of compressive tissue showed no association with the COMI score at 2Y-FU. In the FLDS group, there was a statistically significant correlation between the preoperative CSCA and the change in COMI score preoperatively to 2Y-FU ( P <0.001). The association was retained in the multiple regression analysis, controlling for confounders. A one-degree increase in CSCA was associated with a 0.35-point worse COMI score at 2Y-FU ( P =0.003)., Conclusion: Treatment of far lateral nerve root compression showed an overall good patient-reported outcome, but with less improvement with advanced CSCA. Modified approaches and techniques might be preferable for levels L5/S1., Competing Interests: D.J.: DePuySynthes Spine – Consultant; Medacta – Consultant; Inno4Spine – Stockholder. The remaining authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Peripheral nerve stimulation (PNS) is a useful treatment for chronic pain, but it can cause damage depending on its application site. Here, we describe the case of a 54-year-old man who underwent PNS for brachial plexopathy in 2015. One lead was implanted on the left medial cord to stimulate the medial antebrachial cutaneous nerve, and the other was implanted on the radial nerve to stimulate the posterior antebrachial cutaneous nerve. Both leads were inserted near the shoulder joint but did not cross it. Before PNS, the patient did not move his shoulder and elbow because of severe pain, but the treatment greatly alleviated this pain. Twenty months after the operation, both leads were fractured, and the severe pain returned. Repetitive motion near the joint was closely related to the lead fractures. In conclusion, large joints as the insertion sites of PNS leads should be avoided to prevent lead fractures.

This corrects the article on p. 80 in vol. 81, PMID: 29332324., (Copyright©2018. The Korean Academy of Tuberculosis and Respiratory Diseases.)

Background: The beach-chair position (BCP) results in decreases in venous return, cardiac output, and cerebral perfusion pressure. In this randomized, prospective study, we investigated whether applying thigh-high compression stockings affected the maintenance of regional cerebral tissue oxygen saturation (rSO 2 ) in the BCP., Methods: Patients undergoing orthopedic surgery in the BCP under general anesthesia were included and assigned randomly to the control or the compression stocking group. Appropriately sized thigh-high compression stockings were applied to the patients in the stockings group. All patients were tilted, up to 45°, throughout the operation. Non-invasive blood pressure, invasive arterial blood pressure zeroed at the external auditory meatus, and rSO 2 were recorded., Results: Data were analyzed from 19 patients per group. In the BCP, the values of rSO 2 and blood pressure decreased significantly compared with those at baseline, with no significant difference between the groups. The incidences of cerebral desaturation events (CDEs) were similar between the groups; however, that of hypotension was significantly lower in the compression stocking group. During 36 CDEs, the levels of rSO 2 and blood pressure decreased significantly compared with those at baseline in both groups. No significant correlation was found between rSO 2 and blood pressure., Conclusions: Thigh-high compression stockings reduced the incidence of hypotension but not that of CDEs. Our results suggest that other factors, beyond hypotension itself, contribute to CDEs and in other words, efforts just to reduce the incidence of hypotension may not mainly contribute to a reduction of CDEs occurrence in the BCP under general anesthesia.

Background: Asthma is a disease of chronic airway inflammation with heterogeneous features. Neutrophilic asthma is corticosteroid-insensitive asthma related to absence or suppression of TH2 process and increased TH1 and/or TH17 process. Macrolides are immunomodulatory drug that reduce airway inflammation, but their role in asthma is not fully known. The purpose of this study was to evaluate the role of macrolides in neutrophilic asthma and compare their effects with those of corticosteroids., Methods: C57BL/6 female mice were sensitized with ovalbumin (OVA) and lipopolysaccharides (LPS). Clarithromycin (CAM) and/or dexamethasone (DXM) were administered at days 14, 15, 21, 22, and 23. At day 24, the mice were sacrificed., Results: Airway resistance in the OVA+LPS exposed mice was elevated but was more attenuated after treatment with CAM+DXM compared with the monotherapy group (p<0.05 and p<0.01). In bronchoalveolar lavage fluid study, total cells and neutrophil counts in OVA+LPS mice were elevated but decreased after CAM+DXM treatment. In hematoxylin and eosin stain, the CAM+DXM-treated group showed less inflammation additively than the monotherapy group. There was less total protein, interleukin 17 (IL-17), interferon γ, and tumor necrosis factor α in the CAM+DXM group than in the monotherapy group (p<0.001, p<0.05, and p<0.001). More histone deacetylase 2 (HDAC2) activity was recovered in the DXM and CAM+DXM challenged groups than in the control group (p<0.05)., Conclusion: Decreased IL-17 and recovered relative HDAC2 activity correlated with airway resistance and inflammation in a neutrophilic asthma mouse model. This result suggests macrolides as a potential corticosteroid-sparing agent in neutrophilic asthma., Competing Interests: No potential conflict of interest relevant to this article was reported., (Copyright©2018. The Korean Academy of Tuberculosis and Respiratory Diseases)

Brachial plexus injury (BPI) often causes severe neuropathic pain that becomes chronic and difficult to treat pharmacologically or surgically. Here, we describe two cases of successful treatment of BPI with peripheral nerve stimulation (PNS). Both patients had experienced severe neuropathic pain after incomplete BPI for a long time (32 and 17 years) and did not response to medication, radiofrequency neuroablation, or spinal cord stimulation. After PNS using ultrasound, their pain was relieved by more than 50% over the course of 1 year. Both patients were satisfied with their improved sleep and quality of life. We conclude that PNS could be an alternative therapeutic modality for neuropathic pain after BPI as it provides direct nerve stimulation, has few complications, and is easy to perform.

Objective: The purpose of this study was to present the outcome of the microsurgical foraminotomy via Wiltse paraspinal approach for foraminal or extraforaminal (FEF) stenosis at L5-S1 level. We investigated risk factors associated with poor outcome of microsurgical foraminotomy at L5-S1 level., Methods: We analyzed 21 patients who underwent the microsurgical foraminotomy for FEF stenosis at L5-S1 level. To investigate risk factors associated with poor outcome, patients were classified into two groups (success and failure in foraminotomy). Clinical outcomes were assessed by the visual analogue scale (VAS) scores of back and leg pain and Oswestry disability index (ODI). Radiographic parameters including existence of spondylolisthesis, existence and degree of coronal wedging, disc height, foramen height, segmental lordotic angle (SLA) on neutral and dynamic view, segmental range of motion, and global lumbar lordotic angle were investigated., Results: Postoperative VAS score and ODI improved after foraminotomy. However, there were 7 patients (33%) who had persistent or recurrent leg pain. SLA on neutral and extension radiographic films were significantly associated with the failure in foraminotomy ( p <0.05). Receiver-operating characteristics curve analysis revealed the optimal cut-off values of SLA on neutral and extension radiographic films for predicting failure in foraminotomy were 17.3° and 24°s, respectively., Conclusion: Microsurgical foraminotomy for FEF stenosis at L5-S1 level can provide good clinical outcomes in selected patients. Poor outcomes were associated with large SLA on preoperative neutral (>17.3°) and extension radiographic films (>24°).

Brachial plexopathy usually results from an iatrogenic brachial plexus injury and can sometimes cause severe chronic pain and disability. There are a number of possible treatments for this condition, including medication, physical therapy, nerve blocks, and neuromodulation, but they are not always successful. Recently, combined spinal cord stimulation (SCS) and peripheral nerve stimulation (PNS) have been tried for various chronic pain diseases because of their different mechanisms of action.Here, we describe the case of a 54-year-old man who was diagnosed with brachial plexopathy 8 years ago. He underwent video-assisted thoracoscopic surgery to remove a superior mediastinal mass. However, his brachial plexus was damaged during the surgery. Although he had received various treatments, the pain did not improve. For the management of intractable severe pain, he underwent SCS 2 years ago, which initially reduced his pain from numeric rating scale (NRS) 10/10 to NRS 4 - 5/10, but the pain then gradually increased, reaching NRS 8/10, 6 months ago. At that time, he was refractory to other treatments, and we therefore applied PNS in combination with SCS. The PNS electrode was positioned on the radial nerve under ultrasound guidance. After combined PNS and SCS, his background pain disappeared, although a breakthrough pain (NRS 3 - 4/10) was caused intermittently by light touch. Furthermore, the patient's need for analgesics decreased, and he was satisfied with the outcome of this combined treatment. We concluded that combined SCS and PNS is a very useful treatment modality, which can stimulate the target nerve both directly and indirectly, and hence, relieve pain from brachial plexopathy.

Lead migration is the most common complication of spinal cord stimulation (SCS). However, the only corrective method for lead migration is revision surgery, which may cause additional complications. Here, we describe a new technique for adjusting a transversely migrated SCS lead. The medical records of four patients diagnosed with complex regional pain syndrome (n = 3) or failed back surgery syndrome (n = 1) who underwent implantation of percutaneous leads for SCS were retrospectively reviewed. Transverse lead migration was diagnosed radiographically after patients reported recurrence of pain or numbness in treated sites. The guide wire from the SCS implant kit was bent and inserted into the target epidural space using a 14-gauge Tuohy needle. When the guide wire contacted the migrated SCS lead, they were advanced to the correct location under C-arm guidance. After re-adjustment of the SCS lead, good coverage of the electrical stimulation was confirmed. Patients were followed for 9-19 months and they reported satisfactory pain relief and good electrical coverage after adjusting the SCS lead. Here, we describe a new technique for adjusting a transversely migrated SCS lead using a percutaneous epidural approach as a simple, safe, and cost-effective alternative to revision surgery.

Tarsal tunnel syndrome (TTS) is a compression neuropathy that results from entrapment of the posterior tibial nerve or its branches. TTS may be treated either by conservative measures, including physical therapy, medications, and steroid injections, or by surgical decompression. Despite a variety of treatments, a few cases of TTS will relapse, and many cases of recurrent TTS will require re-operation. Pulsed radiofrequency (PRF) is known to have a number of advantages for pain management, particularly as this technique does not cause neural compromise such as motor weakness. Here, we report a new application of ultrasound-guided PRF in two cases of intractable TTS. Both patients had a long duration of severe foot pain and had been treated with various therapeutic modalities without lasting relief. We applied ultrasound-guided PRF to the affected posterior tibial nerve in each patient, and both had significantly reduced pain intensity scores and analgesic requirements without any complications. Ultrasound-guided PRF for intractable TTS relieved severe foot pain. It may supersede surgery as a reliable treatment for intractable TTS.

Background: The representativeness of cohort studies compared to nationwide data is a major concern. This study evaluated the similarity and seasonality of causative respiratory viruses for chronic obstructive pulmonary disease (COPD) and asthma exacerbations between retrospective multicenter cohort study and nationwide data. Methods: We compared data from the retrospective multicenter cohort study with Korean Influenza and Respiratory Surveillance System data between 2015 and 2018. Correlation, dynamic time warping (DTW), and seasonal autoregressive integrated moving average (SARIMA) analyses were performed. Results: Spearman correlation coefficients [ρ] indicated very strong (respiratory syncytial virus [RSV] [ρ = 0.8458] and influenza virus [IFV] [ρ = 0.8272]), strong (human metapneumovirus [HMPV] [ρ = 0.7177] and parainfluenza virus [PIV] [ρ = 0.6742]), and moderate (rhinovirus [RV] [ρ = 0.5850] and human coronavirus [HCoV] [ρ = 0.5158]) correlations. DTW analyses showed moderate (PIV) and high (IFV, RSV, and HMPV) synchronicity between the two datasets, while RV and HCoV showed low synchronicity. SARIMA analyses revealed 12-month seasonality for IFV, RSV, PIV, and HMPV. The peak season was winter for RSV and IFV, spring to summer for PIV, and spring for HMPV. Conclusions: This was the first study to report the synchronicity between a retrospective multicenter cohort study of viruses that can cause COPD or asthma exacerbations and nationwide surveillance system data. [ABSTRACT FROM AUTHOR]

Background: Radiculopathy can be a debilitating condition. Amniotic membrane/umbilical cord (AM/UC) particulate is a relatively new injectable treatment modality. Herein we report the outcomes of epidural injection of AM/UC particulate in managing lumbar radiculopathy. Methods: Consecutive patients with lumbar radiculopathy who received epidural injection of AM/UC particulate for lumbar radiculopathy were included. Primary outcome was change in pain as measured by the 11-point numerical rating scale. Safety was assessed by AM/UC- and procedure-related complications. Paired t-tests were used to determine statistical significance. Results: A total of 12 patients with a mean age of 56.7 ± 21.0 years were included in the analysis. The patients were previously treated with physical therapy (91.7%), chiropractic corrective measures (16.7%), epidural steroid injection (83.3%), and radiofrequency ablation (8.3%). Two patients (16.7%) were taking opioids for chronic pain syndrome. After AM/UC injection, the average pain score decreased from 6.6 ± 1.5 to 5.2 ± 1.9 at 1-3 months, 2.0 ± 1.4 at 6 months, and 2.9 ± 1.4 at last mean follow-up of 21.3 ± 11.1 months (p < 0.001). No patients required subsequent treatment or surgery. There were also no complications. Conclusion: This case series supports the preliminary safety and shows potential benefit of epidural AM/UC particulate injection in this cohort of patients with lumbar radiculopathy pain. [ABSTRACT FROM AUTHOR]

Introduction: Plantar Fasciitis (PF) is one of the most common causes of heel pain, with a prevalence ranging from 3.6-7% in the general population. Approximately 90% of patients with PF respond well to conservative therapy, including rest, stretching, analgesics, physical therapy, shoe modifications, or steroid injections. However, around 10% of patients have recalcitrant cases that require invasive or surgical interventions. Pulsed Radiofrequency Ablation (PRFA) is a non neurodestructive method that provides non surgical pain relief in such cases. Aim: To compare the effectiveness of ultrasound-guided PRFA of the Medial Calcaneal Nerve (MCN) and Extracorporeal Shockwave Therapy (ESWT) in managing recalcitrant PF. Materials and Methods: This randomised controlled trial was conducted at the Department of Physical Medicine and Rehabilitation, Regional Institute of Medical Sciences, Imphal, Manipur, India over a two-year period from September 2018 to August 2020. A total of 78 patients with PF were included in the study, divided equally into two groups: a study group and a control group, each consisting of 39 participants. The study group received PRFA of the MCN, while the control group received ESWT of the plantar fascia. The Visual Analog Scale (VAS), Plantar Fascia Thickness (PFT), and American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score were measured at 1, 4, 12, and 24 weeks as outcome variables. Data analysis was performed using Statistical Package for the Social Sciences (SPSS) version 21.0, and statistical tests like Chi-square test, t-test, and repeated measures Analysis of Variance (ANOVA) were used. A p-value of <0.05 was considered significant. Results: Of the 78 patients included in the study, 42 (53.8%) were females and 36 (46.2%) were males, with a mean age of 41.08±10.09 years. The VAS score in the study group improved from 5.51±0.82 at baseline to 1.92±0.80 at 24 weeks, while in the control group, the VAS score improved from 5.36±0.97 at baseline to 2.33±0.66 at 24 weeks. PFT in the study group improved from 4.45±0.374 at baseline to 2.26±0.231 at 24 weeks, while in the control group, PFT improved from 4.42±0.366 at baseline to 2.49±0.357 at 24 weeks. The AOFAS score also improved from 50.49±13.13 at baseline to 74.03±11.53 in the study group, and in the control group, the AOFAS score improved from 49.74±12.26 at baseline to 71.36±10.72 at 24 weeks (p-value <0.05). Conclusion: Significant improvements were observed in all outcome measures in both the study and control groups, with a p-value <0.05. However, the improvements were more pronounced in the study group, with minimal to no side-effects. Hence, ultrasound-guided PRFA of the MCN can be considered an effective minimally invasive treatment modality for recalcitrant PF. [ABSTRACT FROM AUTHOR]

Objective: To investigate the clinical features, therapeutic efficacy and symptom time course of post-coronavirus disease 2019 parosmia. Methods: A 22-item online questionnaire was distributed to AbScent research group and Facebook coronavirus disease 2019 anosmia group adult members to assess clinical features, interventions and their subjective efficacy for parosmia. Results: A total of 209 participants (86 per cent females) reported: smell loss on average 3 days after coronavirus symptoms, recovery 4 weeks later, and first parosmia symptoms 12 weeks post infection. Respondents reported 10 per cent body weight loss, and listed onion and garlic as significant parosmia triggers. Regarding quality of life, depression was the most cited item (54 per cent). Smell training was trialled by 74 per cent of participants, followed by nasal corticosteroid spray (49 per cent). Stellate ganglion block, trialled by 16 per cent of respondents, had the highest reported improvement (45 per cent), with 21 per cent reporting a sustained benefit – the highest rate amongst registered treatment options. Conclusion: Post-coronavirus parosmia has a significant impact and remains challenging to treat. Stellate ganglion block appears to be successful relative to other reported treatments. Further research into the pathophysiology, efficacy and mechanism of stellate ganglion block effect is warranted. [ABSTRACT FROM AUTHOR]

Background: The pediatric sizes of BlockBuster supraglottic airway (SGA) have been introduced recently. Its efficacy as a conduit for endotracheal intubation in children has not been assessed. Newer devices are often compared with Air-Q SGA to assess their intubating capability., Aims: The primary objective was to compare the time taken for fiber-optic-guided intubation through the BlockBuster and the Air-Q SGAs., Methods: Sixty children aged 6 months to 12 years with normal airways were randomized into two groups: Air-Q SGA (Group A) and Blockbuster SGA (Group B). After administration of general anesthesia, an appropriately sized SGA was inserted. The time taken for fiber-optic-guided intubation through the SGA, success, ease, and time for SGA insertion and removal were noted. The glottic view was graded by fiber-optic bronchoscopy., Results: Demographic parameters were comparable. The time to intubate with the BlockBuster 62.40 ± 17.2 s was comparable to the Air-Q 60.8 ± 18.5 s (mean difference 1.6 s, 95% CI -7.65 to10.85; p = .73). The average time for SGA insertion in BlockBuster and Air-Q was 14.57 ± 3.2 s and 16.67 ± 5.39 s, respectively (mean difference -2.1, 95% CI -4.39 to 0.19 s; p = .07). The first-attempt intubation success and overall intubation success rates were comparable in both groups, 96.7% and 100%, respectively. In Group B, 25/3/1/1/0 cases had a glottic view grade of 1/2/3/4/5, respectively. In Group A, 23/3/2/2/0 cases had grade of 1/2/3/4/5 glottic views respectively. The average time to SGA removal was comparable between the BlockBuster (20.17 ± 5.8 s) and the Air-Q (22.5 ± 12.8 s) groups (mean difference -2.3 s, 95% CI -7.5 to 2.82 s; p = .37). None of the children had any perioperative complications., Conclusion: BlockBuster SGA may be a useful alternative to Air-Q for SGA-assisted, fiber-optic-guided tracheal intubation in children., (© 2024 John Wiley & Sons Ltd.)

Background: Anosmia and hyposmia significantly affect patients' quality of life and have many etiologies, including trauma, inflammatory conditions including chronic rhinosinusitis, neoplasm, and viral infections, such as rhinovirus and SARS-CoV-2. Objective: Our purpose was to establish whether a consensus exists regarding optimal management of olfactory dysfunction and to provide insight into the treatment of anosmia in the current climate of increased prevalence secondary to COVID-19. Thus, we aimed to systematically review the literature on the management of non-Chronic-rhinosinusitis- related anosmia/hyposmia. Methods: PubMed, EMBASE, and Cochrane databases were searched for articles published since January 1990 using terms combined with Medical Subject Headings (MeSH). We included articles evaluating management of anosmia and hyposmia written in the English language, with original data, a minimum of 3 months of follow-up except for COVID-related studies, at least 2 patients, and well-defined and measurable outcomes. Results: A total of 3013 unique titles were returned upon the initial search. Of these, 297 abstracts were examined, yielding 19 full texts meeting inclusion criteria (8 with level 1 evidence, 3 with level 2, 1 with level 3, and 7 with level 4). The studies included a total of 1522 subjects, with follow up ranging from 3 to 72 months, with an exception for COVID related studies. Endpoints were based on clinically significant improvements of olfactory functions as measured through validated smell tests. Treatments with the most robust data were intranasal corticosteroids and olfactory training. Conclusion: The literature on the treatment of anosmia and hyposmia includes randomized trials showing the efficacy of a few modalities. While further research is needed to expand therapeutic options for this debilitating condition, the current literature supports the use of olfactory training and topical corticosteroids. [ABSTRACT FROM AUTHOR]

Background: Particulate matter10 (PM10) can induce airway inflammation and fibrosis. Recently, chitinase-1 has been shown to play key roles in inflammation and fibrosis. We aimed to investigate the effects of chitinase-1 inhibitor in PM10-treated murine mice models. Methods: In female BALB/c mice, PM10 was intranasally administered six times over 3 weeks, and ovalbumin (OVA) was intraperitoneally injected and then intranasally administered. Chitinase-1 inhibitor (CPX) 6 times over 3 weeks or dexamethasone 3 times in the last week were intraperitoneally administered. Two days after the last challenges, mice were euthanized. Messenger RNA sequencing using lung homogenates was conducted to evaluate signaling pathways. Results: PM10 and/or OVA-induced airway inflammation and fibrosis murine models were established. CPX and dexamethasone ameliorated PM10 or PM10/OVA-induced airway hyper-responsiveness, airway inflammation, and fibrosis. CPX and dexamethasone also reduced levels of various inflammatory markers in lung homogenates. PM10 and OVA also induced changes in mRNA expression across an extreme range of genes. CPX and dexamethasone decreased levels of mRNA expression especially associated with inflammation and immune regulation. They also significantly regulated asthma and asthma-related pathways, including the JACK-STAT signaling pathway. Conclusions: Chitinase-1 suppression by CPX can regulate PM10- and OVA-induced and aggravated airway inflammation and fibrosis via an asthma-related signaling pathway. [ABSTRACT FROM AUTHOR]

Myriad questions regarding perioperative management of patients on glucocorticoids (GCs) continue to be debated including which patients are at risk for adrenal insufficiency (AI), what is the correct dose and duration of supplemental GCs, or are they necessary for everyone? These questions remain partly unanswered due to the heterogeneity and low quality of data, studies with small sample sizes, and the limited number of randomized trials. To date, we know that although all routes of GC administration can result in hypothalamic-pituitary-adrenal (HPA) axis suppression, perioperative adrenal crisis is rare. Correlation between biochemical testing for AI and clinical events is lacking. Some of the current perioperative management recommendations based on daily GC dose and duration of therapy may be difficult to follow in clinical practice. The prospective and retrospective studies consistently report that continuing the daily dose of GCs perioperatively is not associated with a higher risk for adrenal crises in patients with GC-induced AI. Considering that oral GC intake may be unreliable in the early postoperative period, providing the daily GC plus a short course of IV hydrocortisone 25 to 100 mg per day based on the degree of surgical stress seems reasonable. In patients who have stopped GC therapy before surgery, careful assessment of the HPA axis is necessary to avoid an adrenal crisis. In conclusion, our literature review indicates that lower doses and shorter duration of supplemental GCs perioperatively are sufficient to maintain homeostasis. We emphasize the need for well-designed randomized studies on this frequently encountered clinical scenario. [ABSTRACT FROM AUTHOR]

Nemaline myopathy (NM) is a rare congenital myopathy that affects males and females. The incidence is estimated at 1 in 50,000 live births. NM is a genetic disorder (with the exception of sporadic late onset NM, which is an autoimmune disorder) with pathogenic variants that are either sporadic de-novo or else inherited in either an autosomal recessive or dominant fashion. Pathogenic variants in 11 genes have been identified, accounting for approximately 75% of the total genetic burden of the disease (see table). Recessive variants in the nebulin (NEB) gene are the most common cause and account for 50 % of the cases, while ACTA1 variants are the common dominant/de-novo cause (15-25 %). Muscle biopsy shows the presence of 'nemaline bodies', or rod-like structures. Nemaline bodies are extensions of the Z disc and may include aggregates of proteins such as alpha-actinin and actin. The cause of weakness in the majority of NM cases is abnormal thin filament function, including reduced thin filament length and impaired actinmyosin cross bridging. Of note, NM likely exists on a pathological spectrum and some patients with mutations in NM associated genes may have biopsies that, instead, show a congenital fibre-type disproportion or a mixed pattern with cores and rods. The disease is clinically heterogeneous and can be divided into six clinical subtypes based on age of onset and severity. These subtypes are: severe congenital, Amish type, intermediate congenital, typical congenital, childhood-onset and adult-onset. The severe congenital and Amish type are life limiting and affected individuals typically do not survive beyond early childhood due to respiratory failure. The typical congenital type is the most common. It is mild and non-progressive, presenting with hypotonia, extremity weakness, and feeding difficulties in infancy. The childhood-onset and adult-onset are mild and present later. There are some genotype-phenotype correlations, with LMOD3, KLHL40, and KLHL41 related NM associated with the severe congenital subtype. NEB related NM can present with a range of severity, though most commonly it is associated with typical congenital NM. ACTA1 NM exhibits the most extreme variability, with individual presentations ranging from foetal akinesia and severe congenital to mild adolescent or adult onset. Important: with ACTA1, there can be variable expressivity even within families. About 50 % of the adult forms are acquired and associated with the presence of a benign monoclonal gammopathy of undetermined significance (MGUS): they show good therapeutic response to corticotherapy with or without azathioprine or a bone marrow graft. Clinical manifestations include craniofacial (high-arched palate, micrognathia, retrognathia, dental malocclusion and cleft palate) and musculoskeletal (kyphosis, scoliosis, talipes, pectus excavatum and pes cavus) abnormalities. Rarely it is associated with cardiac lesions; either congenital (atrial septal and/or ventricular septal defect, patent ductus arteriosus, aortic regurgitation or infundibular pulmonary stenosis) or direct involvement of the cardiac muscle leading to cardiomyopathy. Cardiac disease has been described in only certain genotypes, such as NEB11 (due to myopalladin mutation) and a small subset of ACTA1 patients. Anaesthetic considerations are a potentially difficult airway (bag-mask ventilation and intubation), difficult intravenous access (due to contractures), poor respiratory reserve, potentially underappreciated chronic hypercapnia, risk of aspiration (potentially leading to pulmonary infection) and cardiac dysfunction. There is no convincing evidence of an association between NM and malignant hyperthermia. While no specific concerns have been noted in NM, neuromuscular blocking agents are best avoided (given the potential risk of exacerbating respiratory muscle weakness). In genetically undefined cases, particularly if there is biopsy evidence of cores with rods, MH precautions are logical. This is because pathogenic variants in RYR1 have been described in a small number of cases of core-rod myopathy or pure NM, and RYR1 variants are also a common cause of congenital fibre-type disproportion. However, if RYR1 variants have been excluded, there is no evidence to support MH risk associated with the other 11 known NM genetic subtypes. [ABSTRACT FROM AUTHOR]

The effects of forced vital capacity (FVC) on clinical outcomes of asthma-chronic obstructive pulmonary diseases overlap (ACO) are still unknown. We conducted this study to examine the association of FVC on clinical outcomes in ACO. Data from the Korean COPD Subgroup Study cohort were analyzed. Patients who fulfilled the ACO criteria were included and grouped according to FVC changes, such as FVC-incline and FVC-decline. No significant differences were observed between the FVC-incline and FVC-decline groups in baseline clinical characteristics. In a year after, FVC-decline group experienced more moderate (47.1% vs. 36.8%, p = 0.02) and moderate-to-severe (49.8% vs. 39.6%, p = 0.03) acute exacerbations (AEs), compared to FVC-incline group. The frequency of moderate AEs (1.3 ± 2.1 vs. 0.9 ± 1.7, p = 0.03) and moderate-to-severe AEs (1.5 ± 2.5 vs. 1.1 ± 1.9, p = 0.04) were higher in the FVC-decline group than in the FVC-incline groups. After adjusting for confounding factors, FVC-decline group was associated with moderate AEs (odds ratio [OR] = 1.58; 95% confidence interval [CI] 1.02–2.44; p = 0.04), and moderate-to-severe AEs (OR = 1.56; 95% CI 1.01–2.41; p < 0.05) in ACO patients, which was not seen in FEV1 changes. FVC changes are associated with clinical outcomes in ACO. [ABSTRACT FROM AUTHOR]

Context: Over 9 million epidural steroid injections (ESIs) are performed annually in the United States. Although these injections effectively treat lumbar radicular pain, they may have adverse consequences, including bone loss. Objective: To investigate acute changes in bone turnover following ESI. We focused on postmenopausal women, who may be at greatest risk for adverse skeletal consequences due to the combined effects of ESIs with aging and estrogen deficiency. Methods: Single-center prospective observational study. Postmenopausal women undergoing lumbar ESIs and controls with no steroid exposure were included. Outcomes were serum cortisol, markers of bone formation, osteocalcin, and procollagen type-1 N-terminal propeptide (P1NP), and bone resorption by C-telopeptide (CTX) measured at baseline, 1, 4, 12, 26, and 52 weeks after ESIs. Results: Among ESI-treated women, serum cortisol declined by ~50% 1 week after injection. Bone formation markers significantly decreased 1 week following ESIs: osteocalcin by 21% and P1NP by 22%. Both markers remained suppressed at 4 and 12 weeks, but returned to baseline levels by 26 weeks. There was no significant change in bone resorption measured by CTX. Among controls, there were no significant changes in cortisol or bone turnover markers. Conclusion: These results provide evidence of an early and substantial reduction in bone formation markers following ESIs. This effect persisted for over 12 weeks, suggesting that ESIs may have lasting skeletal consequences. Given the large population of older adults who receive ESIs, further investigation into the long-term skeletal sequelae of these injections is warranted. [ABSTRACT FROM AUTHOR]

Lingual thyroglossal duct cysts can be a rare cause of feeding difficulties in infants. Here, we describe a case of an infant with vomiting and feeding difficulty diagnosed with Hirschsprung's disease. However, she developed an unexpected difficult airway during anesthesia induction due to an undiagnosed lingual thyroglossal duct cyst. [ABSTRACT FROM AUTHOR]

This literature review summarized studies that evaluated the effects of epidural steroid injections (ESIs) on skeletal health. While evidence is limited, studies suggest that ESIs may cause bone loss. Better understanding of these skeletal consequences will help foster strategies to prevent bone loss in the growing population of patients receiving ESIs. Purpose: Approximately nine million epidural steroid injections (ESIs) are administered annually in the United States to treat radicular back pain. ESIs often provide pain relief and functional improvement. While the overall incidence of adverse events resulting from ESIs is low, their effects on the skeleton are poorly understood. This is an important consideration given the profound skeletal impact of other forms of glucocorticoids. Methods: Ovid MEDLINE and PubMed search results since 2010, including older, frequently referenced publications were reviewed. Results: Systemic absorption of glucocorticoids occurs after ESI, which can cause hyperglycemia and endogenous cortisol suppression. The majority of studies investigating the skeletal effects of ESIs are retrospective. Several have found a relationship between low areal bone mineral density (BMD) by dual-energy x-ray absorptiometry and ESI exposure, but this finding is not uniform. Recently a dose-response relationship between ESI exposure and low spine volumetric BMD by computed tomography has been reported. Few studies have investigated the relationship between ESI exposure and fracture risk. Results of these studies are conflicting, and most have not been adequately powered to detect fracture outcomes. Conclusions: While evidence is limited, studies suggest that ESIs may cause bone loss, particularly those investigating volumetric BMD. Larger doses appear to confer greater risk. Further prospective studies are needed to investigate the relationship between ESI and fracture risk. Better understanding of the skeletal consequences of ESIs will help foster strategies to prevent bone loss in the growing population of patients receiving this treatment. [ABSTRACT FROM AUTHOR]

Background: Prophylaxis for cerebral desaturation events (CDEs) during anesthesia in the beach chair position (BCP) for shoulder surgeries has not been evaluated. We systematically analyzed the effectiveness of various prophylactic measures used in this clinical setting. Methods: We performed a meta-analysis (PROSPERO; no. CRD42020167285) of trials reporting CDEs and regional cerebral oxygen saturation (rSO2) and jugular venous oxygen saturation (SjvO2) values in anesthetized patients undergoing shoulder surgery in BCP. Considering the type of prophylactic measures used (pharmacological or non-pharmacological), a subgroup analysis was planned. Outcomes included (1) rSO2 and SjvO2 data with and without prophylactic measures for CDEs, recorded for different time intervals, and (2) the number of patients experiencing CDEs and hypotension. Results: Twelve studies (786 patients) were included in the analysis. We observed lower absolute rSO2 values for early and all-time periods for vasoactive agent prophylaxis. The lowest achieved rSO2 values were also lower for vasoactive agent prophylaxis. Risk of CDEs was higher with vasoactive agent prophylaxis. Subgroup analysis identified targeted mild hypercarbia as effective in preserving cerebral oxygenation. Similarly, targeted mild hypercarbia prevented the fall in rSO2 with position change. Meta-regressions revealed statistically significant highest estimates for vasoactive agent prophylaxis in contrast to targeted mild hypercarbia. Likelihood of not developing CDEs was higher for targeted mild hypercarbia. In contrast to rSO2, most prophylactic methods reduced hypotensive episodes. Conclusions: Targeted mild hypercarbia can reduce BCP-related CDEs. Evidence does not favor prophylactic use of vasoactive agents for the prevention of cerebral desaturations irrespective of whether their use interferes with cerebral oximetry readings. [ABSTRACT FROM AUTHOR]