Brugada syndrome is characterized by coved-type ST-segment elevations in the precordial leads associated with syncope, life-threatening ventricular tachyarrhythmias and sudden cardiac death. When typical ECG findings are present in the absence of symptoms, it is called Brugada pattern. About 25% of cases are associated with loss-of-function mutation of the cardiac sodium channel SCN5A while others may be triggered by drugs with sodium channel-blocking effects, electrolyte abnormalities, febrile states, or autonomic dysfunction.

A 33-year-old man presented with a 3-day history of intermittent substernal chest pressure. On hospital admission, ECG showed normal sinus rhythm without ST-segment changes and serial cardiac enzymes were normal. Given persistent symptoms and unremarkable recent exercise ECG-stress testing, cardiac CT-angiography was performed which revealed anomalous origin of the right coronary artery (RCA) with approximately 50% luminal narrowing. The patient underwent successful surgical reimplantation of the RCA. Cardiopulmonary bypass was weaned
off and the patient rewarmed from therapeutic hypothermia. Once normothermia was achieved, the patient developed ventricular fibrillation (VF). Following successful resuscitation, ECG revealed ST-segment elevations in V1 and V2 consistent with type 1 Brugada, which completely resolved spontaneously in the subsequent hours and was not reproducible with ajmaline challenge.

It is well known that hyperthermia may trigger Brugada syndrome in predisposed individuals. Studies have shown that mutated sodium channels result in temperature-dependent ionic changes. In febrile states, delayed sodium influx results in heterogeneous depolarization predisposing to VF. On the contrary, severe hypothermia (28.5C) causes sinus bradycardia, QT prolongation, widening of the QRS complex and the pathognomonic Osborn wave. Typical Brugada pattern has been rarely described in hypothermic states. Nonetheless, this pattern has been reproduced in animal models with cooling of the epicardium. Therapeutic hypothermia is targeted in the range of mild hypothermia (32-34C), where VF occurs only rarely, mainly in patients with primary arrhythmic disorders. Tan et al. described a case of transient typical Brugada ECG pattern upon rewarming from therapeutic hypothermia after sudden cardiac death of unknown etiology, with complete resolution with normothermia. These authors proposed that the Brugada pattern was hidden during the hypothermic state. In our patient, however, VF occurred only during the rewarming phase when normothermia was
achieved. We hypothesize that temperature increments, not necessarily hyperthermia, may be associated with increased risk of Brugada syndrome in susceptible patients. Although further research is needed, rewarming from therapeutic hypothermia requires careful monitoring for potentially lethal arrhythmogenic disorders.

A Warming Surprise: Brugada Syndrome After Rewarming from Therapeutic
Hypothermia

Background
Coronary artery disease (CAD) is the leading cause of death in the United States. In Hawaii, three of every ten deaths are due to CAD. Access to cardiac catheterization centers (CCC) is crucial for reducing morbidity and mortality, but most CCCs are concentrated in the capital, Honolulu. No prior studies have assessed the distribution of CCCs in relation to the demand and capacity for catheterization services in Hawaii using Geographic Information Systems (GIS). This study analyzed both current demand vs. capacity for CCCs, as well as projected optimal CCC locations based on time and distance considerations on the island of Oahu. 

Methods
GIS is a powerful tool with which location-allocation problems may be addressed. Data from the Hawaii Department of Health was implemented to estimate the number of patients in need of CCCs. Patients were then randomly distributed across residential areas in the location-allocation model. Using network analysis in GIS, residents’ travel time from their homes to the nearest CCCs was approximated. Travel time and demand vs. capacity maps were created to enable assessment of the accessibility of CCCs in each region and to highlight areas with unmet demand.

Results
Time-to-care analysis showed significant time burdens for patients in certain areas of Oahu. Under optimal traffic conditions, it took >60 minutes for patients in West Oahu and the North Shore, and >40 minutes for patients in Northeast Oahu to reach the nearest CCCs. Analysis of the demand vs. capacity of CCCs revealed the CCC in Central Oahu, which serves many of the patients with significant time burdens, exceeded its annual capacity by more than 985 patients. Meanwhile, all CCCs in South Oahu had significantly higher capacity than demand. To best decrease time burdens and mitigate capacity concerns for the greatest number of patients, an additional CCC should be established in West Oahu.

Conclusion
GIS analysis showed that the current CCCs on Oahu are not positioned to optimize patient outcomes. Patients in areas with significant time-to-CCC burdens likely face worse outcomes when they need emergent catheterization. This disparity could be remedied with the addition of CCCs closer to these regions, particularly in West Oahu. Looking forward, this model may be applied to other healthcare resources, such as emergency departments, to analyze current demand and geographical distributions and to influence future resource allocation. GIS has the power to improve healthcare efficiency, thus enhancing clinical outcomes.

GIS Analysis of Cardiac Catheterization Centers on the Island of Oahu


Background:
Creutzfeldt-Jakob Disease (CJD) is a neurodegenerative process that manifests as a rapidly progressive dementia with a usual poor prognosis within 12 months. CJD can be further grouped into three main categories: sporadic (sCJD), genetic (gCJD), and acquired (aCJD). The worldwide incidence is around 1.5 to 2.0 per million person-years and about 85-95% of CJD can be attributed to sporadic CJD. The presentation of this disease can vary and therefore requires a criterion to make this consideration carefully. For sporadic CJD to meet the criteria for “probable,” it must have 3 main criteria: (1) Clinical findings of a neuropsychiatric disorder with a positive positive Real Time Quaking Induced Conversion (RT-QuiC) test or rapid dementia plus at least two of the following symptoms: myoclonus, visual or cerebellar abnormalities, pyramidal/extrapyramidal signs, and akinetic mutism, (2) a typical EEG findings of periodic sharp wave complexes, positive 14-3-3 CSF assay in disease duration of less than 2 years, or high signal in caudate/putamen regions on MRI brain scan or at least two cortical regions either on DWI or FLAIR, and (3) exclusion of other causes in diagnostic workup.

Case Presentation:
We report the case of a 61-year-old woman with a past medical history of hypothyroidism, psoriasis, and hypertension that presented for acute onset, rapidly progressive cognitive decline that was 1 month in duration. The patient’s clinical presentation of rapid cognitive decline, subtle cerebellar and upper motor neuron findings (e.g. pseudobulbar affect, slow speech), and MRI brain findings of cortical ribboning and restricted diffusion in the caudate nucleus was most consistent with probable sporadic CJD. Cerebral spinal fluid analysis revealed a positive Real Time Quaking Induced Conversion (RT-QuiC) test, t-tau protein of 18531 pg/mL (0-1149 pg/mL), and 14-3-3 gamma protein of 61440 Au/mL (<30-1999 Au/mL). An EEG revealed pseudo periodic triphasic sharp wave complexes over the left frontotemporal regions. Additional laboratory findings were obtained to rule out mimickers such as autoimmune encephalitis, Hashimoto’s encephalopathy, and CNS vasculitis. Upon receiving diagnosis, the patient’s condition rapidly worsened and died after 1 month possibly due to respiratory arrest.

Discussion:
This patient had an “atypical” presentation due to absence of hallmark symptoms such as myoclonus, however, the rapid course of the disease was consistent with the nature and course of sCJD. Definitive diagnosis of CJD requires neuropathological evaluation of brain tissue via immunohistochemistry or protease-resistant PrP/scrapie-associated proteins on Western blot via autopsy post-mortem. The patient presented in this report did not have an autopsy, however, with information gathered based on criteria from Center of Disease and Control, we have high clinical suspicion that this patient had probable sporadic CJD. There is no current FDA approved treatment that is available to treat this disease.


A Rare Case of Probable Sporadic Creutzfeldt-Jakob Disease

Background
Spinal manipulation is one of many therapies for back pain. It is typically done by a chiropractor or physical therapist. A systemic review and meta-analysis concluded that spinal manipulation has moderate-quality evidence for improvement in pain scale and function. However, there is insufficient data for chronic back pain treatment. Like most treatments, there are risks associated with spinal manipulation. While serious adverse effects of spinal manipulation are rare, they include disc herniation, cauda equina syndrome, vertebrobasilar and carotid dissection. The incidence of serious adverse events range between 1/100,000 and 1/6 million manipulations. More commonly, minor complaints (dizziness, lightheadedness, headache, and numbness) are reported following spinal manipulation with rates between 25-60%. In this case, a 50-year-old patient underwent chiropractic spinal manipulation for back pain, resulting in bilateral lower extremity paralysis requiring spinal surgery.
Case Presentation
A 50-year-old male with no past medical history presented with back pain. The patient reported that he had back pain for about a month after lifting a heavy object. He went to the chiropractor for an adjustment two weeks prior to admission. Following the adjustment, he felt better, but the next day he had bilateral leg weakness, numbness, and tingling. He couldn’t walk for two weeks and was using a wheelchair. Sensation was intact. Two days ago, he started experiencing urinary incontinence but no bowel incontinence. On examination, the patient had bilateral leg weakness and saddle anesthesia. Thoracic MRI showed a disc extrusion and epidural hematoma at T10-T11 extending superiorly to the T10 superior endplate and inferiorly to the mid-T11 vertebral body with severe mass effect on the spinal cord and canal stenosis. The patient was started on dexamethasone 4-mg q6-hours. A left thoracotomy, T10-11 left transthoracic corpectomy, and T9-11 anterior-lateral interbody arthrodesis was performed and well tolerated. After two months of inpatient rehab, the patient was able to ambulate using a walker, discharged home, and scheduled for outpatient rehab.
Discussion
This case demonstrates an interesting and rare serious adverse event of spinal manipulation. Generally, it is important to avoid spinal manipulation in patients with documented or suspected disc herniation. In this case, it is unknown whether the patient had a pre-existing herniation but considering that the back pain originally began shortly after lifting a heavy object, it is possible that there was a degree of herniation prior to the chiropractor visit that progressed after the spinal manipulation, causing a mass effect and spinal stenosis.

Thoracic Spine Injury Requiring Neurosurgery following Chiropractic Manipulation: A Case Report

Purpose for Review 
This perspective piece has two goals: first, to describe issues related to artificial intelligence-based applications for cancer control as they may impact health inequities or disparities; and second, to report on a review of systematic
reviews and meta-analyses of artificial intelligence-based tools for cancer control to ascertain the extent to which discussions of justice, equity, diversity, inclusion, or health disparities manifest in syntheses of the field’s best evidence.
Recent Findings 
We found that, while a significant proportion of existing syntheses of research on AI-based tools in cancer control use formal bias assessment tools, the fairness or equitability of models is not yet systematically analyzable across studies. Issues related to real-world use of AI-based tools for cancer control, such as workflow considerations, measures of usability and acceptance, or tool architecture, are more visible in the literature, but still addressed only in a minority of reviews.
Summary
Artificial intelligence is poised to bring significant benefits to a wide range of applications in cancer control, but more thorough and standardized evaluations and reporting of model fairness are required to build the evidence base for AI-based
tool design for cancer and to ensure that these emerging technologies promote equitable healthcare.

Artificial Intelligence and Cancer Control: Toward Prioritizing Justice,
Equity, Diversity, and Inclusion (JEDI) in Emerging Decision Support
Technologies

Background
Diffuse midline glioma (DMG) is an aggressive, almost universally lethal form of high-grade glioma that occurs in children. One reason that DMG are so difficult to treat is that epigenetically unstable tumor cells evolve to resist radiation, chemotherapy, and other forms of treatment. Treating DMG cells with HDAC inhibitors (HDACi) reduces cell viability in mouse models, yet HDACi do not improve clinical outcomes when provided as monotherapies. The overall goal of this research is to identify combination therapies to synergistically reduce the growth and survival of DMG cells. A CRISPR-based genetic screen in DMG cell lines revealed that knockout of polo-like kinase 1 (PLK1), a key regulator of cell cycle progression, may sensitize DMG cells to HDACi. The purpose of this study is to develop PLK1i+HDACi combination therapies for DMG, which have few treatment options.

Methods
We conducted dose curve analyses to analyze changes in DMG cell growth and survival in response to increasing doses of HDACi combined with PLK1 inhibitors using the CellTiterGlo assay to measure cell viability. We also conducted immunofluorescence (IF) imaging of DMG cell lines treated with different HDACi and PLK1i to monitor cell cycle (phos-H3-Ser10) and DNA damage (yH2AX) markers.

Results
We found that co-treatment with PLK1i sensitizes DMG cells to HDAC inhibitors, as shown in the dose curve analyses where the addition of PLK1i (GSK461364, BI2536) lowered the IC50 values for two different HDACi (entinostat and panobinostat) compared to HDACi alone. Analysis of the IF images showed higher %(+) signals for both yH2AX and phos-H3-Ser10 in PLK1i and HDACi treated cells compared to either vehicle-treated controls, or DMG cells treated with HDACi and PLK1i alone. 

Conclusion
We conclude that PLK1i + HDACi drug combinations synergistically reduce DMG viability. We also observe that PLK1i + HDACi combinations affect DMG cell phenotypes via increased DNA damage and induced mitotic arrest. The importance of this work is that it potentially opens more therapeutic approaches for patients with DMG who would otherwise have a poor prognosis and limited treatment options. Future steps for this study are to determine the optimal PLK inhibitors to best sensitize DMG to HDAC inhibitors and to detect changes in signal transduction pathways and gene transcription downstream of PLK1i+HDACi combination therapy by phospho-proteomics and RNA sequencing.

Combinatorial targeting of kinase signaling and chromatin regulation to treat pediatric high grade glioma

Background: Rett Syndrome (RTT) is a progressive X-linked neurodevelopmental disorder affecting 1 in 10,000 live female births, caused by deletions in the methyl-CpG binding protein 2 gene (MECP2). It is characterized by developmental regression, stereotypical hand movements, motor dysfunction, language impairments and seizures. Retrospective case reports have indicated atypical pain perception in patients with RTT. Yet, studies in patients and the MeCP2-/+ heterozygous (Het) mouse model of RTT have been inconclusive, with both hypoalgesia and hyperalgesia reported. Since the MeCP2 protein is a critical transcriptional repressor factor expressed in sensory neurons, mechanisms have been speculated for the modulation of pain by MeCP2. However, few studies have explored its role in atypical pain perception with a translational model of RTT. A better characterization of abnormal pain behavior in an RTT model is critical for future mechanistic studies to provide better care for these patients. 

Methods: MeCP2-/+ female mice and age-matched wild-type (WT) female littermates were used. Two different ages were evaluated: 6-8 weeks (pre-symptomatic) and 4 months (symptomatic) when the RTT phenotype was present and consistent. Phenotype was assessed using a neurobehavioral score (looking at paw clench, respiratory pattern, and mobility) along with Catwalk Gait analysis. Pain sensitivity and thresholds were assessed to mechanical (Von Frey test) and heat (Hargreaves test) stimuli.

Results: MeCP2-/+ mice showed variation in their sensitivity to pain as their disease progressed. Pre-symptomatic mice were hypersensitive to both mechanical and thermal pain, shown by increased responses to tactile stimulus on Von Frey filament testing and decreased paw withdrawal latency on thermal Hargreaves testing. However, with the progression of disease phenotype, MeCP2-/+ mice became hyposensitive to both mechanical and thermal pain. These changes appeared to be independent of their motor ability.

Conclusion: MeCP2-/+ female mice represent a useful preclinical RTT model and exhibit abnormal pain behavior, with initial hyperalgesia and eventual hypoalgesia that appears to be independent of motor function. Since MeCP2 overexpression has been associated with increased pain tolerance, lack of MeCP2 in the Het female mice may contribute to the early pain hypersensitivity. Future studies are needed to explore the cellular and molecular mechanisms involved in this altered pain sensation during the progression of RTT and for developing stage-dependent therapeutic targets.

Changes in pain sensitivity with the progression of Rett Syndrome in MeCP2-/+ female mice

Background : Worldwide studies show an increasing trend of sleep disorders in recent times. We aimed to assess the association of epidemiology and socio-demographic disparities of organic sleep disorders (OSDs) using the National Inpatient Sample Database in the US population.

Methods : A retrospective study of the NIS (2016-2018) using the ICD-10-CM codes was performed. Hospitalizations with the diagnosis of OSDs (REM sleep behavior disorder, parasomnia, circadian rhythm, insomnia, hypersomnia, and narcolepsy) were identified. Weighted analysis was performed using an unpaired t-test & chi-square test. Mix effect multivariate regression analysis was performed to evaluate epidemiology & demographic disparities associated with OSDs.

Results : Out of 87,761,798 hospitalizations, 2,128,329 (2.43%) had organic sleep disorders. Amongst OSDs, prevalence of insomnia-2.32%, REM sleep behavior disorder-0.1%, parasomnia-0.1%, circadian rhythm-0.1%, hypersomnia-0.04%, and narcolepsy-0.06%. Population with OSDs was older (60 vs 58 years) and OSDs were higher in the age group 50-75 years (2.8% vs >75 years: 2.38% vs 18-50 years: 1.98%), male (2.53% vs female: 2.35%), White race (2.74% vs Native American: 2.06% vs Black: 1.83% vs Hispanic: 1.69%) and median household income of 76-100th percentile (2.61% vs 0-25th: 2.26%). Prevalence of hypertension (61.48% vs 55.58%), obesity (17.00% vs 15.77%), drug abuse (13.80% vs 6.70%), alcohol dependence (10.50% vs 5.81%), smoking (22.57% vs 16.10%) and AIDS (10.79% vs 6.03%) was higher amongst OSDs than no OSDs (p<.0001). In regression analysis, we found patients with age 50-75 years (aOR 1.08, 95%CI 1.06-1.10), female (1.05, 1.04-1.05), median income 76-100 percentile (1.10, 1.09-1.11), hypertension (1.18, 1.17-1.19), dyslipidemia (1.27, 1.26-1.28), obesity (1.09, 1.08-1.1) and AIDS (1.88, 1.86-1.9) had significantly higher odds of OSDs.

Conclusion : We identified a higher prevalence of OSD in the male, white, and high socioeconomic status population with insomnia being the most common type. Early identification and risk mitigation are essential to reduce the burden of ODSs. Our study is confounded by the absence of severity, outcomes of disease, causality, and long term follow up of patients


Epidemiology And Socio-demographic Disparities Associated With Organic Sleep Disorders Among USA Hospitalizations - A National Estimate

Background
The biopsychosocial model suggests that health outcomes are determined by the interplay of biological, psychological, and social factors. Within this framework, health follows a social gradient, in which socioeconomic status has a direct impact on health outcomes. In the United States, each group on the social ladder has better health than the group below it. These patterns of inequity are manifested through differential access to resources, including housing, education, and healthcare. 

In order to reduce these health disparities, the Upstate Medical Legal Partnership (MLP) was developed as an integrated, upstream approach to improve health outcomes for marginalized populations throughout Upstate South Carolina. More specifically, through a collaboration between Furman University, Prisma Health Upstate, and South Carolina Legal Services, the Upstate MLP coordinates and streamlines access to non-medical assistance when a medical problem is caused or exacerbated by a social or legal problem. The objective of this study was to qualitatively explore the impact of the MLP on health and quality of life for pediatric clients and their families. 

Methods
This study utilized the WHO social determinants of health (SDoH) framework to develop an interview guide. The interview guide assessed the effect of the MLP on health status, health access, and other SDoH domains. The MLP team interviewed 18 caregivers of pediatric patients who were referred to the MLP for assistance. Data analysis was conducted using the qualitative coding software NVivo using a grounded theory approach to understand the impact of MLP intervention on the health and well-being of pediatric clients and their families. 

Results
Prior to receiving MLP assistance, the caretakers reported three main areas of stress: difficulty balancing work and childcare, challenges adhering to treatment programs, and inhibited overall family functioning. However, by securing additional financial resources (SSI, Medicaid, TANF), facilitating custody proceedings, and providing social support for these families, the MLP was able to reduce the amount of stress perceived by these caregivers. Several downstream effects of this reduced caregiver stress were identified. Caregivers reported improved treatment compliance for themselves and their children, improved ability to balance work and childcare, and improved overall family functioning. 

Conclusion
Medical Legal Partnerships have the potential to improve health outcomes for caregivers and their children by securing economic resources, finalizing custody arrangements, and providing social support. The study demonstrated that MLP intervention allowed caregivers to have increased treatment compliance and improved family functioning, which has positive health implications for the pediatric clients and their caregivers.


Downstream Impacts of the Upstate Medical Legal Partnership: How Embedding Lawyers in Hospitals Can Be Used to Tackle the Social Determinants of Health

Background
A post-dural puncture headache (PDPH) is a common complication following trauma from spinal or epidural procedures. While the gold standard of treatment is an epidural blood patch (EBP), numerous pharmaceuticals have been investigated to prevent and manage symptoms with varying results. In some studies, gabapentin has been shown to decrease the incidence and severity of PDPH and opioid consumption without significant adverse effects.
Case Presentation
A 22-year-old female presented with an intractable headache after a recent lumbar puncture (LP). She was receiving treatment with REPOCH and intrathecal (IT) methotrexate for Burkitt’s Lymphoma and had end-stage renal disease status-post a remote kidney transplant complicated by post-transplant lymphoproliferative disorder. At presentation, her associated symptoms included nausea, vomiting, and severe pain that improved with lying flat, consistent with a PDPH. Initial treatment included fluids, opioids, anti-emetics, and caffeine. However, the patient required hospitalization due to her symptoms for which Anesthesiology and Palliative
Medicine were consulted. Since the patient had future cycles of IT chemotherapy and was a high infectious risk due to her immunocompromised state, an EBP was not recommended. Steroids, acetaminophen, and NSAIDs were contraindicated given her neutropenic fever and renal dysfunction, respectively. Gabapentin 100mg TID was then recommended based on limited evidence. The patient experienced significant symptom relief with gabapentin, decreasing her opioid utilization from over 100 oral morphine equivalents to zero within 24 hours. Gabapentin was prescribed for the patient’s future LP schedule that included three days of prophylactic treatment followed by three days of therapeutic treatment. The patient’s last chemotherapy was completed a few months later without recurrence of her headache.
Discussion
Management of PDPH includes a wide variety of treatment options in the literature with new non-opioid medications undergoing ongoing investigation. Clinicians should consider the use of gabapentin in the treatment and prevention of PDPH for patients who fail standard therapies.

The Use of Gabapentin for Relief of Post-Dural Puncture Headache

Background
Patients who present with cervical dystonia may also present with cervical myelopathy. This presentation can be problematic because patients with cervical myelopathy need fusion surgery such as an anterior discectomy and fusion (ACDF) to stabilize the spine and prevent damage to the spinal cord. The involuntary tremor caused by cervical dystonia can result in problems with boney fusion in the post-operative period. Deep Brain Stimulation (DBS) provides a potential solution to this problem when more conservative treatments like medication, halo vests, and botulinum toxin fail to reduce tremor.
Case Presentation
A 46-year-old female presented to our center with a chief complaint of neck pain. The patient also presented with bilateral upper extremity radiculopathy, paresthesia, and a myelopathic gait. She had a 15-year history of cervical dystonia and had tried various medications and botulinum toxin injections without resolution of symptoms. In addition to this the patient had cervical myelopathy caused by disc herniation at the C5-C6 and C6-C7 level. Although the patient was a candidate for ACDF, she was advised to have her dystonic tremor treated before ACDF to prevent pseudoarthrosis and hardware failure because of the tremor. The patient underwent bilateral DBS in the Globus pallidus interna (GPi) utilizing an Abbott InfinityTM DBS system. After placement of the DBS-GPi leads, batteries were placed, and the system was turned on which was able to provide significant relief of the patient’s tremor. The patient was followed up at 3 months and had a >75% reduction in her tremors. After the significant reduction in tremor, the patient underwent C5-C6 and C6-C7 ACDF at 6 months post DBS-GPi. The patient reported that the paresthesia had improved significantly, and the weakness had gradually improved at 3 months post ACDF. There was no radiographic evidence of hardware loosening or malalignment.
Discussion
The presentation of both Cervical Dystonia and Cervical Myopathy concurrently is a challenging couple of pathologies to manage. Bilateral DBS-GPi prior to ACDF is a viable strategy for managing these pathologies surgically. 


DBS before ACDF for a patient with Cervical Dystonia and Cervical Myelopathy

Opioids are a leading cause of overdose-related deaths in the US, accounting for 70.6% of fatalities in 2019 due primarily to respiratory depression. Epidural electrical stimulation (EES) has emerged as a novel approach for facilitating rhythmic movement such as respiration in humans and rodent models. To reveal the mechanism underpinning modulation of respiratory neural circuits, we compared the effects of dorsal and ventral cervical epidural electrical stimulation (D-CEES, V-CEES) on respiration after opioid-induced respiratory suppression or depression (OIRD) via administration of remifentanil in anesthetized patients undergoing medically necessary spinal cord surgery. We hypothesized that V-CEES activates ventral horn motoneurons while D-CEES recruits local spinal circuits and tracts to supraspinal structures. We enrolled 43 patients receiving opioids during ventral (n = 25) and dorsal (n = 18) cervical spinal surgery. EES was delivered to the spinal cord (C2-C7) for <90 seconds at an optimal intensity (0.5-5mA) at 5Hz or 30Hz. The subjects’ vital signs were recorded intraoperatively. Electromyograms (EMG) were used to monitor respiratory and upper extremity muscles such as the diaphragm, laryngeal, intercostal, genioglossal, and deltoid muscles bilaterally. The anesthesia stage was measured via electroencephalogram (EEG). A pneumotach recorded each patient’s airway pressure. An independent anesthesiologist, tasked with ensuring patient safety, maintained a stable surgical plane of anesthesia via propofol in conjunction with minimal remifentanil prior to EES. We divided the responses into 2 states: ON- and OFF-State. The ON-State condition was defined as suppressed, but still present, respiration compared to baseline through an additional dose of remifentanil (0.001-.05mcg/kg/min). OFF-State condition was produced by dosing the subject with the lowest sufficient concentration of remifentanil (0.05-0.1mcg/kg/min) necessary to induce apnea. We observed four main differences between D- and V-CEES in regulating respiration in the presence of remifentanil: 1) D-CEES alone induced inspiratory phase resetting; 2) D-CEES induced longer lasting respiratory modulation after EES cessation; 3) D-CEES induced both frequency and tidal volume changes of respiration while V-CEES modulated the tidal volume more significantly; and 4) D-CEES respiratory modulation was inhibited more significantly during the OFF-state, while the most responsive spinal level to V-CEES, C6/7, maintained its respiratory modulation in both ON- and OFF-States. These observations suggest D- and V-CEES facilitate respiration via different neural circuits.


Underline digital video library

A Warming Surprise: Brugada Syndrome After Rewarming from Therapeutic Hypothermia

GIS Analysis of Cardiac Catheterization Centers on the Island of Oahu

A Rare Case of Probable Sporadic Creutzfeldt-Jakob Disease

Thoracic Spine Injury Requiring Neurosurgery following Chiropractic Manipulation: A Case Report

Artificial Intelligence and Cancer Control: Toward Prioritizing Justice, Equity, Diversity, and Inclusion (JEDI) in Emerging Decision Support Technologies

Combinatorial targeting of kinase signaling and chromatin regulation to treat pediatric high grade glioma

Changes in pain sensitivity with the progression of Rett Syndrome in MeCP2-/+ female mice

Epidemiology And Socio-demographic Disparities Associated With Organic Sleep Disorders Among USA Hospitalizations - A National Estimate

Downstream Impacts of the Upstate Medical Legal Partnership: How Embedding Lawyers in Hospitals Can Be Used to Tackle the Social Determinants of Health

The Use of Gabapentin for Relief of Post-Dural Puncture Headache

DBS before ACDF for a patient with Cervical Dystonia and Cervical Myelopathy

Dorsal and Ventral Cervical Epidural Electrical Stimulation Opposes Opioid-Induced Respiratory Depression via Different Respiratory Neural Circuits

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