Post-dural puncture headache prevention and treatment with aminophylline or theophylline:a systematic review and meta-analysis

Background@#Post-dural puncture headache (PDPH) is one of the most common complications in patients undergoing spinal anesthesia. The present systematic review and meta-analysis aimed to assess the therapeutic and prophylactic effects of aminophylline and theophylline on PDPH. @*Methods@#Relevant studies were identified by searching the following electronic databases, without language restriction, until June 2020: Scopus, EMBASE, MEDLINE, Google Scholar, Web of Science, Cochrane Library-CENTRAL, and CINAHL Complete. Random effects models were used to calculate the standardized mean difference (SMD) and risk ratios (RRs) with 95% confidence intervals (95% CI) to assess the therapeutic and prophylactic effects of aminophylline and theophylline on PDPH, respectively. The Cochrane tool was used for the quality assessment of the included studies. The certainty of the evidence was rated using the Grading of Recommendations Assessment, Development, and Evaluation method. @*Results@#Of the 1,349 initial records, 15 met our eligibility criteria (6 studies on therapeutic and 9 on prophylactic effects). A significant reduction in the pain score was observed following aminophylline/theophylline treatment (SMD = –1.67; 95% CI, –2.28 to –1.05; P < 0.001, I2 = 84.7%; P < 0.001). Subgroup analysis revealed that the therapeutic effect was significantly higher when these agents were compared to placebo than when conventional therapies were used. The risk of PDPH after aminophylline administration was not significantly reduced (RR = 0.74; 95% CI, 0.42 to 1.31; P = 0.290). @*Conclusions@#Theophylline and aminophylline have therapeutic, but not prophylactic, effects on PDPH.

A rare case of kinked reinforced endotracheal tube in an intensive care unit: a case report / Un caso infrecuente de acodamiento de un tubo endotraqueal reforzado en una unidad de cuidados intensivos: reporte de un caso

Abstract Reinforced endotracheal tubes (ETTs) are regularly applied in anesthetic practices to prevent compression or kinking. Although these tubes are designed to bend easily and prevent obstruction, they still carry a potential hazard of being obstructed following external forces. In this article, we reported an unusual case in which a reinforced ETT was collapsed due to the patient bite. The patient's bite force on the tube resulted in obstruction, hypoxia, and desaturation. To overcome this near-fatally condition, we removed the blocked reinforced ETT.

Resumen Los tubos endotraqueales reforzados (TET) se usan generalmente en la práctica anestésica para evitar la compresión o el acodamiento. Aun cuando dichos tubos están diseñados para flexionarse fácilmente y prevenir obstrucciones, de todos modos, existe la posibilidad de que se obstruyan, como consecuencia de fuerzas externas. En el presente trabajo reportamos un caso inusual en el cual se colapsó el TET a causa de la mordida del paciente. La fuerza de mordida sobre el tubo produjo obstrucción, hipoxia y desaturación. Con el fin de superar esta condición casi fatal, retiramos el TET reforzado bloqueado.

Nutritional assessment in critically III patients

Background: Malnutrition is an important factor in the survival of critically ill patients. The purpose of the present study was to assess the nutritional status of patients in the intensive care unit [ICU] on the days of admission and discharge via a detailed nutritional assessment

Methods: Totally, 125 patients were followed up from admission to discharge at SICUs in Shiraz, Iran. The patients' nutritional status was assessed using subjective global assessment [SGA], anthropometric measurements, biochemical indices, and body composition indicators. Diet prescription and intake was also evaluated

Results: Malnutrition prevalence significantly increased on the day of discharge [58.62%] compared to the day of admission [28.8%] according to SGA [P<0.001]. The patients' weight, mid-upper-arm circumference, mid-arm muscle circumference, triceps skinfold thickness, and calf circumference decreased significantly as well [P<0.001]. Lean mass weight and body cell mass also decreased significantly [P<0.001]. Biochemical indices showed no notable changes except for magnesium, which decreased significantly [P=0.013]. A negative significant correlation was observed between malnutrition on discharge day and anthropometric measurements. Positive and significant correlations were observed between the number of days without enteral feeding, days delayed from ICU admission to the commencement of enteral feeding, and the length of ICU stay and malnutrition on discharge day. Energy and protein intakes were significantly less than the prescribed diet [26.26% ancf 26.48%, respectively]

Conclusion: Malnutrition on discharge day increased in the patients in the ICU according to SGA. Anthropometric measurements were better predictors of the nutritional outcome of our critically ill patients than were biochemical tests

Axillary nerve block in comparison with intravenous midazolam/fentanyl for painless reduction of upper extremity fractures

The painful nature of fractures has made it inevitable to use various anesthetic techniques to reduce or immobilize fractured parts. In the present study, axillary nerve block was compared with intravenous midazolam/fentanyl to induce anesthesia for Painless Reduction of Upper Extremity Fractures. The subjects in the present clinical trial consisted of 60 patients with upper extremity fractures. They were randomly divided into two equal groups of intravenous sedation [IVS] with midazolam/fentanyl and axillary nerve block [ANB]. Rate of anesthesia induction, recovery time, and pain intensities at baseline, during the procedure and at the end of the procedure were recorded in both groups. Data was analyzed and compared between the two groups with SPSS 18 statistical software using appropriate tests. Demographic data, vital signs and means of pain intensities at the beginning of the procedure were equal in the two groups. In the IVS group, the overall duration of the procedure was shorter with more rapid onset of anesthesia [P<0.05]. In contrast, the recovery time was much shorter in the ANB group [P<0.001]. No life or organ threatening complications were observed in the two groups. Axillary nerve block can be considered an appropriate substitute for intravenous sedation in painful procedures of the upper extremity

Sonographic optic nerve sheath diameter as a screening tool for detection of elevated intracranial pressure

Timely diagnosis and treatment of post-traumatic elevated intracranial pressure [EICP] could be reduced morbidity and mortality, and improved patients' outcome. This study is trying to evaluate the diagnostic accuracy of sonographic optic nerve sheath diameter [ONSD] in detection of EICP. Sonographic ONSD of patients with head trauma or cerebrovascular accident suspicious for EICP were evaluated by a trained chief resident of emergency medicine, who was blind to the clinical and brain computed tomography scan [BCT] find-ings of patients. Immediately after ultrasonography, BCT was performed and reported by an expert radiologist without awareness from other results of the patients. Finally, ultrasonographic and BCT findings regarding EICP were compared. To evaluate the ability of sonographic ONSD in predicting the BCT findings and obtain best cut-off level, receiver operating characteristic [ROC] curve were used. Sensitivity, specificity, positive predictive value [PPV], negative predictive value [NPV], positive likelihood ratio [PLR], and negative likelihood ratio [NLR] of so-nographic ONSD in determining of EICP was calculated. P < 0.05 was considered as statistically significant. There were 222 patients [65.3% male], with mean age of 42.2 +/- 19.5 years [range: 16-90 years]. BCT showed signs of EICP, in 28 cases [12.6%]. The means of the ONSD in the patients with EICP and normal ICP were 5.5 +/- 0.56 and 3.93 +/- 0.53 mm, respectively [P<0.0001]. ROC curve demonstrated that the best cut off was 4.85 mm. Sensitivity, specificity, PPV, NPV, PLR, and NLR of ONSD for prediction of EICP were 96.4%, 95.3%, 72.2%, 98.9%, 20.6, and 0.04, respectively. Sonographic diameter of optic nerve sheath could be considered as an available, accurate, and noninvasive screening tool in determining the elevated intracranial pressure in cases with head trauma or cerebrovascular accident

Anxiety and depression in patients with amputated limbs suffering from phantom pain: a comparative study with non phantom chronic pain

Phantom limb pain [PLP] is approximately a common condition after limb amputation, which potentially affects the quality of life. We aimed to evaluate anxiety and depression in patients with amputated limbs suffering from PLP and to compare these psychological dysfunctions with that of patients with non-phantom chronic pain. A total number of 16 male amputees with PLP and 24 male age-matched patients with non-phantom chronic pain were recruited in this study, which was performed at Khatam-Al-Anbia Pain Clinic, Tehran, Iran. A validated Persian version of the hospital anxiety and depression scale [HADS] was used to compare two psychological dysfunctions - anxiety and depression - between the two groups of study. The mean of total anxiety score was significantly lower in patients with PLP [8.00 +/- 3.93 vs. 11.25 +/- 5.23; P = 0.041] and the prevalence of anxiety caseness [HADS-A score >/= 11] was also lower in the PLP group [25% vs. 58.3%; P = 0.112, power = 31.7%]. The mean of total depression score was 7.69 +/- 5.51 and 9.38 +/- 6.11 in patients of PLP and chronic pain groups, respectively [P = 0.340, power = 15%]. Consequently, the prevalence of depression caseness [HADS D score >/= 11] was lower in PLP patients [37.5% vs. 50%; P = 0.710, power = 8%]. Our results indicate that depression and anxiety are not more common in PLP patients, whereas they are more prevalent in subjects with non phantom chronic pain. These lower levels of anxiety and depression in PLP compared with chronic pain is a new finding that needs to be evaluated further, which may lead to new insights into the pathogenesis of phantom pain in further studies

healing effect of teucrium polium in acetic acid-induced ulcerative colitis in the dog as an animal model

Inflammatory bowel diseases [IBD], which include ulcer-ative colitis [UC] and Crohn's disease [CD], are debilitating and chronic disorders with unpredictable courses and complicated treatment measures. Therefore, an efficient treatment protocol seems necessary as therapeutic prophylaxis for these disorders. This study aims to determine the healing effect of Teucrium polium [T. polium] in acetic acid-induced UC in an experimental dog model. From September to December 2010, eight male [20-25 kg] crossbred dogs were used for induction of UC by 6% acetic acid, tran-srectally. After one week, three biopsies [10, 20 and 30 cm proximal to the anal verge] were taken from the colon of each animal for histological studies. In the presence of UC, 400 mg/kg/day of T. polium extract was administered orally and transrectally [via enema] for 30 days in six of the dogs. The remaining two dogs were used as controls and did not receive T. polium. Multiple biopsies were taken 7, 14, and 30 days after discontinuation of T. polium in the same manner as before treatment. After administration of acetic acid, we noted the presence of multiple ulcers, diffuse inflammation, PMN infiltration in the lamina propria, glandular destruction and goblet cell depletion. Treatment with T. polium restored the colonic architecture with an increased number of healthy cells and a reduction in inflammatory cells. Damage of the surface epithelial cells and mucosal layer of the lumen were reversed, which lead to faster ulcer healing. T. polium may be a treatment choice for UC and can broaden the current therapy options for UC

Effect of timing of morphine administration during propofol - remifentanil anesthesia on the requirements of post-operative analgesia / 대한마취과학회지

BACKGROUND: An important concern of intra-operative infusion of remifentanil is the possible development of acute opioid tolerance, which manifests as an increased postoperative analgesia requirement. We have examined the effect of the timing of intra operative morphine administration on the need for morphine consumption for pain control during the first 24 hours after operation. METHODS: Sixty adult patients scheduled for elective open unilateral nephrolithotomy surgery were recruited for this prospective randomized double-blind study. Anesthesia was induced with 0.03 mg/kg midazolam, 1 microg/kg remifentanil, and 1.5-2 mg/kg propofol. Anesthesia was maintained with 100 microg/kg/min propofol, and 0.25 microg/kg/min remifentanil. Both groups received 0.1 mg/kg morphine intravenously at 2 different times; in the first group (group E) immediately after intubation and in the second group (group L) 20-30 min before the anticipated end of operation. RESULTS: There was no difference in pain scores at awakening, the amount of morphine given to the 2 groups for pain control, or the time to discharge from PACU between the 2 groups. The pain scores at admission to ward and at every 4 hours thereafter, until 24 hours, were not significantly different between the 2 groups. The cumulative amount of the first 24 hours morphine consumption in the ward in E group was 28.2 +/- 20.1 mg and 26.5 +/- 15 mg in L group, respectively (P = 0.71). CONCLUSIONS: Early intra-operative administration of morphine compared to that of morphine in the end of surgery did not affect postoperative morphine consumption and pain scores during the first 24 hours after surgery for open nephrolithotomy. Newer pharmacologic interventions for prevention of acute tolerance of opioids seems rational (Clinical trial registration No. ACTRN: 12609000570280).

Xerografting as a novel procedure in the management of syngnathia

Congenital fusion of the maxilla and the mandible is a rare condition. The extent of the problem ranges from simple mucosal adhesion [synechia] to severe bony fusion [syngnathia]. Here we present a patient with zygomatico-mandibular fusion who was treated at neonatal and infancy periods at three different stages without tracheostomy. Having had recurrence for two times, porcine grafting was performed as a novel procedure to increase the chance of success. Ultimately the patient had uneventful outcome for 6 months after the last operation

Accessed criteria to different parts of emergency unit in general teaching hospitals of Shaheed Beheshti medical university

To assess general hospitals of Shaheed Beheshti medical university in terms of emergency unit designing for access to its different parts. Imam Hussein, Loghman, Shohada Tajrish, Taleghani and Shaheed Modares general teaching hospitals of SBMU which had higher visit per year were assessed for 40 criteria of access to different parts of their emergency unit by a checklist. Data have been gathered by an emergency medicine resident through interview with related personnel. Collected data compared with standards which have been used in emergency medicine. Only eleven to sixteen out of 40 criteria had been fulfilled in selected hospitals. Thirteen criteria have been missed and only five criteria were fulfilled in all the hospitals. Others missed in one or more. Some of the essential criteria like cardio respiratory resuscitation room being near the entrance, dissociation between ambulance and outpatient entrance, obvious entrance for emergency unit, easy access to laboratory and radiology from emergency unit, lack of markers for triage were missed in all and criteria for traumatic and psychological patients were missed in almost all. Easy visual access to patients through nursing station, use of elevator and waiting room in emergency unit were observed in all the hospitals. It seems that access criteria are not considered correctly in designing of the study hospitals. Designing hospitals need its requirements and emergency unit location should be considered at first stages of designing

effect of silver nitrate, chloroformic garlic extract, and normal saline in induction of sclerosing cholangitis in rabbits

To evaluate the effects of 0.5% silver nitrate, 20% chloroformic garlic extract, and 0.9% normal saline in induction of sclerosing cholangitis in the bile ducts of rabbits. During a-6-months period from April to September 2006 in Shiraz University Laboratory Animal Research Center, we selected 3 equal groups of rabbits. We injected 0.5% silver nitrate, 20% chloroformic garlic extract, and 0.9% normal saline into the bile ducts of each group. The animals were euthanized, and autopsied after 4 months and the liver and bile ducts were removed and studied histopathologically. Cholangiography was undertaken to evaluate the presence and extent of any sclerosing cholangitis. Animals showed sclerosing cholangitis in silver nitrate group [7 [58%]], one [8%] in chloroformic garlic extract group and one [7%] in normal saline group. The difference between silver nitrate and chloroformic garlic extract groups were statistically significant and similar results were noticed between chloroformic garlic extract and normal saline groups. Twenty percent of chloroformic garlic extract had fewer complications such as sclerosing cholangitis, compared to other materials

effect of betamethasone gel in reducing sore throat, cough, and hoarseness after laryngo-tracheal intubation

Tracheal intubation for general anesthesia often leads to traumatization of the airway mucosa resulting in postoperative sore throat, hoarseness and cough. This study was undertaken to determine the effects of betamethasone gel in reducing these complications. One hundred patients [ASA I-II] to undergo endotracheal intubation, were randomly divided equally into two groups; 50 Case [Group A]. 50 Control [Group B]. The tracheal tubes for Case Group A were lubricated with 0.05% betamethasone gel and for the Control Group B with KY gel. Patients were interviewed at end of procedures and 1 and 24 hour after extubation. The incidence and severity of sore throat, hoarseness and cough, 1 and 24 hours postoperatively was reduced significantly in Case Group A. Betamethasone gel, when was used for lubrication of endotracheal tubes pre-operatively, was shown to be effective in decreasing postoperative sore throat, hoarseness, and cough