Randomized Clinical Trials and Observational Tribulations: Providing Clinical Evidence for Personalized Surgical Pain Management Care Models

Proving clinical superiority of personalized care models in interventional and surgical pain management is challenging. The apparent difficulties may arise from the inability to standardize complex surgical procedures that often involve multiple steps. Ensuring the surgery is performed the same way every time is nearly impossible. Confounding factors, such as the variability of the patient population and selection bias regarding comorbidities and anatomical variations are also difficult to control for. Small sample sizes in study groups comparing iterations of a surgical protocol may amplify bias. It is essentially impossible to conceal the surgical treatment from the surgeon and the operating team. Restrictive inclusion and exclusion criteria may distort the study population to no longer reflect patients seen in daily practice. Hindsight bias is introduced by the inability to effectively blind patient group allocation, which affects clinical result interpretation, particularly if the outcome is already known to the investigators when the outcome analysis is performed (often a long time after the intervention). Randomization is equally problematic, as many patients want to avoid being randomly assigned to a study group, particularly if they perceive their surgeon to be unsure of which treatment will likely render the best clinical outcome for them. Ethical concerns may also exist if the study involves additional and unnecessary risks. Lastly, surgical trials are costly, especially if the tested interventions are complex and require long-term follow-up to assess their benefit. Traditional clinical testing of personalized surgical pain management treatments may be more challenging because individualized solutions tailored to each patient's pain generator can vary extensively. However, high-grade evidence is needed to prompt a protocol change and break with traditional image-based criteria for treatment. In this article, the authors review issues in surgical trials and offer practical solutions.

The Changing Environment in Postgraduate Education in Orthopedic Surgery and Neurosurgery and Its Impact on Technology-Driven Targeted Interventional and Surgical Pain Management: Perspectives from Europe, Latin America, Asia, and The United States

Personalized care models are dominating modern medicine. These models are rooted in teaching future physicians the skill set to keep up with innovation. In orthopedic surgery and neurosurgery, education is increasingly influenced by augmented reality, simulation, navigation, robotics, and in some cases, artificial intelligence. The postpandemic learning environment has also changed, emphasizing online learning and skill- and competency-based teaching models incorporating clinical and bench-top research. Attempts to improve work-life balance and minimize physician burnout have led to work-hour restrictions in postgraduate training programs. These restrictions have made it particularly challenging for orthopedic and neurosurgery residents to acquire the knowledge and skill set to meet the requirements for certification. The fast-paced flow of information and the rapid implementation of innovation require higher efficiencies in the modern postgraduate training environment. However, what is taught typically lags several years behind. Examples include minimally invasive tissue-sparing techniques through tubular small-bladed retractor systems, robotic and navigation, endoscopic, patient-specific implants made possible by advances in imaging technology and 3D printing, and regenerative strategies. Currently, the traditional roles of mentee and mentor are being redefined. The future orthopedic surgeons and neurosurgeons involved in personalized surgical pain management will need to be versed in several disciplines ranging from bioengineering, basic research, computer, social and health sciences, clinical study, trial design, public health policy development, and economic accountability. Solutions to the fast-paced innovation cycle in orthopedic surgery and neurosurgery include adaptive learning skills to seize opportunities for innovation with execution and implementation by facilitating translational research and clinical program development across traditional boundaries between clinical and nonclinical specialties. Preparing the future generation of surgeons to have the aptitude to keep up with the rapid technological advances is challenging for postgraduate residency programs and accreditation agencies. However, implementing clinical protocol change when the entrepreneur-investigator surgeon substantiates it with high-grade clinical evidence is at the heart of personalized surgical pain management.

Elongated odontoid process in late Holocene skeletal remains from B6 archaeological site, Mendoza, Argentina

The odontoid process of the axis can be affected by congenital or acquired pathologies. While abnormalities such as os odontoideum, agenesis, and fractures are reported in archaeological remains, the abnormality of an elongated length of the odontoid process has not been described in the paleopathological literature. The aim of this paper is to evaluate two individuals with elongated odontoid processes from a skeletal assemblage from the B6 archaeological site (Mendoza, Argentina), and to discuss the possible etiologies of the condition, with particular attention given to the relation to trauma and Crowned Dens Syndrome (CDS), a condition characterized by the ossification of ligaments of the odontoid process of the second cervical vertebra.

Transaxillary single-port subtotal parathyroidectomy: feasibility study in cadavers

Objective

to test the minimally invasive technique of single-port transaxillary subtotal parathyroidectomy in non-formalized cadavers to evaluate its viability and reproduction.

Method

we performed ten subtotal parathyroidectomies through a transaxillary TriPort access in cadavers. The technique consisted of access through the axillary fossa, creating a subcutaneous tunnel to the anterior cervical region, for handling of the thyroid gland and dissection and resection of the parathyroid glands.

Results

all surgeries were successful. The mean time of surgery was 65 minutes (57-79 min), with uncomplicated identification of all anatomical structures. There was no need for complementary incisions in the cervical region.

Conclusion

the transaxillary single-port subtotal parathyroidectomy technique was feasible and reproducible, suggesting an alternative for minimally invasive cervical surgery.

Revisiting the Term Neuroprotection in Chronic and Degenerative Diseases

Thanks to the development of several new researches, the lifetime presented a significant increase, even so, we still have many obstacles to overcome – among them, manage and get responses regarding neurodegenerative diseases. Where we are in the understanding of neuroprotection? Do we really have protective therapies for diseases considered degeneratives such as amyotrophic lateral sclerosis and its variants, Parkinson’s disease, Alzheimer’s disease and many others? Neuroprotection is defined by many researches as interactions and interventions that can slow down or even inhibit the progression of neuronal degeneration process. We make some considerations on this neuroprotective effect.

Effect of culture supernatants from two cancer cell lines on healthy donors' monocytes

BACKGROUND

it is well known that culture cells secrete to their medium different factors that can alter their own as well as other cells' metabolism and functions. In the present study we evaluated the effect of culture supernatants originated from two cancer cell lines, Calu-1 (lung epidermoid carcinoma) and A-427 (lung adenocarcinoma) on peripheral blood monocytes (MO) from 20 healthy donors (HD).

METHODS AND RESULTS

MO were incubated with supernatants or with medium only (controls) during 2 or 18 hours. There were determined the expression of HLA-DR antigen by indirect immunofluorescence technique, the formation of reactive oxygen intermediates (NBT reduction capacity) and the phagocytic capacity (Candida albicans- anti Candida albicans system). These determinations were made also in MO from 16 patients with advanced lung cancer (LCP). Percentages of expression (media +/- SE) were: HLA-DR (+) MO: Calu-1 = 30 +/- 2; A-427 = 31 +/- 2; LCP = 52 +/- 3 (p < 0.0001 vs HD: 77 +/- 1%) NBT (+)MO: Calu-1 = 47 +/- 1; A-427 = 49 +/- 1; LCP = 56 +/- 2 (p < 0.01 vs HD: 45 +/- 2%), Phagocytic MO: Calu-1 = 38 +/- 3; A-427 = 39 +/- 2; LCP = 32 +/- 3 (p < 0.0001 vs HD: 50 +/- 1%).

CONCLUSIONS

we conclude that this in vitro model reproduced characteristics found in MO from lung cancer patients, since culture supernatants induced in normal MO phenotypic and functional characteristics also found in MO from patients analyzed.