Efficacy of Cerebellar Transcranial Magnetic Stimulation in Treating Essential Tremor: A Randomized, Sham-Controlled Trial

Background@#and Purpose Repetitive transcranial magnetic stimulation (rTMS) of the cerebellar hemisphere represents a new option in treating essential tremor (ET) patients. We aimed to determine the efficacy of cerebellar rTMS in treating ET using different protocols regarding the number of sessions, exposure duration, and follow-up duration. @*Methods@#A randomized sham-controlled trial was conducted, in which 45 recruit patients were randomly allocated to 2 groups. The first (active group) comprised 23 patients who were exposed to 12 sessions of active rTMS with 900 pulses of 1-Hz rTMS at 90% of the resting motor threshold daily on each side of the cerebellar hemispheres over 4 weeks. The second group (sham group) comprised 22 patients who were exposed to 12 sessions of sham rTMS. Both groups were reassessed at baseline and after 1 day, 1 month, 2 months, and 3 months using the Fahn-Tolosa-Marin tremor-rating scale (FTM). @*Results@#Demographic characteristics did no differ between the two groups. There were significant reductions both in FTM subscores A and B and in the FTM total score in the active-rTMS group during the period of assessment and after 3 months (p=0.031 and 0.011, respectively).However, subscore C did not change significantly from baseline when assessed at 2 and 3 months (p=0.073 and 0.236, respectively). Furthermore, the global assessment score was significantly higher in the active-rTMS group (p>0.001). @*Conclusions@#Low-frequency rTMS over the cerebellar cortex for 1 month showed relative safety and long-lasting efficacy in patients with ET. Further large-sample clinical trials are needed that include different sites of stimulation and longer follow-ups.

[Effect of remifentanil on hemodynamic parameters of parturients and APGAR of the neonate in elective cesarean section under general anesthesia]

Neonatal respiratory depression due to narcotics usage during cesarean section under general anesthesia is an important challenge for anesthesiologists. Remifentanil, due to its pharmacokinetic properties, may be a solution for this challenge. This study was designed to evaluate the effect of this drug on maternal hemodynamics and Apgar scores of their neonates during cesarean section under general anesthesia. In this double blind randomized controlled clinical trial, 84 women who were candidates for elective cesarean section under general anesthesia were randomly allocated into three groups. In the first group remifentanil was infused at a rate of 0.5micro g/kg/min and the second group received an IV bolus of 0.7 micro g/kg of the drug. Control group received an equivalent volume of normal saline. Maternal heart rate and blood pressure were measured and recorded before induction of anesthesia and one minute after tracheal intubation. Neonatal Apgar scores in the first and fifth minutes postnatal were also recorded and compared. Mean maternal HR changes before and after tracheal intubation were not significant between groups [P= 0.33]. Mean arterial pressure [MAP] changes between groups were significantly different [P= 0.001]. MAP changes were smallest in the bolus group and largest in the control group. These changes were not significantly different between infusion and control groups [P= 0.994]. This difference was significant between the bolus group with the infusion and control groups [P=0.001 and 0.002 respectively]. The mean first minute Apgar scores in neonates were significantly different in three groups [p=0.006]. This parameter was not significantly different between bolus and infusion groups [p=0.603]. Mean first minute Apgar scores in the bolus [8.46] and infusion [8.31] groups were significantly less than the control [8.93] group [p= 0.005 and 0.002 respectively]. The mean fifth minute Apgar scores were not significantly different between three groups. None of the neonates in the remifentanil groups needed resuscitation. The results indicated that bolus administration of remifentanil [compared with infusion and control groups] produces more stability in maternal blood pressure during cesarean section under general anesthesia. The decrease in first minute Apgar score in remifentanil groups were clinically negligible [none of these neonates needed resuscitation]. Despite these results, multicenter studies more samples are needed to confirm using remifentanil in elective cesarean section

Comparison of the effect of infra red and hot pack on reduction of pain associated with lumbar discopathy

Disk herniation is one of the causes of low back pain that 90% of people experience this pain. There are many pharmacological and non pharmacological methods to alleviate the low back pain, such as physiotherapy techniques [infra red and hot pack, etc]. In this study we investigated the effect of infra red and hot pack on the low back pain associated with disk herniation. In this experimental study, 60 patients with disk herniation were selected and divided randomly into infra red and hot pack groups. Severity of the pain was measured on the basis of a numerical rating scale up to 10. Intervention was performed three times a week for one month. Severity and duration of pain were measured before and after intervention. SPSS soft ware was used for data analysis. The results of this study showed that the mean scores of pain severity and duration in infra red group was 65.67+/-8.33 minutes which decreased to 44.33+/-5.60 minutes after intervention. The respective values for the hot pack group were 81+/-8.6 and 50.33+/-5.60 minutes before and after intervention. Effect of infra red and hot pack on pain reduction was the same after intervention but infra red was more effective in reducing the duration of pain. Considering the effect of infra red, it can be recommended for pain reduction as a safe non pharmacological method. Hot pack is also effective in reducing pain by producing humid heat and patients compliance with this method will be higher

Simultaneous pancreas and kidney transplantation: first report from Shahid Beheshti University of Medical Sciences and review of anesthesia considerations

We report a 33 year-old woman presented with signs and symptoms of severe uncontrolled diabetes mellitus and chronic renal failure [diabetic nephropathy]. She was prepared for emergency simultaneous pancreas and kidney transplantation [SPK] using hemodialysis and after compensating for the acid - base abnormality. She was discharged from the hospital about 3 week after the surgery with good renal and pancreatic function. A 2-month follow-up revealed no complication and a good renal and pancreatic function. Due to the importance of this kind of treatment and several anesthetic considerations of SPK we present this case report along with some pearls about related anesthetic view points

[Effectiveness of simultaneous rhythmnic breathing and Z-track method in prone position with foot internal rotation on the pain associated with intramuscular injection]

Intramuscular injection is one of the effective methods of drug administration. Yet the procedure is painful and avoided if at all possible. This study examines the effectiveness of simultaneous rhythmic breathing and Z- track method in prone position with foot internal rotation on reducing the pain of intramuscular injection. This quasi experimental [before and after] study included 100 patients who had intramuscular injection of Metocarbamol. Standard method was evaluated against the combination of rhythmic breathing and Z - track method in prone position with foot internal rotation. Pain intensity was measured before and after intervention using visual analog scale. Descriptive statistic was used for demographic information. Means were compared on paired T-test. While before the intervention, 57% and 43% of the patients had severe and very severe pain respectively, after the intervention 24% of the patients experienced a mild pain with 67% reporting a moderate one. In addition, a statically significant difference was observed between the pain intensity means before and after intervention [p<0.0001]. Based on the results, simultaneous rhythmic breathing and Z - track method in prone position with foot internal rotation could reduce the pain associated with intramuscular injection of Metacarbamol

Comparison between CT-scan and trans-abdominal sonography in celiac and splanchnic plexus blocks in patients with advanced pancreatic head cancer

Malignant diseases are usually associated with severe pain during their course especially at the end stages. Pancreatic head cancer is one of these diseases which can be associated with severe intolerable pains in the end stages. Sometimes, these pains are extremely severe and interfere with patient's normal life. There are various techniques to control the pain out of which, celiac and splanchnic plexus blocks [temporary and permanent] are widely accepted procedures especially in severe cases and can control the pain efficiently. There are different approaches for performing this block which are all acceptable technically but are different in case of efficacy, accuracy and potential complications. Two groups were studied prospectively in 3 academic centers to evaluate different techniques of celiac plexus block in terms of feasibility and complications. For this purpose, 61 patients with a confirmed pancreatic head cancer who experienced severe pains were divided into two groups. CT- and sonographically-guided celiac and splanchnic plexus blocks were evaluated in group 1 [n=32] and group 2 [n=29], respectively. This study showed that the pain control and patients' satisfaction were greater in the CT-scan group [group A, p=0.18]. The success rate of performing a ganglion block was higher in the ultrasound group [group B, p=0.000]. The need for a re-block was also higher in the latter group. But, the quality of life improved more in the first group [CT-scan group]. However, no statistically significant difference was found between the two groups regarding these two variables. Pain relief started earlier and lasted longer in the CT-scan group. No complication was detected except for one case of abdominal infection in the sonography group and in some cases a mild pain [score<3] was reported which was not significant. Considering the limited number of cases, it seems that although there was no significant difference in the outcome of plexus block or related complications between the two above-mentioned procedures, the suggested imaging technique for celiac plexus block is CT-scan because of its feasibility, accuracy and lower number of trials to achieve a favorable result. More complementary assessments are recommended to obtain more precise results

Clinical analysis of EEG parameters in prediction of the depth of anesthesia in different stages: a comparative study

Evaluation of depth of anesthesia is especially important in adequate and efficient management of patients. Clinical assessment of EEG in the operating room is one of the major difficulties in this field. This study aims to find the most valuable EEG parameters in prediction of the depth of anesthesia in different stages. EEG data of 30 patients with same anesthesia protocol [total intravenous anesthesia] were recorded in all anesthetic stages in Shohada-e-Tajrish Hospital. Quantitative EEG characteristics are classified into 4 categories of time, frequency, bispectral and entropy-based characteristics. Their sensitivity, specificity and accuracy in determination of depth of anesthesia were yielded by comparing them with the recorded reference signals in awake, light anesthesia, deep anesthesia and brain dead patients. Time parameters had low accuracy in prediction of the depth of anesthesia. The accuracy rate was 75% for burst suppression response. This value was higher for frequency- based characteristics and the best results were obtained in beta spectral power [accuracy: 88.9%]. The accuracy rate was 89.9% for synch fast slow bispectral characteristics. The best results were obtained from entropy-based characteristics with the accuracy of 99.8%. Analysis of the entropy-based characteristics had a great value in predicting the depth of anesthesia. Generally, due to the low accuracy of each single parameter in prediction of the depth of anesthesia, we recommend multiple characteristics analysis with greater focus on entropy-based characteristics

[Medical Errors in the Health system]

Background: the health system is never as safe worldwide as everybody assumes. In recent years, many studies have been conducted to assess the magnitude of medical errors and its impact on the health system. This article reviews the studies performed in this issue to find out a strategy for approaching medical errors

Materials and methods: in a review literature, Pubmed was searched using these keywords error, medical and health system. In the complementary search, error mechanisms, error classification, reporting system and error reporting systems were also added to the search

Conclusions: medical errors are inevitable mishaps in the health system. Would there be a systematic approach in the health system for analyzing the errors and finding the root causes, the health system would maximize its benefits as much and possible future events with similar mechanism would be prevented

Results: in our health system, it is mandatory to introduce and improve such a system for quality improvement of the system

Transcutaneous electrical nerve stimulation for pain control during labor and delivery

To review the effectiveness and safety of transcutaneous electrical nerve stimulation [TENS] for pain relief during labour. TENS in a very simple term is a method utilizes small amounts of electric current applied to the skin to achieve pain relief. A small battery-powered current generator is used and attached to the skin by two electrodes. The stimulation provided by this is not painful but may cause a tingling sensation. Design: Randomized controlled trial. Setting: Department of Obstetric and Gynaecology of El Mataryia Teaching Hospital and a private hospital. Patients and The study group consisted of 60 women, full term with parity between 2 and 4, all of whom used the TENS device pain relief during labour. The criteria for inclusion were willingness to try TENS and ability to understand the procedure. Outcome Measures: Analgesic and adverse effect outcomes. Result The majority of subjects [45%] rated TENS as moderately and [30%] as excellent effective pain relieving. Forty four percent among moderately pain relieving received additional analgesic. Most of the participants expressed a willingness to use TENS if they gave birth again. No significant difference was found in fetal heart rate tracing. TENS is an effective non-pharmacological, non-invasive adjuvant pain relief modality for use in labour. There were no adverse effects on mother or newborn

Intrauterine Device Insertion at Cesarean Section

IUD insertion during cesarean delivery has the advantage of high motivation, ease of insertion and convenience for both the patient and the service providers. Direct insertion of IUD's at cesarean section is not without drawbacks, better patient selection would minimize its drawbacks and improve its safety. To evaluate the efficacy of the IUD insertion at cesarean section deliveries regarding the rate of bleeding, pain, infection, pregnancy and expulsion. Department of obstetrics and gynecology, El Matareya Teaching Hospital, during the period from March 2001 to February 2002. This was a non-randomized study in which participants self-selected into either a treatment group whose members choose to receive IUD insertion at cesarean section or into a control group whose members choose not to receive IUD insertion at cesarean section. The study included 55 women who chose to have IUD insertion at cesarean section and 50 women as a control group. The incidence menorrhagia was 22 percent among IUD user and 14 percent in the control group. The incidence of pain was 44 percent and 38 percent in both groups respectively. The incidence of pelvic infection was zero. As regard pregnancy there was no single case reported. No case presented with device expulsion or displacement. Inserting the IUD at cesarean section will be safe and effective contraceptive modality. It is suitable for women in less developed countries where availability of contraceptive services are usually limited

Ectopic pregnancy: presentation, predisposing factors and diagnosis

Ectopic pregnancy remains one of the most serious gynaecological emergencies and is one of the main causes of maternal death. It accounts for 10% of all maternal deaths in the United kingdom, an is the main cause of maternal death in the United States. A review of 100 cases of ectopic pregnancies is presented together with a discussion of predisposing factors and diagnosis