SleepTalker September 2020

Dr. Gan received this letter from a Stony Brook faculty member who was a patient at the Pain Clinic

    I am writing this letter to let you know about my incredibly pleasant recent experience at the Pain Management Center at Stony Brook University. For the past 5 years, I have suffered from what I thought was an ephemeral lower back pain that would go away with exercise and/or anti-inflammatory drugs. However, that was not the case. Therefore, upon recommendation by a colleague, who also suffered from the same ailment and was treated at the Pain Center at Stony Brook, I went to see Dr. William Caldwell. What is likeable about him from the word "go" is his confidence, incredibly honest and compassionate demeanor, that made you feel that you are indeed in good hands. Upon examination of my MRI, he was honest enough to tell me that my stenosis is really bad and although he could give me epidural injections, I may eventually need to have surgery. Because of my tight schedules with national and international travels, I decided to have epidural injections before each trip in order to get a reprieve from pain, while I was at conferences.

    However, as Dr. Caldwell honestly and correctly suggested, my injections lasted no more than 4-5 weeks, after which the same pains reappeared. I finally followed Dr. Caldwell’s suggestion and decided to have my back surgery. I am now 4 weeks post-surgery and although it may still be too early to rejoice, I cannot tell you how thrilled I am to think that, after 5 years of suffering, I may actually have my active ”happy” life back without the routine shooting pains down my legs that made my life miserable! For this, I am greatly indebted to Dr. Caldwell.

    The purpose of this letter is, therefore, to tell you how proud I am that we have a Center for Pain Management led by Dr. Caldwell, who in the opinion of many like myself who were treated at the Center, think that he is an outstanding, skilled, compassionate and incredibly honest physician. With his leadership, I have no doubt that the Center of Pain Management will grow into a Center of Excellence, that will make all of us at Stony Brook, very proud. However, if we are to maintain such “Centers of Excellence” we should do our level best to recognize and encourage outstanding young talents like Dr. Caldwell, who in my humble opinion is a rising star. He has already put the Pain Center on the map for Stony Brook!

Dr. Gan received the following message from Richard J. Scriven, MD, Associate Professor of Surgery and Pediatrics, Stony Brook Medicine

    I just want to pass along an "atta boy" to Dr. Robert Moore and Dr. Usama Siddique. Yesterday we did a tough lung resection (carcinoid tumor, bloody and chronically infected). Rob and his team were great, a very good balance of letting us operate and then getting the sats up. Calm the whole time.

  Dr. Sergio Bergese and his colleagues will present two abstracts at virtual SASM meeting to be held October 1-2, 2020.

• Driver CN, Laporta ML, Bergese SD, Urman RD, Di Piazza F, Sprung J, Weingarten TN. Temporal Distribution of Postoperative Respiratory Depression

• Laporta ML, Driver CN, Bergese SD, Urman RD, Di Piazza F, Sprung J, Weingarten TN. PRODIGY Risk Assessment Score and Frequency of Opioid-Induced Respiratory Depression

  Dr. Richard Keegan, who graduated from from Dr. Josh Dubnau's lab in May, has taken on the role of Regional Medical Director for Life Molecular Imaging. The company produces PET tracers for the diagnosis of AD and other dementias. As his territory is located within the Northeast region, we hope he will be able to remain in contact with Stony Brook!

Editor’s note. This is first installment of what I hope will become a regular feature of SleepTalker. Sometimes I read a research article and wonder how the authors developed an interest in the topic. In “A Peek Behind the Publication” we ask the authors to tell us. This month, two eager volunteers fill us in about their recent publications. How did it begin? What did you learn? Where will you take it from here? I hope you enjoy reading what they have to say! jpd

Michelino Puopolo, PhD

Contribution of T-type calcium channels to spinal cord injury induced hyperexcitability of nociceptors.
Lauzadis J, Liu H, Yong L, Rebecchi MJ, Kaczocha M, Puopolo M.

    Chronic neuropathic pain is a major comorbidity of spinal cord injury (SCI), affecting up to 70-80% of patients. SCI-induced neuropathic pain (SCI-pain) is often lifelong and therapeutically intractable, resulting in severe decline of quality of life and increased risks for depression, anxiety, and addiction.

   A hyperexcitable state and spontaneous activity of SCI-nociceptors have been proposed as a possible underlying cause for the development of chronic neuropathic pain following SCI. Gabapentin (which targets high voltage activated calcium channels) and mexiletine (which targets sodium channels) are first line analgesics used to treat SCI-pain, but their efficacy is very low. These observations suggested to us that both high voltage-activated calcium channels and sodium channels play only a minimal role in driving SCI-nociceptors into a hyperexcitable state, and prompted us to consider low voltage-activated T-type calcium channels. By using a preclinical rat model of SCI, we found that T-type calcium channels are upregulated in SCI-nociceptors. Pharmacological inhibition of T-type calcium channels rescued the hyperexcitable state of SCI-nociceptors in vitro and reduced chronic neuropathic pain in vivo. Our findings suggest that T-type calcium channels may represent a pharmacological target to treat SCI-induced neuropathic pain.

   In future experiments we aim to determine which isoform(s) of T-type calcium channels (CaV3.1, CaV3.2, or CaV3.3) is upregulated following SCI. To this purpose, we will use a virus to deliver shRNA to knock down each individual isoform. In addition, because we found that the upregulation of T-type calcium channels in SCI-nociceptors is not simply caused by increased expression levels of mRNA, we will investigate the role of posttranslational modifications (i.e. phosphorylation, glycosylation, ubiquitinylation, increased membrane expression) in this process.

Zhaosheng Jin, MBBS, BSc

Postoperative delirium: perioperative assessment, risk reduction, and management.
Jin Z, Hu J, Ma D.

    Delirium is a highly distressing postoperative complication associated with significant morbidity and mortality. With the ever-increasing number of older patients undergoing major surgeries, delirium management will likely become even more relevant to everyday practice. As there are currently very limited treatment options available for established delirium, I undertook this project to find out what can be done in the perioperative setting to minimize the risk of delirium, and what areas require further studies.

    Intraoperative interventions which have been shown to reduce delirium risk include multimodal analgesia, regional anesthesia, and intraoperative/postoperative dexmedetomidine. Most notably, there is currently no clear evidence regarding the effect of blood pressure management on the risk of delirium.

    Clinically, I will incorporate the delirium risk assessment as part of my preoperative assessment. In patients who are high risk, I will ensure that patients have adequate postoperative analgesia, minimize deliriogenic medications, be mindful of the depth of anesthesia and intraoperative blood pressure. In the future, I hope to get involved in clinical research on intraoperative management of delirium risk.

Figure from Lauzadis et al 2020

• Lauzadis J, Liu H, Yong L, Rebecchi MJ, Kaczocha M, Puopolo M. Contribution of T-type calcium channels to spinal cord injury induced hyperexcitability of nociceptors. J Neurosci. 2020 Aug 24
• Jin Z, Hu J, Ma D. Postoperative delirium: perioperative assessment, risk reduction, and management. Br J Anaesth. 2020 Aug 11
• Maloney LM, Yang AH, Princi RA, Eichert AJ, Hébert DR, Kupec TV, Mertz AE, Vasyltsiv R, Vijaya Kumar TM, Walker GJ, Peralta EJ, Hoffman JL, Yin W, Page CR. A COVID-19 Airway Management Innovation with Pragmatic Efficacy Evaluation: The Patient Particle Containment Chamber. Ann Biomed Eng. 2020 Aug 27
• Izrailtyan I, Poppers J, Kowal R, Zabirowicz E, Nie L, Gan TJ, Bennett-Guerrero E. Comprehensive Quality Improvement Program for Intraoperative Transesophageal Echocardiography: Development, Implementation, and Initial Experience. J Cardiothorac Vasc Anesth. 2020 Aug 7

James P. Dilger, PhD