Effect of transforaminal anterior epidural steroid injection on neuropathic pain, quality of sleep and life.

OBJECTIVES: Transforaminal anterior steroid injections are frequently used for low back pain. In the current study, It was aimed to investigate the effects of transforaminal anterior epidural steroid injection (TAESI) in patients with low back pain in regards to quality of life and sleep, and neuropathic pain. METHODS: Ethics committee approval and patient consent were obtained. Patients with low back pain scheduled to receive transforaminal epidural steroid injections between October 2011 and October 2012 were included into the study. Pittsburgh Sleep Quality Index (PSQI), Short form 12 (SF 12), DN4 tests and Visual Analog Scale Score (VAS) were measured prior to procedure and three months later. All the tests were compared with baseline evaluations prior to injections. RESULTS: One hundred and two (female/male: 52/50) patients with a mean age of 53.3 ± 1.4 were included. Primary diagnoses were lumbar disc herniation in eighty-seven patients, spinal stenosis in seven and failed back surgery syndrome in eight patients. Statistically significant improvement was seen in the total VAS, DN4 and PSQI scores (p=0.0001) of the patients at the third month follow-up. Sleep duration (p=0.0001), habitual sleep efficiency (p=0.0001), subjective sleep quality (p=0.003), sleep latency (p=0.014), sleep disturbances (p<0.001), sleep medication use (p=0.003), and day time dysfunction (p=0.015) showed a significant decrease in sub-components. There was no significant difference in SF 12 quality of life. CONCLUSION: It was determined in the study that transforaminal epidural steroid injection provided a substantial improvement in patients' pain and neuropathic pain and quality of sleep, but had no effect on the quality of life.

The use of train of four monitoring for clinical evaluation of the axillary brachial plexus block.

The axillary approach of brachial plexus anesthesia is the most commonly used technique for forearm and hand surgery. Dynamometer is known as objective test for the clinical assessment of motor block of the nerves in brachial plexus block. However, the use of this device may not always be practical in operating room. The train-of-four (TOF) test is a non-invasive peripheral nerve stimulator that shows the level of motor block of muscle relaxants. The aim of the study is to investigate the use of TOF testing as a peripheral nerve stimulator for objective clinical evaluation of motor block at axillary brachial plexus block. 44 patients were randomized according to the development of partial or complete motor in the axillary brachial plexus block. The nerves were selectively localized by nerve stimulation and ultrasound guidance. After obtaining an appropriate peripheral motor response, predetermined volumes of bupivacaine were selectively injected to the 4 nerves. Sensory, motor block levels and TOF values were measured at 10th, 20th, 30th minutes immediately after the axillary brachial plexus block. TOF values were gradually decreased and significant difference was observed between the development of a complete and partial motor block at 30th minute. TOF values were also significantly less in patients of complete sensory block than the patients of partial sensory block at 30th minute. The use of TOF monitoring may be beneficial to assess the objective clinical effect of motor block in the patients with axillary brachial plexus nerve block.

Lornoxicam in extracorporeal shock-wave lithotripsy; comparison with tenoxicam and placebo in terms of analgesic consumption.

OBJECTIVE: To assess the analgesic efficacy of lornoxicam and compare it with that of tenoxicam in patients undergoing extracorporeal shock-wave lithotripsy (ESWL) for renal stones. MATERIAL AND METHODS: The study was carried out in a randomized, double-blind fashion and involved 60 patients (American Society of Anesthesiologists physical status I-II) undergoing ESWL who were divided into three groups. Patients in the placebo group (n = 20) received saline and those in the lornoxicam group (n = 20) received lornoxicam 8 mg intravenously 60 min before the procedure. In the tenoxicam group, patients (n = 20) received tenoxicam 20 mg intravenously at the same time point. All patients were started on patient-controlled i.v. meperidine analgesia during the procedure. The effectiveness was assessed by using a visual analog scale (VAS) and by calculating the total analgesic consumption of meperidine during the procedure. Arterial blood pressure, oxygen saturation, and respiratory rate were recorded throughout the procedure; nausea and vomiting, agitation, and respiratory depression were assessed. RESULTS: Compared with patients in the placebo group, patients in the lornoxicam and tenoxicam groups received smaller doses of meperidine at all time points (p < 0.05). After 30, 45, and 60 min of ESWL, patients in the lornoxicam group required significantly smaller doses of meperidine than those in the tenoxicam group (p < 0.05). Patients in the placebo group showed higher VAS scores than those in the lornoxicam and tenoxicam groups at 15, 30 and 60 min. The VAS score in the lornoxicam group was lower than that in the tenoxicam group at 15, 30, and 45 min, but the difference between the groups was statistically significant only at 45 min (1 and 3, respectively; p < 0.05). CONCLUSION: In patients undergoing ESWL the i.v. administration of a single dose of 8 mg lornoxicam provides significantly better pain control compared with tenoxicam 20 mg and placebo, without increasing adverse side-effects.

Prevalence of asthma among preschool children in Edirne, Turkey.

Allergic diseases generally begin early during childhood, but a late diagnosis is common. This study aimed to evaluate the prevalence of asthma and asthma-related symptoms among kindergarten children in Edirne, Turkey. 873 subjects based on a modified ISAAC questionnaire were included. The prevalence of 'wheezing ever' and 'wheezing during the previous year' was 23.3% and 8.6%, respectively. Prior physician diagnoses existed for 36 of 873 (4.1%) children. The prevalence of children undiagnosed with asthma, but reporting asthma-related symptoms was 3.1%, 51.9% of which had previous beta-agonist prescriptions. However, none of these children received inhaled anti-inflammatory medications. In conclusion, it was found that a large population of preschool children had undiagnosed respiratory symptoms suggestive of asthma. Conducting simple surveys of young children is particularly important, as identification of asthma early in the disease course will facilitate effective prevention and treatment.

Effects of tramadol on myocardial ischemia-reperfusion injury.

OBJECTIVES: The aim of the present study was to evaluate the effect of tramadol on isolated rat hearts subjected to global ischemia-reperfusion injury. DESIGN: Langerdorff perfused isolated rat hearts were subjected to 60 min of global ischemia following 60 min of reperfusion. In group I and III hearts were received tramadol before the onset of ischemia. Following the ischemic period, group II and III hearts were received tramadol infusion. Group I and IV hearts were subjected to saline at the same time point. The myocardial postischemic recovery was compared using hemodynamic, coronary flow, biochemical parameters from coronary effluent, and oxidative stress markers from heart tissue homogenates. RESULTS: There were significant differences between tramadol and saline used groups in hemodynamic parameters. GPx values of groups I and III were significantly lower than group IV (p<0.05). SOD values of groups I, II and III were higher than group IV (p<0.05). LDH values of groups I and II were significantly lower than groups III and IV (p<0.05). CONCLUSION: Tramadol provides a cardioprotective effect against myocardial ischemia-reperfusion in isolated rat heart.

High C-reactive protein and low cholesterol levels are prognostic markers of survival in severe sepsis.

STUDY OBJECTIVE: To evaluate serum C-reactive protein and cholesterol as a prognostic factor for survival in patients with severe sepsis. DESIGN: Prospective study. SETTING: University hospital. PATIENTS: The study population consisted of 96 patients (age range, 18-75 years; median, 56 years; men/women ratio, 40:56) in whom severe sepsis was diagnosed. INTERVENTIONS: Patients' serum levels of C-reactive protein and cholesterol were measured upon admission to an intensive care unit, two days later, and on the day of discharge from the intensive care unit or on the day of death. MEASUREMENTS AND MAIN RESULTS: Cholesterol levels were significantly lower among the nonsurviving patients (day 1, 92.2 +/- 25.1 mg/dL; day 2, 92.1 +/- 21.7 mg/dL; death/discharge day, 92.2 +/- 21.7 mg/dL) than surviving patients (day 1, 175.1 +/- 38.6 mg/dL [P < 0.001]; day 2, 173.0 +/- 39.3 mg/dL [P < 0.001]; death/discharge day, 171.8 +/- 39.6 mg/dL [P = 0.010]). Median C-reactive protein levels were significantly higher among the nonsurvivors (day 1, 32 mg/dL [range, 20.5-64.5 mg/dL]; day 2, 33 mg/dL [range, 22-74.5 mg/dL]; death/discharge day, 30 mg/dL [range, 22-57 mg/dL]) than survivors (day 1, 10 mg/dL [range, 6-14 mg/dL]; day 2, 9 mg/dL [range, 5-10 mg/dL]; death/discharge day, 6 mg/dL [range, 3-9 mg/dL]; P < 0.001). CONCLUSION: Serum C-reactive protein and cholesterol are a predictor of survival in patients with severe sepsis. Low cholesterol and high C-reactive protein levels appear as a valuable tool for individual risk assessment in severe sepsis patients and for stratification of high-risk patients in future intervention trials.

Analysis of intervariable relationships between major risk factors in the development of coronary artery disease: a classification tree approach.

OBJECTIVE: The purpose of this study is to determine how the major risk factors are related to each other in the development of coronary artery disease (CAD) using Chi-squared Automatic Interaction Detection (CHAID). METHODS: All patients with suspected CAD seen in the cardiology clinic between January 1999 and February 2003 who underwent coronary angiography were included in the study. A retrospective analysis was performed in 1381 patients. In all patients' sex, age, type II diabetes mellitus, hypercholesterolemia, systemic hypertension, smoking status, family history of CAD, body mass index (BMI) were assessed. RESULTS: According to classification tree, first-level split produced the two initial branches: female (unadjusted presence percentage = 48.07%) versus male (unadjusted presence percentage = 78.02%). For the male aged between 49-81 years and the female aged between 15-48, 49-60 and 61-71 years, diabetes mellitus was the most prominent risk factor. However, hypercholesterolemia was the best predicting variable for the females aged between 72-81 years. For the females of 15-48 years and 49-60 years age categories without diabetes mellitus, smoking status and family history of CAD had important contribution to the model. CONCLUSION: Sorting the major risk factors of CAD from the most to least according to the classification importance was resulted as sex, age, diabetes mellitus, hypercholesterolemia, family history of CAD and smoking status.

Contrast-enhanced MR 3D angiography in the assessment of brain AVMs.

BACKGROUND AND PURPOSE: Digital subtraction angiography (DSA) is the current reference standard for the diagnosis, assessment, and management of brain arteriovenous malformations (AVMs). The purpose of this study was to compare the diagnostic utility of three-dimensional (3D) time-of-flight (TOF) magnetic resonance angiography (MRA) and contrast-enhanced 3D MRA in patients with intracranial arteriovenous malformations (AVMs) in different sizes and locations. The AVM diagnosis was proved via DSA and almost half of the patients had also hematoma. MATERIALS AND METHODS: Two radiologists, experienced on neurovascular imaging and independent from each other, retrospectively reviewed two MRA techniques and DSA with regard to the assessment of feeding arteries, AVM nidus, and venous drainage patterns on 20 patients with 23 examinations by scoring system. Disagreements were resolved by consensus. RESULTS: An excellent agreement between contrast-enhanced MRA and DSA was found in order to assess the numbers of arterial feeders and draining veins (Spearman r=0.913, P<0.001). The average scores in contrast-enhanced MRA for feeders, nidi, and drainers were respectively 2.26, 2.69, and 2.48, while in TOF-MRA they are 1.96, 1.35, and 0.89, respectively. CONCLUSION: Compared to TOF-MRA, 3D contrast-enhanced MRA is useful for visualization by subtraction technique of malformation components presented by hematoma or by haem product. On the other hand, for the cases presented by slow or complex flow that is especially in around or nidi or around the venous portion is also advantageous because of the independence from flow-related enhancement. Therapeutic effects were clearly demonstrated in three follow-up patients. A major limitation of this technique is the low spatial resolution. Since there is such a limitation, arterial feeder of a case with micro-AVM is not detected by contrast-enhanced MRA and nidus for the same case was observed retrospectively. In this respect, we believe that 3D contrast-enhanced MRA is a less invasive and inexpensive angiographic tool, but not a safe substitute for DSA. Yet, it can be a beneficial supplement to DSA in patients with cerebral AVMs at both initial diagnosis and at follow-up processes after therapy.

[Pediatric head injuries: a retrospective analysis of 280 patients.]. / Çocukluk çagi kafa travmalari: 280 olgunun retrospektif degerlendirmesi.

BACKGROUND: To assess etiological factors, clinical features, radiological findings and recovery rates in pediatric head injuries. METHODS: Patients (n =280) with head injuries (age range: 0 - 16 years) hospitalized in Trakya University Department of Neurosurgery between January 1995 and 2004 were analyzed statistically. RESULTS: According to Glasgow Coma Scale (GCS) the patients had minor (GCS: 13- 15 ; 70.1% ), moderate (GCS: 9- 12; 17,1% ), or severe (GCS: 3 to 8; 6,8% ). head injuries The most common etiological factor was fall from a height (34,3%); and the most frequently associated injury was extra-spinal skeletal injury (12,9%). Fifty-one patients (18,2%) underwent neurosurgical operation. 87.5% of them recovered completely, while 12,5% showed partial recovery or died, as graded by Glasgow Outcome Scale (GOS). There was a moderately strong correlation between initial GCS and GOS (r=0,53, p=0,01). CONCLUSIONS: Nearly half of the pediatric head injuries were caused by falls with good prognoses. In the school age, motor vehicle accident (MVA) was the most frequent trauma type. MVA was the most serious type of trauma as demonstrated by its low GCS and GOS scores. Polytraumas, subdural hematomas, cerebral contusions, subarachnoid or intracerebral hemorrhages, cerebral edemas, diffuse axonal injuries, and any cranial lesion which required surgery were found to be related with poor prognosis.

[Comparison of multiple prediction models for hypertension (Neural networks, logistic regression and flexible discriminant analyses)]. / Hipertansiyonun tahmini için çoklu tahmin modellerinin karsilastirilmasi (Sinir aglari, lojistik regresyon ve esnek ayirma analizleri).

OBJECTIVE: In this study, we compared performances of logistic regression analysis (LR), flexible discriminant analysis (EAA) and neural networks (SA) in prediction of primary hypertension. METHODS: Predictor variables were family history, lipoprotein A, triglyceride, smoking and body mass index. The data were collected from Cardiology Clinic of Trakya University Medical Faculty in Turkey, 2001. Logistic regression analysis, flexible discriminant analysis and neural networks were used for prediction of control and hypertension groups. Comparison of the performance of all models was done using receiver operating characteristic (ROC) curve analysis. RESULTS: All models had areas under the ROC curve in the range of 0.793-0.984 and SA had sensitivity, specificity, and accuracy greater than 90% at ideal threshold. ROC curve areas of SA and LR, and SA and EAA were statistically different (p<0.001 and p<0.001 respectively), while ROC curve areas of EAA and LR did not differ (p>0.05). CONCLUSION: We concluded that family history, lipoprotein A, triglyceride, smoking and body mass index variables can be used for prediction of control and hypertension groups with statistically better performance of SA over LR and EAA.

Predictive value of thyroid hormones on the first day in adult respiratory distress syndrome patients admitted to ICU: comparison with SOFA and APACHE II scores.

BACKGROUND: Thyroid hormone dysfunction could affect outcome and increase mortality in critical illness. Therefore, in a prospective, observational study we analyzed and compared the prognostic accuracy of free tri-iodothyronine (fT3), free thyroxine (fT4), thyroid-stimulating hormone (TSH), along with the APACHE II and SOFA scoring systems in predicting intensive care unit (ICU) mortality in critically ill patients. PATIENTS AND METHODS: Physiology scores were calculated for the first 24 hours after ICU admission in 206 patients with acute respiratory distress syndrome. APACHE II and SOFA scores were employed to determine the initial severity of illness. Thyroid hormones were measured within the first 24 hours. Logistic regression models were created for APACHE II scores, SOFA scores, and thyroid hormone levels. The models predicted high- and low-risk subgroups. Models that showed a good fit were stratified by Kaplan-Meier survival curves. RESULTS: There were 98 (47.6%) survivors and 108 (52.4%) non-survivors. The survivors had a lower APACHE II score (11.50 vs 15.82, P < 0.0005), a lower SOFA score (6.06 vs 9.42, P < 0.0005), a younger age (57 vs 70 years, P = 0.008), a shorter ICU stay (13 vs 16 days, P = 0.012), and a higher fT3 level (2.18 vs 1.72 pg/mL, P = 0.002) than non-survivors. ICU survival was most closely predicted by a model that included age and fT3 and a model that included APACHE II and APACHE II*sex. CONCLUSION: In critically ill patients, serum fT3 concentrations markedly decreased after ICU admission among non-survivors. According to our findings, fT3 levels might have additive discriminatory power to age, SOFA and APACHE II scores in predicting short-term mortality in ARDS patients admitted to ICU.

Analgesic effects of gabapentin after spinal surgery.

BACKGROUND: A combination of opioid and nonopioid analgesic drugs may improve the quality of postoperative analgesia as well as reduce opioid requirements and their associated side effects. Studies have shown synergism between gabapentin and morphine in animal and human experiments and in the treatment of incisional pain. Therefore, the authors investigated, in a randomized, placebo-controlled, double-blind study, the effects of gabapentin on acute postoperative pain and morphine consumption in patients undergoing spinal surgery. METHODS: After standard premedication, 25 patients in the control group received oral placebo, and 25 patients in the gabapentin group received 1,200 mg of gabapentin, 1 h before surgery in a randomized fashion. Anesthesia was induced with propofol and cisatracurium and was maintained with sevoflurane and remifentanil. The total intraoperative remifentanil consumption by each patient was noted. All patients postoperatively received patient-controlled analgesia with morphine (1 mg/ml) with an incremental dose of 2 mg, a lockout interval of 10 min, and a 4-h limit of 40 mg. The incremental dose was increased to 3 mg, and the 4-h limit to 50 mg, if analgesia was inadequate after 1 h. Patients were questioned for the first 1 h in the PACU and were later evaluated in the ward at 1, 2, 4, 6, 12, and 24 h. Pain scores, heart rate, oxygen saturation measured by pulse oximetry, mean blood pressure, respiratory rate, sedation, morphine use, and total dose of morphine were recorded. RESULTS: Overall, pain scores at 1, 2, and 4 h were significantly lower in the gabapentin group when compared with the placebo group. Total morphine consumption in the gabapentin group was 16.3 +/- 8.9 mg (mean +/- SD) versus 42.8 +/- 10.9 mg in the placebo patients. The incidence of vomiting and urinary retention was significantly (P < 0.05) higher in the placebo group, but there was no difference in incidence of other adverse effects between the groups. CONCLUSIONS: Preoperative oral gabapentin decreased pain scores in the early postoperative period and postoperative morphine consumption in spinal surgery patients while decreasing some morphine-associated side effects.

Adding dexmedetomidine to lidocaine for intravenous regional anesthesia.

UNLABELLED: Dexmedetomidine is approximately 8 times more selective toward the alpha-2-adrenoceptors than clonidine. It decreases anesthetic requirements by up to 90% and induces analgesia in patients. We designed this study to evaluate the effect of dexmedetomidine when added to lidocaine in IV regional anesthesia (IVRA). We investigated onset and duration of sensory and motor blocks, the quality of the anesthesia, intraoperative-postoperative hemodynamic variables, and intraoperative-postoperative pain and sedation. Thirty patients undergoing hand surgery were randomly assigned to 2 groups to receive IVRA. They received 40 mL of 0.5% lidocaine and either 1 mL of isotonic saline (group L, n = 15) or 0.5 microg/kg dexmedetomidine (group LD, n = 15). Sensory and motor block onset and recovery times and anesthesia quality were noted. Before and after the tourniquet application at 5, 10, 15, 20, and 40 min, hemodynamic variables, tourniquet pain and sedation, and analgesic use were recorded. After the tourniquet deflation, at 30 min, and 2, 4, 6, 12, and 24 h, hemodynamic variables, pain and sedation values, time to first analgesic requirement, analgesic use, and side effects were noted. Shortened sensory and motor block onset times, prolonged sensory and motor block recovery times, prolonged tolerance for the tourniquet, and improved quality of anesthesia were found in group LD. Visual analog scale scores were significantly less in group LD in the intraoperative period and 30 min, and 2, 4, and 6 h after tourniquet release. Intra-postoperative analgesic requirements were significantly less in group LD. Time to first analgesic requirements was significantly longer in group LD in the postoperative period. We conclude that the addition of 0.5 microg/kg dexmedetomidine to lidocaine for IVRA improves quality of anesthesia and perioperative analgesia without causing side effects. IMPLICATIONS: This study was designed to evaluate the effect of dexmedetomidine when added to lidocaine for IV regional anesthesia. This is the first clinical study demonstrating that the addition of 0.5 microg/kg dexmedetomidine to lidocaine for IV regional anesthesia improves quality of anesthesia and intraoperative-postoperative analgesia without causing side effects.