Nicholas Mangano

Perioperative myocardial ischemia and myocardial injury after noncardiac surgery (MINS) remain prevalent contributors to postoperative morbidity and mortality. Recent advances, including high-sensitivity biomarkers and updated 2024 American Heart Association/American College of Cardiology (AHA/ACC) guidelines, have modified the clinical approach to preoperative ischemic evaluation. This review intends to synthesize contemporary evidence and provide a framework for perioperative ischemic workup. A narrative review of the current literature and major society guidelines was conducted, focusing on perioperative risk stratification, functional capacity assessment, biomarker utilization, noninvasive and invasive diagnostic modalities, and perioperative medical optimization strategies. Contemporary perioperative evaluation favors a stepwise, risk-based approach that uses clinical risk indices, functional capacity, and selective diagnostic testing. Biomarkers such as natriuretic peptides and cardiac troponins enhance risk prediction and enable the detection of MINS, which is strongly associated with increased mortality. Evidence does not support routine preoperative stress testing or prophylactic coronary revascularization in stable patients. Guideline-directed medical therapy, including sustained statin use and attentive management of antiplatelet and beta-blocker therapy, remains central to risk mitigation. Modern perioperative ischemic workup prioritizes individualized, evidence-based evaluation over routine testing. Integration of biomarkers, structured risk assessment, and multidisciplinary management may improve outcomes, though additional research is needed to define optimal strategies for detecting and treating MINS.

Background: Chronic pain remains a major clinical challenge, which is often resistant to conventional treatments. Spinal cord stimulation has been used for decades to manage refractory pain, traditionally relying on open-loop systems with fixed-output stimulation. However, these systems fail to account for physiological variability, leading to inconsistent pain relief. Closed-loop spinal cord stimulation represents a significant advancement by utilizing evoked compound action potentials to continuously modulate stimulation intensity in real-time, ensuring more stable and effective pain management. Methods: A comprehensive literature review was conducted using PubMed and ClinicalTrials.gov to identify and synthesize relevant published and ongoing studies with a focus on open-loop spinal cord stimulation for managing lower back pain. Results: Clinical trials, including the Avalon and Evoke studies, have demonstrated that closed-loop spinal cord stimulation provides superior pain relief, functional improvement, and reduced opioid dependence compared to traditional open-loop systems. Patients receiving closed-loop stimulation reported significantly higher rates of sustained pain reduction, improved quality of life, and fewer complications related to overstimulation. Emerging studies suggest its potential for conditions beyond back pain, such as neuropathic pain, cancer-related pain, and Raynaud’s phenomenon. Furthermore, cost-effectiveness analyses indicate that closed-loop spinal cord stimulation is a more economically viable treatment option compared to conventional medical management and open-loop systems. Conclusions: Closed-loop spinal cord stimulation represents a transformative development in neuromodulation, offering personalized and adaptive pain management that is distinct from open-loop spinal cord stimulation. Further research is warranted to explore its long-term durability, broader applications, and integration with emerging technologies in pain management.

Biomedical sciences have made immense progress and numerous discoveries aimed at improving the quality of life and life expectancy in modern times. Anesthesiology is typically tailored to individual patients as its clinical effects depend on multiple factors, including a patient’s physiological and pathological states, age, environmental exposures, and genetic variations. Sex differences are also paramount for a complete understanding of the effects of specific anesthetic medications on men and women. However, women-specific research and the inclusion of women in clinical trials, specifically during child-bearing years, remain disproportionately low compared to the general population at large. This review describes and summarizes genetic variations, including sex differences, that affect responses to common anesthetic medications such as volatile anesthetics, induction agents, neuromuscular blocking drugs, opioids, and local anesthetics. It also discusses the influence of genetic variations on anesthesia outcomes, such as postoperative nausea and vomiting, allergic reactions, pain, depth of anesthesia, awareness under anesthesia and recall, and postoperative delirium.

Pathological pain is defined as pain that outlives its usefulness as a protective warning system and becomes debilitating, disrupting normal life function. Understanding the mechanism of transition from physiological to pathological pain is essential to provide the effective prevention of chronic pain. The main subcategories of pathological pain are nociceptive pain, neuropathic pain, and nociplastic pain. Glial cells play pivotal roles in the development and maintenance of each of these pathological pain states, specifically neuropathic pain. Consequently, targeting these cells has emerged as a promising therapeutic strategy, as limited efficacy and harmful adverse effects are associated with current pharmacotherapies. This paper aims to review specific antibiotics that modulate glial cells, which can be used to treat neuropathic pain. These antibiotics include minocycline, doxycycline, ceftriaxone, and azithromycin. The potential of these antibiotics appears promising, particularly given the extensive prior research and use of these antibiotics in humans for other illnesses. However, each presents its own set of limitations, ultimately making the translation from preclinical findings to human therapies for neuropathic pain challenging.

Biomedical sciences have made immense progress and numerous discoveries aimed at improving quality of life and life expectancy in modern times. Anesthesiology is typically tailored to individual patients as its clinical effects depend on multiple factors, including a patient’s physiological and pathological states, age, environmental exposures and genetic variations. Sex differences are also paramount for a complete understanding of the effects of specific anesthetic medications on men and women. However, women-specific research and the inclusion of women in clinical trials, specifically during child-bearing years, remain disproportionately low compared to the general population at large. This review describes and summarizes genetic variations, including sex differences, that affect responses to common anesthetic medications such as volatile anesthetics, induction agents, neuromuscular blocking drugs, opioids and local anesthetics. It also discusses the influence of genetic variations on anesthesia outcomes such as post-operative nausea and vomiting, allergic reactions, pain, depth of anesthesia, awareness under anesthesia and recall, and post-operative delirium.