Opioid-free general anaesthesia is safe, effective and dramatically decreases postoperative nausea, according to a single-centre study of more than 1,000 patients.
Using opioid alternatives during general anaesthesia is part of an effort by TEAMHealth Anesthesia at Select Physicians Surgery Center in Tampa, Florida to reduce the use of opioids during and after surgery. The study findings suggest physician anaesthesiologists are helping pave the way to promote pain management alternatives to opioids, and making headway in reducing the use of the addictive medications.
“Opioids crept into general anaesthesia over the years because they don’t cause problems with the cardiovascular system, but our research suggests we can use alternatives safely and effectively,” said David Samuels, M.D., lead author of the study and medical director of anaesthesia at Select Physicians Surgery Center and medical director for TEAMHealth Anesthesia, Tampa. “By avoiding the use of opioids intraoperatively and helping surgeons understand the value and importance of offering patients different options for pain after surgery, physician anaesthesiologists can be agents of change in addressing the opioid dependency crisis.”
Opioids – usually fentanyl, an opioid 50 times more powerful than heroin – are typically included in the combination of medications given to patients for general anaesthesia during surgery. In the study, 1,009 patients having head and neck surgery (including laryngoscopy, complex facial plastic surgery, middle ear surgery and nasal or sinus surgery) received general anaesthesia without opioids. Instead, patients received various combinations of magnesium, sub-anaesthetic ketamine, lidocaine and ketorolac, depending on the patient’s age and health. Surgeons and patients expressed a high degree of satisfaction with the new anaesthesia protocol and postoperative pain management.
After surgery, 11 percent of patients experienced nausea, whereas 50 to 80 percent of patients typically suffer from nausea after surgery. Additionally, 64 percent of patients did not require any pain medication in the PACU.
The traditional use of fentanyl in general anaesthesia can cause hyperalgesia, or increased sensitivity to pain, Dr. Samuels said.
“Hyperalgesia leads to increased pain, so patients request more opioids in the recovery area, and then go home with an excessive number of pills,” said Enrico M. Camporesi, M.D., co-author of the study and professor emeritus at the University of South Florida and director of research for TEAMHealth Anesthesia Research Institute, Tampa. “We believe that not using fentanyl during surgical anaesthesia, as well as not providing patients too many pills after surgery, may help decrease the likelihood of opioid abuse. Studies show that 1 in 15 patients who has surgery is still taking prescription opioids 90 days afterwards,” he said.
Three of the 19 surgeons who participated in the study now prescribe patients daily oral magnesium, gabapentin and ibuprofen for pain management after surgery. They also prescribe five hydrocodone pills for any breakthrough pain. Previously, these surgeons prescribed 50 hydrocodone pills. The change to five pills will lead to 27,000 fewer prescribed hydrocodone pills in one year’s time for these surgeons at their practice.
American Society of Anesthesiologists (ASA) www.asahq.org/about-asa/newsroom/news-releases/2017/10/eliminating-opioids-from-anesthesia-decreases-post-surgery-nausea

Patients who choose to receive alternative therapy as treatment for curable cancers instead of conventional cancer treatment have a higher risk of death, according to researchers from the Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center at Yale School of Medicine and Yale Cancer Center.
There is increasing interest by patients and families in pursuing alternative medicine as opposed to conventional cancer treatment. This trend has created a difficult situation for patients and providers. Although it is widely believed that conventional cancer treatment will provide the greatest chance at cure, there is limited research evaluating the effectiveness of alternative medicine for cancer. 
While many cancer patients use alternative therapy in addition to conventional cancer treatments, little is known about patients who use alternative therapy as their only approach to treating their cancer.
“We became interested in this topic after seeing too many patients present in our clinics with advanced cancers that were treated with ineffective and unproven alternative therapies alone,” said the study’s senior author, Dr. James B. Yu, associate professor of therapeutic radiology at Yale Cancer Center. 
To investigate alternative medicine use and its impact on survival compared to conventional cancer treatment, the researchers studied 840 patients with breast, prostate, lung, and colorectal cancer in the National Cancer Database (NCDB) — a joint project of the Commission on Cancer of the American College of Surgeons and the American Cancer Society. The NCDB represents approximately 70% of newly diagnosed cancers nationwide. Researchers compared 280 patients who chose alternative medicine to 560 patients who had received conventional cancer treatment.
The researchers studied patients diagnosed from 2004 to 2013. By collecting the outcomes of patients who received alternative medicine instead of chemotherapy, surgery, and/or radiation, they found a greater risk of death. This finding persisted for patients with breast, lung, and colorectal cancer. The researchers concluded that patients who chose treatment with alternative medicine were more likely to die and urged for greater scrutiny of the use of alternative medicine for the initial treatment of cancer.
“We now have evidence to suggest that using alternative medicine in place of proven cancer therapies results in worse survival,” said lead author Dr. Skyler Johnson. “It is our hope that this information can be used by patients and physicians when discussing the impact of cancer treatment decisions on survival.” 

Yale University
news.yale.edu/2017/08/10/using-only-alternative-medicine-cancer-linked-lower-survival-rate

Researchers from the University of Houston have shown for the first time that the use of a brain-computer interface augmented with a virtual walking avatar can control gait, suggesting the protocol may help patients recover the ability to walk after stroke, some spinal cord injuries and certain other gait disabilities.
Researchers said the work, done at the University’s Non-invasive Brain-Machine Interface System Laboratory, is the first to demonstrate that a brain-computer interface can promote and enhance cortical involvement during walking.
Jose Luis Contreras-Vidal, Cullen professor of electrical and computer engineering at UH and senior author of the paper, said the data will be made available to other researchers. While similar work has been done in other primates, this is the first to involve humans, he said. Contreras-Vidal is also site director of the BRAIN Center (Building Reliable Advances and Innovation in Neurotechnology), a National Science Foundation Industry/University Cooperative Research Center.
Contreras-Vidal and researchers with his lab use non-invasive brain monitoring to determine what parts of the brain are involved in an activity, using that information to create an algorithm, or a brain-machine interface, which can translate the subject’s intentions into action.
“Voluntary control of movements is crucial for motor learning and physical rehabilitation,” they wrote. “Our results suggest the possible benefits of using a closed-loop EEG-based BCI-VR (brain-computer interface-virtual reality) system in inducing voluntary control of human gait.”
Researchers already knew electroencephalogram (EEG) readings of brain activity can distinguish whether a subject is standing still or walking. But they hadn’t previously known if a brain-computer interface was practical for helping to promote the ability to walk, or what parts of the brain are relevant to determining gait.
In this case, they collected data from eight healthy subjects, all of whom participated in three trials involving walking on a treadmill while watching an avatar displayed on a monitor. The volunteers were fitted with a 64-channel headset and motion sensors at the hip, knee and ankle joint.
The avatar first was activated by the motion sensors, allowing its movement to precisely mimic that of the test subject. In later tests, the avatar was controlled by the brain-computer interface, meaning the subject controlled the avatar with his or her brain.
The avatar perfectly mimicked the subject’s movements when relying upon the sensors, but the match was less precise when the brain-computer interface was used.
Contreras-Vidal said that’s to be expected, noting that other studies have shown some initial decoding errors as the subject learns to use the interface. “It’s like learning to use a new tool or sport,” he said. “You have to understand how the tool works. The brain needs time to learn that.”
The researchers reported increased activity in the posterior parietal cortex and the inferior parietal lobe, along with increased involvement of the anterior cingulate cortex, which is involved in motor learning and error monitoring.

University of Houstonhttp://tinyurl.com/y9p8o5dr

One of the first studies testing the effectiveness of different operating room (OR) head coverings in preventing airborne contamination has found that surgeon’s caps that expose small amounts of the ears and hair are not inferior to the bouffant-style, disposable scrub hats that cover those features.
“Recently there have been concerns that exposed hair in the OR could increase the risk of surgical site infections, although there is no definitive evidence that it does,” said principal investigator Troy A. Markel, MD, FACS, assistant professor of Paediatric surgery at Riley Hospital for Children at Indiana University Health, Indianapolis. “In fact, there are very few published scientific data supporting what the optimal headgear in the OR is.”
For their study, the researchers tested three common styles of commercially available surgical headgear. Disposable shower cap-like bouffant hats underwent testing, as did two types of surgical skullcaps, another name for the tie-in-the-back, close-fitting caps that are popular with surgeons: disposable caps with paper sides, and freshly home-laundered, reusable, cloth skullcaps.
Unlike most tests for environmental quality, which Dr. Markel said are typically done in a static laboratory, their airborne contamination testing was performed in an actual OR under changing conditions. For each style of hat the OR team wore, they performed a one-hour mock operation, which included gowning and gloving, passing surgical instruments, leaving and re-entering the OR, and performing electrocautery on a piece of raw steak to generate particles that were discharged into the air. Each hat style underwent testing four times, twice at each of two different hospitals. Both ORs had high-efficiency air-cleansing ventilation systems, according to the researchers.
The multidisciplinary research team—a microbiologist, engineers specializing in ventilation, an industrial air hygienist, and a surgeon—used their previously developed method involving multiple tests of what they call environmental quality indicators. In one test using a particle counter, they counted tiny airborne particles, such as hair and skin cells, that landed in various parts of the room. They also measured microbial shedding, the bacteria and other micro-organisms collected and grown in Petri dishes placed at the sterile operating field and the instrument table in the back of the room.
During the mock operations, the bouffant hats and the disposable surgical skullcaps had similar airborne particle counts, the study investigators reported. However, cloth skullcaps, which do not have a porous crown like their disposable counterparts, reportedly outperformed bouffant hats, showing lower particle counts and significantly lower microbial shedding at the sterile field compared with bouffant hats.
Additionally, the investigators tested the fabric of each hat style for permeability (air flow), penetration (amounts of particles that pass through), and porosity (pore, or hole, size). Results of fabric analysis revealed that the bouffant hats had greater permeability than either of the other caps, the investigators reported.
“Some organizations and hospitals have suggested that all OR personnel wear disposable bouffant-type hats, but we found no apparent infection-control reason to disallow disposable skullcaps in the OR,” Dr. Markel reported.
The researchers did not compare the amounts of airborne contaminants with infections at the surgical site. However, because they observed no statistically significant difference in the amounts of airborne contaminants in the OR between the disposable skullcaps and the disposable bouffant hats, he said, “I think it is difficult to say that one disposable hat is better than the other to prevent surgical site infections.”
Their study results have the potential to make an impact on the OR attire policies of hospitals and health care regulatory bodies, according to Dr. Markel.
“I expect our findings may be used to inform surgical headgear policy in the United States,” he said. “Based on these experiments, surgeons should be allowed to wear either a bouffant hat or a skullcap, although cloth skull caps are the thickest and have the lowest permeability of the three types we tested.”
American College of Surgeons
www.facs.org/media/press-releases/2017/markel