Bilateral Greater Occipital Nerve Block; Distal Versus Proximal Approach for Postdural Puncture Headache: A Randomized Clinical Trial.

BACKGROUND: One of the common neuraxial anesthesia complications is postdural puncture headache (PDPH). Greater occipital nerve block (GONB) is a simple and safe maneuver with a faster onset than other treatment modalities. OBJECTIVES: Our work aims to compare the pain-relieving effect between distal and proximal ultrasound (US)-guided bilateral GONBs for PDPH. STUDY DESIGN: A randomized, double-blinded study. SETTING: Aswan University Hospital, Egypt. METHODS: The study included 50 patients of both genders, aged 20 to 60 years, who had PDPH with a sitting Numeric Rating Scale (NRS-11) >= 4. Patients were randomized into 2 equal groups. Group D received a US-guided distal bilateral GONB (at the superior nuchal line level). Group P received a US-guided proximal bilateral GONB (at the second cervical vertebra level). Three milliliters of isobaric bupivacaine 0.5% and 4 mg dexamethasone were injected in both blocks. RESULTS: There was a significant decrease in lying down and sitting NRS-11 at 10 minutes, 6, 12, 24, 36, and 48 hours after the intervention compared to before the intervention in both groups. Only sitting NRS-11 was significantly lower in group P than group D in all measurements after the intervention. Success rate (sitting NRS-11 < 4) at 24 hours was 60% in group D and 84% in group P, with an insignificant difference. The total 48-hour paracetamol and tramadol consumption was significantly lower in group P than in group D (P = 0.038 and 0.036, respectively). Transient cervicalgia occurred in 8% of each group. LIMITATIONS: The small number of cases to prove the secondary outcomes and the absence of a control group. CONCLUSIONS: US-guided proximal and distal GONBs were minimally invasive, simple, and effective ways to treat PDPH, with the superiority of proximal GONB in alleviating PDPH. KEY WORDS: Postdural puncture headache, distal, proximal, greater occipital nerve, block, ultrasound, pain-relieving, neuraxial anesthesia.

IVUS-guided versus OCT-guided PCI among patients presenting with acute coronary syndrome.

BACKGROUND: Intravascular imaging modalities such as intravascular ultrasound (IVUS) and, more recently, optical coherence tomography (OCT) improved the visualization of coronary anatomy and plaque pathology. We aimed to compare the procedural and short-term outcomes between IVUS-guided and OCT-guided percutaneous coronary interventions (PCIs) in patients with acute coronary syndrome (ACS). METHODS: In the present retrospective study, we reviewed the data of 50 patients who had IVUS-guided PCI and 50 patients who had OCT-guided PCI for ACS between January 2020 and June 2021. Intravascular imaging was done before and after stenting. Both groups were compared in terms of minimal luminal area (MLA), stent dimensions, final minimal stent area (MSA) and stent expansion as well as negative angiographic outcomes. Patients were followed for six months to record major adverse cardiac events (MACE). RESULTS: The patients' mean age was 57 ± 13 years with male predominance (78%). The radiation time and dose were significantly higher among IVUS group. Pre-stenting MLA was significantly higher in IVUS group (2.63 mm vs. 2.22 mm in OCT, P = 0.013). Stent expansion was significantly higher among OCT group (97% vs. 93% in IVUS group, P = 0.001) with no significant difference between both groups regarding MSA [mm2] (8.88 ± 2.87 in IVUS vs. 8.1 ± 2.76 in OCT, P = 0.169). No significant difference between both groups was noted regarding contrast volume, edge dissection, tissue prolapse, and no reflow. The rates of six-month MACE were significantly higher in the IVUS group. CONCLUSIONS: OCT-guided PCI in ACS is safe and is associated with similar MSA to that of IVUS-guided PCI. Future randomized trials are needed to confirm these findings.

Effect of Dexmedetomidine, Dexamethasone, and Ondansetron on Postoperative Nausea and Vomiting in Children Undergoing Dental Rehabilitation: A Randomized Controlled Trial.

BACKGROUND: Postoperative nausea and vomiting (PONV) are common unpleasant adverse effects after surgery. The incidence of PONV in pediatric patients is often twice as high as in adults. OBJECTIVES: This study aimed to evaluate the effects of dexmedetomidine, dexamethasone, and ondansetron for preventing PONV in children undergoing dental rehabilitation surgery. STUDY DESIGN: A prospective, randomized controlled clinical trial. SETTING: Sharurah Armed Forces Hospital, Ministry of Defense Medical Services, Saudi Arabia. METHODS: One hundred patients (6-12 years old) scheduled for dental rehabilitation were included. Patients were randomly allocated into 4 groups (25 each) to receive either 0.15 mg/kg dexamethasone (DEX), 0.05 mg/kg ondansetron (OND), 0.3 microgram/kg dexmedetomidine (DEXMED), or normal saline (control[CONT]) in DEX, OND, DEXMED or CONT groups, respectively, via infusion after induction of anesthesia. The primary outcome was a PONV incident in the first 24 hours. Secondary outcomes were: granisetron doses during 24 hours postoperative, Paediatric Anaesthesia Emergence Delirium (PAED) scale, Pediatric Objective Pain Scale (POPS) for 4 hours postoperatively, and complications in the first 24 hours. RESULTS: The reduction of PONV and the overall number of patients who developed PONV was statistically significant in the DEXMED group compared to the CONT group (P = 0.041). However, the DEXMED group was higher compared to the DEX and OND groups but not statistically significant. Granisetron requirements and doses were statistically significantly lower in the DEXMED group than in the CONT group. PAED and POPS scores were much better in the DEXMED group than in the other groups with a statistically significant difference in most of the time measurements. LIMITATION: Optimal dexmedetomidine dose for better effect on PONV without affecting hemodynamic stability requires more studies. CONCLUSION: Dexmedetomidine is effective in reducing PONV in children undergoing dental rehabilitation with better sedative and analgesic scores as compared to the control group.

Pediatric Postoperative Pain Control With Quadratus Lumborum Block and Dexamethasone in Two Routes With Bupivacaine: A Prospective Randomized Controlled Clinical Trial.

BACKGROUND: Ultrasound-guided Quadratus Lumborum block (QLB) is a regional analgesia approach that has been reported to provide effective post-operative pain relief for both abdominal and retroperitoneal surgery. Bupivacaine is the most often used and well documented local anesthetic medication in children. Dexamethasone is a systemic glucocorticoid that is often used to minimize postoperative nausea, vomiting, and pain to improve recovery quality after surgery. OBJECTIVES: To evaluate postoperative analgesia of QLB in pediatric patients undergoing renal surgeries by the addition of dexamethasone to bupivacaine compared to intravenous administration. STUDY DESIGN: A prospective, randomized, controlled clinical trial. SETTING: Pediatric surgery unit in a university hospital. METHODS: One hundred and five patients (6-12 years old) scheduled for renal surgeries were randomly allocated into 3 groups, with 35 patients in each group. Randomization was based on computer-generated codes. The groups were DEX1 (QLB with IV dexamethasone group), DEX2 (QLB dexamethasone group), and QLB CONTROL (QLB alone). The 1st time for rescue analgesia request, total morphine consumption, Pediatric Objective Pain Scale (POPS), and parents' satisfaction score were measured in 24 hours follow-up to evaluate postoperative pain control. RESULTS: The time to 1st rescue analgesics request (hours), total morphine consumption (mg), and the parents' satisfaction scores were much better in groups DEX1 and DEX2 as compared to group CONTROL with statistical significance. However, group DEX2 was better than DEX1 in the previous outcomes but without statistical significance. In respect, the pediatric objective pain scale was much lower with a significant difference in groups DEX1and DEX2 in comparison with group CONTROL up to 18 hours postoperatively. LIMITATIONS: Difficult to assess the block as all children were sedated, plus this was a unilateral surgical procedure with limited surgical incision, so the effect of QLB needed to be studied when there is a bilateral surgical procedure. CONCLUSIONS: Dexamethasone may be more effective when added to bupivacaine than when given systemically in analgesic effects without any impact on the other secondary pain-related outcomes. Dexamethasone as an adjuvant to bupivacaine has a marked hand on prolongation of the postoperative duration of analgesia, less request for rescue analgesia, and fewer side effects as compared to bupivacaine if used as a sole agent in QLB.

Effect of intravenous versus intraperitoneal magnesium sulfate on hemodynamic parameters and postoperative analgesia during laparoscopic sleeve gastrectomy-A prospective randomized study.

BACKGROUND AND AIMS: Hemodynamic changes to pneumoperitoneum and postoperative pain can be detrimental in obese patients; we investigated whether intravenous (IV) or intraperitoneal (IP) magnesium sulphate (MgSo4) administration could attenuate the hemodynamic stress response to pneumoperitoneum and improve postoperative pain control after laparoscopic sleeve gastrectomy (LSG). MATERIAL AND METHODS: In total, 120 patients scheduled for LSG were randomized to either, control group (Group C, IV and IP saline), Group I (IV 30 mg/kg MgSo4), or Group P (IP 30 mg/kg MgSo4). Outcome variables were mean arterial pressure (MAP), heart rate (HR), postoperative pain score, total analgesic consumption, and incidence of adverse events. RESULTS: MAP and HR were significantly lower in Groups I and P than that in control group. Pain score was better in Groups I and P than in control group up to 2 h postoperative (P = 0.023, 0.010, respectively); it was significantly lower in Group P than other two groups at 4 h postoperative (P <0.001). Significantly, reduced postoperative analgesic consumption with delayed onset to first analgesic request were observed in magnesium groups compared to control (P = 0.001, respectively). Moreover, onset to first analgesic request was longer in Group P than Group I (P = 0.001). No serious side effects were noticed. CONCLUSION: The IV and IP administration of MgSo4 significantly attenuated the circulatory response to pneumoperitoneum and reduced postoperative pain as well as opioid consumption as compared to controls in obese patients undergoing LSG with no serious adverse effects.

Pressure-controlled ventilation could decrease intraoperative blood loss and improve airway pressure measures during lumbar discectomy in the prone position: A comparison with volume-controlled ventilation mode.

BACKGROUND AND AIMS: Prone positioning may induce alterations of hemodynamic and airway pressure parameters that may affect intraoperative (IO) blood loss. Pressure-controlled ventilation (PCV) may modify these alterations. To observe the relation between ventilation mode and hemodynamic, airway pressure changes, and blood loss during lumbar discectomy performed in the prone position. MATERIAL AND METHODS: Volume-controlled ventilation (VCV) patients were using tidal volume (TV) of 8-10 ml/Kg, but for pressure-controlled ventilation (PCV) patients peak inspiratory pressure (PIP) was adjusted to provide the same TV according to ideal body weight. Respiratory and hemodynamic parameters were recorded in supine (T1), on turning to prone (T2), and on returning to the supine position (T3). Primary outcome included amount of IO blood loss; Secondary outcome included need for blood transfusion, IO hemodynamics, and airway pressure changes. RESULTS: IO blood loss and central venous pressure (CVP) were significantly higher with VCV than PCV patients. Heart rate and blood pressure were significantly reduced in the prone position with little impact of ventilation mode. Prone positioning resulted in significant increase of P-peak and non-significant decrease of P-mean pressure with VCV, while with PCV resulted in a significantly increased airway pressures. P-peak pressure was significantly lower with PCV in supine and prone positions than VCV. P-mean pressure was significantly lower in supine but significantly higher in the prone position with PCV than VCV. CONCLUSIONS: Prone positioning and VCV were associated with increased CVP and IO blood loss, while PCV could lessen these effects and significantly improve airway pressures.

Endothelial nitric oxide synthase Glu 298 Asp (G894T) and Apolipoprotein E gene polymorphism as possible risk factors for coronary heart disease among Egyptians.

In Egypt, The prevalence of chronic heart disease (CHD) is 8.3%. It is the principal cause of death and is responsible for 22% of total mortality. The age-adjusted mortality rate is 174 per 100,000 of population. There are many studies on traditional risk factors and CHD in Egypt but the study of novel risk factors is deficient. OBJECTIVES: The aim of the present case control study was to investigate the relation between CHD susceptibility and Endothelial Nitric Oxide Synthase (eNOS) Glu 298 Asp (G894T) and Apolipoprotein E (ApoE) gene polymorphism in a cohort of Egyptian individuals. METHODS: Genotyping of eNOS (Glu298Asp) and Apo E genes polymorphisms were done using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method for 100 CHD cases and 100 age and sex matched healthy controls. RESULTS: A statistically significant association was observed between GT and TT genotypes of endothelial nitric oxide synthase gene with CHD with OR = 2.03 and 3.5; respectively. Also, carriers of E4 allele and especially E3/E4 genotype were at higher risk of CHD with OR = 3.3 for both. Significant association was also observed between the presence of combined GTE3E4 genotype and CHD with OR = 6.6. CONCLUSION: GT and TT genotypes of endothelial nitric oxide synthase gene, E3/E4 genotype of Apo E gene polymorphism and combined GTE3E4 genotype can be considered risk factors for the development of CHD among Egyptians.

Unusual behavior of diffuse large B-cell lymphoma as cardiac invasion with rapid spontaneous regression after fine needle aspiration cytology.

OBJECTIVE: Spontaneous regression (SR) of lymphoma is a rare phenomenon. While the precise mechanism of SR remains unknown, apoptosis may be associated with its process. Here, we present a case of a 52-year-old woman was admitted to our hospital with cough and orthopnea for 2 weeks. Multi-detector computed tomography of whole body showed anterior and middle mediastinal soft tissue mass with multiple adjacent malignant lymphadenopathy. The mediastinal mass invaded right atrium and pericardium. Another left subphrenic retro-pancreatic mass was detected. This mass surrounded upper pole of left kidney. Fine needle aspiration cytology was done and revealed lymphocytic smear with advised tru-cut biopsy. CT guided tru-cut was taken after 8 days. During CT guided technique; marked regression of left subphrenic mass was detected. Post-contrast MDCT scan was done and revealed partial response of the masses after 8 days. The partial regressive course of this disease suggests the effectiveness of fine needle aspiration cytology in initiating spontaneous regression. Tru-cut biopsy revealed non-Hodgkin lymphoma (diffuse large B-cell type). We report a case of NHL with abnormal location and spontaneous regression.

Primary cardiac hemangioendothelioma of the mitral valve.

Primary cardiac hemangioendothelioma is a very rare tumor. Up to now, <20 cases have been reported worldwide; involvement of mitral valve by the tumor is extremely rare. In this report, a case of hemangioendothelioma arose from the mitral valve and was successfully resected, and after few months the tumor recurred and infiltrated the heart.