“The ASRA research awards recognize HSS’s tireless pursuit of patient safety and innovative treatments in pain management,” said Stavros Memtsoudis, MD, PhD, MBA, Chief of Anesthesiology, Critical Care and Pain Management at HSS and principal investigator of one of the award-winning studies, “Preoperative GLP-1 Agonist Use is Not Associated with Perioperative Aspiration or Pneumonia: A National Observational Study.” “These accolades validate our leadership in research, reinforcing our efforts to enhance safety standards and improve patient outcomes in pain management through evidence-based practices and multidisciplinary collaborations.”

The ASRA Research Committee selects three out of the top 10 highest-scoring scientific abstracts that have met all ASRA Pain Medicine abstract submission requirements and ASRA Pain Medicine membership to be Best of Meeting Abstract winners.

The Patient Safety Award was created in the spirit of Alice Romie to recognize exemplary patient safety work. Alice was an advocate for patient safety who contributed to standardizing medication safety and educating peers about this issue and who passed away from breast cancer in May 2021.

The two Best of Meeting award-winning studies were titled “Effects of Perioperative Dronabinol Use in Total Knee Arthroplasty” and “Preoperative GLP-1 Agonist Use is Not Associated with Perioperative Aspiration or Pneumonia: A National Observational Study.” 

Dronabinol is a synthetic tetrahydrocannabinol (THC) agent that is FDA-approved to treat nausea and vomiting from chemotherapy and to stimulate appetite in patients with HIV or AIDS. Prior studies suggest that cannabinoids may also have pain-relieving properties. While cannabis contains both THC and cannabidiol (CBD), the plant is federally illegal, so it is difficult to study its effects in a hospital setting. As a legal alternative, researchers sought to examine whether 5mg of perioperative dronabinol twice a day could reduce pain and opioid consumption 24 to 48 hours after total knee arthroplasty compared with placebo.

While there were no statistically significant differences in opioid consumption compared with placebo, this study adds to the literature on the effects of THC (in the form of dronabinol) in the perioperative period. Further research examining different dosing regimens of dronabinol for acute pain is warranted.

“In an attempt to decrease perioperative use of opioids in view of the opioid epidemic, it has become even more important to study drugs such as the cannabinoids known to have potential analgesic properties,” said HSS anesthesiologist and lead study author Kethy Jules-Elysee, MD. “Dronabinol was not effective in decreasing pain or opioid consumption in this study with such a rigorous design. However, it was well tolerated. Future studies looking at patients with a history of cannabis use or chronic opioid use should be done, and different dosages of dronabinol should be explored.” Researchers at HSS are also conducting a pilot study examining CBD (Epidiolex) in bilateral total knee replacements.

In the study “Preoperative GLP-1 Agonist Use is Not Associated with Perioperative Aspiration or Pneumonia,” researchers examined whether glucagon-like peptide-1 (GLP-1) medications might affect aspiration or pneumonia risk in patients undergoing surgery. The medications mimic hormones produced in the gut that reduce appetite and cause the body to release insulin, and they are commonly prescribed for diabetes management or weight loss. 

“The increased prescribing of these medications in recent years is likely to result in an increase in patients scheduled for surgery that are on these medications,” said Dr. Memtsoudis. “In a cohort (using MarketScan commercial claims 2017 to 2021 data) of lower extremity joint replacement, hysterectomy, appendectomy and cholecystectomy surgery, preoperative GLP-1 use appears not to be associated with odds of perioperative aspiration or pneumonia. This information may help guide clinical decision-making regarding the use of GLP-1 medications in the preoperative period. However, further research and consideration of broader implications would be necessary before implementing any policy changes.”

In the study that won the 2024 ASRA Patient Safety Award, “Is Spinal Anesthesia Safe in Patients with a History of Guillain-Barré Syndrome Undergoing Orthopedic Surgery?” researchers examined whether regional anesthesia, which has many safety and pain management benefits compared with general anesthesia, is safe for patients with Guillain-Barré syndrome. 

“Guillain-Barré Syndrome (GBS) is a rare autoimmune disorder which results in acute demyelination of the peripheral nervous system, typically after some sort of symptomatic infection,” explained David Lee, MD, an anesthesiologist at HSS and lead study author. “As such, the issue of whether to perform a neuraxial anesthetic technique in these patients has remained a controversial topic due to fears that a spinal may predispose this patient population to worsening neurological symptoms or result in a recurrence of GBS. Because there are many positive benefits to performing a neuraxial anesthetic technique versus general anesthesia, such as decreased mortality, decreased postoperative nausea and vomiting (PONV), and reduced incidence of deep-vein thrombosis, we sought to examine our experience with GBS patients undergoing lower extremity orthopedic procedures over the past 10 years using EPIC to see whether there were any differences in recovery or neurological outcome after administration of a spinal anesthetic.”

In this observational retrospective chart review of 103 patients with a documented history of GBS who underwent some type of lower extremity orthopedic procedure at HSS from 2014 to 2023, 79 patients received a spinal anesthetic and 18 received a general anesthetic. The researchers found no appreciable difference between the groups in postoperative neurological outcomes, length of stay in the post-anesthesia care unit, or length of hospital stay. Similarly, there were also no appreciable differences between the groups in terms of time to achieving physical therapy milestones or incidence of postoperative nausea and vomiting.   

“Because the incidence of GBS is rare (the CDC estimates 3,000 to 6,000 cases per year), the total volume of cases in this study represents a small fraction of the 41,500-plus orthopedic surgeries performed annually at HSS, 85 percent of which are done with a regional anesthetic technique,” said Dr. Lee. “These findings should give both patients and clinicians some measure of assurance that neuraxial anesthetic techniques can be safely performed in someone who has had prior GBS. Larger longitudinal studies would be beneficial to corroborate these findings, so new policies and ASRA guidelines can be established with confidence with regards to the use of neuraxial anesthesia in patients with a prior history of GBS.”

“HSS's commitment to researching new techniques for better outcomes is evident in its dedication to advancing patient care through rigorous scientific inquiry and clinical innovation,” said Dr. Memtsoudis. “By exploring emerging technologies and refining procedural techniques, HSS remains at the forefront of anesthesia administration, pain management, and critical care, ensuring that patients receive the highest standards of care.”

In addition to these three award-winning studies, HSS also presented 20 abstracts and either lectured at or moderated more than 25 sessions, workshops, problem-based learning discussions, poster sessions, and special interest group meetings at this year’s ASRA conference.

References

1. Thor P, Perlstein M, Illescas A, Lauzadis J, Sheetz M, Tailor M, Puglisi A, Popovic M, Oxendine J, Lin Y, Kirksey M, YaDeau J, Kumar K, Baaklini L, Liu J, Cheng S, Mayman D, Jerabek S, Westrich G, Cushner F, Cross M, Sculco P, Sculco T, Ast M, Gonzalez-Della Valle A, Sideris A, Jules-Elysee KM. “Effects of Perioperative Dronabinol Use in Total Knee Arthroplasty.” Presented at: 49th Annual Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine (ASRA), March 21-23, 2024; San Diego, CA.

2. Jashvant Poeran, Yhan Colon Iban, Haoyan Zhong, Alex Illescas, Crispiana Cozowicz, Lisa Reisinger, Jiabin Liu, Stavros Memtsoudis. “Preoperative GLP-1 Agonist Use is Not Associated with Perioperative Aspiration or Pneumonia: A National Observational Study.” Presented at: 49th Annual Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine (ASRA), March 21-23, 2024; San Diego, CA.

3. Tra BM, Haidar J, Lauzadis, J, Illescas A, Lee D. “Is Spinal Anesthesia Safe in Patients with a History of Guillain-Barré Syndrome Undergoing Orthopedic Surgery?” Presented at: 49th Annual Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine (ASRA), March 21-23, 2024; San Diego, CA.

Endothelial injury, or damage to the lining of the blood vessels, can be a major cause of blood clots after surgery. It has also been found in patients infected with COVID-19. 

Investigators aimed to gain insights into whether the risk of endothelial dysfunction continues after an infection with COVID-19 resolves, and if there is a need for more aggressive Deep Vein Thrombosis (DVT) prophylaxis in TKR patients with a history of COVID-19 infection. Aggressive DVT prophylaxis consists of pharmacologic and nonpharmacologic measures to diminish the risk of deep vein thrombosis and pulmonary embolism.

“Previous studies have demonstrated endothelial dysfunction in patients with active COVID-19 infection as manifested by higher rates of thromboembolic events. Consequently, therapeutic anticoagulation is recommended for hospitalized patients with acute and significant disease from the virus,” said HSS anesthesiologist Kethy Jules-Elysee, MD. “It remains unknown to what extent this predisposition to endothelial dysfunction persists upon resolution of active COVID-19 infection, implying a possible need for higher level of thromboprophylaxis in these patients postoperatively.”

She continued “Postoperative thrombosis is always a concern in patients undergoing total knee arthroplasty (TKA). This has been attributed to endothelial dysfunction from Virchow's triad. Given the projected increase in demand of TKA surgeries and the continued rise of COVID-19 cases, it is significantly important to assess the risks of postoperative thrombosis in the setting of both TKA and previous COVID-19 infection.”

Fifty-three patients with SARS-CoV-2 antibodies were identified for the case group and 48 patients without SARS-CoV-2 for the control group; all had received a primary TKR for knee osteoarthritis. Endothelial function was analyzed non-invasively via a reactive hyperemia procedure with a VENDYS-II device, once before surgery and once on postoperative day 1. Endothelial function was quantified using the vascular reactivity index (VRI) ranging between 0 (poor) to 3.5 (excellent). 

There was no significant difference between the average pre- and postoperative VRI in both patient groups, nor was there a significant difference in VRI scores before surgery vs after surgery. 

“Findings suggest no increased risk of DVT after TKA in SARS-CoV-2 IgG positive patients,” Dr. Jules-Elysee noted.

Postoperative VRI was not correlated with the duration or severity of COVID-19 infection. Decreased postoperative VRI was also not associated with increased length of hospital stay.

These results indicate that more aggressive DVT prophylaxis is likely not needed in TKR patients who have fully recovered from COVID-19.

When considering follow-up studies, Dr. Jules-Elysee noted “Since patients with a history of severe or prolonged infection with COVID-19 were not included in the study, further research on these patients is needed.”

Reference

1. Kethy Jules-Elysee, Carola Hanreich, Friedrich Boettner, Anna Jungwirth-Weinberger, Alison Zhao, Robyn Schultz, Ilya Bendich, Lisa Mandl. “Risk of thromboembolic events as measured by endothelial function is not elevated in total knee replacement patients with history of COVID disease.” Presented at: 47th Annual Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine (ASRA), March 31-April 2, 2021; Las Vegas, NV.

HSS is the world’s largest academic medical center specialized in musculoskeletal health, spanning orthopedics, rheumatology and related disciplines. The HSS Research Institute maintains 20 laboratories dedicated to solving debilitating orthopedic and rheumatic conditions such as arthritis, bone and soft tissue injuries, autoimmune diseases, and musculoskeletal pain and deformities. There, more than 300 dedicated personnel focus on tissue repair, improving surgical outcomes, autoimmunity and inflammation, genomics, new treatments, and precision medicine.

“HSS has a long history of contributing to the collective base of clinical and basic science knowledge and finding healthcare solutions for complex conditions,” said Louis A. Shapiro, President and CEO, HSS. “We’re proud that through the joint efforts of our institution and philanthropic support, we will have the ability to make a strong impact on this growing and vital area of research.”

“As experts in inflammatory disorders and in the development of interventions for overactive immune responses, the clinicians and researchers at HSS are well-positioned to investigate many of the adverse effects of COVID-19,” says Lionel B. Ivashkiv, MD, Chief Scientific Officer at the HSS Research Institute. “This includes studying the causes of these adverse effects as well as how to prevent and treat them.”What follows are descriptions of the first group of funded projects in basic/translational research:

Activation of pDCs by SARS-CoV-2 and Its Impact on Macrophage Response

Principal Investigator: Franck Barrat, PhD

Co-Investigator: Marie-Dominique Ah Kioon, PhD

This project will study cell types that are responsible for cytokine storm syndrome — the hyperactive immune response seen in people with COVID-19 — by looking at how certain immune cells are activated by SARS-CoV-2. Research in mice infected with SARS-CoV, a coronavirus similar to the one that causes COVID-19, has suggested that plasmacytoid dendritic cell precursors (pDCs) are key to the immune response to infection. These pDCs activate macrophages, which in turn secrete cytokines. In the SARS-CoV research, depletion of pDCs appeared to protect the mice from lethal lung injury. Using blood samples from donors, the investigators will study the pathway by which pDCs activate macrophages and look at ways to therapeutically block that process.

Inhibiting RNA Polymerase II Transcription Complexes in Macrophages to Target COVID-19–Associated Cytokine Storm

Principal Investigator: Inez Rogatsky, PhD

Co-Investigators: Steven Josefowicz, PhD, and Robert P. Fisher, MD, PhD

This pilot project will dissect the role of macrophages in SARS-CoV-2-induced acute respiratory distress syndrome (ARDS), the main driver of COVID-19-associated mortality. We will test small-molecule inhibitors of RNA Polymerase II (Pol II) transcription complexes for their ability to modulate type I interferon and inflammatory pathways in monocytes/macrophages. This research will be done using cultured macrophages as well as donor blood and blood from COVID-19 patients.

Mechanisms of Cytokine Storm in Patients with COVID-19

Principal Investigator: Mary K. Crow, MD

Co-Investigators: Mikhail Olferiev, MD, and Lionel B. Ivashkiv, MD

The objectives of this study are to describe the process of the cytokine storm in people with COVID-19 and to identify biologic predictors of a favorable outcome in patients with severe cases of the disease. The project aims to characterize immune cell populations seen in COVID-19 patients who experience cytokine storm and compare them to those patients who do not, to compare the immune response before and after patients are given the anti-inflammatory drug anakinra, and to identify measures that suggest patients are more likely to decline and eventually require mechanical ventilation. The research will employ blood samples from HSS patients who are being treated for COVID-19 at New York–Presbyterian Hospital and who meet certain other qualifications.

What follows are descriptions of the first group of funded projects in the areas of clinical and health outcomes research:

Response to and Recovery from TKA in Patients with Antibodies to SARS-CoV-2

Principal Investigator: Miguel Otero, PhD

Co-Investigators: Meghan Kirksey, MD, PhD, and Peter K. Sculco, MD

It is unknown if people who have been exposed to COVID-19 may be at higher risk of experiencing an abnormal immune response following surgery, resulting in poor outcomes. This study will evaluate the response to and recovery from total knee arthroplasty (TKA) in people who have antibodies to COVID-19 — a marker of exposure. This study will include both patients who have COVID-19 antibodies and those who don’t, to act as controls. Patients will be followed for six weeks after surgery and evaluated for the presence of certain immune markers in the blood, as well as symptoms of inflammation including pain and stiffness in the joint.

SARS-CoV-2 Exposure and the Role of Vitamin D Among Hospital Employees

Principal Investigator: Emily M. Stein, MD, MS

Co-Investigators: Theresa T. Lu, MD, PhD; Andy O. Miller, MD; Jeri Nieves, PhD; and Alana Serota, MD

It is unknown if people with vitamin D deficiency may be more likely to become infected with COVID-19. This study will investigate vitamin D status and associated immune markers as risk factors for COVID-19 infection in a cohort of healthcare workers. Healthcare workers are at higher risk of contracting COVID-19 than the general population, making them a good group to study. Vitamin D is critical for immune function and is known to be protective against respiratory-tract infection and tuberculosis. This prospective, observational study will follow healthcare workers at HSS and at other healthcare facilities for one year, to determine whether levels of vitamin D and certain immune cells in the blood make someone more susceptible to COVID-19 infection.

Association of Immunomodulatory Medication Use and Social Determinants of Health with COVID-19 Infection in Systemic Rheumatic Disease Patients in New York City

Principal Investigator: Medha Barbhaiya, MD, MPH

Co-Investigators from HSS: Lisa Mandl, MD, MPH; Catherine MacLean, MD, PhD; Vinicius Antao, MD, PhD; Jane Salmon, MD; and Mayu Sasaki, MPH

Other Co-Investigators: Candace Feldman, MD, MPH (of Brigham and Women’s Hospital); Debra D’Angelo, MS (of Weill Cornell Medicine)

Using data from the INSIGHT Clinical Research Network, a central repository containing longitudinal electronic health data for residents of New York City, investigators will assemble a cohort of patients being treated with immunomodulatory medications for rheumatic disease. This patient population will then be used to study the effect of these medications on COVID-19 incidence and outcomes. Retrospective data will be used to evaluate the incidence and severity of COVID-19 in these patients. Patients will also be studied prospectively to determine whether there’s a relationship between COVID-19 infection and future rheumatic disease as well as to study connections between infection and future psycho-social issues.

Assessment of Surgical Outcomes in the COVID-19 Pandemic Era

Principal Investigator: Andy O. Miller, MD

Co-Investigators: Scott A. Rodeo, MD, and Mark Fontana, PhD

Investigators will implement a patient registry to evaluate how COVID-19 affects outcomes and complication rates after orthopedic surgery. This registry, along with COVID-19 screening procedures, will provide the tools to address specific research questions. Among these questions are determining the incidence of current and prior infection among the HSS surgical population, the clinical features associated with current and prior infections in this patient population, and whether COVID-19 status affects short-term complication rates.

What follows is a description of an integrated multidisciplinary study being undertaken jointly by the Adult Reconstruction and Joint Replacement (ARJR) Perioperative Research Group, Anesthesiology and Rheumatology:

Prediction and Prevention of Postoperative Blood Clots in COVID-19 Patients

Principal Investigators: Friedrich Boettner, MD; Kethy M. Jules-Elysee, MD; Lisa A. Mandl, MD, MPH

Co-Investigators: ARJR surgeons: Alejandro Gonzalez Della Valle, MD; Jason Blevins, MD; David J. Mayman, MD; Peter K. Sculco, MD; Geoffrey H. Westrich, MD and Thomas P. Sculco, MD

Medicine/Rheumatology: Medha Barbhaiya, MD, MPH; Doruk Erkan, MD, MPH; Deanna Jannat-Khah, DrPH

Pathology: Thomas W. Bauer, MD, PhD

Anesthesiology: Stavros G. Memtsoudis, MD, PhD, MBA; Alexandra Sideris, PhD

ARJR: Amethia Joseph, MHA; Ethan Krell, MS

Weill Cornell Medicine: Raymond David Pastore, MD

Recent literature suggests that one of the major complications seen in people with COVID-19 is thrombosis (the formation of blood clots) due to endothelial dysfunction, persistent inflammation and potentially antiphospholipid antibodies. As elective surgeries resume, those with prior exposure to SARS-CoV-2 will inevitably present for treatment, and some may have perioperative management considerations related to their risk of deep-vein thrombosis. This project will use, a noninvasive device that can determine clotting risks, to investigate whether people who have had COVID-19 have a more dysfunctional endothelium preoperatively and at 24 hours after surgery. The investigators will measure antiphospholipid antibodies and inflammatory markers, and evaluate the prevalence of asymptomatic post-operative deep-vein thrombosis in people who undergo TKR and have SARS-CoV-2 antibodies.

COVID-19 Translational Research Core at HSS

Principal Investigator: Theresa Lu, MD, PhD

Co-Investigators: Jessica Andrés-Bergós, PhD; Miguel Otero, PhD and Emily M. Stein, MD, MS

The COVID-19 Translational Research Core (TRC) was designed to fill critical gaps in the resources needed to promote the broad range of COVID-19–related clinical and translational research at HSS. The TRC will provide consultation on the design and implementation of COVID-19 research in the areas of orthopedics, rheumatology and metabolic bone disease; support for a COVID-19 biobank; and technical expertise and facilities required for clinical and translational researchers working on COVID-19–related projects. The TRC staff will help to acquire, house, and track biospecimens from investigator-initiated COVID-19–related research studies.