Usefulness of a single-parameter tool for the prediction of large vessel occlusion in acute stroke.

BACKGROUND: In acute stroke, large vessel occlusion (LVO) should be promptly identified to guide patient's transportation directly to comprehensive stroke centers (CSC) for mechanical thrombectomy (MT). In many cases, prehospital multi-parameter scores are used by trained emergency teams to identify patients with high probability of LVO. However, in several countries, the first aid organization without intervention of skilled staff precludes the on-site use of such scores. Here, we assessed the accuracy of LVO prediction using a single parameter (i.e. complete hemiplegia) obtained by bystander's telephone-based witnessing. PATIENTS AND METHODS: This observational, single-center study included consecutive patients who underwent intravenous thrombolysis at the primary stroke center and/or were directly transferred to a CSC for MT, from January 1, 2015 to March 1, 2020. We defined two groups: patients with initial hemiplegia (no movement in one arm and leg and facial palsy) and patients without initial hemiplegia, on the basis of a bystander's witnessing. RESULTS: During the study time, 874 patients were included [mean age 73 years (SD 13.8), 56.7% men], 320 with initial hemiplegia and 554 without. The specificity of the hemiplegia criterion to predict LVO was 0.88, but its sensitivity was only 0.53. CONCLUSION: Our results suggest that the presence of hemiplegia as witnessed by a bystander can predict LVO with high specificity. This single criterion could be used for decision-making about direct transfer to CSC for MT when the absence of emergency skilled staff precludes the patient's on-site assessment, especially in regions distant from a CSC.

Assessment of the operating room efficiency by the real time of room occupancy.

BACKGROUND: The operating room is the most cost consuming area of hospitals. However, it still suffers from a non-optimized organization. AIM: To evaluate the performance of our operating rooms by the real room occupancy time (RROT), to identify the main causes of its alteration and to analyze the problem of deprogramming. METHODS: This is an observational and descriptive study conducted in two operating rooms in Sahloul teaching Hospital during August 2016. For the two studied rooms, a pre-established data sheet was filled during the days of scheduled activity. Collected parameters were  total RROT,  different periods of RROT, room occupancy rate, room overflow rate, incidence and causes of non-compliance with the surgical program and causes of RROT alteration. RESULTS:   The mean start time of the activity was 41.93 min/day. The mean overflow time was 11.51 min/day. The RROT was 246.56 min/day, corresponding to an average occupancy rate of 68.49%. On average 1.86 acts were performed per room and per morning with a total of 86 interventions. The deprogramming problem was noted in 38 cases. Its main causes were the overshoot of the vacation time offered to surgeons (36.84%), the emergencies (18.42%) and the non-respect of the anesthesia instructions (15.78%). CONCLUSION: The occupancy rate in our structures is relatively acceptable but should not hide the need to optimize the use of available resources. Corrective actions focusing primarily on delayed start-up and periodic reassessments are essential.

Acute urinary retention due to benign prostatic hyperplasia associated with cystitis glandularis in a 22-year-old patient.

A 22-year-old man has consulted in emergency for acute urinary retention and left renal colic. Bladder catheterization was performed. Symptomatic treatment was provided with no improvement. MRI showed a pseudotumoral bladder wall thickening associated with vesical floor budding with prostate median lobe infiltration. The patient got an endoscopy that concluded to an inflammatory aspect of the bladder mycosa and a solid mass in the bladder neck arising. The biopsy during examination concluded to a glandular cystitis. Ultrasonography performed six months later still showed an enlarged prostate of 60g volume, post void residue of 280ml and bilateral hydronephrosis. A second cystoscopy showed an obstructive prostate with a median lobe. A transurethral resection of this lobe was performed. The pathological examination concluded to a benign prostate hyperplasia. This case is likely to be the first reported so far about a BPH in a young male associated with Cystitis Glandularis. Neither etiology nor evidence of the cause behind this case has been identified so far. Although Benign Prostate Hypertrophia is rare among young males, its ethiopathogenesis is not well known, its relation with cystitis glanduralis in young patients has never been described before. Both medical and surgical approaches remain similar to the adults.

Effects of Gabapentinoids Premedication on Shoulder Pain and Rehabilitation Quality after Laparoscopic Cholecystectomy: Pregabalin versus Gabapentin.

Introduction: Gabapentinoids are increasingly used in preoperative premedication despite controversial results. The aim of our study was to evaluate the effects of preemptive use of gabapentin or pregabalin on postoperative shoulder pain and rehabilitation quality after laparoscopic cholecystectomy. Methods: This is a clinical trial comparing the effects of a preoperative premedication with 600 mg of gabapentin or 150 mg of pregabalin versus placebo on postoperative pain and recovery quality after laparoscopic cholecystectomy. Premedication was taken 2 hours before the surgery beginning. Ninety patients were included and randomized into 3 groups (gabapentin, pregabalin, and placebo). The anesthetic protocol was the same for all patients. Primary endpoint was the shoulder pain intensity at the 48th postoperative hour. Secondary endpoints were postoperative nausea and vomiting (PONV), sleep quality during the first night, and the onset time for the first standing position. Results: During the first 48 postoperative hours, the gabapentin and pregabalin groups had significantly lower shoulder pain than the placebo group (p < 0.05). In gabapentinoids groups, the incidence of PONV was lower and the sleep quality during the first postoperative night was better with significant results. Mean Spiegel scores were 22.43 ± 1.45, 22.30 ± 1.44, and 17.17 ± 1.66, respectively, in pregabalin, gabapentin, and placebo groups (p < 0.05). The delay for the first standing position was 14.9 ± 4.9 hours in the pregabalin group, 9.7 ± 3.6 hours in the gabapentin group, and 21.6 ± 2.1 hours in the placebo group. No superiority was found between gabapentin and pregabalin. Conclusion: Preemptive premedication with gabapentinoids can enhance postoperative rehabilitation quality after laparoscopic cholecystectomy by reducing postoperative shoulder pain, decreasing PONV incidence, and improving sleep quality during the first postoperative night. This trial is registered with ClinicalTrial.gov (NCT03241875).

Magnesium Sulfate as Adjuvant in Prehospital Femoral Nerve Block for a Patient with Diaphysial Femoral Fracture: A Randomized Controlled Trial.

Introduction: Prehospital management of traumatic pain is commonly based on morphine while locoregional analgesia techniques, especially the femoral nerve block (FNB), can be safely and efficiently used. Adjuvants uses can reduce local anesthetic doses and decrease their related risk. The aim of the study was to assess the analgesic effect of magnesium sulfate when used as an adjuvant in prehospital FNB. Methods: This is a randomized double-blinded trial conducted in a prehospital medical department of an academic hospital. Patients with isolated diaphysial femoral fracture and eligible to participate were randomized into 2 groups. Group C had a FNB with 15 ml of lidocaine with epinephrine (300 mg) and 3 ml of normal saline solution. Group I had a FNB with 15 ml of lidocaine with epinephrine (300 mg) and 3 ml of MgS 15% (450 mg). The FNB was performed according to the WINNIE technique. Primary endpoints were morphine consumption and pain intensity during the first 6 hours. Secondary endpoints were the duration of the sensory block, time to the first analgesic request, and side effects occurrence. Results: Twenty-four patients were enrolled in each group. Both groups were comparable according to demographic characteristics, initial pain scores, and vital constants. In group I, morphine requirements were significantly lower (2 ± 2 mg versus 5 ± 3 mg, p < 10-3), analgesic onset was significantly faster, and the average time to the first analgesic request was longer (276 ± 139 min versus 160 ± 79 min, p < 10-3). The average duration of sensory block was longer in group I (226 ± 64 min versus 116 ± 70 min p < 10-3). No side effects were recorded. Conclusion: Magnesium sulfate should be considered as an efficient and safe adjuvant to lidocaine in prehospital FNB. This trial is registered with (NCT03597945).

Ketoprofen versus Diclofenac sodium in the treatment of renal colic.

INTRODUCTION: Adult renal colic is a frequent lombo-abdominal painful syndrome in emergencies. Treatment is based on nonsteroidal anti-inflammatory drug (NSAID) but the choice between different NSAIDs remains a subject of controversy. Our aim was to compare the efficacy and the safety of two intramuscularly NSAIDs in renal colic. METHODS: We conducted a 32-week, randomized, double-blind, single-center study . Patients who had renal colic with a visual analogue scale (VAS) ≥ 5 were randomly assigned to receive, by intramuscularly injection, 100 mg of Ketoprofen (GK) or 75 mg of diclofenac (GD). If VAS > 3 after 40 minute, 1 g of paracetamol was administered as rescue analgesia. Primary endpoint was successful treatment. Secondary outcome was the occurrence of side effects. RESULTS: We have included 80 patients. the average age was 39 ± 13 years for GK versus 43 ± 14 years for GD. The mean VAS on admission was also similar in both arms. We objectified a therapeutic success rate of 92% in both groups. This success was similar in both arms. The use of rescue medication was 32.5% in the GK versus 47.5% in the GD (P=0.17). We have observed in 46% (n =37) of the study population side effects. These effects were only minor and no major intolerance expression was registered. CONCLUSION: the efficacy and tolerance of NSAIDs in the treatment of renal colic was the same for diclofenac and ketoprofen.

Inhaled nitrous oxide during the make stitches : Randomized double blind prospective study.

INTRODUCTION: Inhaled nitrous oxide (MEOPA) ensures short-term analgesia of a patient in spontaneous ventilation through a mask. It ensures analgesic coverage during the painful gesture while saving to the patient the phenomena of memorization. AIM: To study the efficacy and safety of the use of MEOPA during the make stitches. METHODS: Randomized double blind prospective study including any patient aged > 16 years admitted to the emergency for make stitches during a period of 3 months. After consent, patients were randomized to 2 groups (MEOPA versus placebo). When the stitches were made, if the patient has a VAS (visual analog scale) > 30%, an emergency analgesia with 2% subcutaneous xylocaine is performed. The primary endpoint was the degree of analgesia according to VAS. The secondary endpoints were the occurrence of side effects, patient and operator satisfaction. RESULTS: We collected 115 patients comparable in age, sex and pain at baseline. The mean of the VAS during suturing was 11.1±5.8% (MEOPA) versus 47.8±13.9% (placebo); and the mean at the end of the procedure was 5.2±5% (MEOPA) versus 27.6±12.8% (placebo) with p=0.000. Only minor adverse events (22% versus 16%) were observed with P = 0.306. CONCLUSION: We affirm the interest of this non-invasive, safe, innocuous analgesic technique that satisfies caregivers, patients and caregivers in suturing.

First medical contact and physicians' opinion after the implementation of an electronic record system.

Hospitals implement electronic medical record systems (EMRSs) that are intended to support medical and nursing staff in their daily work. Evolution toward more computerization seems inescapable. Nevertheless, this evolution introduced new problems of organization. This before-and-after observational study evaluated the door-to-first-medical-contact (FMC) times before and after the introduction of EMRS. A satisfaction questionnaire, administered after the "after" period, measured clinicians' satisfaction concerning computerization in routine clinical use. The following 5 questions were asked: Do you spare time in your note taking with EMRS? Do you spare time in the medical care that you provide to the patients with EMRS? Does EMRS improve the quality of medical care for your patients? Are you satisfied with the EMRS implementation? Would you prefer a return to handwritten records? Results showed an increase in door-to-FMC time induced by EMRS and a lower triage capacity. In the satisfaction questionnaire, clinicians reported minimal satisfaction but refused to return to handwritten records. The increase in door-to-FMC time may be explained by the improved quantity/quality of data and by the many interruptions due to the software. Medical reorganization was requested after the installation of the EMRS.