trending research topics in surgery

Infections after surgery are more likely due to bacteria already on your skin than from microbes in the hospital − new research

Assistant Professor of Anesthesiology, School of Medicine, University of Washington

Associate Professor of Allergy and Infectious Diseases, School of Medicine, University of Washington

Disclosure statement

Dustin Long receives funding from the National Institutes of Health.

Dr Bryson-Cahn receives funding from the Gordon and Berry Moore Foundation and is the co-medical director for Alaska Airlines.

University of Washington provides funding as a member of The Conversation US.

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Health care providers and patients have traditionally thought that infections patients get while in the hospital are caused by superbugs they’re exposed to while they’re in a medical facility. Genetic data from the bacteria causing these infections – think CSI for E. coli – tells another story: Most health care-associated infections are caused by previously harmless bacteria that patients already had on their bodies before they even entered the hospital.

Research comparing bacteria in the microbiome – those colonizing our noses, skin and other areas of the body – with the bacteria that cause pneumonia , diarrhea , bloodstream infections and surgical site infections shows that the bacteria living innocuously on our own bodies when we’re healthy are most often responsible for these bad infections when we’re sick.

Our newly published research in Science Translational Medicine adds to the growing number of studies supporting this idea. We show that many surgical site infections after spinal surgery are caused by microbes that are already on the patient’s skin .

Surgical infections are a persistent problem

Among the different types of heath care-associated infections, surgical site infections stand out as particularly problematic. A 2013 study found that surgical site infections contribute the most to the annual costs of hospital-acquired infections, totaling over 33% of the US$9.8 billion spent annually. Surgical site infections are also a significant cause of hospital readmission and death after surgery.

In our work as clinicians at Harborview Medical Center at the University of Washington – yes, the one in Seattle that “Grey’s Anatomy” was supposedly based on – we’ve seen how hospitals go to extraordinary lengths to prevent these infections. These include sterilizing all surgical equipment, using ultraviolet light to clean the operating room, following strict protocols for surgical attire and monitoring airflow within the operating room.

Still, surgical site infections occur following about 1 in 30 procedures , typically with no explanation. While rates of many other medical complications have shown steady improvement over time, data from the Agency for Healthcare Research and Quality and the Centers for Disease Control and Prevention show that the problem of surgical site infection is not getting better.

In fact, because administering antibiotics during surgery is a cornerstone of infection prevention, the global rise of antibiotic resistance is forecast to increase infection rates following surgery.

BYOB (Bring your own bacteria)

As a team of physician-scientists with expertise including critical care , infectious diseases , laboratory medicine , microbiology , pharmacy , orthopedics and neurosurgery , we wanted to better understand how and why surgical infections were occurring in our patients despite following recommended protocols to prevent them.

Prior studies on surgical site infection have been limited to a single species of bacteria and used older genetic analysis methods. But new technologies have opened the door to studying all types of bacteria and testing their antibiotic resistance genes simultaneously.

We focused on infections in spinal surgery for a few reasons. First, similar numbers of women and men undergo spine surgery for various reasons across their life spans, meaning our results would be applicable to a larger group of people. Second, more health care resources are expended on spinal surgery than any other type of surgical procedure in the U.S. Third, infection following spine surgery can be particularly devastating for patients because it often requires repeat surgeries and long courses of antibiotics for a chance at a cure.

Over a one-year period, we sampled the bacteria living in the nose, skin and stool of over 200 patients before surgery. We then followed this group for 90 days to compare those samples with any infections that later occurred.

Our results revealed that while the species of bacteria living on the back skin of patients vary remarkably between people, there are some clear patterns . Bacteria colonizing the upper back around the neck and shoulders are more similar to those in the nose; those normally present on the lower back are more similar to those in the gut and stool. The relative frequency of their presence in these skin regions closely mirrors how often they show up in infections after surgery on those same specific regions of the spine.

In fact, 86% of the bacteria causing infections after spine surgery were genetically matched to bacteria a patient carried before surgery. That number is remarkably close to estimates from earlier studies using older genetic techniques focused on Staphylococcus aureus .

Nearly 60% of infections were also resistant to the preventive antibiotic administered during surgery, the antiseptic used to clean the skin before incision or both. It turns out the source of this antibiotic resistance was also not acquired in the hospital but from microbes the patient had already been living with unknowingly. They likely acquired these antibiotic-resistant microbes through prior antibiotic exposure, consumer products or routine community contact.

Preventing surgical infections

At face value, our results may seem intuitive – surgical wound infections come from bacteria that hang out around that part of the body. But this realization has some potentially powerful implications for prevention and care.

If the most likely source of surgical infection – the patient’s microbiome – is known in advance, this presents medical teams with an opportunity to protect against it prior to a scheduled procedure. Current protocols for infection prevention, such as antibiotics or topical antiseptics, follow a one-size-fits-all model – for example, the antibiotic cefazolin is used for any patient undergoing most procedures – but personalization could make them more effective.

If you were having a major surgery today, no one would know whether the site where your incision will be made was colonized with bacteria resistant to the standard antibiotic regimen for that procedure. In the future, clinicians could use information about your microbiome to select more targeted antimicrobials. But more research is needed on how to interpret that information and understand whether such an approach would ultimately lead to better outcomes.

Today, practice guidelines , commercial product development , hospital protocols and accreditation related to infection prevention are often focused on sterility of the physical environment. The fact that most infections don’t actually start with sources in the hospital is probably a testament to the efficacy of these protocols. But we believe that shifting toward more patient-centered, individualized approaches to infection prevention has the potential to benefit hospitals and patients alike.

• Infectious diseases
• Microbiology
• Antibiotic resistance
• Hospital infections
• New research
• Skin microbiome
• Multidrug-resistant microbes
• STEEHM new research

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GRAINS RESEARCH AND DEVELOPMENT CORPORATION CHAIRPERSON

Current trends in thoracic surgery

Affiliation.

• 1 Department of Thoracic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
• PMID: 32581397
• PMCID: PMC7276403
• DOI: 10.18999/nagjms.82.2.161

Thoracic surgery has evolved drastically in recent years. Although thoracic surgeons mainly deal with tumorous lesion in the lungs, mediastinum, and pleura, they also perform lung transplantation surgery in patients with end-stage lung disease. Herein, we introduce various major current topics in thoracic surgery. Minimally invasive surgical procedures include robot-assisted thoracic surgery and uniportal video-assisted thoracic surgery. Novel techniques for sublobar resection include virtual-assisted lung mapping, image-guided video-assisted thoracic surgery, and segmentectomy using indocyanine green. Three-dimensional (3D) computed tomography (CT) simulation consists of surgeon-friendly 3D-CT image analysis systems and new-generation, dynamic 3D-CT imaging systems. Updates in cadaveric lung transplantation include use of marginal donors, including donation after circulatory death, and ex vivo lung perfusion for such donors. Topics in living donor lobar lung transplantation include size matching, donor issues, and new surgical techniques. During routine clinical practice, thoracic surgeons encounter various pivotal topics related to thoracic surgery, which are described in this report.

Keywords: lung transplantation; robotic surgery; three-dimensional computed tomography; uniportal surgery; video-assisted thoracic surgery.

Publication types

• Imaging, Three-Dimensional
• Living Donors*
• Lung Neoplasms / surgery*
• Lung Transplantation*
• Mediastinal Neoplasms / surgery*
• Organ Preservation
• Pleural Neoplasms / surgery*
• Pneumonectomy*
• Robotic Surgical Procedures*
• Surgery, Computer-Assisted
• Thoracic Surgery, Video-Assisted*
• Thoracic Surgical Procedures / trends*
• Tissue and Organ Procurement / trends
• Tomography, X-Ray Computed

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The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.

PRENATAL OBSTETRICS

Congenital anomaly risk with methadone or buprenorphine exposure (April 2024)

Data regarding the teratogenic risk of medications for opioid use disorder (MOUD) are limited. In a population-based study comparing over 9500 pregnancies exposed to buprenorphine in the first trimester with nearly 3900 methadone-exposed pregnancies, buprenorphine use was associated with a lower overall risk of congenital anomalies (5 versus 6 percent) [ 1 ]. Although the analysis adjusted for multiple potential confounding factors, unmeasured confounders may explain some of the observed associations. We base the choice of buprenorphine versus methadone for MOUD on other factors ( table 1 ). (See "Opioid use disorder: Pharmacotherapy with methadone and buprenorphine during pregnancy", section on 'Risk of structural anomalies' .)

Maternal sepsis risk with membrane rupture before 23 weeks of gestation (April 2024)

Chorioamnionitis can be a cause or a consequence of preterm prelabor rupture of membranes (PPROM), especially before 24 weeks of gestation. Development of maternal sepsis is a major concern in these pregnancies. In a prospective study of 364 patients with PPROM between 16 weeks 0 days and 22 weeks 6 days, maternal sepsis developed in 10 percent of patients with singleton pregnancies who chose to undergo pregnancy termination soon after diagnosis of PPROM and in 13 percent of those who initially chose to continue the pregnancy [ 2 ]. Two patients died. These findings underscore the importance of close maternal monitoring, early diagnosis of chorioamnionitis, timely fetal extraction, and appropriate antibiotic treatment in patients with PPROM. (See "Prelabor rupture of membranes before and at the limit of viability", section on 'Maternal sepsis and death' .)

Perinatal depression and mortality (March 2024)

Perinatal depression is associated with an increased risk of death. An analysis of a national register from Sweden compared outcomes among individuals with and without a diagnosis of depression during pregnancy or postpartum, matched by age and year of delivery [ 3 ]. After controlling for potential confounding factors, all-cause mortality was greater in those with perinatal depression over 18 years of follow-up; the increased risk was largely driven by suicide. These results confirm previous data on the risks of perinatal depression and support our practice of screening for depression during pregnancy and postpartum. Services to ensure follow-up for diagnosis and treatment should accompany screening efforts. (See "Unipolar major depression during pregnancy: Epidemiology, clinical features, assessment, and diagnosis", section on 'All cause' .)

Noninsulin antidiabetic medications and pregnancy (February 2024)

Noninsulin antidiabetic medications such as glucagon-like peptide 1 (GLP-1) agonists, sodium-glucose cotransporter 2 (SGLT-2) inhibitors, and dipeptidyl peptidase 4 (DPP-4) inhibitors are commonly used in nonpregnant individuals but avoided in pregnancy because of lack of safety data in humans and harms observed in animal studies. However, in a multinational population-based cohort study including nearly 2000 individuals with preconception/first trimester exposure to these medications, the frequency of congenital anomalies was not increased compared with insulin [ 4 ]. A limitation of the study is that it did not adjust for potential differences in A1C, diabetes severity, or diabetes duration, which could obscure true effects on risk for congenital anomalies. We continue to avoid use of GLP-1 agonists, SGLT-2 inhibitors, and DPP-4 inhibitors in females planning to conceive and in pregnancy. (See "Pregestational (preexisting) diabetes: Preconception counseling, evaluation, and management", section on 'Patients on preconception noninsulin antihyperglycemic agents' .)

Updates to the United States perinatal HIV clinical guidelines (February 2024)

The United States Department of Health and Human Services has released updates to the perinatal HIV clinical guidelines [ 5 ]. Ritonavir-boosted darunavir is now a preferred agent only for treatment-naïve pregnant individuals who have used cabotegravir-based pre-exposure prophylaxis, because of the concern for integrase inhibitor-resistant mutations; for other pregnant individuals, it is now an alternative rather than preferred agent. Additionally, bictegravir, which was previously not recommended for initial therapy in pregnant individuals, is now an alternative agent based on new pharmacokinetic data that support its use during pregnancy. Our approach to treating HIV during pregnancy is consistent with these updated guidelines. (See "Antiretroviral selection and management in pregnant individuals with HIV in resource-rich settings", section on 'Selecting the third drug' .)

Combined use of metformin and insulin for treating diabetes in pregnancy (February 2024)

In patients with type 2 diabetes, insulin is the mainstay for managing hyperglycemia in pregnancy. The addition of metformin improves maternal glucose control and reduces the chances of a large for gestational age newborn, but a prior randomized trial reported an increased risk for birth of a small for gestational age (SGA) infant. A recent randomized trial comparing use of insulin alone with insulin plus metformin in nearly 800 adult pregnant patients with either preexisting type 2 diabetes or diabetes diagnosed in early pregnancy confirmed the previously reported benefits but found that both treatment groups had low and similar rates of SGA [ 6 ]. The discordancy in SGA risk needs to be explored further, as metformin cotreatment would be undesirable if this risk is real. (See "Pregestational (preexisting) diabetes mellitus: Antenatal glycemic control", section on 'Metformin' .)

Fetoplacental GDF15 linked to nausea and vomiting of pregnancy (February 2024)

Almost all pregnant people experience nausea with or without vomiting in early pregnancy; however, the pathogenesis of the disorder has been unclear. Previous studies have shown that GDF15 is expressed in a wide variety of cells, with the highest expression in placental trophoblast, and that its protein (GDF15) appears to regulate appetite. A recent study confirmed the fetoplacental unit as a major source of GDF15 and also found that higher GDF15 levels correlated with more severe nausea and vomiting of pregnancy [ 7 ]. In the future, drugs targeting the production or action of GDF15 are a potential novel pathway for treating nausea and vomiting of pregnancy, if safety and efficacy are established. (See "Nausea and vomiting of pregnancy: Clinical findings and evaluation", section on 'Pathogenesis' .)

Use of cerebroplacental ratio at term does not reduce perinatal mortality (February 2024)

Cerebral blood flow may increase in chronically hypoxemic fetuses to compensate for the decrease in available oxygen and can be assessed by the cerebroplacental ratio (CPR; middle cerebral artery pulsatility index divided by the umbilical artery pulsatility index). However, increasing evidence indicates that use of the CPR does not reduce perinatal mortality in low-risk pregnancies. In a randomized trial comparing fetal growth assessment plus revealed versus concealed CPR in over 11,000 low-risk pregnancies at term, knowledge of CPR combined with a recommendation for delivery if the CPR was <5th percentile did not reduce perinatal mortality compared with usual care (concealed group) [ 8 ]. We do not perform umbilical artery Doppler surveillance, including the CPR, in low-risk pregnancies. (See "Doppler ultrasound of the umbilical artery for fetal surveillance in singleton pregnancies", section on 'Low-risk and unselected pregnancies' .)

Low- versus high-dose calcium supplements and risk of preeclampsia (January 2024)

In populations with low baseline dietary calcium intake, the World Health Organization recommends 1500 to 2000 mg/day calcium supplementation for pregnant individuals to reduce their risk of developing preeclampsia. However, a recent randomized trial that evaluated low (500 mg) versus high (1500 mg) calcium supplementation in over 20,000 nulliparous pregnant people residing in two countries with low dietary calcium intake found low and similar rates of preeclampsia in both groups [ 9 ]. These findings suggest that a 500 mg supplement is sufficient for preeclampsia prophylaxis in these populations. For pregnant adults in the United States, we prescribe 1000 mg/day calcium supplementation, which is the recommended daily allowance to support maternal calcium demands without bone resorption. (See "Preeclampsia: Prevention", section on 'Calcium supplementation' .)

Respectful maternity care (January 2024)

Respectful maternity care is variably defined but broadly involves both absence of disrespectful conduct and promotion of respectful conduct toward pregnant individuals. A systematic review found that validated tools to measure respectful maternity care were available, but the optimal tool was unclear and high quality studies were lacking on the effectiveness of respectful maternity care for improving any maternal or infant health outcome [ 10 ]. Respectful maternal care is a basic human right, but how to best implement and monitor it and assess outcomes requires further study. (See "Prenatal care: Initial assessment", section on 'Effectiveness' .)

Outcome of a multifaceted intervention in patients with a prior cesarean birth (January 2024)

Patients with a pregnancy after a previous cesarean birth must choose between a trial of labor (TOLAC) and a planned repeat cesarean. The optimal care of such patients is unclear. In a multicenter, cluster-randomized trial including over 20,000 patients with one prior cesarean birth, a multifaceted intervention (patient decision support, use of a calculator to assess chances of a vaginal birth after cesarean [VBAC], sonographic measurement of myometrial thickness, clinician training in best intrapartum practices during TOLAC) reduced perinatal and major maternal morbidity composite outcomes compared with usual care [ 11 ]. VBAC and uterine rupture rates were similar for both groups. Further study is needed to identify the most useful component(s) of the intervention for reducing morbidity. (See "Choosing the route of delivery after cesarean birth", section on 'Person-centered decision-making model' .)

Serial amnioinfusions for bilateral renal agenesis (January 2024)

Bilateral renal agenesis (BRA) is incompatible with extrauterine life because prolonged oligohydramnios results in pulmonary hypoplasia, leading to postnatal respiratory failure. A prospective study (RAFT) assessed use of serial amnioinfusions to treat 18 cases of BRA diagnosed at <26 weeks of gestation [ 12 ]. Of the 17 live births, 14 survived ≥14 days and had placement of dialysis access, but only 6 survived to hospital discharge. Of the 4 children alive at 9 to 24 months of age, 3 had experienced a stroke and none had undergone transplant. These findings show that serial amnioinfusions for BRA mitigates pulmonary hypoplasia and increases short-term survival and access to dialysis; however, long-term outcome remains poor with no survival to transplantation. Serial amnioinfusions remain investigational and should be offered only as institutional review board-approved research. (See "Renal agenesis: Prenatal diagnosis", section on 'Investigative role of therapeutic amnioinfusion' .)

Prenatal genetic testing for monogenic diabetes due to glucokinase deficiency (December 2023)

In pregnant individuals with monogenic diabetes due to glucokinase (GCK) deficiency, management depends on the fetal genotype. If the fetus inherits the maternal GCK variant, maternal hyperglycemia will not cause fetal hyperinsulinemia and excessive growth, and maternal hyperglycemia does not require treatment. However, if the fetus does not inherit the pathogenic variant, maternal insulin therapy is indicated to prevent excessive fetal growth. Fetal ultrasound has been used to predict fetal genotype but has limited diagnostic utility. In a cohort of 38 pregnant individuals with GCK deficiency, fetal genetic testing using cell-free DNA in maternal blood had higher sensitivity (100 versus 53 percent) and specificity (96 versus 61 percent) for prenatal diagnosis of GCK deficiency compared with ultrasound measurement of fetal abdominal circumference [ 13 ]. When available, noninvasive prenatal genotyping should be used to guide management of GCK deficiency during pregnancy. (See "Classification of diabetes mellitus and genetic diabetic syndromes", section on 'Glucokinase' .)

Early metformin treatment of gestational diabetes mellitus (November 2023)

Usual initial gestational diabetes mellitus (GDM) care (ie, medical nutritional therapy, exercise) may result in a few weeks of hyperglycemia before a need for pharmacotherapy is established. In a randomized trial evaluating whether initiating metformin at the time of GDM diagnosis regardless of glycemic control improves clinical outcomes compared with usual care, the metformin group had a lower rate of insulin initiation and favorable trends in mean fasting glucose, gestational weight gain, and excessive fetal growth, but more births <2500 grams [ 14 ]. Rates of preeclampsia, neonatal intensive care unit admission, and neonatal hypoglycemia were similar for both groups. Given these mixed results, we recommend not initiating metformin at the time of GDM diagnosis except in a research setting. (See "Gestational diabetes mellitus: Glucose management and maternal prognosis", section on 'Does early metformin initiation improve glycemic control and reduce need for insulin?' .)

Automated insulin delivery in pregnant patients with type 1 diabetes (October 2023)

Hybrid closed-loop insulin therapy is associated with improved glucose control in nonpregnant adults and in children, but little information is available in pregnant people. In the first randomized trial in this population, hybrid closed-loop insulin delivery beginning at 11 weeks gestation improved glycemic control compared with standard insulin therapy in 124 patients with type 1 diabetes, without increasing their risk of severe hypoglycemia [ 15 ]. The system allowed customization of glycemic targets appropriate to pregnancy, in contrast to other commercially available systems in the United States. Additional study is needed to confirm these findings, evaluate the effects on obstetric and neonatal outcomes, and identify optimal candidates. (See "Pregestational (preexisting) diabetes mellitus: Antenatal glycemic control", section on 'Continuous subcutaneous insulin infusion (insulin pump)' .)

Respiratory syncytial virus vaccination in pregnancy (April 2023, Modified October 2023)

Respiratory syncytial virus (RSV) is a major cause of morbidity and mortality in infants. In October 2023, the United States Centers for Disease Control and Prevention, along with guidelines from other expert groups, endorsed RSV vaccination of pregnant individuals to reduce severe RSV infections in their infants [ 16-19 ]. Nirsevimab , a monoclonal antibody that can be given to infants postnatally to reduce the risk of severe RSV, has also been recently approved and endorsed by expert guidance panels. In settings where nirsevimab is not available, we suggest vaccination of pregnant individuals between 32 0/6 and 36 6/7 weeks of gestation in September through January (in the northern hemisphere) with inactivated nonadjuvanted recombinant RSV vaccine (RSVPreF; Abrysvo). In settings where both maternal vaccination and nirsevimab are available, the optimal preventive strategy remains uncertain, and, in most cases, it will not be possible to use both. For such patients, both options should be discussed and shared decision-making undertaken. (See "Immunizations during pregnancy", section on 'Choosing the optimal strategy' .)

INTRAPARTUM AND POSTPARTUM OBSTETRICS

Updates on congenital fibrinogen disorders (April 2024)

Congenital fibrinogen disorders are rare and remain underdiagnosed. New publications address the clinical manifestations of these disorders and provide obstetric guidance:

● A new report from the Rare Bleeding Disorders database described 123 patients with afibrinogenemia, hypofibrinogenemia, and dysfibrinogenemia and characterized bleeding and thrombotic manifestations [ 20 ]. (See "Disorders of fibrinogen", section on 'Clinical manifestations' .)

● New guidelines from the International Society on Thrombosis and Hemostasis (ISTH) provide target fibrinogen levels and advice for managing postpartum bleeding and thromboprophylaxis in individuals with congenital fibrin disorders [ 21 ]. (See "Disorders of fibrinogen", section on 'Conception and pregnancy' .)

A high index of suspicion for these disorders and multidisciplinary management are required.

Intrauterine postpartum hemorrhage control devices for managing postpartum hemorrhage (February 2024)

Intrauterine balloon tamponade and vacuum-induced uterine compression are the most common devices used for intrauterine postpartum hemorrhage (PPH) control in patients with atony, but it is unclear which device is superior as few comparative studies have been performed. In a retrospective study including nearly 380 patients with PPH, quantitative blood loss after placement, rate of blood transfusion, and discharge hematocrit were similar for both devices [ 22 ]. Based on these and other data, in the setting of ongoing uterine bleeding, rapid use of one of these devices is likely to be more important than the choice of device when both devices are available. (See "Postpartum hemorrhage: Use of an intrauterine hemorrhage-control device", section on 'Choice of method' .)

Labor epidural analgesia and risk of emergency delivery (December 2023)

It is well established that contemporary neuraxial labor analgesia does not increase the overall risk of cesarean or instrument-assisted vaginal delivery. However, a new retrospective database study of over 600,000 deliveries in the Netherlands reported that epidural labor analgesia was associated with an increased risk of emergency delivery (cesarean or instrument-assisted vaginal) compared with alternative analgesia (13 versus 7 percent) [ 23 ]. Because of potential confounders and lack of detail on epidural and obstetric management, we consider these data insufficient to avoid neuraxial analgesia or change the practice of early labor epidural placement to reduce the potential need for general anesthesia in patients at high risk for cesarean delivery. (See "Adverse effects of neuraxial analgesia and anesthesia for obstetrics", section on 'Effects on the progress and outcome of labor' .)

Delayed cord clamping in preterm births (December 2023)

Increasing evidence supports delaying cord clamping in preterm births. In an individual participant data meta-analysis of randomized trials of delayed versus immediate cord clamping at births <37 weeks (over 3200 infants), delaying cord clamping for >30 seconds reduced infant death before discharge (6 versus 8 percent) [ 24 ]. In a companion network meta-analysis evaluating the optimal duration of delay, a long delay (≥120 seconds) significantly reduced death before discharge compared with immediate clamping; reductions also occurred with delays of 15 to <120 seconds but were not statistically significant [ 25 ]. For preterm births that do not require resuscitation, we recommend delayed rather than immediate cord clamping. We delay cord clamping for at least 30 to 60 seconds as approximately 75 percent of blood available for placenta-to-fetus transfusion is transfused in the first minute after birth. (See "Labor and delivery: Management of the normal third stage after vaginal birth", section on 'Preterm infants' .)

Vacuum-induced intrauterine tamponade for postpartum hemorrhage (November 2023)

Intrauterine tamponade (with a balloon, packing, or vacuum) may be used to manage patients with postpartum hemorrhage (PPH) resulting from uterine atony that is not controlled by uterotonic medications and uterine massage. However, outcome data regarding vacuum-induced tamponade are limited. A study of data from a postmarketing registry of over 500 patients with PPH and isolated atony treated with vacuum-induced tamponade reported that the device controlled bleeding without treatment escalation or bleeding recurrence in 88 percent following cesarean birth and 96 percent following vaginal birth, typically within five minutes [ 26 ]. These data are consistent with previously published outcomes. Given its efficacy and ease of use, vacuum-induced tamponade is an important option for managing PPH in centers where this device is available. (See "Postpartum hemorrhage: Use of an intrauterine hemorrhage-control device", section on 'Vacuum-induced tamponade' .)

Risk of pregnancy-associated venous and arterial thrombosis in sickle cell disease (November 2023)

Sickle cell disease (SCD) and pregnancy both confer an increased risk of venous thromboembolism (VTE), but the magnitude of the risk is unclear. In a new administrative claims data study involving >6000 people with SCD and >17,000 age- and race-matched controls who were followed for one year postpartum, the risk of VTE was 11.3 percent in the patients with SCD, versus 1.2 percent in controls [ 27 ]. Arterial thromboembolism was also increased (5.2 percent, versus 0.6 percent in controls). This study emphasizes the value of postpartum VTE prophylaxis in people with SCD and the need for vigilance in evaluating suggestive symptoms. (See "Sickle cell disease: Obstetric considerations", section on 'Maternal risks' .)

Racial disparities in anemia during pregnancy (October 2023)

A new study has found that racial disparities in anemia during pregnancy persist and may be increasing. This analysis involved nearly four million births in the state of California from 2011 to 2020 [ 28 ]. Antepartum anemia was most common in Black individuals (22 percent), followed by Pacific Islanders (18 percent), Native American and Alaska Native peoples (14 percent), multiracial individuals (14 percent), Hispanic individuals (13 percent), Asian individuals (11 percent), and White individuals (10 percent). Antepartum anemia is associated with an increase in severe maternal morbidity. The reasons for disparities are multifactorial. (See "Anemia in pregnancy", section on 'Racial disparities' .)

Intrapartum magnesium sulfate before preterm birth and cerebral palsy (October 2023)

Magnesium sulfate is typically administered to pregnant women with impending preterm birth <32 weeks of gestation to decrease the incidence and severity of cerebral palsy in offspring. However, the recent MAGENTA trial comparing the effects of magnesium sulfate versus placebo administered before impending preterm birth between 30 and 34 weeks of gestation found that it did not prevent cerebral palsy among surviving infants [ 29 ]. These findings do not change our current practice because the trial used a single 4 g bolus of magnesium sulfate alone, whereas we also provide an ongoing 1 g/hour infusion until delivery and do not use the medication after 32 weeks; the trial was likely underpowered to find a significant difference. (See "Neuroprotective effects of in utero exposure to magnesium sulfate", section on 'Lower and upper gestational age' .)

OFFICE GYNECOLOGY

Infertility and autism spectrum disorder (December 2023)

Patients with infertility often ask about the impact of the disorder and its treatment on risk of autism spectrum disorder (ASD) in offspring. In a large population-based cohort study comparing ASD risk among children whose parents had subfertility (an infertility consultation without treatment), infertility treatment, or neither (unassisted conception), children in the subfertility and infertility treatment groups had a small increased risk of ASD compared with unassisted conception but the absolute risk was low (2.5 to 2.7 per 1000 person-years versus 1.9 per 1000 person-years with unassisted conception) [ 30 ]. The increased risk was similar in the subfertile and infertility treatment groups, suggesting that infertility treatment was not a major risk factor. Obstetrical and neonatal factors (eg, preterm birth) appeared to mediate a sizeable proportion of the increased risk for ASD. (See "Assisted reproductive technology: Infant and child outcomes", section on 'Confounders' .)

Macular changes related to pentosan polysulfate sodium (November 2023)

Macular eye disease has been reported in patients who have taken pentosan polysulfate sodium (PPS), which is used for the treatment of interstitial cystitis. In a prospective cohort study of 26 eyes with PPS maculopathy and >3000 g cumulative PPS exposure, progression of macular changes continued 13 to 30 months after drug cessation [ 31 ]. Median visual acuity decreased slightly; most patients reported progression of symptoms, including difficulty in low-light environments and blurry vision. These results indicate that PPS maculopathy progresses despite drug discontinuation, underscoring the importance of regular screening for maculopathy in patients with current or prior PPS exposure. (See "Interstitial cystitis/bladder pain syndrome: Management", section on 'Pentosan polysulfate sodium as alternative' .)

Vaginal laser therapy not effective for genitourinary syndrome of menopause (November 2023)

Laser devices, including the fractional microablative CO 2 laser, have been marketed for treatment of patients with genitourinary syndrome of menopause (GSM), but data regarding their safety and efficacy are limited. In a randomized trial including nearly 50 postmenopausal patients with GSM, treatment with CO 2 laser did not improve symptom severity compared with sham therapy [ 32 ]. Change in vaginal histology, which is a common surrogate determinant of treatment success, was similar in both groups at six months postprocedure. In addition, histologic features associated with a hypoestrogenic state correlated poorly with the severity of vaginal symptoms. Although the trial had limitations, these findings are consistent with other data and support our practice of not using laser treatment for patients with GSM. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment", section on 'Laser or radiofrequency devices' .)

Use of vaginal estrogen in breast cancer patients taking aromatase inhibitors (October 2023)

Use of vaginal estrogen to manage symptoms of genitourinary syndrome of menopause (GSM) may be harmful in patients with breast cancer on aromatase inhibitors (AIs). In a subgroup analysis of a claims-based analysis, vaginal estrogen therapy was associated with a higher rate of breast cancer recurrence in patients taking versus not taking an AI [ 33 ]. Time to recurrence in the AI group was approximately 140 days. While this study had many limitations, these data support our general practice of avoiding vaginal estrogen for the management of GSM in most patients with breast cancer taking AIs. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment", section on 'Patients with breast cancer' .)

GYNECOLOGIC SURGERY

Risk of unplanned hysterectomy at time of myomectomy (February 2024)

Myomectomy is an option for patients with bothersome fibroid symptoms (eg, bleeding, bulk); however, data are limited regarding the risk of unplanned hysterectomy at the time of myomectomy. In a retrospective study of the American College of Surgeons' National Surgical Quality Improvement Program database from 2010 to 2021 including over 13,000 patients undergoing myomectomy, the risk of unplanned hysterectomy was higher in those undergoing laparoscopic myomectomy compared with an open abdominal or hysteroscopic approach (7.1, 3.2, and 1.9 percent respectively) [ 34 ]. While much lower risks have been reported (<0.4 percent), and expert surgeons at high-volume centers may have fewer conversions to hysterectomy, this study highlights the importance of discussing the risk of unplanned hysterectomy during the informed consent process. (See "Uterine fibroids (leiomyomas): Laparoscopic myomectomy and other laparoscopic treatments", section on 'Unplanned hysterectomy' and "Uterine fibroids (leiomyomas): Open abdominal myomectomy procedure", section on 'Unplanned hysterectomy' and "Uterine fibroids (leiomyomas): Hysteroscopic myomectomy", section on 'Unplanned hysterectomy' .)

Risk of subsequent hysterectomy after endometrial ablation (January 2024)

Endometrial ablation is an alternative to hysterectomy in selected premenopausal patients with heavy menstrual bleeding. Most ablations are performed using a non-resectoscopic technique; however, the long-term efficacy of this approach is unclear. In a meta-analysis of 53 studies including over 48,000 patients managed with non-resectoscopic endometrial ablation (NREA), the rates of subsequent hysterectomy were 4 percent at 12 months, 8 to 12 percent at 18 to 60 months, and 21 percent at 120 months [ 35 ]. Hysterectomy rates were similar for the different NREA devices (eg, thermal balloon, microwave, radiofrequency). These findings are useful for counseling patients about the long-term risk for hysterectomy after NREA. (See "Endometrial ablation: Non-resectoscopic techniques", section on 'Efficacy' .)

Pregnancy and childbirth after urinary incontinence surgery (January 2024)

Patients with stress urinary incontinence (SUI) have historically been advised to delay midurethral sling (MUS) surgery until after childbearing because of concerns for worsening SUI symptoms following delivery. In a meta-analysis of patients with MUS surgery who were followed for a mean of nearly 10 years, similar low SUI recurrence and reoperation rates were reported for the 381 patients with and the 860 patients without subsequent childbirth [ 36 ]. Birth route did not affect the findings. Although the total number of recurrences and reoperations was small, this study adds to the body of evidence suggesting that subsequent childbirth does not worsen SUI outcomes for patients who have undergone MUS. (See "Surgical management of stress urinary incontinence in females: Retropubic midurethral slings", section on 'Subsequent pregnancy' .)

GYNECOLOGIC ONCOLOGY

Types of hysterectomy in patients with stage IB1 cervical cancer (March 2024)

Patients with stage IB1 cervical cancer (ie, >5 mm depth of stromal invasion and ≤2 cm in greatest dimension) are typically treated with radical hysterectomy; however, less extensive surgery is being evaluated. In a randomized trial including over 640 patients with stage IB1 cervical cancer, radical hysterectomy and simple hysterectomy plus lymph node assessment resulted in similar rates of recurrence at three years (2.2 and 2.5 percent, respectively) [ 37 ]. Although the study has limitations, including a short follow-up period, simple hysterectomy with lymph node assessment may be an acceptable alternative to radical hysterectomy in patients with IB1 cervical cancer. (See "Management of early-stage cervical cancer", section on 'Type of surgery' .)

Increasing incidence of cervical and uterine corpus cancer in the United States (February 2024)

In January 2024, the American Cancer Society published their annual report of cancer statistics in the United States [ 38 ]. Notable trends in regard to gynecologic cancers include a 1.7 percent increase in the annual incidence of cervical cancer from 2012 to 2019 in individuals aged 30 to 44 years, after decades of decline. Cancer of the uterine corpus (all ages) continued to increase by approximately 1 percent annually and was the only cancer in the report in which survival decreased. These and other data emphasize the continued importance of both early detection and prevention (eg, for cervical cancer: human papillomavirus vaccination and screening for precursor lesions; for endometrial cancer: achieving and maintaining a normal body mass index). (See "Invasive cervical cancer: Epidemiology, risk factors, clinical manifestations, and diagnosis", section on 'Incidence and mortality' and "Endometrial carcinoma: Epidemiology, risk factors, and prevention", section on 'Epidemiology' and "Endometrial carcinoma: Clinical features, diagnosis, prognosis, and screening", section on 'Prognosis' .)

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Research Hotspots and Trends of the Latest Advancements in the Field of Aesthetic Surgery: a Bibliometric Analysis Based on Four Authoritative Journals

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• Published: 25 October 2022
• Volume 85 , pages 834–842, ( 2023 )

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• MingMing Liu 1 , 2   na1 ,
• Rong Guo 3   na1 ,
• Lingling Jia 3 ,
• Yazhou Yan 4 &
• Jiachao Xiong   ORCID: orcid.org/0000-0003-3002-1171 3  

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With the continuous development of aesthetic surgery, a large number of excellent publications have been reported on aesthetic surgery. However, no relevant studies have reported the latest advancements and hot trends in aesthetic surgery in recent years. In this study, we extracted relevant publications from four authoritative aesthetic surgery journals ( Plastic and Reconstructive Surgery , Aesthetic Surgery Journal , Aesthetic Plastic Surgery , and Journal of Cosmetic Dermatology ) and used bibliometrics to comprehensively analyze current hot trends. We found a significant increase in the number of quality studies in aesthetic surgery, and the USA was the leading country in the field of aesthetic surgery, as evidenced by the fact that it ranks first worldwide for the total number of publications and citations. Currently, the prevention and treatment of complications related to aesthetic surgery remain research hotspots. Meanwhile, androgenetic alopecia, hyperplastic scarring, and stem cell research are hot directions for future research, and more research is required for exploration.

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An Analysis of the “Classic” Papers in Aesthetic Surgery

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Data Availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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This work was supported by the East Hospital Affiliated to Tongji University that introduced talent research startup fund (grant numbers DFRC2019008) and the featured clinical discipline project of Shanghai Pudong (grant number WYts2021-07).

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MingMing Liu, Rong Guo, and Lingling Jia contributed equally to this work.

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Qiangdao University, Qingdao, China

MingMing Liu

Department of Hand Surgery, 971 Hospital of PLA, Qingdao, China

Department of Plastic Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China

Rong Guo, Lingling Jia & Jiachao Xiong

Department of Neurosurgery, 971 Hospital of PLA, Qingdao, China

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Jiachao Xiong and Yazhou Yan designed the study; MingMing Liu, Lingling Jia, and Rong Guo performed and drafted the experiment; MingMing Liu revised manuscript, and all authors approved the final version of the manuscript.

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Liu, M., Guo, R., Jia, L. et al. Research Hotspots and Trends of the Latest Advancements in the Field of Aesthetic Surgery: a Bibliometric Analysis Based on Four Authoritative Journals. Indian J Surg 85 , 834–842 (2023). https://doi.org/10.1007/s12262-022-03592-0

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100+ Medical Surgical Nursing Project Topics [Updated]

Medical surgical nursing is a crucial aspect of healthcare that focuses on providing care to patients before, during, and after surgical procedures. Medical surgical nursing includes many tasks, like checking patients before surgery and taking care of them afterward. Research is really important in making medical surgical nursing better by finding new information and helping patients get better. In this blog, we’ll delve into various medical surgical nursing project topics that can inspire both students and professionals alike.

What Is The Basic Concept Of Medical Surgical Nursing?

Table of Contents

The basic concept of medical surgical nursing revolves around providing comprehensive care to patients undergoing surgical procedures or experiencing medical conditions requiring surgical intervention.

This includes preoperative preparation, intraoperative support, and postoperative recovery, as well as the management of medical conditions that may necessitate surgery.

Medical surgical nurses focus on promoting patient well-being, preventing complications, and facilitating optimal outcomes throughout the surgical process.

100+ Medical Surgical Nursing Project Topics: Category Wise

Clinical practice topics.

• Nursing Care for Patients with Chronic Obstructive Pulmonary Disease (COPD)
• Management of Patients with Diabetes Mellitus undergoing Surgery
• Postoperative Pain Management Strategies
• Nursing Interventions for Patients with Gastrointestinal Bleeding
• Care of Patients with Acute Kidney Injury (AKI) in the Surgical Setting
• Assessment and Management of Perioperative Hypertension
• Preparing Patients for Orthopedic Surgery: Education and Rehabilitation
• Surgical Site Infection Prevention Measures
• Nursing Care for Patients with Sepsis following Surgery
• Role of the Nurse in Preoperative Assessment and Optimization

Surgical Intervention Topics

• Care of Patients undergoing Total Joint Replacement Surgery
• Nursing Management of Patients with Traumatic Injuries
• Postoperative Complications in Abdominal Surgery: Recognition and Management
• Nursing Care for Patients undergoing Bariatric Surgery
• Perioperative Care of Patients undergoing Organ Transplantation
• Management of Patients with Pressure Ulcers following Surgery
• Nursing Interventions for Patients undergoing Cosmetic Surgery
• Surgical Wound Dehiscence and Evisceration: Nursing Management
• Role of the Nurse in Intraoperative Patient Safety
• Care of Patients with Surgical Drains: Assessment and Management

Cardiovascular Nursing Topics

• Nursing Care for Patients undergoing Coronary Artery Bypass Graft (CABG) Surgery
• Management of Patients with Heart Failure undergoing Surgery
• Postoperative Arrhythmia Management
• Role of the Nurse in Cardiovascular Assessment during Surgery
• Nursing Interventions for Patients with Peripheral Vascular Disease undergoing Surgery
• Hypothermia Prevention Strategies during Cardiac Surgery
• Care of Patients undergoing Cardiac Catheterization
• Nursing Management of Patients with Aortic Aneurysm
• Postoperative Care of Patients with Myocardial Infarction
• Nursing Interventions for Patients with Cardiogenic Shock

Neurological Nursing Topics

• Care of Patients undergoing Craniotomy Surgery
• Management of Patients with Spinal Cord Injuries undergoing Surgery
• Postoperative Care of Patients with Brain Tumors
• Nursing Interventions for Patients with Stroke undergoing Surgery
• Role of the Nurse in Intraoperative Neurological Monitoring
• Perioperative Care of Patients with Multiple Sclerosis
• Nursing Management of Patients with Traumatic Brain Injury
• Postoperative Delirium: Assessment and Management
• Care of Patients undergoing Deep Brain Stimulation Surgery
• Nursing Interventions for Patients with Epilepsy undergoing Surgery

Gastrointestinal Nursing Topics

• Nursing Care for Patients with Gastrointestinal Cancer undergoing Surgery
• Management of Patients with Inflammatory Bowel Disease undergoing Surgery
• Postoperative Nutrition Support Strategies
• Nursing Interventions for Patients with Hepatic Encephalopathy following Surgery
• Role of the Nurse in Intraoperative Bowel Management
• Perioperative Care of Patients with Peptic Ulcer Disease
• Nursing Management of Patients with Pancreatitis undergoing Surgery
• Postoperative Care of Patients with Intestinal Obstruction
• Care of Patients with Gastroesophageal Reflux Disease undergoing Surgery
• Nursing Interventions for Patients with Appendicitis undergoing Surgery

Respiratory Nursing Topics

• Nursing Care for Patients with Lung Cancer undergoing Surgery
• Management of Patients with Pneumonia undergoing Surgery
• Postoperative Respiratory Assessment and Monitoring
• Nursing Interventions for Patients with Chronic Respiratory Failure undergoing Surgery
• Role of the Nurse in Intraoperative Airway Management
• Taking care of patients with COPD before, during, and after surgery
• Helping patients with ARDS after surgery breathe better and managing their care
• Postoperative Care of Patients with Pulmonary Embolism
• Care of Patients with Sleep Apnea undergoing Surgery
• Nursing Interventions for Patients with Asthma undergoing Surgery

Renal Nursing Topics

• Nursing Care for Patients with Renal Cell Carcinoma undergoing Surgery
• Management of Patients with Acute Kidney Injury (AKI) undergoing Surgery
• Postoperative Fluid and Electrolyte Management
• Nursing Interventions for Patients with Chronic Kidney Disease undergoing Surgery
• Role of the Nurse in Intraoperative Renal Function Monitoring
• Perioperative Care of Patients with Renal Calculi
• Nursing Management of Patients with Hydronephrosis following Surgery
• Postoperative Care of Patients with Renal Transplantation
• Care of Patients with Polycystic Kidney Disease undergoing Surgery
• Nursing Interventions for Patients with Renal Artery Stenosis undergoing Surgery

Endocrine Nursing Topics

• Nursing Care for Patients with Thyroid Disorders undergoing Surgery
• Management of Patients with Diabetes Mellitus undergoing Endocrine Surgery
• Postoperative Hormonal Assessment and Monitoring
• Nursing Interventions for Patients with Adrenal Disorders undergoing Surgery
• Role of the Nurse in Intraoperative Endocrine Function Monitoring
• Perioperative Care of Patients with Pituitary Disorders
• Nursing Management of Patients with Parathyroid Disorders following Surgery
• Postoperative Care of Patients with Gonadal Disorders
• Care of Patients with Neuroendocrine Tumors undergoing Surgery
• Nursing Interventions for Patients with Pancreatic Disorders undergoing Surgery

Oncology Nursing Topics

• Nursing Care for Patients with Breast Cancer undergoing Surgery
• Management of Patients with Colorectal Cancer undergoing Surgery
• Postoperative Symptom Management in Cancer Patients
• Nursing Interventions for Patients with Prostate Cancer undergoing Surgery
• Role of the Nurse in Intraoperative Oncological Safety Measures
• Perioperative Care of Patients with Ovarian Cancer
• Nursing Management of Patients with Lung Cancer following Surgery
• Postoperative Care of Patients with Melanoma
• Care of Patients with Head and Neck Cancer undergoing Surgery
• Nursing Interventions for Patients with Gynecological Cancers undergoing Surgery

Pediatric Nursing Topics

• Nursing Care for Pediatric Patients undergoing Surgery
• Management of Pediatric Patients with Congenital Anomalies undergoing Surgery
• Postoperative Pain Management in Children
• Nursing Interventions for Pediatric Patients with Cleft Lip and Palate undergoing Surgery
• Role of the Nurse in Intraoperative Pediatric Safety Measures
• Perioperative Care of Pediatric Patients with Hydrocephalus
• Nursing Management of Pediatric Patients with Spina Bifida following Surgery
• Postoperative Care of Pediatric Patients with Appendicitis
• Care of Pediatric Patients with Hirschsprung Disease undergoing Surgery
• Nursing Interventions for Pediatric Patients with Congenital Heart Disease undergoing Surgery

Gerontological Nursing Topics

• Nursing Care for Geriatric Patients undergoing Surgery
• Management of Geriatric Patients with Fractures undergoing Surgery
• Postoperative Delirium Prevention Strategies in Older Adults
• Nursing Interventions for Geriatric Patients with Dementia undergoing Surgery
• Role of the Nurse in Intraoperative Geriatric Safety Measures

How Do You Write A Nursing Project?

Writing a nursing project involves several key steps to ensure clarity, thoroughness, and relevance to the chosen topic. Here’s a general guide on how to write a nursing project:

• Select a Topic: Choose a topic that aligns with your interests, expertise, and the requirements of your assignment or research objectives. Consider the significance of the topic in the field of nursing and its potential impact on patient care or nursing practice.
• Research: Find books, articles, and other info about your topic. Look at what’s already been studied to see what’s missing or needs more info.
• Outline: Plan out your project with sections like intro, background, methods, results, and conclusion. Make it fit what you need.
• Introduction: Start your project with a bit about your topic, why it’s important, and what you’re trying to learn.
• Review: Look at all the info you found and figure out what’s important. See where there are questions or disagreements.
• Methods: Explain how you did your project, like who you studied, what you measured, and how you did it.
• Results: Show what you found in a clear way, like with tables or graphs. Talk about what it means.
• Implications: Think about what your findings mean for nursing. How can it help patients or other nurses? What else should be looked at?
• Conclusion: Sum up what you learned and why it’s important. Say what you think should happen next.
• Cite Sources: Give credit to the info you used in your project. Make sure to do it right.
• Proofread: Check your project for mistakes and fix them. Make sure it all makes sense and looks good.
• Seek Feedback: Before finalizing your project, seek feedback from peers, mentors, or instructors to gain valuable insights and suggestions for improvement. Consider incorporating constructive feedback to strengthen your project before submission or publication.

Future Directions and Recommendations

• Areas for Further Research in Medical Surgical Nursing: Identify emerging areas of interest and potential research gaps in medical surgical nursing, such as the impact of healthcare disparities on surgical outcomes , patient-reported outcomes following surgery, and the integration of complementary and alternative therapies into perioperative care.
• Strategies for Improving Surgical Nursing Practice: Propose recommendations for enhancing surgical nursing practice, including interdisciplinary collaboration, continuing education and professional development opportunities, and the implementation of evidence-based guidelines and protocols.

In conclusion, medical surgical nursing offers a vast array of fascinating project topics that can enrich our understanding of patient care, contribute to evidence-based practice, and drive innovation in healthcare delivery.

Whether you’re a student embarking on a research project or a seasoned nurse seeking to explore new avenues in your practice, these Medical surgical nursing project topics provide an excellent starting point for exploration and discovery in the dynamic field of medical surgical nursing.

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What the data says about abortion in the U.S.

Pew Research Center has conducted many surveys about abortion over the years, providing a lens into Americans’ views on whether the procedure should be legal, among a host of other questions.

In a  Center survey  conducted nearly a year after the Supreme Court’s June 2022 decision that  ended the constitutional right to abortion , 62% of U.S. adults said the practice should be legal in all or most cases, while 36% said it should be illegal in all or most cases. Another survey conducted a few months before the decision showed that relatively few Americans take an absolutist view on the issue .

Find answers to common questions about abortion in America, based on data from the Centers for Disease Control and Prevention (CDC) and the Guttmacher Institute, which have tracked these patterns for several decades:

How many abortions are there in the U.S. each year?

How has the number of abortions in the u.s. changed over time, what is the abortion rate among women in the u.s. how has it changed over time, what are the most common types of abortion, how many abortion providers are there in the u.s., and how has that number changed, what percentage of abortions are for women who live in a different state from the abortion provider, what are the demographics of women who have had abortions, when during pregnancy do most abortions occur, how often are there medical complications from abortion.

This compilation of data on abortion in the United States draws mainly from two sources: the Centers for Disease Control and Prevention (CDC) and the Guttmacher Institute, both of which have regularly compiled national abortion data for approximately half a century, and which collect their data in different ways.

The CDC data that is highlighted in this post comes from the agency’s “abortion surveillance” reports, which have been published annually since 1974 (and which have included data from 1969). Its figures from 1973 through 1996 include data from all 50 states, the District of Columbia and New York City – 52 “reporting areas” in all. Since 1997, the CDC’s totals have lacked data from some states (most notably California) for the years that those states did not report data to the agency. The four reporting areas that did not submit data to the CDC in 2021 – California, Maryland, New Hampshire and New Jersey – accounted for approximately 25% of all legal induced abortions in the U.S. in 2020, according to Guttmacher’s data. Most states, though,  do  have data in the reports, and the figures for the vast majority of them came from each state’s central health agency, while for some states, the figures came from hospitals and other medical facilities.

Discussion of CDC abortion data involving women’s state of residence, marital status, race, ethnicity, age, abortion history and the number of previous live births excludes the low share of abortions where that information was not supplied. Read the methodology for the CDC’s latest abortion surveillance report , which includes data from 2021, for more details. Previous reports can be found at  stacks.cdc.gov  by entering “abortion surveillance” into the search box.

For the numbers of deaths caused by induced abortions in 1963 and 1965, this analysis looks at reports by the then-U.S. Department of Health, Education and Welfare, a precursor to the Department of Health and Human Services. In computing those figures, we excluded abortions listed in the report under the categories “spontaneous or unspecified” or as “other.” (“Spontaneous abortion” is another way of referring to miscarriages.)

Guttmacher data in this post comes from national surveys of abortion providers that Guttmacher has conducted 19 times since 1973. Guttmacher compiles its figures after contacting every known provider of abortions – clinics, hospitals and physicians’ offices – in the country. It uses questionnaires and health department data, and it provides estimates for abortion providers that don’t respond to its inquiries. (In 2020, the last year for which it has released data on the number of abortions in the U.S., it used estimates for 12% of abortions.) For most of the 2000s, Guttmacher has conducted these national surveys every three years, each time getting abortion data for the prior two years. For each interim year, Guttmacher has calculated estimates based on trends from its own figures and from other data.

The latest full summary of Guttmacher data came in the institute’s report titled “Abortion Incidence and Service Availability in the United States, 2020.” It includes figures for 2020 and 2019 and estimates for 2018. The report includes a methods section.

In addition, this post uses data from StatPearls, an online health care resource, on complications from abortion.

An exact answer is hard to come by. The CDC and the Guttmacher Institute have each tried to measure this for around half a century, but they use different methods and publish different figures.

The last year for which the CDC reported a yearly national total for abortions is 2021. It found there were 625,978 abortions in the District of Columbia and the 46 states with available data that year, up from 597,355 in those states and D.C. in 2020. The corresponding figure for 2019 was 607,720.

The last year for which Guttmacher reported a yearly national total was 2020. It said there were 930,160 abortions that year in all 50 states and the District of Columbia, compared with 916,460 in 2019.

• How the CDC gets its data: It compiles figures that are voluntarily reported by states’ central health agencies, including separate figures for New York City and the District of Columbia. Its latest totals do not include figures from California, Maryland, New Hampshire or New Jersey, which did not report data to the CDC. ( Read the methodology from the latest CDC report .)
• How Guttmacher gets its data: It compiles its figures after contacting every known abortion provider – clinics, hospitals and physicians’ offices – in the country. It uses questionnaires and health department data, then provides estimates for abortion providers that don’t respond. Guttmacher’s figures are higher than the CDC’s in part because they include data (and in some instances, estimates) from all 50 states. ( Read the institute’s latest full report and methodology .)

While the Guttmacher Institute supports abortion rights, its empirical data on abortions in the U.S. has been widely cited by  groups  and  publications  across the political spectrum, including by a  number of those  that  disagree with its positions .

These estimates from Guttmacher and the CDC are results of multiyear efforts to collect data on abortion across the U.S. Last year, Guttmacher also began publishing less precise estimates every few months , based on a much smaller sample of providers.

The figures reported by these organizations include only legal induced abortions conducted by clinics, hospitals or physicians’ offices, or those that make use of abortion pills dispensed from certified facilities such as clinics or physicians’ offices. They do not account for the use of abortion pills that were obtained  outside of clinical settings .

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The annual number of U.S. abortions rose for years after Roe v. Wade legalized the procedure in 1973, reaching its highest levels around the late 1980s and early 1990s, according to both the CDC and Guttmacher. Since then, abortions have generally decreased at what a CDC analysis called  “a slow yet steady pace.”

Guttmacher says the number of abortions occurring in the U.S. in 2020 was 40% lower than it was in 1991. According to the CDC, the number was 36% lower in 2021 than in 1991, looking just at the District of Columbia and the 46 states that reported both of those years.

(The corresponding line graph shows the long-term trend in the number of legal abortions reported by both organizations. To allow for consistent comparisons over time, the CDC figures in the chart have been adjusted to ensure that the same states are counted from one year to the next. Using that approach, the CDC figure for 2021 is 622,108 legal abortions.)

There have been occasional breaks in this long-term pattern of decline – during the middle of the first decade of the 2000s, and then again in the late 2010s. The CDC reported modest 1% and 2% increases in abortions in 2018 and 2019, and then, after a 2% decrease in 2020, a 5% increase in 2021. Guttmacher reported an 8% increase over the three-year period from 2017 to 2020.

As noted above, these figures do not include abortions that use pills obtained outside of clinical settings.

Guttmacher says that in 2020 there were 14.4 abortions in the U.S. per 1,000 women ages 15 to 44. Its data shows that the rate of abortions among women has generally been declining in the U.S. since 1981, when it reported there were 29.3 abortions per 1,000 women in that age range.

The CDC says that in 2021, there were 11.6 abortions in the U.S. per 1,000 women ages 15 to 44. (That figure excludes data from California, the District of Columbia, Maryland, New Hampshire and New Jersey.) Like Guttmacher’s data, the CDC’s figures also suggest a general decline in the abortion rate over time. In 1980, when the CDC reported on all 50 states and D.C., it said there were 25 abortions per 1,000 women ages 15 to 44.

That said, both Guttmacher and the CDC say there were slight increases in the rate of abortions during the late 2010s and early 2020s. Guttmacher says the abortion rate per 1,000 women ages 15 to 44 rose from 13.5 in 2017 to 14.4 in 2020. The CDC says it rose from 11.2 per 1,000 in 2017 to 11.4 in 2019, before falling back to 11.1 in 2020 and then rising again to 11.6 in 2021. (The CDC’s figures for those years exclude data from California, D.C., Maryland, New Hampshire and New Jersey.)

The CDC broadly divides abortions into two categories: surgical abortions and medication abortions, which involve pills. Since the Food and Drug Administration first approved abortion pills in 2000, their use has increased over time as a share of abortions nationally, according to both the CDC and Guttmacher.

The majority of abortions in the U.S. now involve pills, according to both the CDC and Guttmacher. The CDC says 56% of U.S. abortions in 2021 involved pills, up from 53% in 2020 and 44% in 2019. Its figures for 2021 include the District of Columbia and 44 states that provided this data; its figures for 2020 include D.C. and 44 states (though not all of the same states as in 2021), and its figures for 2019 include D.C. and 45 states.

Guttmacher, which measures this every three years, says 53% of U.S. abortions involved pills in 2020, up from 39% in 2017.

Two pills commonly used together for medication abortions are mifepristone, which, taken first, blocks hormones that support a pregnancy, and misoprostol, which then causes the uterus to empty. According to the FDA, medication abortions are safe  until 10 weeks into pregnancy.

Surgical abortions conducted  during the first trimester  of pregnancy typically use a suction process, while the relatively few surgical abortions that occur  during the second trimester  of a pregnancy typically use a process called dilation and evacuation, according to the UCLA School of Medicine.

In 2020, there were 1,603 facilities in the U.S. that provided abortions,  according to Guttmacher . This included 807 clinics, 530 hospitals and 266 physicians’ offices.

While clinics make up half of the facilities that provide abortions, they are the sites where the vast majority (96%) of abortions are administered, either through procedures or the distribution of pills, according to Guttmacher’s 2020 data. (This includes 54% of abortions that are administered at specialized abortion clinics and 43% at nonspecialized clinics.) Hospitals made up 33% of the facilities that provided abortions in 2020 but accounted for only 3% of abortions that year, while just 1% of abortions were conducted by physicians’ offices.

Looking just at clinics – that is, the total number of specialized abortion clinics and nonspecialized clinics in the U.S. – Guttmacher found the total virtually unchanged between 2017 (808 clinics) and 2020 (807 clinics). However, there were regional differences. In the Midwest, the number of clinics that provide abortions increased by 11% during those years, and in the West by 6%. The number of clinics  decreased  during those years by 9% in the Northeast and 3% in the South.

The total number of abortion providers has declined dramatically since the 1980s. In 1982, according to Guttmacher, there were 2,908 facilities providing abortions in the U.S., including 789 clinics, 1,405 hospitals and 714 physicians’ offices.

The CDC does not track the number of abortion providers.

In the District of Columbia and the 46 states that provided abortion and residency information to the CDC in 2021, 10.9% of all abortions were performed on women known to live outside the state where the abortion occurred – slightly higher than the percentage in 2020 (9.7%). That year, D.C. and 46 states (though not the same ones as in 2021) reported abortion and residency data. (The total number of abortions used in these calculations included figures for women with both known and unknown residential status.)

The share of reported abortions performed on women outside their state of residence was much higher before the 1973 Roe decision that stopped states from banning abortion. In 1972, 41% of all abortions in D.C. and the 20 states that provided this information to the CDC that year were performed on women outside their state of residence. In 1973, the corresponding figure was 21% in the District of Columbia and the 41 states that provided this information, and in 1974 it was 11% in D.C. and the 43 states that provided data.

In the District of Columbia and the 46 states that reported age data to  the CDC in 2021, the majority of women who had abortions (57%) were in their 20s, while about three-in-ten (31%) were in their 30s. Teens ages 13 to 19 accounted for 8% of those who had abortions, while women ages 40 to 44 accounted for about 4%.

The vast majority of women who had abortions in 2021 were unmarried (87%), while married women accounted for 13%, according to  the CDC , which had data on this from 37 states.

In the District of Columbia, New York City (but not the rest of New York) and the 31 states that reported racial and ethnic data on abortion to  the CDC , 42% of all women who had abortions in 2021 were non-Hispanic Black, while 30% were non-Hispanic White, 22% were Hispanic and 6% were of other races.

Looking at abortion rates among those ages 15 to 44, there were 28.6 abortions per 1,000 non-Hispanic Black women in 2021; 12.3 abortions per 1,000 Hispanic women; 6.4 abortions per 1,000 non-Hispanic White women; and 9.2 abortions per 1,000 women of other races, the  CDC reported  from those same 31 states, D.C. and New York City.

For 57% of U.S. women who had induced abortions in 2021, it was the first time they had ever had one,  according to the CDC.  For nearly a quarter (24%), it was their second abortion. For 11% of women who had an abortion that year, it was their third, and for 8% it was their fourth or more. These CDC figures include data from 41 states and New York City, but not the rest of New York.

Nearly four-in-ten women who had abortions in 2021 (39%) had no previous live births at the time they had an abortion,  according to the CDC . Almost a quarter (24%) of women who had abortions in 2021 had one previous live birth, 20% had two previous live births, 10% had three, and 7% had four or more previous live births. These CDC figures include data from 41 states and New York City, but not the rest of New York.

The vast majority of abortions occur during the first trimester of a pregnancy. In 2021, 93% of abortions occurred during the first trimester – that is, at or before 13 weeks of gestation,  according to the CDC . An additional 6% occurred between 14 and 20 weeks of pregnancy, and about 1% were performed at 21 weeks or more of gestation. These CDC figures include data from 40 states and New York City, but not the rest of New York.

About 2% of all abortions in the U.S. involve some type of complication for the woman , according to an article in StatPearls, an online health care resource. “Most complications are considered minor such as pain, bleeding, infection and post-anesthesia complications,” according to the article.

The CDC calculates  case-fatality rates for women from induced abortions – that is, how many women die from abortion-related complications, for every 100,000 legal abortions that occur in the U.S .  The rate was lowest during the most recent period examined by the agency (2013 to 2020), when there were 0.45 deaths to women per 100,000 legal induced abortions. The case-fatality rate reported by the CDC was highest during the first period examined by the agency (1973 to 1977), when it was 2.09 deaths to women per 100,000 legal induced abortions. During the five-year periods in between, the figure ranged from 0.52 (from 1993 to 1997) to 0.78 (from 1978 to 1982).

The CDC calculates death rates by five-year and seven-year periods because of year-to-year fluctuation in the numbers and due to the relatively low number of women who die from legal induced abortions.

In 2020, the last year for which the CDC has information , six women in the U.S. died due to complications from induced abortions. Four women died in this way in 2019, two in 2018, and three in 2017. (These deaths all followed legal abortions.) Since 1990, the annual number of deaths among women due to legal induced abortion has ranged from two to 12.

The annual number of reported deaths from induced abortions (legal and illegal) tended to be higher in the 1980s, when it ranged from nine to 16, and from 1972 to 1979, when it ranged from 13 to 63. One driver of the decline was the drop in deaths from illegal abortions. There were 39 deaths from illegal abortions in 1972, the last full year before Roe v. Wade. The total fell to 19 in 1973 and to single digits or zero every year after that. (The number of deaths from legal abortions has also declined since then, though with some slight variation over time.)

The number of deaths from induced abortions was considerably higher in the 1960s than afterward. For instance, there were 119 deaths from induced abortions in  1963  and 99 in  1965 , according to reports by the then-U.S. Department of Health, Education and Welfare, a precursor to the Department of Health and Human Services. The CDC is a division of Health and Human Services.

Note: This is an update of a post originally published May 27, 2022, and first updated June 24, 2022.

Support for legal abortion is widespread in many countries, especially in Europe

Nearly a year after roe’s demise, americans’ views of abortion access increasingly vary by where they live, by more than two-to-one, americans say medication abortion should be legal in their state, most latinos say democrats care about them and work hard for their vote, far fewer say so of gop, positive views of supreme court decline sharply following abortion ruling, most popular.

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• v.43(4); Oct-Dec 2009

Basic research in orthopedic surgery: Current trends and future directions

Chuanyong lu.

Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California at San Francisco, San Francisco General Hospital, 2550 23rd St., San Francisco, CA 94110 USA

Jenni M. Buckley

Céline colnot, ralph marcucio, theodore miclau.

Musculoskeletal problems continue to represent a growing source of death and disability world-wide, particularly with the growing burden of disease associated with an aging population and increase in the rates of road traffic accidents. To address the societal and economic burdens presented by musculoskeletal disorders, research in the normal biology of musculoskeletal tissues, the diseases and injuries associated with these tissues, and the underlying mechanisms of musculoskeletal tissue regeneration continue to gain importance. These investigations often require multidisciplinary approaches ranging from basic cellular and molecular biology, bioengineering, biomechanics, and clinical research. It is clear that collaboration between disciplines and centers with expertise in biology, mechanics, and clinical research is essential to continue to advance the field. The purpose of this review is to address issues that may be of interest to the development of new basic science research programs and initiatives, including a brief review of current and developing areas of orthopaedic research, and the resources required for the successful creation of new biology and mechanical research laboratories.

D IRECTIONS IN O RTHOPEDIC R ESEARCH

The musculoskeletal system involves a diverse organization of tissues exposed to a complex series of biological and mechanical stimuli. A thorough understanding of the normal biology of the musculoskeletal tissues, the behavior of these tissues associated with disease and injury, and the underlying mechanisms of musculoskeletal tissue regeneration is necessary to address the growing burden of disease. Research programs, both in developed and developing countries, must target those orthopedic conditions of greatest importance to their populations in order to diminish the societal and economic burdens caused by an inability to resume necessary physical function. The potential areas for investigation within the field of orthopedics continue to grow, particularly as the basic and applied body of scientific knowledge and technology develop. While these areas for basic research in orthopedics are too numerous to list, below are examples of some of the current and future directions in the field.

Musculoskeletal injury and repair

Bone repair, whether it happens following a fracture or a bone graft, involves a well organized set of events that lead to reconstitution of the biological and mechanical integrity of bone. The regeneration process is initiated by an inflammatory response, which plays an important role in stimulating repair. 1 Simultaneously, skeletal progenitor cells are recruited and begin differentiating into chondrocytes and osteoblasts that will deposit new cartilage and bone matrix necessary for bone bridging. The origins of these progenitor cells and the influence of the inflammatory response on their recruitment are not well understood. Following extracellular matrix deposition, cartilage is replaced by bone and new trabecular bone is converted to lamellar bone during the remodeling phase of repair. 2 – 4

Numerous molecules and growth factors are keys to each step of the repair process and their functions are slowly being elucidated through analyses of various animal models of bone repair. 2 , 5 These investigations will lead to a better understanding of the cellular and molecular bases of bone repair, better diagnosis of skeletal repair defects, and development of new strategies to accelerate healing. Surgeons have now the choice between various surgical techniques, improved implants and biological approaches to treat complex injuries. Current approaches use autografts, allografts, or bone morphogenetic proteins (BMPs). However, these approaches are not always successful and are costly, which necessitates the development of new therapies.

The muscles, tendons and ligaments along with blood vessels and nerves are closely associated with the bone. Musculoskeletal injuries may involve one or more of these tissues and the extent of injury is highly linked to the success of repair. For example, delayed union or non-union occurs in 5 to 10% of all fractures but is increased up to 46% in patients with extreme trauma and soft tissue damage. 6 Therefore the role of numerous tissues must be taken in account in the majority of musculoskeletal diseases or injuries. Advances are being made in the basic biology of bone and individual soft tissues surrounding bone. The basic biology of muscle and muscle repair is well understood compared to other soft tissues. Muscle repair is composed of three phases including degeneration/ inflammation, regeneration and fibrosis. Many molecular markers and disease models are available. Muscle has been an ideal target to test new gene therapies and cell based therapies, however further advances are needed to treat devastating diseases such as Duchenne Muscular Dystrophy and to improve muscle repair. Vascular biology is also an area of intense investigation but more efforts need to be made to apply the data to the orthopedic field. The biology of tendons and ligaments is now being better understood with the identification of key molecular pathways involved in these tissues. Injury of tendons and/or ligament independent of bone can lead to complications and extended periods of recovery, which can also have debilitating effects. Like muscle and bone healing, tendon and ligament healing is initiated by an inflammatory response that may be modulated to stimulate repair. Little is know about the intrinsic capacities of tendon and ligament to heal and the cell sources that participate in repair.

Cartilage biology

Regeneration of cartilage is a hot topic. Cartilage can be damaged by injury, inflammation, infection, and degeneration. Destruction of articular cartilage in rheumatoid arthritis and osteoarthritis involves inflammatory cytokines such as TNF-α, IL-1, or IL-6, which have been the target for current therapies. 7 – 11 After injury, articular cartilage has a poor capacity to repair itself and tends to heal through the formation of fibrocartilage, which has inferior biomechanical characteristics to resist compression stress compared to normal articular hyaline cartilage. For decades scientists and surgeons have been exploring treatments that facilitate cartilage repair, including micro fractures and more recently cell-based tissue engineering using autologous chondrocytes and mesenchymal stem cells combined with scaffolds. Mesenchymal stem cells can be collected from many sources including bone marrow, adipose tissue, synovium, and muscles. Study on embryonic stem cells has also been initiated and this research direction could be very fruitful. Many cell factors may be exploited to improve these approaches, among which are TGF-β, IGF-1, FGF-2, and BMP-7. 12 Nanotechonology may also improve the biomaterial properties of scaffolds. A better understanding of the cellular and molecular mechanisms of chondrocyte differentiation and phenotype maintenance may provide insights to develop novel techniques that can guide cultured chondrocytes and stem cells differentiation.

Regeneration of intervertebral discs (IVD) is equally, if not more challenging. A clinical study has shown that injection of disc chondrocytes reduces back pain and improves fluid contents of the treated disc. 13 Experimental studies have demonstrated that injected mesenchymal stem cells can maintain viability and proliferate within the IVD. 14 Although there are significant advances in the research of IVD regeneration, this area of research is still in its early stages. The intervertebral disc is composed of three tissues, the cartilage endplate, nucleus pulposus, and annulus fibrosus, and is more complex than articular cartilage. Successful regeneration of IVD may require the regeneration of all three tissues in one implant. The right scaffolds, cells, and techniques of implantation need to be determined and developed. 15

Orthopedic biomechanics

Orthopedic biomechanics is a specific sub-field of orthopedic research that involves the application of engineering principles to examine the mechanical behavior of the human musculoskeletal system. Topics of interest within orthopaedic biomechanics include mechanical testing of orthopaedic tissues and structures, medical implant design and testing, kinesiology (the study of human motion), and tissue engineering. A select list of currently popular research topics in Orthopedic Biomechanics for particular subspecialties is presented in Table 1 .

Examples of cutting-edge research topics in orthopedic biomechanical research

MEMS = Microelectro mechanical system

In order to develop more effective surgical and non-surgical techniques for treating orthopedic diseases, orthopedic biomechanical research is performed to characterize the mechanical factors contributing to orthopaedic injury or resulting from underlying orthopaedic biological conditions. One example of this type of research is the investigation of the contribution of ligamentous structures to the stability of the knee 16 or elbow 17 and may apply to optimizing diagnostic tests for clinical instability or modifying joint replacement designs to better preserve surrounding soft tissues. Another active area of biomechanical research is the characterization of the mechanical threshold for micro- and macro-level bone failure. These studies are primarily focused on common anatomic sites of fragility fractures, such as the hip, 18 distal radius 19 , 20 and thoracolumbar spine 21 and acute trauma of the skull, 22 acetabulum 23 and distal tibia and fibula. Lastly, there is a large body of research focused on characterizing differences between normal versus diseased orthopedic tissues at the tissue-level, such as elastic compressive behavior of the annulus fibrosus as a function of intervertebral disc degeneration. 24 , 25 The potential applications of this work include specifying design parameters for tissue-engineered implants, quantifying the effects of different drug therapies on tissue-level mechanical behavior, and providing accurate material property information for computational models.

The application of new technology to the prevention and treatment of orthopaedic disease is another ongoing area of research in orthopedic biomechanics. Advancements in medical imaging, such as rapid-scanning MRI and low radiation dosage CT scans, have allowed for the development of patient-specific volumetric models of specific anatomy that can be used for pre-operative planning or injury prevention. For example, there have been clinical 26 and cadaver-based biomechanical studies demonstrating the benefits of pre-operative planning using CT-based 3-D image processing for periacetabular osteotomy surgery (PAO) software to reduce operative time and improve surgical outcomes. Additionally, biomechanical studies have been instrumental in integrating recent advancements in materials science into orthopaedic implant design. For example, shape-memory alloys are now being used increasingly in minimally-invasive spinal surgeries, and cadaver-based biomechanical studies have been instrumental in demonstrating the safety and efficacy of these new implants.

Finally, a substantial portion of orthopedic biomechanical research is focused on the evaluation of existing orthopaedic techniques. These studies frequently involve head-to-head comparisons of the ex-situ or in-situ mechanical performances of currently used orthopedic implants or surgical techniques. These types of studies determine which procedure is most mechanically competent, and the data can be interpreted in the context of any existing clinical information regarding relative rates of patient morbidity and mortality, the amount of surgical skill needed to perform the procedure, and cost and availability of any technology necessary to perform the procedure. Examples of this type of research include overload of flexor tendons repaired with different stitching techniques 27 and the effect of bone cement to augment laterally plated tibial plateau constructs.

D EVELOPMENT OF AN O RTHOPEDIC R ESEARCH P ROGRAM

The initiation of research programs requires complex decision-making as directional, logistical, financial, and other considerations must be evaluated. The greatest barriers to the development of new basic research facilities include available technical expertise, space, and finances. This section reviews the basic infrastructure and equipment needs for the development of orthopedic molecular biology and biomechanical research laboratories, as well as some of the financial considerations required to develop these facilities.

Infrastructure and equipments: Molecular biology laboratory

The infrastructure required to run an Orthopaedic Surgery Research laboratory is similar to any other biological laboratory. Fume hoods are required to vent noxious and dangerous chemicals. An animal housing facility is necessary if work is performed on any number of model organisms. If work is to be performed on established or primary cell lines, then a separate cell culture room should be considered. By isolating cell culture facilities, reduced foot traffic in and around the incubators and hoods will aid in keeping cultures free of bacteria and mold. Another part of the laboratory should be set aside for processing, sectioning, and staining of histological specimens. This area should be located in a “dust-free” area away from drafts that will create difficulty handling ribbons of sections. Work with radioactive materials can be made safer by defining and restricting use of these materials to dedicated areas of the laboratory. Similarly a dedicated imaging suite that contains all the microscopes that will be used for documentation and analysis of data will allow undisturbed specimen viewing, will allow the room to be darkened for specialized imaging such as epifluorescence, and will reduce the amount of dust that accumulates on working parts of the microscope.

Equipment for an Orthopedic Surgery laboratory performing molecular and cellular biology experiments includes microtomes, thermal cyclers, bacterial shaking incubators and incubator ovens, electrophoresis equipment for assessing DNA, RNA, and proteins, table top microfuge, centrifuge, safety cabinets to store flammable liquids. If work is primarily focused on in vitro analyses, then cell culture incubator(s), laminar flow hoods, and at least one inexpensive inverted phase contrast microscope for visualizing cells are required. More specialized equipment can be used as the necessity of the laboratory dictates. For example, quantitative reverse transcriptase PCR (qPCR) can be used to assess gene expression patterns in cells and tissues.

Infrastructure and equipment: Orthopedic biomechanics laboratory

Research programs of Orthopedic Biomechanics generally have either experimental or computational focus, with a select group of more established laboratories undertaking both investigative approaches. The computational approach is generally preferred by new research groups in the US and Europe with limited financial resources. It can be established with minimal investment in infrastructure [ Table 2 ] and may be staffed effectively by mechanical or computer engineers with basic familiarity with 3-D software and finite element techniques. As projects are fundamentally computer-based, collaborations may be established internationally with communication largely through video conferencing, secure file transfer protocols, and other forms of electronic communication.

Recommended lab design for developing orthopedic biomechanics programs (Designs for both computationally-focused and experimentally-focused programs are provided)

Experimentally-focused orthopedic biomechanics research programs are substantially more challenging to develop, as they involve substantial up-front investment in laboratory infrastructure, have high operational costs, and require close clinical collaboration and experienced technical staff. Well-established, experimentally-based biomechanics programs in the US and Europe typically: 1) own $500K-$1M (United States Dollars, USD) of custom laboratory equipment; 2) occupy temperature-controlled, 1000+ assignable square foot laboratory spaces with Biosafety-level 2 certification to handle human cadaveric tissue; 3) have two to four full-time staff. It is possible for new programs to successfully participate in the international research community with a scaled-down version [ Table 2 ] of the aforementioned “established” experimental laboratory design; however, these programs must carefully select research projects to not over-tax their in-house resources.

R ESEARCH C OLLABORATIONS AND O PPORTUNITIES

Numerous countries around the world have highly developed infrastructures for the support of basic research. While there are often opportunities for young scientists to obtain research training in these countries, including graduate and post-graduate instruction, perhaps the greatest long-term opportunities exist through the creation of productive collaborations. The first step to assuring a successful collaboration is to define a specific question and identify particular needs, which can be adapted to the local environment based on the available techniques, expertise, and models. The perceived needs should be well-defined before seeking outside expertise, and will facilitate the identification of appropriate collaborators. Potential collaborators may be identified through research or other professional societies, publications, or scientific meetings. In the US, for example, such collaborations could be identified through organizations such as the Orthopedic Research Society or the Society of Mechanical Engineers Bioengineering Division and journals such as the Journal of Orthopedic Research or Journal of Biomechanics, where the major orthopedic research centers in the United States are generally represented. New techniques or models may be learned via sending laboratory members to the collaborating laboratory. More advanced collaboration may be based on sharing research efforts on a project and might involve the acquisition of funding from one or all of the collaborating centers.

C ONCLUSIONS

The field of orthopedic research will continue to grow in order to address the increasing global burden of musculoskeletal injury and disease. New basic scientific discoveries in biological and mechanical research will continue to advance rapidly, and present opportunities to bring these new discoveries to the clinic. The complex nature of the musculoskeletal system requires multi-disciplinary collaborations between investigators that possess a wide diversity of expertise. Although the development of research laboratories and opportunities require extensive planning and resource development, ultimately basic discoveries have the potential to develop into translational projects that can impact patient care. Several such discoveries have already developed into large-scale multi-national clinical trials, which are the end-goal for basic science research.

R EFERENCES

Global research team finds no clear link between maternal diabetes during pregnancy and ADHD in children

An international research team led by Professor Ian Wong Chi-kei, Head of the Department of Pharmacology and Pharmacy at LKS Faculty of Medicine of the University of Hong Kong (HKUMed) has just provided valuable evidence through a 20-year longitudinal study to address the longstanding debate concerning the potential impact of maternal diabetes on attention-deficit/hyperactivity disorder (ADHD) in children. This study, analysing real-world data from over 3.6 million mother-baby pairs in China's Hong Kong, Taiwan, New Zealand, Finland, Iceland, Norway and Sweden, showed that maternal diabetes during pregnancy is unlikely to be a direct cause of ADHD. The findings of this groundbreaking study were published today (8 April) in Nature Medicine .

Globally, approximately 16% of women have high blood sugar levels during pregnancy, and the prevalence of diabetes during pregnancy has been on the rise owing to factors like obesity and older maternal age. This can negatively affect the baby's brain and nervous system development. ADHD is one of the most common neurodevelopmental disorders in children, which can have severe negative consequences. Individuals with ADHD are prone to poor outcomes such as emotional problems, self-harm, substance misuse, educational underachievement, exclusion from school, difficulties in employment and relationships, and even criminality.

The impact of maternal diabetes on the risk of ADHD in children has been a subject of debate because of inconsistent findings in previous studies. As a result, concerns regarding pregnancies in women with diabetes and the potential connection to the risk of ADHD in children have persisted. Recognising the importance of identifying risk factors for ADHD, especially for women of childbearing age, the cross-regional study, funded by the Hong Kong Research Grants Council, utilised population-based data from China's Hong Kong, Taiwan, New Zealand, Finland, Iceland, Norway and Sweden to comprehensively assess the association between maternal diabetes and the risk of ADHD in offspring.

Research methods and findings

This extensive study, which included a remarkable sample size of over 3.6 million mother-child pairs from 2001 to 2014, with follow-up until 2020, yielded crucial observations regarding the association between maternal diabetes during pregnancy and the risk of ADHD. The research team first found that children born to mothers with any type of diabetes, whether before or during pregnancy, had a slightly higher risk of ADHD compared to unexposed children, with a hazard ratio of 1.16. The study further identified elevated risks of ADHD for both gestational diabetes (diabetes during pregnancy) and pregestational diabetes (diabetes before pregnancy). The hazard ratio for gestational diabetes was 1.10, indicating a modestly increased risk, whereas the hazard ratio for pregestational diabetes was 1.39, suggesting a more substantial association.

However, an intriguing finding emerged when the research team compared the risk of ADHD between siblings with discordant exposure to gestational diabetes and found no significant difference. This unexpected result indicates that the previously identified risk of ADHD when children were exposed to gestational diabetes during pregnancy is likely due to shared genetic and familial factors, rather than gestational diabetes per se. These findings challenge previous studies that suggested maternal diabetes during or before pregnancy could heighten the risk of ADHD in children.

Research significance

According to Professor Ian Wong Chi-kei, Lo Shiu Kwan Kan Po Ling Professor in Pharmacy, and Head of the Department of Pharmacology and Pharmacy, HKUMed, the process of coordinating with renowned scholars from around the world analysing cross-regional cases spanning over 20 years was no mean feat. This collaborative effort aimed to establish a comprehensive understanding of the matter at hand.

'In contrast to previous studies, which hypothesised that maternal diabetes during pregnancy could significantly increase the risk of ADHD, our study found only a modest association between maternal diabetes and ADHD in children after considering the intricate interplay of various influential factors. Notably, sibling comparisons showed this association is likely influenced by shared genetic and familial factors, particularly in the case of gestational diabetes,' explained Professor Wong.

He highlighted the need for deliberate consideration and future research. 'This implies that women who are planning pregnancy should look at their holistic risk profile rather than focusing solely on gestational diabetes,' he said. 'Moving forward, it is crucial for future research to investigate the specific roles of genetic factors and proper blood sugar control during different stages of embryonic brain development in humans.

About the research team

The research was jointly led by Professor Ian Wong Chi-kei, Lo Shiu Kwan Kan Po Ling Professor in Pharmacy, and Head of the Department of Pharmacology and Pharmacy, HKUMed; Dr Kenneth Man Keng-cheung, Honorary Assistant Professor of the Department of Pharmacology and Pharmacy, HKUMed, and Lecturer of the School of Pharmacy, University College London; Dr Carolyn Cesta, Assistant Professor of the Centre for Pharmacoepidemiology, Karolinska Institute, Sweden; Professor Edward Lai Chia-cheng, School of Pharmacy, National Cheng Kung University, Taiwan; Professor Helga Zoega, Associate Professor of the School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Australia. The first authors were Dr Adrienne Chan Yu-ling, Senior Research Assistant, and Dr Gao Le, Postdoctoral Fellow, Department of Pharmacology and Pharmacy, HKUMed; Dr Miyuki Hsieh Hsing-chun, School of Pharmacy, National Cheng Kung University, Taiwan; and Dr Lars Kjerpeseth, Department of Chronic Diseases, Norwegian Institute of Public Health.

Other members in the research team included experts in child psychiatry and epidemiology. They were Dr Raquel Avelar; Professor Tobias Banaschewski; Dr Amy Chan Hai-yan; Professor David Coghill; Dr Jacqueline M Cohen; Dr Mika Gissler; Professor Jeff Harrison; Professor Patrick Ip Pak-keung, Clinical Professor, Department of Paediatrics and Adolescent Medicine, School of Clinical Medicine, HKUMed; Dr Øystein Karlstad; Dr Wallis CY Lau, Honorary Research Associate, Department of Pharmacology and Pharmacy, HKUMed; Dr Maarit K Leinonen; Dr Leung Wing-cheong; Liao Tzu-chi; Dr Johan Reutfors; Dr Shao Shih-chieh; Professor Emily Simonoff; Professor Kathryn Tan Choon-beng, Department of Medicine, School of Clinical Medicine, HKUMed; Professor Katja Taxis; and Andrew Tomlin.

Acknowledgements

This work was supported by the General Research Fund of the Hong Kong Research Grants Council.

• Attention Deficit Disorder
• Diseases and Conditions
• Mental Health Research
• Pregnancy and Childbirth
• Chronic Illness
• Personalized Medicine
• Children's Health
• Attention-deficit hyperactivity disorder
• Methylphenidate
• Adult attention-deficit disorder
• Diabetes mellitus type 1
• Maternal bond
• Diabetes mellitus type 2
• Amphetamine

Story Source:

Materials provided by The University of Hong Kong . Note: Content may be edited for style and length.

Journal Reference :

• Adrienne Y. L. Chan, Le Gao, Miyuki Hsing-Chun Hsieh, Lars J. Kjerpeseth, Raquel Avelar, Tobias Banaschewski, Amy Hai Yan Chan, David Coghill, Jacqueline M. Cohen, Mika Gissler, Jeff Harrison, Patrick Ip, Øystein Karlstad, Wallis C. Y. Lau, Maarit K. Leinonen, Wing Cheong Leung, Tzu-Chi Liao, Johan Reutfors, Shih-Chieh Shao, Emily Simonoff, Kathryn Choon Beng Tan, Katja Taxis, Andrew Tomlin, Carolyn E. Cesta, Edward Chia-Cheng Lai, Helga Zoega, Kenneth K. C. Man, Ian C. K. Wong. Maternal diabetes and risk of attention-deficit/hyperactivity disorder in offspring in a multinational cohort of 3.6 million mother–child pairs . Nature Medicine , 2024; DOI: 10.1038/s41591-024-02917-8

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Strange & offbeat.

Emerging Drug Trends

• Emerging drugs, which include designer drugs and new psychoactive substances , are substances that have appeared or become more popular in the drug market in recent years.
• Emerging drugs have unpredictable health effects . They may be as powerful or more powerful than existing drugs, and may be fatal.
• Because drug markets change quickly, NIDA supports the National Drug Early Warning System (NDEWS) , which tracks emerging substances. NIDA also advances the science on emerging drugs by supporting research on their use and on their health effects.

What are emerging drugs?

Emerging drugs are mind-altering substances that have become more common in recent years. They may be sold in drug markets or at convenience stores and online. Since 2013, the United Nations Office on Drugs and Crime has identified more than 1,000 emerging drugs worldwide. 1

These substances, which include designer drugs and new psychoactive substances , come from many sources. Some were first developed as potential treatments or research chemicals. Others originate in illicit labs and are created to mimic the effects of drugs regulated under the Controlled Substances Act . These emerging substances often produce similar effects and/or are chemically similar to illegal or prescription opioids, stimulants, benzodiazapines (“benzos”), or other existing types of drugs.

People may seek out these drugs for recreation or use them to self-medicate without medical supervision. They may also be added to other drugs without a buyer knowing it. As a result, the health effects of emerging drugs are largely unknown, potentially posing a public health threat and contributing to the overdose crisis . 2,3

NIDA monitors emerging drug trends through its Designer Drug Research Unit and through support for the National Drug Early Warning System (NDEWS) , which tracks drug-related emergency calls.

What are the effects of emerging drugs?

An emerging drug’s effects depend on the type of substance it is—for instance, if it is a new type of opioid , depressant , synthetic cannabinoid , psychedelic , or stimulant. Its effects may be unpredictable and unwanted, especially if it is an unknown ingredient in another drug. A person may not know what substance or substances they have really taken. And because these substances are new to the drug market, clinicians or researchers may not know their effects or how potent (powerful) they are until people begin to visit emergency departments or clinics with symptoms of negative health effects. 4

In addition, emerging substances are usually not included in emergency department drug tests and are not routinely included in the toxicology tests used after a fatal overdose. The delay in this data means there is also a delay in understanding how widespread use of the drug is, why and how these drugs have their effects, and how to care for people who experience negative effects of those substances.

NIDA researchers and grantees collaborate to identify how these emerging drugs work and their potential health effects, including those that have the potential to impact the overdose crisis. NIDA also supports the National Drug Early Warning System (NDEWS) to track emerging substances and their impact on drug-related emergency calls.

What are nitazenes?

Nitazenes are a class of lab-made (synthetic) opioids that may be as powerful or more powerful than fentanyl. 4   They were developed in research labs in the 1950s as potential pain relievers but never marketed. Nitazenes are most often sold as a white powder or tablets. People may not be aware that they have taken nitazenes, as they may be added to other substances, including fentanyl, heroin, and benzodiazepines. 5

Nitazenes began to re-emerge in the drug supply in 2019, after the U.S. Drug Enforcement Administration banned fentanyl-related substances. 6,7 Researchers and authorities are monitoring nitazenes, including isotonitazene, protonitazene, etonitazene, N-piperidinyl etonitazene, and metonitazene. Many nitazenes are listed as Schedule 1 drugs under the Controlled Substances Act. 

Like all opioids , nitazenes can slow breathing, blood pressure, and heart rate to dangerously low levels, potentially contributing to overdose . Preliminary NIDA-supported research shows that the opioid overdose reversal medication naloxone is effective with isonitazene, metonitazene, and etonitazene, though it may require repeated doses. More research is needed to confirm these findings with additional nitazenes and in larger groups of people. Fentanyl test strips do not detect nitazenes.

What is tianeptine?

Tianeptine is an antidepressant medication that is not approved for use in the United States. NIDA-funded research suggests that most people take tianeptine in dietary supplements marketed as cognitive enhancers or nootropics, often sold in convenience stores and online. It may be blended with or taken at the same time as other nootropics (like phenibut and racetams) and is also used with substances such as kratom , kava, and gabapentin.

Tianeptine is not an opioid but at high doses it can have opioid-like effects, such as dangerous drops in blood pressure, heart rate, or breathing rate. Research shows that other effects include problems with brain, heart, and digestive function.

Research has shown that tianeptine can cause symptoms of a substance use disorder, including tolerance—which is when you need to take more of a drug for it to have the same level of effect—and withdrawal. Withdrawal from tianeptine has been associated with pain and problems with brain, heart, and digestive function. Early evidence suggests that tianeptine-related substance use disorder can be treated with medications for opioid use disorder , such as buprenorphine. 8

What are new psychoactive substances?

“New psychoactive substances” is a term used to describe lab-made compounds created to skirt existing drug laws . The category may include medications created by pharmaceutical companies or researchers that were never meant to reach the public .

These substances belong to a number of drug classes:

• Synthetic opioids. These drugs are chemically different from existing lab-made opioids like fentanyl . They include brorphine and U-47700. Researchers first identified brorphine in the unregulated drug supply in 2018. New synthetic opioids may slow breathing, blood pressure, and heart rate to dangerously low levels, potentially contributing to overdose. Emerging opioids can be as powerful or more powerful than fentanyl, which itself is 50 to 100 times more powerful than morphine.
• Synthetic cannabinoids , sometimes called “K2” or “Spice.” Lab-made cannabinoids are chemically similar to the cannabis plant but may have very different effects. Newer synthetic cannabinoids include ADMB-5,Br-BUTINACA and MDMB-4en-PINACA. MDMB-4en-PINACA has been associated with hallucinations, paranoia, and confusion. These substances have been found in people who died from accidental overdose. 9
• Synthetic cathinones , also known as “Bath Salts.” Lab-made cathinones are stimulants that are chemically related to, but not derived from, the khat plant. People sometimes take synthetic cathinones as a less expensive alternative to other stimulants, but cathinones have also been found as an added ingredient in other recreational drugs. Emerging cathinones include eutylone, N,N-dimethylpentylone (dipentylone), and pentylone. These substances have been found in people who died from overdose. 10
• Synthetic benzodiazapines. Benzodiazapenes are a class of lab-made depressants that include prescription medications such as diazepam (sometimes sold as Valium), alprazolam (sometimes sold as Xanax), and clonazepam (sometimes sold as Klonopin). Recent data show that new versions of recreationally manufactured bezodiazapines include bromazolam, disalkylgidazepam, and flubromazepam. 11

How does NIDA support research into emerging drugs?

NIDA supports research tracking the emergence of new drugs into the unregulated drug supply, including via the National Drug Early Warning System (NDEWS) , collaboration with other researchers, partners around the world, and social media. The Institute studies or supports research on changes in the lab-made drug supply and how these emerging substances work in the brain, as well as their health effects and potential as therapeutic treatments.

NIDA also researches ways to prevent substance use and misuse , and studies whether and how harm reduction methods may prevent, reverse, or reduce rates of overdose.

Latest from NIDA

Law enforcement seizures of psilocybin mushrooms rose dramatically between 2017-2022

Can science keep up with designer drugs?

Xylazine appears to worsen the life-threatening effects of opioids in rats

Find more resources on emerging drugs.

• See recent data on Overdose Rates from the Centers for Disease Control and Prevention (CDC). 
• Stay up to date on new and emerging substances at the National Drug Early Warning System website
• Early warning advisory on new psychoactive substances. United Nations Office on Drugs and Crime. Accessed April 15, 2024. https://www.unodc.org/LSS/Page/NPS
• Singh VM, Browne T, Montgomery J. The emerging role of toxic adulterants in street drugs in the US illicit opioid crisis . Public Health Rep . 2020;135(1):6-10. doi:10.1177/0033354919887741
• Gladden RM, Chavez-Gray V, O'Donnell J, Goldberger BA. Notes from the field: overdose deaths involving eutylone (psychoactive bath salts) - United States, 2020 . MMWR Morb Mortal Wkly Rep . 2022;71(32):1032-1034. Published 2022 Aug 12. doi:10.15585/mmwr.mm7132a3
• Pergolizzi J Jr, Raffa R, LeQuang JAK, Breve F, Varrassi G. Old drugs and new challenges: A narrative review of nitazenes . Cureus . 2023;15(6):e40736. Published 2023 Jun 21. doi:10.7759/cureus.40736
• Ujváry I, Christie R, Evans-Brown M, et al. DARK classics in chemical neuroscience: Etonitazene and related benzimidazoles . ACS Chem Neurosci . 2021;12(7):1072-1092. doi:10.1021/acschemneuro.1c00037
• Benzimidazole opioids, other name: nitazenes. Drug Enforcement Agency. Issued January 2024. Accessed April 15, 2024. https://www.deadiversion.usdoj.gov/drug_chem_info/benzimidazole-opioids.pdf
• Papsun DM, Krotulski AJ, Logan BK. Proliferation of novel synthetic opioids in postmortem investigations after core-structure scheduling for fentanyl-related substances . Am J Forensic Med Pathol . 2022;43(4):315-327. doi:10.1097/PAF.0000000000000787
• Trowbridge P, Walley AY. Use of buprenorphine-naloxone in the treatment of tianeptine use disorder . J Addict Med . 2019;13(4):331-333. doi:10.1097/ADM.0000000000000490
• Simon G, Kuzma M, Mayer M, Petrus K, Tóth D. Fatal overdose with the cannabinoid receptor agonists MDMB-4en-PINACA and 4F-ABUTINACA: A case report and review of the literature . Toxics . 2023;11(8):673. Published 2023 Aug 5. doi:10.3390/toxics11080673
• Ehlers PF, Deitche A, Wise LM, et al. Notes from the field: Seizures, hyperthermia, and myocardial injury in three young adults who consumed bromazolam disguised as alprazolam - Chicago, Illinois, February 2023 . MMWR Morb Mortal Wkly Rep . 2024;72(5253):1392-1393. Published 2024 Jan 5. doi:10.15585/mmwr.mm725253a5