Search Results (441)

Background: Migraine is a neurological disorder affecting approximately 15% of the general population, and autonomic nervous system (ANS) dysfunction is a well-characterized feature of the condition. Sympathovagal imbalance during acute migraine attacks has been linked to cardiac electrical instability. This study aimed to evaluate atrial and ventricular myocardial repolarization markers in migraine patients at three serial electrocardiography (ECG) time points. Methods: A prospective observational cross-sectional study was conducted in a tertiary emergency department (ED), enrolling 70 migraine patients and 70 age- and sex-matched healthy controls. Three 12-lead ECGs were obtained per patient: during the migraine attack (within 60 min of ED admission), after analgesic treatment (verbal pain relief or Numeric Rating Scale [NRS] decrease greater than 4 points), and in the pain-free period (at least 24 h after the attack, within 7 days). Measured parameters included P-wave duration, P-wave dispersion, QT interval, QT dispersion, corrected QT (QTc) duration (Bazett formula), QTc dispersion, Tpeak–Tend (Tp-e) interval, Tp-e dispersion, and Tp-e/QTc ratio. ECGs were evaluated by two blinded emergency medicine specialists. Results: All repolarization markers were significantly higher in migraine patients than in controls (p < 0.05 for all). Comparing the first (ictal) with the second (post-treatment) measurements, all markers except P-wave dispersion decreased significantly (p < 0.05). All markers were significantly higher during the attack than in the pain-free period (p < 0.05 for all). Tp-e interval and Tp-e/QTc ratio showed a further significant reduction between the second and third measurements (p = 0.016 and p = 0.004, respectively). P-wave dispersion was significant only for the first-to-second comparison (p = 0.034) and did not differ significantly between the first and third (p = 0.137) or second and third (p = 0.725) measurements. Pulse rate was significantly higher in the migraine group than in controls (p = 0.012). Conclusions: Acute migraine attacks were associated with significant elevation of both atrial and ventricular repolarization markers, with near-normalization during pain-free periods. These findings are consistent with a proposed mechanism of ANS-mediated cardiac electrical instability during acute attacks, although direct confirmation in future studies is required. Clinicians managing acute migraine in the ED should consider ECG monitoring in patients with cardiovascular risk factors. For anesthesiologists and intensivists, the elevated Tp-e and Tp-e/QTc observed ictally indicate that preoperative ECG assessment in migraine patients may be warranted to guide anesthetic planning. Full article

Peripherally restricted (‘second-generation’) cannabinoid CB₁ receptor (CB₁R) antagonists have been suggested to have therapeutic potential in numerous diseases. However, their effects on the cardiovascular system require further research. The peripheral CB₁R antagonist AM6545 failed to modify the decrease in blood pressure (BP) elicited by inhibition of anandamide degradation in spontaneously hypertensive rats. The aims of the present study were to examine the effect of AM6545 on BP and its interaction with endocannabinoid-evoked effects in deoxycorticosterone acetate (DOCA)-salt rats. For this purpose, we applied methanandamide (MethAEA), a stable analogue of anandamide, and URB597, an inhibitor of its degradation, in urethane-anesthetized animals. AM6545 did not affect BP by itself. MethAEA elicited a biphasic effect (a rise in BP, followed by its fall); both phases were antagonized by AM6545. URB597 induced a monophasic hypotensive effect, which was abolished by AM6545 in DOCA-salt rats but further enhanced in control animals. AM6545 also unmasked an additional increase in BP after URB597 in both groups of rats. In conclusion, AM6545 modifies the cardiovascular effects of endocannabinoids in hypertension in a model-dependent manner. The cardiovascular effects of CB₁R antagonists should be carefully evaluated when assessing their potential therapeutic significance, as they may unmask an increase in BP. Full article

Background: Anesthetizing frail patients for hip surgery is challenging; spinal (SA) and general anesthesia (GA) often cause hemodynamic instability. Traditional nerve blocks provide analgesia but rarely complete surgical anesthesia without motor block. We evaluate the clinical feasibility of the SAFE (Subarachnoid-alternative Anaesthesia For Endoprosthesis) protocol—combining Anterior Pericapsular Nerve Group (A-PENG), POsterior pericapsular Nerve Group (PONG), and Local Infiltration Analgesia (LIA) under intravenous sedation—as a primary anesthetic preserving motor function and avoiding SA/GA. Methods: This single-center retrospective series analyzed patients undergoing elective or trauma-related hip surgery using the SAFE protocol between September 2022 and April 2026. The primary outcome was success rate (completion without SA/GA conversion). Secondary outcomes included procedural timings, recovery room (RR) transit, and motor preservation. Variables are reported as medians [IQR]. Results: We included 48 patients (median age 83.5 years [IQR: 68.7–87.2]; 66.7% female) undergoing hip hemiarthroplasty (n = 28) or total hip arthroplasty (n = 20). The success rate was 100%, without SA/GA conversion or advanced airway management. Median anesthetic preparation and surgical durations were 55 [IQR: 50–76.2] and 85 min [IQR: 74–110], respectively. RR transit times (recorded for 35 patients) were brief (40 min [IQR: 34.0–67.5]). Crucially, lower-limb motor capacity was preserved in 100% of cases. The technique also proved opioid-sparing, substantially reducing postoperative opioid consumption. Conclusions: The SAFE protocol is a clinically feasible primary anesthetic strategy for hip surgery. By preserving motor function and enabling rapid fast-tracking, it aligns with ERAS pathways, offering a promising alternative to conventional anesthesia for elective and frail trauma patients. Randomized controlled trials are warranted to validate these outcomes. Full article

Peripheral nerve blocks can effectively reduce the use of general anesthesia and opioids in situations where robust pain management is critical, such as severe extremity trauma and hip, femur, and knee surgeries. Despite these benefits, nerve blocks are underutilized due to the high skill required to accurately insert a needle and safely deliver local anesthetic. To overcome this challenge, ultrasound image guidance enabled by artificial intelligence (AI) offers a semi-automated solution for regional anesthesia delivery by non-specialists. As a first step towards realizing an integrated platform for AI-guided nerve blocks, the main objective of this study is to develop and characterize deep learning algorithms to interpret anatomical landmarks on ultrasound images in real time and identify aimpoints for needle placement. Our AI system was trained on over 55,000 images from 20 porcine models and demonstrated an average area under the precision–recall curve of 0.92 (SD = 0.03) for in vivo landmark detection in the femoral nerve region. In prospective live animal testing, aimpoint identification had a 98.3% success rate with an average time of 40.5 s (SD = 33.5). Future work will focus on integrated testing with handheld robotics towards a more accessible method for delivering regional anesthesia in settings from point of injury to medical transport to hospitals. Full article

Background/Objective: Childhood obesity induces physiological changes that alter drug distribution and clearance; however, these patients are often excluded from clinical trials, creating a critical safety gap for high-alert medications (HAM). The Objective was to evaluate HAM dosing strategies and pharmacokinetic (PK) alterations in overweight and obese pediatric patients. Methods: A systematic review was conducted and registered in PROSPERO (CRD42023452126). A search of MEDLINE, EMBASE, Web of Science, and Cochrane CENTRAL (1990–March 2026) identified studies reporting dosing strategies or PK of HAM in obese or overweight pediatric patients. Studies were included if they reported dosing recommendations or PK parameters. Eligible designs comprised prospective and retrospective, randomized and non-randomized, observational (cohort, case-control, and cross-sectional), case series, case reports, and narrative and systematic reviews. Study selection, data extraction, and quality assessment were conducted independently by two reviewers. Methodological quality was assessed using validated tools, and results were synthesized qualitatively. Results: Of 5801 records, 91 studies were included, providing evidence for only 27% of the evaluated HAM. Total body weight (TBW) appeared to be appropriate for insulin and vancomycin, although close monitoring was required. TBW-based dosing was associated with approximately 20% overexposure for enoxaparin, supporting the use of fat-free mass (FFM) or reduced dosing strategies. Increased clearance may justify higher doses for amlodipine and consideration of adult-equivalent dosing for metformin in adolescents. For gentamicin, FFM appeared to be the most appropriate descriptor, while adjusted body weight was used for valproic acid. In anesthetics and sedatives, reduced TBW-based dosing may be considered for propofol, whereas ideal body weight (IBW) or FFM were generally preferred for ketamine and dexmedetomidine. Analgesics such as fentanyl and morphine may require IBW- or FFM-based dosing, and maintenance dosing of paracetamol may require adjustment. Conclusions: Evidence remains limited and heterogeneous, with no standardized dosing approach. Model-informed strategies—such as population PK (PopPK) and physiologically based PK model (PBPK) approaches—may be useful for hypothesis generation and exploring PK variability; however, their clinical applicability is constrained by the limited and heterogeneous evidence base, and they should be considered exploratory. Full article

Background/Objectives: Metabolic and bariatric surgery (MBS) is increasingly performed worldwide and requires specific anesthetic management due to the complex physiological alterations associated with severe obesity. Although several international guidelines provide recommendations for perioperative care in bariatric patients, their implementation in routine clinical practice may vary. This study aimed to report anesthetic practices among Polish anesthesiologists providing anesthesia for bariatric procedures. Methods: A cross-sectional survey study was conducted in October 2025 among Polish anesthesiologists. The questionnaire consisted of 13 closed-ended questions addressing demographic characteristics, anesthetic management and blood pressure management, including preoperative thresholds for postponement of elective surgery and intraoperative thresholds for pharmacological treatment of hypotension. The survey was distributed via social media platforms. Participation was anonymous and voluntary. Results: A total of 71 anesthesiologists participated in the study. The most commonly used intubation device was the Macintosh laryngoscope (57.7%), while videolaryngoscopy was used by 42.2% of respondents. Positive end-expiratory pressure (PEEP) was routinely applied by most respondents, with 63.4% adjusting its level according to patient body weight. Multimodal analgesia components were commonly used, with paracetamol (95.8%), dexamethasone (91.5%), metamizole (90.1%), and lignocaine (84.5%) being the most frequently administered drugs. Most anesthesiologists reported postponing elective surgery when blood pressure exceeded 180/110 mmHg. More experienced anesthesiologists more often considered lower thresholds for postponement of elective surgery (p = 0.006). Conclusions: Reported practices among surveyed anesthesiologists for MBS in Poland are generally consistent with international recommendations, particularly regarding the use of PEEP. However, variability remains in airway management strategies and the use of videolaryngoscopy, highlighting the need for continued education and broader implementation of evidence-based perioperative protocols. Full article

Background: Rocuronium onset time shows interindividual variability, yet its hemodynamic determinants remain incompletely characterized. The peripheral perfusion index (PI), derived non-invasively from pulse oximetry, reflects integrated cardiac output and peripheral vascular tone. We hypothesized that early PI dynamics during anesthesia induction are associated with rocuronium onset time. Methods: This single-center retrospective observational cohort study included 1377 adults who received rocuronium 0.6 mg/kg under a standardized induction protocol with quantitative electromyographic train-of-four monitoring. Baseline PI was categorized as low-PI (PI < 0.7), intermediate-PI (0.7 ≤ PI < 1.4), or normal-PI (PI ≥ 1.4), and patients were further stratified by anesthetic method (TIVA or volatile anesthesia), yielding six subgroups. The 60 s PI change after propofol bolus (ΔPI₆₀) was selected as the primary dynamic variable and classified into equal-frequency tertiles (Slow-Rise, Mid-Rise, Fast-Rise). Sequential multivariable linear regression model was used to quantify independent contributions of induction-phase variables on onset time. Results: In the overall cohort, onset time differed significantly across baseline PI groups (p = 0.033), though this was not replicated within either anesthetic subgroup (TIVA: p = 0.200; volatile: p = 0.137). In contrast, ΔPI₆₀ tertile was significantly associated with onset time in both subgroups (both p < 0.001), with median onset times of 211, 183, and 170 s in the Slow-Rise, Mid-Rise, and Fast-Rise groups, respectively. In the regression model, ΔPI₆₀ tertile produced the largest single increment in model fit (adjusted R² Δ0.060, p < 0.001); Slow-Rise and Mid-Rise groups had 32.7% and 18.8% longer onset times relative to Fast-Rise, respectively. Conclusions: ΔPI₆₀ was most strongly associated with rocuronium onset time among the variables examined, independent of baseline characteristics and anesthetic method. These findings provide hypothesis-generating evidence that induction-phase PI dynamics may serve as a physiologically grounded, non-invasive marker of rocuronium delivery conditions, warranting prospective validation. Full article

Background/Objectives: Hypoglossal nerve palsy is a rare but disabling complication of general anesthesia, typically associated with tracheal intubation and head and neck surgery. This study evaluated the incidence, clinical characteristics, and potential mechanisms of postoperative tongue deviation after breast reconstruction and other surgeries performed under general anesthesia with orotracheal intubation. Methods: We retrospectively reviewed 240,646 consecutive general anesthetic procedures with orotracheal intubation performed at two tertiary hospitals between September 2011 and October 2025. Eighteen patients who developed new-onset postoperative tongue deviation were identified, and demographic features, surgical department, breast reconstruction status, anesthetic details, patient positioning, laterality of deviation, symptom duration, and recovery outcomes were analyzed. Results: Postoperative tongue deviation was documented in 18 patients, corresponding to an overall incidence of approximately 0.01%, most frequently after breast reconstruction (7/18, 38.9%), followed by vascular (27.8%), head and neck tumor (16.7%), neurosurgical (11.1%), and hepatobiliary–pancreatic surgery (5.6%). All seven breast-reconstruction cases occurred at the breast-cancer center hospital, corresponding to 0.31% of 2256 breast reconstructions. The median age was 58.0 years; 66.7% patients were female. Most patients (77.8%) achieved complete recovery, whereas 16.7% had residual deviation. Conclusions: Postoperative hypoglossal nerve palsy with tongue deviation is an exceptionally rare event after general anesthesia. In our two-center cohort, it was observed most frequently among patients undergoing breast reconstruction at one participating center; this pattern is confounded by institution-specific anesthetic and positioning practices and should not be interpreted as evidence that the procedure itself carries inherent risk. The findings are hypothesis-generating and suggest that prolonged operating time, repeated intraoperative position changes, and specific head-fixation and tube-fixation practices warrant prospective investigation. Meticulous head–neck alignment, careful tube fixation, and a structured postoperative cranial-nerve check (tongue-protrusion and voice-quality assessment in the recovery room and on postoperative day 1) may aid the early detection of this complication. Full article

Background: Recessive dystrophic epidermolysis bullosa (RDEB) is a rare inherited disorder characterized by extreme epithelial fragility and progressive cicatrization, frequently leading to severe ocular surface disease and early visual impairment. Surgical interventions such as ocular surface reconstruction (OSR) in childhood are often delayed because of anesthetic risks and concerns regarding recurrence. Consequently, the effectiveness of OSR, including amniotic membrane transplantation (AMT), and its impact on visual development remain poorly documented. Methods: We report a case series of two pediatric patients (three eyes) with genetically confirmed RDEB who underwent single-step OSR using AMT. Clinical outcomes, long-term visual acuity, perioperative management, and histopathological findings were evaluated. Results: Ocular manifestations included corneal epithelial damage, symblepharon, and pseudopterygium extending over the cornea. One patient underwent symblepharon lysis, superficial keratectomy, and AMT onto the bare sclera in the right eye at age 4 and in the left eye at age 8, both under intubated general anesthesia. The other patient underwent the same procedure in the right eye at age 6. Best spectacle-corrected visual acuity improved from ≤20/300 to 20/30 in all eyes, and pupillary zone clarity was maintained during the follow-up period (up to 6 years). Histopathology confirmed pseudopterygium with squamous metaplasia, goblet cell loss, and fibrovascular stroma. Safe general anesthesia was achieved through meticulous multidisciplinary perioperative planning involving anesthesiologists, dermatologists, and pediatricians. No systemic complications related to anesthesia or perioperative management were observed. Conclusions: Single-step OSR with on-lay AMT can restore and preserve visual function in pediatric RDEB. Early surgical intervention may prevent profound amblyopia and provide durable ocular surface stability. A multidisciplinary approach enables safe general anesthesia and perioperative management. Full article

The progressive aging of the atrial fibrillation (AF) population, frequently characterized by high ischemic and bleeding risks, has led to a substantial increase in referrals for left atrial appendage occlusion (LAAO). The expansion of indications and the high procedural success rate of LAAO have further contributed to rising procedural volumes. However, this growth introduces important challenges: LAAO candidates are often elderly and frail, with increased anesthesia-related risks, and high-volume catheterization laboratories may face logistical constraints, particularly in centers without dedicated anesthesiology support. The current gold standard approach, transesophageal echocardiography (TEE) under general anesthesia (GA), ensures optimal imaging and procedural control but may increase procedural complexity and perioperative risks. In response, minimalist strategies are increasingly explored, targeting either the anesthetic protocol or the imaging modality. Conscious sedation (CS) protocols have been adopted to reduce anesthesia-related burden while maintaining TEE guidance. Alternatively, imaging-based strategies aim to replace TEE with less invasive modalities, including intracardiac echocardiography (ICE), transesophageal–intracardiac echocardiography (TE-ICE), and MicroTEE. Each approach presents specific advantages and limitations regarding safety, feasibility, operator expertise, and institutional resources. Taken together, these findings support a patient-centered approach to LAAO, whether traditional or minimalist, in which the choice of anesthetic strategy and echocardiographic guidance is driven by institutional resources, operator expertise, and individual patient characteristics rather than by expected differences in procedural or clinical efficacy. This review summarizes current evidence on minimalist LAAO pathways and discusses their role in achieving a tailored, resource-conscious procedural model. Full article

Target-controlled infusion (TCI) enables the precise delivery of intravenous anesthetics based on pharmacokinetic–pharmacodynamic (PK–PD) models and represents a key component of total intravenous anesthesia (TIVA). However, its use in obstetric anesthesia remains limited, as current TCI algorithms are derived from non-pregnant populations and do not account for pregnancy-related physiological changes or maternal–fetal drug distribution. This narrative review examines the clinical application of TIVA-TCI in caesarean delivery under general anesthesia, summarizing evidence from recent observational studies and national audits, which suggest feasibility but limited adoption in routine obstetric practice. Pregnancy induces significant alterations in drug distribution, protein binding, metabolism, and clearance, which may affect anesthetic pharmacokinetics and fetal exposure. Physiologically based pharmacokinetic (PBPK) modeling is explored as a complementary approach that may improve understanding of maternal–fetal drug disposition by integrating physiological and drug-specific parameters. Although promising, these model-based strategies require further validation before clinical implementation. Overall, current evidence supports the cautious use of TIVA-TCI in selected obstetric settings while highlighting the need for pregnancy-specific pharmacokinetic models and prospective clinical studies. Full article

Background/Objectives: Despite high recanalization rates associated with mechanical thrombectomy (MT), disability and death remain possible for many patients. Baseline stroke severity and reperfusion status predict outcomes; however, the influence of modifiable perioperative factors during general anesthesia (GA) remains unclear. We investigated actionable perioperative determinants of functional outcomes and 90-day mortality following MT under GA. Methods: We retrospectively analyzed 166 patients with acute ischemic stroke who underwent emergency MT with GA over 10 years (2014–2024). Poor functional outcomes were defined as a 90-day modified Rankin Scale score of 3–6, with all-cause 90-day mortality as the secondary endpoint. Independent predictors were identified using multivariable logistic regression, and discrimination was assessed using receiver operating characteristic analysis. Results: At 90 days, 56.6% of patients had poor functional outcomes, and mortality was 24.1%. Independent predictors of poor outcomes included preoperative hyperglycemia ≥ 140 mg/dL, vasopressor requirement, incomplete reperfusion, prolonged ventilator duration, and severe post-procedural neurological deficit. Optimal anesthetic induction dosing was strongly protective. Shorter groin puncture-to-recanalization time predicted better functional recovery. Mortality was associated with hyperglycemia, National Institutes of Health Stroke Scale ≥ 16, poor reperfusion, and prolonged ventilation. The models demonstrated excellent discrimination (area under the curve, 0.879 for poor outcomes; 0.923 for mortality). Perioperative physiological factors remained associated with outcomes independent of procedural success. Conclusions: Beyond technical success, perioperative physiological stability strongly influenced outcomes following MT under GA. Optimization of metabolic control, hemodynamic stability, procedural efficiency, and early ventilator liberation represents a clinically actionable strategy for improving neurological recovery and survival. Full article

Introduction: Propofol is one of the most commonly used intravenous anesthetics worldwide and is considered safe for all age groups. However, there have been reports that propofol can induce severe atrioventricular block in humans, and several studies have shown that propofol hinders or prevents the inducibility of arrhythmias during electrophysiological studies (EPS) and radiofrequency (RF) ablation. Objectives: To compare arrhythmia inducibility during electrophysiological study and radiofrequency ablation in pediatric patients with Wolff–Parkinson–White syndrome undergoing propofol-based sedation versus sevoflurane-based general anesthesia. Methods: We conducted a retrospective observational cohort study including 45 pediatric patients aged 0–18 years. Patients were identified through a review and analysis of a database of individuals with Wolff–Parkinson–White syndrome who were referred for electrophysiological study and/or radiofrequency ablation at the Electrophysiology Laboratory of the Institute of Cardiology (IC/FUC) in Porto Alegre over the past five years (2019–2024). Patients with prior ablation, structural heart disease, or ongoing antiarrhythmic therapy were excluded. The patients were divided into two groups and designated as group S (who received sedation) or group G (who received general anesthesia). Sedation (group S) was performed with midazolam (0.08–0.2 mg/kg), fentanyl (0.1–0.2 μcg/kg), and propofol 50–60 µg/kg/min in continuous infusion. General anesthesia (group G), in turn, was performed with sevoflurane at an average dose of 2% (1 MAC according to age). Results: From 4874 invasive electrophysiology procedures performed during the study period, 45 involved pediatric patients with WPW. The sedation group (n = 29) had significantly older patients (14.6 ± 2.5 vs. 10.3 ± 2.8 years, p < 0.001) with higher weight (65.9 ± 16.3 vs. 41.2 ± 7.8 kg, p < 0.001) compared to the general anesthesia group (n = 16). Arrhythmia was successfully induced in 15/29 (51.7%) patients in the sedation group compared to 13/16 (81.2%) in the general anesthesia group (p = 0.062, Fisher’s exact test). Although this difference did not reach statistical significance, it represents a clinically relevant 29.5% lower induction rate in the sedation group. Post hoc power analysis revealed the study was underpowered (49.8%), suggesting a possible Type II error. Analysis of the “procedure room time” revealed a longer duration in the general anesthesia group (97.8 ± 36.7 vs. 67.8 ± 24.4 min), and this difference was statistically significant (p = 0.002). Conclusions: This study compared propofol-based sedation with sevoflurane-based general anesthesia in pediatric WPW patients. While sedation with propofol did not show a statistically significant reduction in arrhythmia inducibility, there was a concerning trend toward lower induction rates (29.5% difference) that may be clinically relevant. The study’s limited statistical power (49.8%) suggests these findings should be interpreted cautiously, and larger prospective studies are needed to definitively establish whether propofol affects arrhythmia inducibility in this population. Propofol remains a viable option for these procedures, but clinicians should be aware of the potential for reduced inducibility, particularly in cases where arrhythmia induction is critical for diagnosis and treatment. Full article

Peripheral nerves provide a direct connection between the brain and the tumor microenvironment. This connection allows the nervous system to influence processes associated with the development, progression, and metastasis of different tumor types. Therefore, tumor innervation by peripheral nerve fibers is currently emerging as a characteristic that contributes to multiple hallmarks of cancer. Several experimental studies have shown that cancer progression involves actively inducing the ingrowth of autonomic and sensory nerve fibers into tumor tissue. In this process, known as neoaxonogenesis, cancer and other cells in the tumor microenvironment play an important role by synthesizing and releasing neurotrophic factors (e.g., nerve growth factor, brain-derived neurotrophic factor, glial cell line-derived neurotrophic factor), axonal guidance molecules (netrins, semaphorins, ephrins, slits), exosomes (containing microRNA and axonal guidance molecules), and other molecules present in the tumor microenvironment (e.g., granulocyte colony-stimulating factor, leukemia inhibitory factor), which modulate the ingrowth of nerve fibers into the tumor. This results in an increased nerve supply to tumor tissue, which is primarily linked to its growth. However, there are also studies demonstrating the protective effects of increased nerve fiber density against processes associated with cancer progression in certain types of cancer. The findings from these studies contribute to the complexity of neuro-cancer interactions, which is probably based on the type of cancer and the physiological specializations of the nerve fibers in a given organ. Despite contrasting findings, the stimulatory effects of nerve fibers on cancer growth are supported by several studies that described reducing the negative impact of nerve fibers on tumors and thus inhibiting cancer progression. The most significant approaches to reducing neural effects appear to be denervation, the administration of neurotransmitter receptor antagonists, the administration of local anesthetics, and the administration of antibodies against neurotrophic factors. Other significant approaches include methods that improve quality of life, such as psychotherapy and heart rate variability biofeedback. Despite their therapeutic potential, there are several limitations to using approaches that manipulate cancer innervation in clinical practice. These limitations include impaired normal tissue function and nervous system function, as well as the problematic direct application of the therapeutic agent to the tumor site, dosage-dependent, cancer type-dependent, cancer stage-dependent, duration-dependent, and timing-dependent effects. Procedures that modify neoaxonogenesis and nerve fiber signaling appear to be a promising new therapeutic approach in oncology. However, more research is needed to better understand their effects on cancer progression. In the future, the assessment of the presence and density of nerve fibers in tumors, as well as the evaluation of approaches aimed at reducing their negative impact, could be part of personalized anticancer therapy. As part of this therapy, a fresh tumor sample would be collected from the patient to generate patient-derived organoid models to test and consider the possibility of using supportive therapy and to predict its efficacy. Based on these results, it would be possible to evaluate the applicability of nerve-fiber-targeted therapy for a given patient. This review article summarizes and describes the current knowledge concerning the significance of nerve fibers in cancer progression, with a particular emphasis on neoaxonogenesis in tumors and the various factors that influence this process. Full article

Although radiotherapy is a cornerstone in the management of several pediatric malignancies, its administration in children poses unique anesthetic challenges. Unlike adults, pediatric patients, particularly younger children, often require repeated sedation or general anesthesia to ensure immobility and reduce psychological distress during daily treatment sessions that may extend over several weeks. This narrative review summarizes current evidence on anesthetic strategies for children undergoing radiotherapy, focusing on clinical indications, pharmacological approaches, safety considerations, and organizational aspects. We discuss the main sedation and anesthesia techniques used in non-operating room anesthesia (NORA) settings, including deep sedation with midazolam, propofol, ketamine, and dexmedetomidine, as well as general anesthesia with laryngeal mask airway management. Particular attention is given to the cumulative effects of repeated anesthetic exposure, airway management challenges in remote radiation environments, and the risk of respiratory and hemodynamic complications. The review also highlights the importance of individualized, protocol-driven management, rapid recovery strategies, and continuous remote monitoring systems. Non-pharmacological interventions and audiovisual-assisted techniques are also discussed as potential strategies to reduce anesthesia requirements in selected patients. A multidisciplinary approach involving anesthesiologists, radiation oncologists, nurses, psychologists, and technical staff is essential to optimize safety, treatment adherence, and overall quality of care. Tailored anesthetic management, supported by standardized protocols and specialized pediatric expertise, remains crucial to balancing procedural efficacy with short- and long-term safety in this vulnerable population. Full article