Pilot Study Evaluating the Trends in Utilization of Compounded Products Pre- and Post- COVID-19 Pandemic

Objectives: To assess utilization differences in compounded products before and after the COVID-19 pandemic. Secondary objectives were to understand if there were changes in patient cost sharing and types of products compounded pre- and post- pandemic. Method(s): A cross-sectional study was completed using a large national claims database for patients who received at least one COVID-related vaccine, test, or treatment from October 2015 to July 2022. Claims included in the analysis are those identified as paid, listed as compounded, and were filled in 2019, 2020, or 2021. Chi-Square and T-Tests were used to determine if there are differences between each year. Result(s): The prevalence of paid claims for compounded products was 0.00055% (14,101) in 2019, 0.00042% (11,551) in 2020, and 0.00048% (14,005) in 2021. In each year, most claims for compounded products were through commercial insurance 70% in 2019, 62% in 2020, and 65% in 2021. On average there were approximately 2 claims per patient. The most frequently compounded product was lidocaine hydrochloride 20mg/ML topical solution. In 2020 there was an increase in utilization of naltrexone hydrochloride, a treatment for opioid use disorder (OUD). Between 2019 and 2020 the number of compounded claims decreased 17.6% while the number of total claims increased by 9.01%. From 2020 to 2021 the number of claims for compounded products returned to pre-pandemic levels with a 21.24% increase. In the same period, the total number of claims increased 5.86%. The average patient cost sharing for compounded products was $42.57 (SD: $60.02) in 2019, $40.07 ($80.36) in 2020, and $42.61 ($60.02) in 2021. Conclusion(s): We found that there were fewer patients receiving compounded products following the COVID-19 pandemic. We found no change in the number of compounded claims for hydroxychloroquine and ivermectin, though in 2020, there was a notable increase in the number of claims for naltrexone hydrochloride.Copyright © 2023

Report of the Association Between Multisystem Inflammatory Syndrome and Severe Myocarditis

Introduction: The people worldwide have been affected by severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) infection since its appearance in December, 2019. Kawasaki disease-like hyperinflammatory shock associated with SARS-CoV-2 infection in previously healthy children has been reported in the literature, which is now referred to as a multisystem inflammatory syndrome in children (MIS-C). Some aspects of MIS-C are similar to those of Kawasaki disease, toxic shock syndrome, secondary hemophagocytic syndrome, and macrophage activation syndrome. Case Presentation: This study reported an 11-year-old boy with MIS-C presented with periorbital and peripheral edema, abdominal pain, elevated liver enzymes, severe right pleural effusion, moderate ascites, and severe failure of right and left ventricles. Conclusion(s): Due to the increasing number of reported cases of critically ill patients afflicted with MIS-C and its life-threatening complications, it was recommended that further studies should be carried out in order to provide screening tests for myocardial dysfunction. Adopting a multidisciplinary approach was found inevitable.Copyright © 2023, Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

Mild Androgen Insensitivity Syndrome presenting in male with infertility and sexual difficulties

Androgen insensitivity syndrome has a wide spectrum of presentations. It results from a mutation in androgen receptor (AR) gene. It ranges from mild androgen insensitivity syndrome (MAIS) which is the mildest form to complete androgen insensitivity syndrome (CAIS). In case of MAIS, the abnormality that can be observed appears to be male infertility and sexual difficulties including premature ejaculation and erectile dysfunction. In this case report, we discuss a case of MAIS in a 37-year-old male who presented with infertility, premature ejaculation, and secondary erectile dysfunction.Copyright © 2023, Ibn Sina Trust. All rights reserved.

Spinal Versus General Anesthesia for Spine Surgery During the COVID-19 Pandemic: A Case Series

Background: Hospitals are one of the primary resources for disease transmission, so many guidelines were published, and neuro-surgeons were advised to postpone elective spine surgeries during the COVID-19 pandemic. Objective(s): To avoid pulmonary complications and reduce the risk of spreading the virus and contracting the disease during the COVID-19 era, we operated a group of our patients under spinal anesthesia rather than general anesthesia. Method(s): We retrospectively analyzed all patients who underwent discectomy surgery for lumbar spinal disc herniation under SA between September 2020 and 2021. Result(s): Sixty-four patients diagnosed with lumbar disc herniation underwent lumbar discectomy with SA. All patients except three were male. The mean age was 44.52 +/- 7.95 years (28 to 64 years). The mean procedure time for SA was 10 minutes. The duration of the surgery was 40 to 90 minutes per each level of disc herniation. The mean blood loss was 350 cc (200 to 600 cc). The most common involved level was L4/L5 intervertebral disc (n = 40 patients;63.5%). The mean recovery time was 20 minutes. Only three patients requested more analgesics for relief of their pain postoperatively. All patients with discectomy were discharged a day after surgery, and in the case of fusion, two days after surgery. All the patients were followed up for six months, showing no recurrence symptoms, good pain relief, satisfaction with the surgery, and no bad memory of the surgery. Conclusion(s): Spinal anesthesia is a good alternative or even the main anesthesia route for patients with lumbar disc herniation. More studies are needed to elucidate the best candidate for SA in patients with lumbar pathology.Copyright © 2023, Author(s).

COVID-19 and Spontaneous Coronary Artery Dissection: Association or Causality

Clinical Information Patient Initials or Identifier Number: JS Relevant Clinical History and Physical Exam: A 55-year old woman was brought to emergency department complaining of sudden onset squeezing chest pain radiating to her arm and jaw and associated with giddiness. She had flu like illness a day prior to her presentation associated with malaise, arthralgia and dry cough. She had history of hypertension. Physical examination revealed dual heart sounds and clear lung fields to auscultation. Relevant Test Results Prior to Catheterization: Electrocardiogram (ECG) showed normal sinus rhythm and the cardiac enzymes were elevated;high sensitivity troponin-I, 23000 ng/L (range0-10 ng/L). RNA PCR was positive for SARS-CoV-2 (COVID-19). D-Dimer was 303microgram/L (normal <500). Transthoracic echocardiogram showed severe hypokinesis of the mid inferolateral wall with left ventricular ejection fraction (LVEF) 52%. Chest X-ray showed no focal consolidation. [Formula presented] [Formula presented] Relevant Catheterization Findings: Invasive coronary angiogram showed tortuous coronary arteries with abrupt narrowing of mid- distal Ramus Intermiedius and discrete lesion of mid PDA. SCAD (spontaneous Coronary dissection) of Ramus Intermedius and mid PDA (posterior descending artery) was suspected, and patient was treated conservatively. Repeat coronary angiography, few months later showed complete resolution of SCAD with normal appearance of affected vessels. [Formula presented] [Formula presented] [Formula presented] Interventional Management Procedural Step: After obtaining an informed consent right Radial access was achieved with 6F Terumo sheath using over the wire technique. 1% lignocaine was used as local anaesthetic. 5F JL 3.5 (Judkin's) and JR 4 catheters were used to engage left main stem (LMS) and right coronary artery (RCA) and selective coronary angiography was performed. No percutaneous coronary intervention was performed. After the procedure hemoband (TR band) was applied to access site. Patient remained hemodyanamically stable throughout the procedure. [Formula presented] [Formula presented] [Formula presented] Conclusion(s): SCAD is a potential cause of type II myocardial infarction in patients with COVID-19, but more studies are needed to establish causality. Infection-related SCAD may occur at any time during index events and could be difficult to diagnose. Conservative management seems like a safe strategy.Copyright © 2023

The use of ilioinguinal and iliohypogastric nerve block anesthesia in inguinal bladder hernia repair Minimally invasive anesthesia technique in inguinal bladder hernia repair

Aim: There are data showing that the use of minimally invasive anesthesia methods (local anesthesia, nerve blocks) as an alternative to traditional anesthesia methods used in inguinal hernia repair surgery is safe and effective. During the COVID-19 pandemic, which affected the whole world, we aimed to evaluate the use of minimally invasive anesthesia methods in patients with inguinal bladder hernia, as well as their perioperative and postoperative results in our pilot study. Material(s) and Method(s): We evaluated the perioperative and postoperative data of five patients with inguinal bladder hernia, who underwent surgery with local anesthesia and ilioinguinal/iliohypogastric nerve blockade, four of which were performed during the COVID-19 pandemic. Result(s): It is possible to perform inguinal bladder hernia surgery with local anesthesia and ilioinguinal/iliohypogastric nerve block, including in secondary cases. Better hemodynamic stabilization in the intraoperative period reduces the need for narcotic analgesics by providing effective analgesia in the postoperative period, as well as reducing the risk of contamination in airway control. Discussion(s): Performing inguinal bladder hernia surgery using local anesthesia and ilioinguinal/iliohypogastric nerve block provides reliable and effective analgesia during the perioperative and postoperative periods.Copyright © 2023, Derman Medical Publishing. All rights reserved.

Intentional Taxus Baccata Ingestion Presenting with Cardiogenic Shock and Ventricular Tachycardia

Background The prevalence of anxiety and depression has increased following the COVID pandemic. Young women are disproportionally at risk of suicidal behaviors. Ingestion of Taxus baccata (English Yew) may lead to cardiotoxicity and death. Intoxication is known to be resistant to standard treatments with no effective antidotes. Case A 20-year-old female with a history of major depressive disorder presented to our emergency department unresponsive in pulseless ventricular tachycardia (VT) (figure 1A). She underwent CPR and achieved ROSC, however, was persistently hypotensive despite multiple pressors and was subsequently placed on VA ECMO. Review of a home journal revealed a plan to ingest 50 grams of Yew with suicidal intent. Decision-making Taxoids have been reported to have similar properties to digoxin and therefore digoxin-specific FAB antibodies were administered. She was also started on amiodarone and lidocaine for management of VT. After 3 hours she converted into sinus rhythm and had no further episodes of VT. Her clinical course was complicated by severe LV dysfunction and dilation while on VA-ECMO necessitating placement of an LV impella. By day three, all mechanical support was weaned off and she had normalization of her EF. Patient was discharged to an inpatient psychiatry facility on day 7 of hospitalization. Conclusion Ingestion of English Yew with suicidal intent is rare but may cause cardiogenic shock and VT requiring aggressive hemodynamic support until the toxin is metabolized. [Formula presented]Copyright © 2023 American College of Cardiology Foundation

Less aerolization with superior laryngeal nerve block compared to intravenous lidocaine at extubation.

Introduction: coughing is a physiological response to protect the airway, it produces aerosols that are identified by imaging reaching a speed of up to 8 meters per second. Extubation produces cough, hypertension, tachycardia, apnea and laryngospasm, there are methods to minimize its occurrence. Due to the COVID-19 pandemic, intravenous lidocaine and superior laryngeal nerve block have been used as cough reflex prophylaxis. The aim was to compare them in cough inhibition. Material and methods: patients aged 18-60 years, elective surgery with balanced general anesthesia, ASA 1-3, with intubation less than 3 hours, were selected. A total of 90 patients were randomized, 45 in each group. A total of 10 patients were eliminated because they presented hemodynamic instability at the end of surgery, and because the intravenous dose of lidocaine was not administered within the established time. Results: there was no statistically significant difference in the number of patients who presented cough in both groups (13 vs 10, p = 0.4684), of these there was a statistically significant difference in the number of decibels in favor of the block group (75.6 vs 67, p < 0.001). Conclusions: block presents less aerolization than intravenous lidocaine in extubation. (English) [ FROM AUTHOR] Introducción: la tos es una respuesta fisiológica de protección de la vía aérea, produce aerosoles que se identifican por imagen y alcanza una velocidad de hasta ocho metros por segundo. La extubación produce tos, hipertensión, taquicardia, apnea y laringoespasmo, existen métodos para minimizar su aparición. Debido a la pandemia de COVID-19 se han utilizado como profilaxis del reflejo tusígeno, la lidocaína intravenosa y el bloqueo del nervio laríngeo superior. El objetivo fue compararlos en la inhibición de la tos. Material y métodos: se seleccionaron pacientes entre 18-60 años, cirugía electiva con anestesia general balanceada, ASA 1-3, con intubación menor a tres horas. Se aleatorizó un total de 90 pacientes, 45 en cada grupo, se eliminó un total de 10 pacientes por presentar inestabilidad hemodinámica al final de la cirugía o por no administrar dosis intravenosa de lidocaína en el tiempo establecido. Resultados: no hubo diferencia estadísticamente significativa en el número de pacientes que presentaron tos en ambos grupos (13 vs 10, p = 0.4684), de éstos se obtuvo una diferencia estadísticamente significativa en el número de decibeles a favor del grupo de bloqueo (75.6 vs 67, p < 0.001). Conclusiones: el bloqueo (selectivo) presenta menos aerolización que la lidocaína intravenosa en la extubación. (Spanish) [ FROM AUTHOR] Copyright of Revista Mexicana de Anestesiologia is the property of Colegio Mexicano de Anestesiologia and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Successful Use of Biventricular Assist Devices in Fulminant Myocarditis

Background Fulminant myocarditis can cause biventricular dysfunction with a mortality rate over 40%. We report a case with severe biventricular failure due to fulminant myocarditis that was successfully supported by left and right ventricular assist devices. Case A 65-year-old woman presented with chest pain, abdominal pain and diarrhea. She was hypotensive and labs revealed elevated troponin-T of 13.5 ng/mL and lactate of 4.3 mmol/L. She was positive for COVID by antigen testing. She was started on multiple vasopressor infusions and admitted to the intensive care unit. Echocardiogram revealed a severely reduced left ventricular ejection fraction of 15% and severe global hypokinesis. The following day, she developed a wide complex tachycardia that was refractory to amiodarone, lidocaine and multiple defibrillation attempts. She was transferred emergently to the cardiac cath lab where coronary angiography revealed an isolated 70% stenosis of the distal left circumflex artery. A Swan-Ganz catheter was placed that yielded a cardiac index by Fick of 1.2 L/min/m2, systemic vascular resistance of 1270 dynesseccm-5 and mixed venous oxygen saturation of 35%. Decision was made to emergently insert an Impella CP device. That evening, she developed complete heart block and transvenous pacing wire was inserted. Due to frequent suction alarms, decision was made to insert ProtekDuo device, which resulted in hemodynamic stabilization. A temporary coronary sinus pacing lead for atrial capture was inserted to improve atrioventricular synchrony. After several days of monitoring, repeat echocardiogram showed complete recovery of biventricular function and Impella CP and ProtekDuo devices were removed. Decision-making The decision of early implantation of ProtekDuo device was made to provide adequate blood flow to the left ventricular assist device for hemodynamic support. In addition, increased atrioventricular synchrony via insertion of temporary coronary sinus pacing wire improved cardiac output. Conclusion Fulminant myocarditis involving biventricular dysfunction can be supported by the use of simultaneous left and right ventricular assist devices.Copyright © 2023 American College of Cardiology Foundation

Vulvar Aphthous Ulcers in Children with COVID-19: A case series

Background: Vulvar aphthous ulcers are defined by acute onset of painful genital lesions that are associated with viral illness. They classically present in non-sexually active girls and are diagnosed once other more common cause of genital ulcerations, including STIs or autoimmune bullous diseases, have been excluded. Previous reports of vulvar aphthous ulcers associated with COVID-19 have described treatment of the symptoms with either local or systemic corticosteroids. This case series illustrates the ability to manage these patients conservatively resulting in complete and spontaneous resolution of the ulcers. Case: Four females, ages ranging from 10 to 21, presented to the emergency department for vulvar pain. Each patient was diagnosed with vulvar aphthous ulcers based on physical examination. All four patients were diagnosed with COVID-19 with rapid antigen testing. With directed counseling, each patient and their family were instructed on a regimen of acetaminophen, sitz baths, and voiding in the bath. Topical analgesics such as lidocaine gel were not administered and steroids were not prescribed. All four patients were able to manage their symptoms at home and did not require admission to the hospital. All patients experienced spontaneous and complete restoration of anatomy in 1-2 weeks. Comments: The novel coronavirus pandemic caused by SARS-CoV02 has resulted in considerable morbidity and mortality. While immunocompromised hosts are more susceptible to complications of COVID-19, patients with intact immune systems may also experience distressing viral related symptoms. The pathogenesis of these ulcers has been hypothesized to be a result of non-specific inflammatory response to a viral systemic illness resulting in blistering of the mucosal genital surfaces It has been proposed that the ulcers are secondary to a cytokine storm that occurs in SARS-CoV-2 infections. Elevated cytokines, including TNF-alpha, result in neutrophil chemotaxis to mucosal tissue and subsequent ulceration of the tissue. Previous case studies discussing vulvar aphthous ulcers associated with COVID-19 all required hospitalization for pain control and/or urinary retention and treatment with steroids. Hospitalization can be a traumatic experience for both child and adolescent patients as well as their family. The added isolation and precautions required for treating COVID positive patients can have a further psychological impact. Through directive counseling, all patients in our case series were able to avoid hospitalization and supportive care of the genital lesions in the outpatient setting was sufficient.Copyright © 2023

Getting to the root of it: contact anaphylaxis from polyethylene glycol in a dental lubricant

A 46-year-old man with no known allergies or history of atopy was referred for the investigation of a severe anaphylactic reaction following root canal dental treatment. The procedure had been done under local anaesthetic and involved drilling the tooth, removal of dental pulp, cleaning and insertion of a temporary filling. Preliminary skin prick tests (SPTs) and intradermal tests were negative to natural rubber latex, articaine (the local anaesthetic used for his procedure), lidocaine and chlorhexidine. He had negative specific IgE to chlorhexidine and latex, and a negative lidocaine challenge, confirming that he was not allergic to lidocaine. He returned for further dental treatment, which was done without local anaesthetic. As the procedure was completed, he developed severe anaphylaxis again. He made a full recovery and his dentist was asked for detailed information and samples of all the materials used during the procedure. Subsequent SPT showed a positive weal of 12 x 6 mm to the dental lubricant, Glyde, which was used on both occasions. Its ingredients included polyethylene glycol (PEG) 4253. SPT to other high-weight macrogol-containing products showed positive reactions to a 5% lidocaine ointment, Movicol, EMLA cream and Depomedrone. On further questioning he recalled minor immediate irritation after using a brand of children's shampoo, but a SPT to the shampoo was negative. An open test, closed test and SPT to a lower-molecular-weight patch-test allergen (PEG400 in petrolatum) were negative. PEGs or 'Macrogols' are hydrophilic polymers used in food, cosmetics and pharmaceutical reagents. They have recently attracted attention as they are excipients in several COVID-19 vaccines and have been suggested as a possible cause of anaphylaxis. Anaphylaxis to higher-molecular-weight PEGs has been reported from the use of bowel preparations and parenteral steroids. There are a handful of reports of contact urticaria to PEG-containing medicaments. We report this case to raise awareness of severe immediate hypersensitivity to these apparently innocuous ingredients and a novel source of exposure. A low index of suspicion, lack of standardized nomenclature and commercial reagents for testing are current barriers to diagnosis.

Urticaria After Lidocaine Use for Pecto-Intercostal Nerve Block.

Urticaria within one hour of lidocaine injection is a sign of type I (immediate) hypersensitivity to lidocaine, yet most patients suspected of having a lidocaine allergy do not exhibit urticaria. Aside from being a sign of a rare lidocaine allergy, urticaria can also be a symptom of COVID-19. COVID-19 patients who experience urticaria after receiving lidocaine require careful evaluation to determine the cause. Here, we present a case of a patient exhibiting urticaria one hour after a lidocaine injection for the Pecto-intercostal nerve block to treat COVID-19-induced costochondritis.

Lidocaine reinforces the anti-inflammatory action of dexamethasone on myeloid and epithelial cells activated by inflammatory cytokines or SARS-CoV-2 infection.

BACKGROUND: Severe cases of Coronavirus Disease 2019 (COVID-19) that require admission to the Intensive Care Unit (ICU) and mechanical ventilation assistance show a high mortality rate with currently few therapeutic options available. Severe COVID-19 is characterized by a systemic inflammatory condition, also called "cytokine storm", which can lead to various multi-organ complications and ultimately death. Lidocaine, a safe local anesthetic that given intravenously is used to treat arrhythmias, has long been reported to have an anti-inflammatory and pro-homeostatic activity. METHODS: We studied the capacity of lidocaine to modulate cytokine secretion of mouse and human myeloid cell lines activated by different cytokines or Toll Like Receptor (TLR) ligands (flagellin (FliC), Lipopolysaccharide (LPS), Polyinosinic:polycytidylic acid (Poly I:C) and N-Palmitoyl-S- [2,3-bis(palmitoyloxy)-(2RS)-propyl]-(R)-cysteinyl-(S)-seryl-(S)-lysyl-(S)-lysyl-(S)-lysyl-(S)-lysine x 3HCl (Pam3Cys-SKKKK)) or by Severe acute respiratory syndromecoronavirus 2 (SARS-CoV-2) infection to epithelial cells. Reporter cell lines were used to study modulation of lidocaine of specific signaling pathways. RESULTS: Lidocaine used in combination with dexamethasone, had an additive effect in the modulation of cellular inflammatory response triggered by Tumoral Necrosis Factor alpha (TNFα), Interleukin 1 beta (IL-1ß) as well as different TLR ligands. We also found that lidocaine in combination with dexamethasone modulates the Nuclear factor kappa B (NF-κB) pathway, inflammasome activation as well as interferon gamma receptor (IFNγR) signaling without affecting the type I interferons (Type I IFNs) pathway. Furthermore, we showed that lidocaine and dexamethasone treatment of epithelial cells infected with SARS-CoV-2 modulated the expression of chemokines that contribute to pro-inflammatory effects in severe COVID. CONCLUSIONS: We reported for the first time in vitro anti-inflammatory capacity of lidocaine on SARS-CoV-2 triggered immune pathways. These results indicated the potential of lidocaine to treat COVID-19 patients and add tools to the therapeutic options available for these concerning cases.

Lidocaine inhibits influenza a virus replication by up-regulating IFNα4 via TBK1-IRF7 and JNK-AP1 signaling pathways.

Influenza A viruses (IAV), significant respiratory pathogenic agents, cause seasonal epidemics and global pandemics in intra- and interannual cycles. Despite effective therapies targeting viral proteins, the continuous generation of drug-resistant IAV strains is challenging. Therefore, exploring novel host-specific antiviral treatment strategies is urgently needed. Here, we found that lidocaine, widely used for local anesthesia and sedation, significantly inhibited H1N1(PR8) replication in macrophages. Interestingly, its antiviral effect did not depend on the inhibition of voltage-gated sodium channels (VGSC), the main target of lidocaine for anesthesia. Lidocaine significantly upregulated early IFN-I, interferon α4 (IFNα4) mRNA, and protein levels, but not those of early IFNß in mouse RAW 264.7 cell line and human THP-1 derived macrophages. Knocking out IFNα4 by CRISPR-Cas9 partly reversed lidocaine's inhibition of PR8 replication in macrophages. Mechanistically, lidocaine upregulated IFNα4 by activating TANK-binding kinase 1 (TBK1)-IRF7 and JNK-AP1 signaling pathways. These findings indicate that lidocaine has an incredible antiviral potential by enhancing IFN-I signaling in macrophages. In conclusion, our results indicate the potential auxiliary role of lidocaine for anti-influenza A virus therapy and even for anti-SARS-CoV-2 virus therapy, especially in the absence of a specific medicine.

Compound lidocaine/prilocaine cream combined with tetracaine prevents cough caused by extubation after general anaesthesia: a randomised controlled trial.

BACKGROUND: Coughing caused by tracheal extubation is common following general anaesthesia. Heavy aerosol production by coughing during recovery from general anaesthesia in patients with respiratory infections (especially COVID-19) may be one of the highest risk factors for infection in healthcare workers. The application of local anaesthetics to the endotracheal tube is an effective method to reduce coughing. The most commonly used anaesthetics are compound lidocaine/prilocaine cream and tetracaine spray. However, coughing still occurs when the two anaesthetics are used alone. We speculated that the application of compound lidocaine/prilocaine combined with tetracaine spray would better prevent coughing caused by tracheal extubation. METHODS: Patients scheduled for laparoscopic cholecystectomy or cholecystectomy combined with common bile duct exploration under general anaesthesia were randomly assigned to Group C (saline spray), Group L (2 g compound lidocaine/prilocaine cream contains 5 mg of lidocaine and 5 mg prilocaine)), Group T (tetracaine) and Group F (compound lidocaine/prilocaine cream combined with tetracaine). The incidence of coughing, the endotracheal tube tolerance assessment, the incidence of agitation, the active extubation rate, the incidence of postoperative pharyngeal pain and the incidence of postoperative cough were recorded and analysed. Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), and the plasma concentrations of epinephrine and norepinephrine were measured immediately before extubation and 1 min after extubation. RESULTS: A total of 211 patients were randomly assigned to Group C (53 cases), Group L (52 cases), Group T (52 cases) and Group F (54 cases). The primary result is assessment of the incidence of cough. The patients emerged from general anaesthesia, 96% of Group C had cough, which was significantly reduced in Group L (61.5%, P < 0.001), Group T (75%, P < 0.05) and Group F (22.2%, P < 0.001). Group F had a significantly reduced incidence of cough compared to Group L and Group T (P < 0.05 or P < 0.01, respectively). The secondary results were assessed. The endotracheal tube tolerance score in Group C ((1, 3) 4, P < 0.001) was higher than Group L ((0, 1) 2), Group T ((0, 1.25) 3) and Group F ((0, 0) 1). Group F had a significantly lower score than Group L and Group T (P < 0.05, P < 0.01, respectively). The incidence of agitation and the active extubation rate were also higher in Group C (96.2% and 71.7%, respectively, P < 0.001) than Group L (48.1% and 15.4%, respectively), Group T (61.5% and 26.9%, respectively) and Group F (17.3% and 7.7%, respectively). Blood pressure, HR and plasma concentrations of epinephrine and norepinephrine were significantly higher in Group C than in all other groups at the time of extubation and 1 min after extubation (P < 0.001). Group F exhibited significantly reduced blood pressure, heart rate and plasma concentrations of epinephrine and norepinephrine compared to Group L and Group T (P < 0.05, P < 0.01 or P < 0.001, respectively). The incidence of postoperative pharyngeal pain and the incidence of postoperative cough were not significantly different among the groups. CONCLUSIONS: Compound lidocaine/prilocaine cream combined with tetracaine may be a more effective approach for preventing coughing and stabilising circulation during extubation following general anaesthesia. This may play an important role in preventing medical staff from contracting respiratory infectious diseases. TRIAL REGISTRATION: Chinese Clinical Trial Registry: ChiCTR2200058429 (registration date: 09-04-2022) "retrospectively registered".

Current Evidence Involving WALANT Surgery.

Wide-awake local anesthesia no-tourniquet (WALANT) surgery is an attractive option for hand surgeons, particularly during resource-scarce periods, as it eliminates dependence on main operating rooms or hospital-based procedures. The limited prepping or draping used for WALANT field sterility is as effective, if not more effective, than standard sterile prepping or draping. Patient anxiety surrounding WALANT surgery is similar to or less than that of general or local anesthesia with or without tourniquet. Patients use the same or lower amounts of postoperative narcotics after WALANT as compared to after the other anesthetic methods. Wide-awake local anesthesia no-tourniquet surgery saves significant costs for the same surgeries when performed under general or local anesthesia with or without tourniquet. There are very few complications associated with the WALANT method of anesthesia; rare case reports include vasovagal syncope and cardiac arrhythmia due to inadvertent intravascular injection of epinephrine.

XyloFUNS: Xylocaine to freeze during unpleasant nasopharyngeal swabs in children-a randomized controlled trial.

Objectives: To evaluate the efficacy of intranasal vaporized lidocaine in reducing pain for children undergoing a nasopharyngeal (NP) swab in the Emergency Department (ED). Study Design: A randomized blinded clinical trial was conducted in a paediatric ED. Both participants and the researcher evaluating the primary outcome were blinded. Children aged 6 to 17 years old requiring a NP swab were eligible. Participants were randomly allocated to receive intranasal lidocaine or a sham treatment prior to their NP swab. The primary outcome measure was pain during the swab as assessed by the visual analog scale. Secondary outcome measures were pain using the verbal numeric rating scale, fear using the children fear scale, and adverse effects of the intervention. Results: Eighty-eight participants were enrolled-45 in the lidocaine group and 43 controls. The mean visual analog scale scores for pain were 46 mm in the lidocaine group and 53 mm in the control group (mean difference 7 mm; 95% CI: -5 to 19 mm). No serious adverse events were observed. Conclusions: Intranasal lidocaine administered prior to NP swabs in the ED failed to show an improvement in pain scores for school-aged children and youth.