Exposure to general anaesthesia could increase the risk of dementia in elderly

Regional Anesthesia for Spine Surgery

Recent advancements in spine surgery anesthesia techniques and pain management has led to a paradigm shift from conventional open spinal procedures to minimally invasive spine surgeries performed on an outpatient basis. Spinal anesthesia and epidural anesthesia alone or in combination with spinal are common regional anesthesia modalities used in spine surgeries. New modalities of regional analgesia have emerged recently including erector spinae and thoracolumbar interfascial plane block, aimed at decreasing perioperative pain and enhancing early recovery in patients undergoing spine surgery. In this narrative review we discuss the characteristics of regional anesthesia including its types, indications, contraindications, benefits, and potential complications along with new modalities of regional analgesia.

Comparison of two protocols for the management of asymptomatic postmenopausal women with adnexal tumours - a randomised controlled trial of RMI/RCOG vs Simple Rules

BACKGROUND

Adnexal tumours are frequently diagnosed in asymptomatic postmenopausal women due to more liberal use of modern high-resolution imaging. This study's objective was to determine if there would be a difference in the intervention rates when using the Simple Rules Management Protocol (SRMP) as compared to the Risk of Malignancy Index in the Royal College of Obstetricians and Gynaecologists guideline (RMI/RCOG).

METHODS

This was a prospective randomised controlled trial with the participants and the researchers non-blinded, and the surgeons and pathologists blinded. We recruited pain-free postmenopausal women who were diagnosed with an adnexal tumour on ultrasound scan. Women were randomised to either of the two protocols, which then determined if they were offered conservative or surgical management. An intention-to-treat analysis was performed. The primary outcome measure was rate of surgical interventions for ovarian cysts up to 12 months after randomisation. The secondary outcome measures were the number of staging surgical procedures, surgical complications and number of delayed diagnoses of ovarian cancer.

RESULTS

A total of 148 women were randomised over 39 months with 73 in the RMI/RCOG arm and 75 in the SRMP arm with outcome data for 136 at 12 months. The two groups were balanced in terms of age, length of time since menopause and use of hormone replacement therapy. There were 18 out of 68 (28.1%) women in the RMI/RCOG arm who had surgery vs 7 out of 68 (10.3%) women in the SRMP arm (P=0.015, χ²-test). The difference in these proportions was 16.2% (95% confidence interval (CI): 3.4-28.9%) and the relative risk was 2.57 (95% CI: 1.15-5.76). There were no significant differences in the number of staging surgical procedures and the surgical complications between the two groups and there were no delayed diagnoses of ovarian cancer at 12 months.

CONCLUSIONS

Surgical intervention rates in asymptomatic postmenopausal women with an ultrasound diagnosis of adnexal tumours are significantly lower when the novel SRMP protocol is used for triaging compared to the standard RMI/RCOG protocol without an increase in delayed malignant diagnoses.

Neuroprotective Effects Against POCD by Photobiomodulation: Evidence from Assembly/Disassembly of the Cytoskeleton

Postoperative cognitive dysfunction (POCD) is a decline in memory following anaesthesia and surgery in elderly patients. While often reversible, it consumes medical resources, compromises patient well-being, and possibly accelerates progression into Alzheimer's disease. Anesthetics have been implicated in POCD, as has neuroinflammation, as indicated by cytokine inflammatory markers. Photobiomodulation (PBM) is an effective treatment for a number of conditions, including inflammation. PBM also has a direct effect on microtubule disassembly in neurons with the formation of small, reversible varicosities, which cause neural blockade and alleviation of pain symptoms. This mimics endogenously formed varicosities that are neuroprotective against damage, toxins, and the formation of larger, destructive varicosities and focal swellings. It is proposed that PBM may be effective as a preconditioning treatment against POCD; similar to the PBM treatment, protective and abscopal effects that have been demonstrated in experimental models of macular degeneration, neurological, and cardiac conditions.

Prion Protein Signaling in the Nervous System—A Review and Perspective

Prion protein (PrPC) was originally known as the causative agent of transmissible spongiform encephalopathy (TSE) but with recent research, its true function in cells is becoming clearer. It is known to act as a scaffolding protein, binding multiple ligands at the cell membrane and to be involved in signal transduction, passing information from the extracellular matrix (ECM) to the cytoplasm. Its role in the coordination of transmitters at the synapse, glyapse, and gap junction and in short- and long-range neurotrophic signaling gives PrPC a major part in neural transmission and nervous system signaling. It acts to regulate cellular function in multiple targets through its role as a controller of redox status and calcium ion flux. Given the importance of PrPC in cell physiology, this review considers its potential role in disease apart from TSE. The putative functions of PrPC point to involvement in neurodegenerative disease, neuropathic pain, chronic headache, and inflammatory disease including neuroinflammatory disease of the nervous system. Potential targets for the treatment of disease influenced by PrPC are discussed.

Peri-operative management of older people undergoing surgery

Increasing numbers of older people are undergoing both emergency and elective surgery. However, they remain at increased risk of adverse outcome in comparison with younger patients. This may relate to the association of ageing with physiological deterioration, multi-morbidity and geriatric syndromes such as frailty, all of which are independent predictors of adverse post-operative outcome. Although there is an emerging evidence base for the identification and management of these predictors, this has not yet translated into routine clinical practice. Older patients undergoing surgery often receive sub-optimal care and surgical pathways are not well suited to complex older patients with multi-pathology. Evidence is emerging for alternative models of care that incorporate the evolving evidence base for optimal peri-operative management of the older surgical patient, including risk assessment and optimization. This article aims to provide a practical overview of the literature to all disciplines working in this field.