Comparing spinal anesthesia approaches for transurethral lithotripsy in patients with proximal ureteral stones: A randomized clinical trial of bupivacaine alone versus bupivacaine with fentanyl.

Despite the benefits of spinal anesthesia and the preference of anesthesiologists for this technique, it is less accepted by urologists due to the proximity of the stone place in the ureter and the possibility of pain, restlessness, and occasional movements of the patient during surgery. The current study investigated the success of bupivacaine plus intrathecal fentanyl in patients undergoing transurethral lithotripsy (TUL). In this randomized clinical trial, from April 2021 to September 2021, 54 patients with proximal urolithiasis candidates for TUL were enrolled. Patients were randomly categorized into two groups: group A received bupivacaine 10 mg and 0.5 ml of normal saline, while group B received bupivacaine 10 mg with 0.5 ml (25µg) of intrathecal fentanyl. According to our findings, about 74% of the patients were men, and the mean age of the patients was 66.14±22.46 years. The onset time of the sensory block, sensory block level, pain score, degree of relaxation, depth of the motor block, occurrence of anesthesia complications, oxygen saturation, and mean arterial blood pressure were not significantly different between the two groups. However, the duration of the motor block in group B was longer than in group A (p<0.001). Also, retropulsion was observed only in five patients (18.5%) in group A, significantly higher than in group B (p=0.019). Bupivacaine with fentanyl 25µg provided adequate spinal anesthesia with lower retropulsion in patients with urolithiasis who are candidates for TUL.

Comparison of two Intranasal Sedatives, Midazolam versus Dexmedetomidine, in Children with High Dental Fear: a Randomized Clinical Trial.

Statement of the Problem: Pharmacologic management of uncooperative behavior is a growing trend in dentistry. Determining the most appropriate drug, route of administration, and proper candidate for sedation have been the goal of several investigations. Purpose: The aim of this study was to compare the sedative effect of intranasal (IN) sedation of midazolam (MDZ) in compare to dexmedetomidine (DEX) while taking into consideration the effect of dental fear, and psychological status on sedation success. Materials and Method: This double-blind randomized clinical trial included 92 uncooperative dental patients aged 4-6. Study participants were randomly assigned to receive either 0.2mg/kg IN MDZ or 1µg/kg DEX. Sedation was evaluated using the Houpt sedation rating scale. Vital signs were recorded before and during sedation. Prior to sedation, the level of dental fear was determined through children's fear survey schedule-dental subscale (CFSS-DS). Psychological characteristics were screened using the strengths and difficulties questionnaire (SDQ). Data were analyzed using T-test, Mann-Whitney, Chi-square, and repeated-measures analysis of variance (ANOVA). Results: Overall ratings of sedation and subscales of sleep, crying, and movement were comparable between groups (p> 0.05); however, more acceptable behavior (overall scores (4+5+6) was observed in MDZ group compared to DEX group (64% vs. 47.7%) (p= 0.007). All participants were found to have abnormal levels of dental fear (CFSS-DS≥38). However, according to SDQ, the study participants have mainly shown normal behavioral status. A significant association was found between dental fear and sedation success (MDZ, p= 0.001, DEX, p= 0.03), while similar findings were not observed for psychological characteristics (MDZ, p= 0.09 and p= 0.41; DEX, p= 0.71 and p= 0.53). Physiological parameters remained within normal limits in both groups. Conclusion: Sedation with IN MDZ resulted in overall behaviors, which were more satisfactory in highly fearful pediatric dental patients. Despite baseline uncooperative behaviors, the psychological status of study participants were close to average and were not associated with sedation failure.

Survey of Maximum Blood Ordering for Surgery (MSBOS) in elective general surgery, neurosurgery and orthopedic surgery at the Poursina Hospital in Rasht, Iran, 2017

ABSTRACT Introduction: Blood is a valuable life resource that depends on the donation of blood by the community. As a result, it is crucial that the manner in which this expensive resource is used be correct and reasonable. Objective: The purpose of this study was to investigate the Maximum Blood Ordering for Surgery (MSBOS) in general, orthopedic and neurosurgical elective surgeries at the Poursina Hospital in Rasht in 2017. Methods: According to the patient file number information, such as gender, age, type of surgery, number of blood units requested, number of cross-matched blood units, number of blood units transfusion, number of patients undergoing transfusion, number of patients who were cross-matched, initial hemoglobin and the underlying disease, was extracted from the HIS (Hospital Information System). Based on the collected data, a descriptive report of the cross-match to transfusion ratio (C/T), transfusion index (TI) and transfusion probability (%T) was performed, using average and standard deviation, by using the SPSS 16. Results: In the present study, 914 patients from the neurosurgery, orthopedic and general surgery wards of the Poursina Hospital were studied. Of these, 544 were male (59.5%) and 370 were female (40.5%), aged 1-99 years, with a mean age of 43 years. The frequency distribution of C/T in this study was 1.29 in neurosurgery, 1.95 in orthopedic surgery and 1.96 in general surgery. This study indicated that the C/T index was above the normal standard level in four different kinds of surgery, including leg fracture (2.71), cholecystectomy(2.71), forearm fracture (2.70), and skin graft (2.62).The C/T index was at the maximum normal level in thyroidectomy surgery (2.5). The other surgeries had the normal C/T index. Conclusion: Overall, all of the MSBOS indices were at the standard level in this study, although C/T indices were higher than the standard level in the surgeries for cholecystectomy, leg fracture, forearm fracture, hand fracture and skin graft.

Efficacy of intranasal ketamine and midazolam for pediatric sedation: A double-blind, randomized clinical trial.

BACKGROUND: Pediatric patients feel significant fear and anxiety when undergoing surgeries. The ideal drug and its administration route have not been found yet. The aim of this study was to compare the efficacy and safety of intranasal (IN) ketamine and midazolam as premedication in children. METHODS: We studied 71 eligible pediatric patients undergoing elective urologic surgeries, aged 2 to 6 years. The degree of sedation and separation scores was compared between the two groups. Additionally, hemodynamic parameters, before premedication, after induction of anesthesia, and during surgery were documented and compared between two groups. Postoperatively, any side effect was recorded as well. RESULTS: Finally, the data from 71 children were analyzed. Recovery time was significantly longer in group K (ketamine) compared to group M (midazolam); 27.86±4.42 vs 38.19± 6.67 minutes respectively (P=0.01). No significant difference was observed in terms of sedation score between two groups of K & M; 3.29±0.78 vs 3 ±0.71 respectively (P=0.17), and not regarding separation score; 2.51±0.61 & 2.31±0.52 respectively (P=0.01). Vital signs were kept within the physiological limits in both groups with no marked fluctuations. CONCLUSION: To produce sedation in young children, both midazolam and ketamine were effective and safe by IN route.

The effectiveness of training on daily progress note writing by medical interns.

INTRODUCTION: There is no formal education or training course about daily progress note writing in Iranian medical interns' curriculum. The current study aimed to assess the effectiveness of a training intervention on daily progress note writing by Iranian medical interns. METHODS: This quasi-experimental study (pre- and post-test) was conducted on 150 medical interns selected through the census method at Razi Hospital of Rasht, north of Iran from October-2018 to May-2019. In the baseline, daily progress notes written by 150 medical interns were assessed using a Subjective, Objective, Assessment, and Plan (SOAP)-based questionnaire by the expert panel. Content validity of the questionnaire was confirmed by experts and internal consistency was determined using Cronbach's alpha coefficient. In the intervention phase, training sessions (4 one-hour sessions) on how to write the daily progress note, based on SOAP format and its importance, were held for the interns. All medical interns were given a week to meet the SOAP standards. Then, the same expert panel reviewed and assessed the newly written daily progress notes of the same medical interns. Finally, the scores from the evaluation of progress note writing, before and after the intervention, were compared with paired sample t-test. RESULTS: The mean age of the medical interns was 23.1±5.2 years. The majority of them were male (56%). There was a significant improvement in all SOAP notes' components written by medical interns between the pre- and post-intervention periods (general rules: 52.7±24.5 vs. 85.4±18.2, P<0.001; subjective: 21.2±18.3 vs. 61.7±24.3, P<0.001; objective: 25.3±18.3 vs. 71.3±25.2, P<0.001; assessment: 10.7±13.0 vs. 51.4±29.6, P<0.001; plan: 11.2±15.2 vs. 49.6±27.5, P<0.001; total: 21.9±13.0 vs. 61.8±23.0, P<0.001). But the scores were still far from the desirable level after the training intervention. CONCLUSION: The finding of the present research suggests that a training intervention can lead to some improvements in the daily progress notes written by Iranian medical interns.

Survey of Maximum Blood Ordering for Surgery (MSBOS) in elective general surgery, neurosurgery and orthopedic surgery at the Poursina Hospital in Rasht, Iran, 2017.

INTRODUCTION: Blood is a valuable life resource that depends on the donation of blood by the community. As a result, it is crucial that the manner in which this expensive resource is used be correct and reasonable. OBJECTIVE: The purpose of this study was to investigate the Maximum Blood Ordering for Surgery (MSBOS) in general, orthopedic and neurosurgical elective surgeries at the Poursina Hospital in Rasht in 2017. METHODS: According to the patient file number information, such as gender, age, type of surgery, number of blood units requested, number of cross-matched blood units, number of blood units transfusion, number of patients undergoing transfusion, number of patients who were cross-matched, initial hemoglobin and the underlying disease, was extracted from the HIS (Hospital Information System). Based on the collected data, a descriptive report of the cross-match to transfusion ratio (C/T), transfusion index (TI) and transfusion probability (%T) was performed, using average and standard deviation, by using the SPSS 16. RESULTS: In the present study, 914 patients from the neurosurgery, orthopedic and general surgery wards of the Poursina Hospital were studied. Of these, 544 were male (59.5%) and 370 were female (40.5%), aged 1-99 years, with a mean age of 43 years. The frequency distribution of C/T in this study was 1.29 in neurosurgery, 1.95 in orthopedic surgery and 1.96 in general surgery. This study indicated that the C/T index was above the normal standard level in four different kinds of surgery, including leg fracture (2.71), cholecystectomy(2.71), forearm fracture (2.70), and skin graft (2.62).The C/T index was at the maximum normal level in thyroidectomy surgery (2.5). The other surgeries had the normal C/T index. CONCLUSION: Overall, all of the MSBOS indices were at the standard level in this study, although C/T indices were higher than the standard level in the surgeries for cholecystectomy, leg fracture, forearm fracture, hand fracture and skin graft.

Electroconvulsive Therapy-Related Anxiety: A Survey in an Academic Hospital in the North of Iran.

BACKGROUND: Electroconvulsive therapy (ECT) is a medical treatment most commonly used in the most severe psychiatric diseases; however due to unreal anxiety, it is not widely accepted by patients and their families. OBJECTIVES: The present study aimed to investigate the main causes of ECT-related anxiety (ERA) in an academic hospital in the north of Iran. METHODS: In this study, the participants were hospitalized psychiatric patients with proper communication skills. A 12-item questionnaire encompassing four sections (namely ECT side-effects, procedure factors, medical team communication, and familial, social, and economic factors) were filled out by a responsible psychiatric resident through a face-to-face interview. The participants' demographic information, including gender, age, psychiatry disorder, level of education, and history of ECT, were also recorded. RESULTS: In this study, 353 cases were analyzed, among whom 329 patients (93.2%) reported at least one item for ERA, and 143 patients (85.6 %) had the history of ECT. All the participants (100%) had no experience in this regard (P = 0.0001). The most common cause of ERA was ECT-related side effects (70.7%) such as memory impairment (60.4%), disablement (24.9%), and death (14.7%) followed by procedure factors (27.2%), general anesthesia (GA) (73.2 %), and electric current (26.8 %). A significant relationship was observed between gender and the history of ECT with the patients' anxiety reasons (P = 0.0001); however, the other variables, including age (P = 0.72), type of disease (P = 0.144), and the level of education (P = 0.012) had no impact on the results. CONCLUSIONS: In this paper, the main causes of ERA were general anesthesia, memory impairment, and electric current. Obviously, a multidisciplinary approach is required to help these patients to handle their fear and anxiety successfully.

Effectiveness of spinal anesthesia combined with obturator nerve blockade in preventing adductor muscle contraction during transurethral resection of bladder tumor.

OBJECTIVE: To determine whether spinal anesthesia combined with obturator nerve blockade (SOB) is effective in preventing obturator nerve stimulation, jerking and bladder perforation during transurethral resection of bladder tumor (TURBT). MATERIAL AND METHODS: In this clinical trial, 30 patients were randomly divided into two groups: spinal anesthesia (SA) and SOB. In SA group, 2.5 cc of 0.5% bupivacaine was injected intrathecally using a 25-gauge spinal needle and in SOB after spinal anesthesia, a classic obturator nerve blockade was performed by using nerve stimulation technique. RESULTS: There was a statistically significant difference between jerking in both groups (p=0.006). During the TURBT, surgeon satisfaction was significantly higher in SOB group compared to SA group (p=0.006). There was no significant correlation between sex, patient age and location of bladder tumor between the groups (p>0.05). CONCLUSION: Obturator nerve blockade by using 15 cc lidocaine 1% is effective in preventing adductor muscle spasms during TURBT.

Efficacy and Safety of Orally Administered Intravenous Midazolam Versus a Commercially Prepared Syrup.

BACKGROUND: Among different categories of sedative agents, benzodiazepines have been prescribed for more than three decades to patients of all ages. The effective and predictable sedative and amnestic effects of benzodiazepines support their use in pediatric patients. Midazolam is one of the most extensively used benzodiazepines in this age group. Oral form of drug is the best accepted route of administration in children. OBJECTIVES: The purpose of this study was to compare the efficacy and safety of a commercially midazolam syrup versus orally administered IV midazolam in uncooperative dental patients. Second objective was to determine whether differences concerning sedation success can be explained by child's behavioral problems and dental fear. PATIENTS AND METHODS: Eighty eight uncooperative dental patients (Frankl Scales 1,2) aged 3 to 6 years, and ASA I participated in this double blind, parallel randomized, controlled clinical trial. Midazolam was administered in a dose of 0.5 mg/kg for children under the age 5 and 0.2 mg/kg in patients over 5 years of age. Physiologic parameters including heart rate, respiratory rate, oxygen saturation and blood pressure were recorded. Behavior assessment was conducted throughout the course of treatment using Houpt Sedation Rating Scale and at critical moments of treatment (injection and cavity preparation) by North Carolina Scale. Dental fear and behavioral problems were evaluated using Child Fear Schedule Survey-Dental Subscale (CFSS-DS), and Strength and Difficulties Questionnaire (SDQ). Independent t-test, Chi-Square, and Pearson correlation were used for statistical analysis. RESULTS: Acceptable overall sedation ratings were observed in 90% and 86% of syrup and IV/Oral group respectively; Chi-Square P = 0.5. Other domains of Houpt Scale including: sleep, crying and movement were also not significantly different between groups. Physiological parameters remained in normal limits during study without significant difference between groups. CONCLUSIONS: "Orally administered IV midazolam" preparation can be used as an alternative for commercially midazolam syrup.

Predicting difficulty score for spinal anesthesia in transurethral lithotripsy surgery.

BACKGROUND: Spinal anesthesia (SA) is the most common regional anesthesia (RA) conducted for many surgical procedures. OBJECTIVES: The current study aimed to predict the difficulty score of SA, by which to reduce the complications and ultimately improve the anesthesia quality. MATERIALS AND METHODS: Transurethral Lithotripsy (TUL) surgery candidates were enrolled in this observational study from 2010 to 2011. Before SA, the patient`s demographic information along with the Body Mass Index (BMI), lumbar spinous process status, spinal deformity, radiological signs of lumbar vertebrae, and a history of spinal surgery or difficult SA were recorded, then the patients underwent SA in L3-L4 interspinous process space. Information about Cerebrospinal Fluid (CSF) visibility at the first attempt (easy SA) and the times of trying with shifting in that space or trying the second space (moderate SA) and the third space (difficult SA) were recorded. Multinominal regression and relative operating characteristic (ROC) curve were used for statistical analysis. RESULTS: Hundred and one patients were enrolled. Of these patients, 50 (49.5%) underwent SA by the first attempt of the first space, in 36 patients (35.6%) it was moderate and in 15 patients (14.9%) it was difficult. There was no significant relationship between difficulty score of SA and gender, age, height, and history of previous difficult SA. But there was a significant relationship between difficulty score of SA and lumbar spinous process status (P =0.0001), radiological profile of the lumbar spine (P = 0.0001), the status of lumbar deformity (P = 0.007), and BMI (P = 0.006). Then using the ROC curve to predict the difficult SA, the cutoff point was 8.5 with 86.7% and 86% sensitivity and specificity, respectively. CONCLUSIONS: It seems that considering the clinical examination of patients before SA focusing on lumbar spinous process status, presence of lumbar deformity, calculation of BMI and radiological signs of lumbar vertebrae can be helpful in predicting SA difficulty.

Survey on blood ordering and utilisation patterns in elective urological surgery.

BACKGROUND: Blood transfusion is an important part of the medical care service. As there has not been a regional study about blood requests for operations, this study was done to assess blood ordering for various types of elective urological surgery. MATERIALS AND METHODS: In a descriptive, retrospective, cross-sectional study, blood requests for all patients undergoing elective urological surgery in Razi Hospital (Rasht, Iran) during the first 6 months of 2010 were studied. The patients' data (age, sex, weight, type of surgery, haemoglobin level before and after surgery, number of units of blood cross-matched and number of units transfused in the operating theatre and in the 3 days after surgery) were collected from their clinical records. Patients with a history of coagulopathy or anticoagulant drug use were excluded. The cross-match to transfusion ratio (C/T ratio), transfusion index (TI) and transfusion probability (T%) were calculated. The level of statistical significance was set at P =0.05. RESULTS: Of the 435 patients studied, 327 (75.1%) were male and 108 (24.9%) were female. The mean age of patients was 51.74 ± 19.33 years. The mean number of units of blood requested for each operation was 2.8 ± 1.2, whereas the mean number transfused was 0.59 ± 0.24; the difference was statistically significant (P<0.05). The relationships between pre-operative haemoglobin concentration and both blood requested and blood used were also statistically significant (P =0.038 and P <0.001, respectively). Calculated for all the operations, the C/T ratio was 14.16, the TI was 0.11 and the T% was 8.85%. Overall, only 8.5% of the patients (n=37) need blood transfusion in the operating theatre and only 10.8% (n=47) required transfusion within the 72 hours after surgery. DISCUSSION: The amount of blood requested and cross-matched for elective urological surgery is much greater than the real level of consumption. An appropriate, standard blood order guideline would reduce costs and staff workload.

Thymectomy for myasthenia gravis: prognostic factors in 70 patients.

Thymectomy has become increasingly accepted as an efficacious procedure for myasthenia gravis, with high rates of complete clinical remission. Predictors of the response to thymectomy for myasthenia gravis vary in the literature. We retrospectively reviewed the clinical records of 70 patients (63% female; mean age, 38 years) diagnosed with myasthenia gravis from August 1993 to August 2004, to determine the factors predicting outcome. Complications occurred in 20%, but there was no hospital mortality. Complete clinical remission was obtained postoperatively in 47%. Our results indicate that patients with less than 1 year's duration of disease have a better prognosis, and Osserman stages I, IIa, and IIb are also associated with higher clinical remission rates. Female patients have a better prognosis than males, and the younger the patient the better the outcome. Thymectomy is indicated for myasthenia gravis as early as possible in the course of the disease.