Effect of vitamin C on adrenal suppression following etomidate for rapid sequence induction in trauma patients: a randomized clinical trial.

BACKGROUND: Etomidate is an imidazole derivative that is widely used in the emergency department for Rapid Sequence Intubation (RSI). Although it has a safe hemodynamic profile, there are some concerns about its suppressant effects on the adreno-cortical axis. Vitamin C, as an antioxidant, can play a protective role in this issue. METHOD: In a controlled clinical trial, we studied adult traumatic patients who needed RSI with etomidate. In one group underwent RSI with etomidate and cortisol levels were measured three hours later. In the other group, we administered one gram of vitamin C before etomidate administration, and the cortisol level was measured three hours later. RESULTS: Fifty-one patients have been studied. The serum cortisol level was significantly lower after RSI with etomidate in both groups. In the Vitamin C group, there was a significantly higher cortisol level after RSI in comparison to the control group. CONCLUSION: Etomidate can suppress the cortisol level in trauma patients who undergo RSI. Vitamin C can reduce this suppressant effect of etomidate. TRIAL REGISTRATION: IRCT registration number: IRCT20090923002496N11, URL of trial registry record: https://en.irct.ir/trial/34586 , Date of trial registration: 19/04/2019. Full date of the first registration: 30/05/2019.

Comparison of tracheal tube cuff pressure with two technique: fixed volume and minimal leak test techniques.

Introduction: There is a correlation between endotracheal cuff pressure and airway complication; therefore, cuff pressure measurement is of an essential importance. The gold standard technique is measuring the cuff pressure by a calibrated manometer. However, there are several methods that injects air into balloon pilot and measures the cuff pressure. The aim of this study is to compare the tracheal cuff pressure measurement by two methods: fixed volume and minimal leak test (MLT). Methods: This descriptive study was performed at the emergency department on 110 patients. Patients were randomized into two groups. For one group, fixed volume technique and for the other group MLT was used. Results: Mean cuff pressure was 46.07±23.54 cmH2O in the fixed volume group and 33.72±9.14 cmH2O in the MLT group (P=0.05) which is significantly higher in the fixed volume group (P=0.028). In addition, 56.4% and 78.2% of the subjects had normal cuff pressure in the fixed volume group and MLT group, respectively; indicating a significantly higher rate in MLT group (P=0.025). Conclusion: Both techniques cause above normal intracuff pressure; however, MLT produces more acceptable pressure than fixed volume. It seems that the volume of 10 cc produces high pressures; therefore, fixed values may yield more appropriate results in lower volumes.

Comparison of tracheal tube cuff pressure with two techniques: fixed volume versus pilot balloon palpation.

Introduction: Filling tracheal tube cuff (TTC) after intubation is necessary to provide a safe airway in intubated patients. On the other hand, excessive increase or decrease in the pressure of TTC's balloon leads into the dangerous complications such as necrosis and/or aspiration. Accordingly, in the present study, we tried to evaluate the most two common fixed volume and pilot balloon palpitation methods to control TTC pressure. Methods: In a prospective cross-sectional study that was carried out in the emergency department of Tabriz Imam Reza hospital upon 194 patients who needed intubation and from April 2015 to June 2016. The patients were randomly allocated into two equal groups. For the first the Pilot Balloon Palpation technique and for the second group 10 cc fixed volume cuff filling technique was assigned. After that, the pressure was checked with manometer and data were analyzed using SPSS software. Results: TTC pressure average in fixed volume group was 44.96±21.77 cmH2O and for palpation group, it was 118.15±22.15 cmH2O. There was a meaningful difference between two groups in terms of cuff inside pressure (P value <0.001) and it was meaningfully lower in fixed volume group than the first one. Conclusion: The present study showed that pilot balloon palpation or fixed volume method was not appropriate methods to assess cuff pressure during intubation and the cuff pressure must be controlled by the manometer.

Antimicrobial effect of Pistacia atlantica leaf extract.

The antimicrobial effect of the mastic tree (Pistacia atlantica) under in vitro conditions has been reported. Therefore, it is of interest to evaluate the effect of the plant leaf extract (aqueous) on bacterial load in mouth and saliva. The leaf of the Pistacia atlantica plant was collected and cleaned, dried at 40°c and then powdered. The extraction was carried out using the maceration method in vacuum with the rotary evaporator device. Bacterial inhibition (Streptococcus species) by the leaf extract was studied using the disc diffusion and embedding sink diffusion methods. The values of MIC and MBC were determined. The collected data was further analyzed using t-test and repeated measure statistical tests. The disc diffusion technique showed a significant inhibitory effect for Pistacia atlantica leaf extract on S. mutans (ATCC 35668) and S. mitis (ATCC 49456) with inhibition zones of 19 and 25 millimeters, respectively. This is for the highest leaf extract concentration used in this study (p<0.01). The values of MIC and MBC for S.mutans was 60, 90 µg/ml and for S. mitis was 75, 110 µg/ml (p<0.01 significance). The leaf extract has no significant effect on S. salivarius (ATCC 13419). Thus, the antimicrobial properties of the aqueous leaf extract from Pistacia atlantica is demonstrated in this study.

Antifungal drug resistance pattern of Candida. spp isolated from vaginitis in Ilam-Iran during 2013-2014.

Vaginal Candidiasis is the most common and important opportunistic fungal infection in women. By increasing use of antifungal drugs in recent years, it has caused drug resistance. This study aims to evaluate antifungal drugs susceptibility of Candida. spp isolated of women with vaginitis from Ilam-Iran during 2013-2014. samples were collected and cultured from 385 women with vaginitis, then Candida.spp was diagnosed by standard method. Antifungal drug susceptibility test for nystatin 100 unit/disk, fluconazole 10µg/disk, itraconazole 10µg/disk, ketoconazole 10µg/disk, amphotericinB 20µg/disk, clotrimazole 10µg/disk, posaconazole 5µg/disk, and voriconazole 1µg/disk were carried out by M44-A method(CLSI). From all culture positive samples, 150 isolates were Candida albicans and 89 isolates were non-albicans. The resistance to fluconazole, itraconazole, ketoconazole, clotrimazole, voriconazole, posaconazole, nystatin and amphotericin B was 76%, 62%, 72%, 55%, 6%, 7%, 1% and 0%. The highest resistance was seen for fluconazole , itraconazole, and the highest susceptible was seen for nystatin and amphotericin B. These results indicate nystatin and amphotericin B can be used as the first line for empirical therapy of vaginal candidiasis in the district.

In vitro Osteogenic impulse effect of Dexamethasone on periodontal ligament stem cells.

Periodontium is a complex organ composed of mineralized epithelial and connective tissue. Dexamethasone could stimulate proliferation of osteoblast and fibroblasts. This study aimed to assess the osteogenic effect of dexamethasone on periodental ligament (PDL) stem cells. PDL stem cells were collected from periodontal ligament tissue of root of extracted premolar of young and healthy people. The stem cells were cultured in α-MEM Medium in three groups, one group with basic medium contains (α- MEM and FBS 10 % and 50 mmol of ß_ gelisrophosphat and L_ ascorbic acid µg/ml), the second group: basic medium with dexamethasone and the third one: basic medium without any osteogenic stimulant. Mineralization of cellular layer was analyzed with Alizarin red stain method. Osteogenic analysis was done by Alkaline phosphates and calcium test. These analysis indicated that the amount of intra-cellular calcium and alkaline phosphates in the Dexamethasone group was far more than the control and basic group (P<0.05). The results of Alizarin red stain indicated more mineralization of cultured cells in Dexamethasone group (P<0.05). The study results showed that Dexamethasone has significant osteogenic effect on PDL stem cells and further studies are recommended to evaluate its effect on treatment of bone disorders.

Anti-fungal resistance in candida isolated from oral and diaper rash candidiasis in neonates.

The purpose of the present study is to evaluate the sensitivity of Candida species isolated from oral candidiasis and diaper dermatitis infections in children. The children referring to private and public clinics in Ilam, Iran were exmined for oral candidiasis and diaper dermatitis. In this study, 248 oral candidiasis and diaper dermatitis samples were collected and cultured.Candida species were identified by using standard methods. Resistance and sensitivity to amphotericin B, nystatin, ketoconazole, fluconazole, itraconazole, clotrimazole, and posaconazole were determined using the CLSI M44-A standard disk diffusion method. From the 248 studied samples, 149 were positive for Candida, among which the Candida albicans was the most prevalent (64.4%). The resistance of different Candida species to nystatin, itraconazole, fluconazole, ketoconazole, clotrimazole, voriconazole, and posaconazole were 4, 43, 34.2, 34.9, 21.5, 6, and 6.7%, respectively. No resistance to amphotericin B was observed. Considering rather low resistance to nystatin, this drug is the best choice for oral candidiasis and diaper dermatitis.

Study of the inhibitory effect of Quercus Coccifera's aqueous extract on Staphylococcus aureus and Pseudomonas aeruginosa In vitro.

The use of therapeutic herbs has become of great importance these days due to the increase in drug resistance. From a long time ago the Venus' navel plant has been used to treat infections. In this study the antibacterial effect of the aqueous extract from the Quercus coccifera (jaft) herb, under laboratory conditions. This study was carried out experimentally. After collecting the Venus navel herb, it was dried in a warm dry environment away from direct sunlight in the shade. The alcoholic extract was prepared using a standard method. Clinical samples of staphylococcus aureus and pseudomonas aeruginosa were acquired from Ilam's health care institutes. The inhibitory effect of the extracts was analysed in the Mueller Hinton using the disk diffusion method for both bacteria. Then MIC and MBC of the extracts was determined using the Macro broth dilution method. At its highest concentration the aqueous extract had an inhibition zone of 27.2 and 23.7 mm on staphylococcus aureus and pseudomonas aeruginosa consecutively. The MIC and MBC for staphylococcus aureus were 10 and 12.5 µg/ml and for pseudomonas aeruginosa they were 10 and 17.5 µg/m consecutively. The results of this study show the strong antimicrobial effect of jaft's aqueous extract on staphylococcus aureus and pseudomonas aeruginosa and if more studies are based on this topic it could be a substitute for common antibiotics.

Evaluation of dairy allergy among ulcerative colitis patients.

The intestine is the largest mucosal organ of the body and also the first line immune homeostasis. Inflammatory bowel disease or IBD is divided into ulcerative colitis and Crohn's disease. One of the problems that can occur with UC is dietary allergy to some foods. This study aimed to evaluated the dairy allergy among patients with ulcerative colitis. This study is a Case - control study, that studied 72 patients with Ulcerative Colitis, after recording history of the disease, colonoscopy and confirmed by biopsy and 72 person without history of colitis. In this study, in order to investigate of food allergy, used of the EUROMMUM kit with an international code number DP3420-1601-11E. We used chi-square and Monte Carlo method for analysis of data. Among UC patients, 30.6% mild, 52.8% moderate and 16.6% of cases were in sever stage. 9.7% of them reported a history of abdominal surgery due to disease. According to the chi-square and Monte Carlo methods, dairy allergy (including: cow milk, cow milk UHT and casein) in UC group was significant (P=0.00). This study indicated that there is significant relationship between UC and cow milk, cow milk UHT and casein. UC patients who are allergic to dairy products and the use of dairy products can increase the severity of UC.

Data from a randomized and controlled trial of LCarnitine prescription for the treatment for Non- Alcoholic Fatty Liver Disease.

Non-alcoholic fatty liver disease (NAFLD) consists of a range of complication. The disease describes clinical , para clinical and pathological conditions from simple steatosis in non-alcoholic steato hepatitis (NASH) to fibrosis, cirrhosis and hepato cellular carcinoma. Therefore, it is of interest to evaluate the grade of fatty liver and Liver Function Test in NAFLD patients. We collected samples and data from 80 patients referred to gastrointestinal clinic of Emam Reza hospital with sonography diagnosed NAFLD and were evaluated in two groups in a randomized clinical trial. The effects of L-Carnitine (500 mg) prescription twice a day on liver enzymes and echogenicity changes in case group was documented and compared with the control group. The mean age of the patients was 40.7±8 in the age range of 25 to 62 years old with 66 (82.5%) male and 14 (17.5%) female patients. Data show that fatty liver changes were not significantly different in the two groups (P=0.23). It is observed that the ALT was the only enzyme with significant changes (P=0.01) after a 24-week interval. It is also noted that the difference in fatty liver sonographic grading was also significant in the two groups (P=0.0001). Thus, proper therapeutic protocols can be adopted beside diet and weight loss to control the disease trend in consideration to the significant changes observed both in enzymatic levels and sonographic grading between the two groups of patients with NAFLD.

Baby cuff as a reason for laryngeal mask airway cuff malfunction during airway management for anesthesia.

Placement of laryngeal mask airway (LMA) is a blind procedure without requiring laryngoscopy. The reported success rate for LMA insertion at the first attempt is almost 95%; however, many functioning LMAs may not be in an ideal anatomic place. It seems that disposable LMAs have more stable cuff pressure compared to reusable LMAs; therefore, Anesthesiologists should bear in mind this fact when using reusable LMAs to achieve a proper sealing and safe airway management. In this report, we introduced a case with malfunction of LMA cuff during the airway management.

Comparison of three methods in improving bag mask ventilation.

INTRODUCTION: Increasedlife expectancy in populations has brought along specific new scenarios in the fields of medicine for the elderly; prevalence of physical complications such as edentulism and patients with dentures is growing. Management of anesthesia and ventilation in this group of patients has turned into a great challenge. Some researchers suggest dentures to be left in place during bag-mask ventilation; yet, no unanimous agreement exists in this regard. METHODS: In a single blind randomized clinical trial, we studied 300 patients with ASA class I, II (American Society of Anesthesiologists), Mallampati class (I, II) and aged over 55 years in three groups. After induction of anesthesia, in group G dentures were removed and in each buccal space an eight-layer 10 × 10 cm gauze and an oral airway were placed. In group D, the dentures and an oral airway were left in place. In group C (control), after removing dentures just an appropriate oral airway was placed. Then, each three group underwent bag-mask ventilation. Success of bag-mask ventilation (BMV) was considered as increase in end-tidal carbon dioxide to more than 20 mmHg and back to baseline with fresh gas flow of 3 L/min and adjustable pressure limiting valve pressure of 20 cm H2O. Success rates were evaluated between groups. RESULTS: Effective BMV was possible in 91 (91%), 64 (64%) and 41 (41%) patients in groups G, D and C respectively. The differences were statistically significant. Successful BMV rate was significantly higher in female patients in group G compared to group C; 43/44 versus 25/46 individuals, P = 0.0001, odds ratio = 0.03, 95% confidence interval (0.00, 0.22). CONCLUSIONS: Leaving dentures in place in edentulous patients after inducing anesthesia improves bag-mask ventilation. However, placing folded compressed gauze in buccal space leads to more significant improvement in BMV compared to leaving dentures in place.

Sensitivity of palm print, modified mallampati score and 3-3-2 rule in prediction of difficult intubation.

BACKGROUND: This study evaluated the performance of modified Mallampati score, 3-3-2 rule and palm print in prediction of difficult intubation. METHODS: In a prospective descriptive study, data from 500 patients scheduled for elective surgery under general anesthesia were collected. An anesthesiologist evaluated the airway using mentioned tests and another anesthesiologist evaluated difficult intubation. Laryngoscopic views were determined by Cormack and Lehane score. Grades 3 and 4 were defined as difficult intubation. Sensitivity, specificity, positive predictive value, negative predictive value and Youden index were determined for all tests. RESULTS: Difficult intubation was reported in 8.9% of the patients. There was a significant correlation between body mass index and difficult intubation (P : 0.004); however, other demographic characteristics didn't have a significant correlation with difficult intubation. Among three tests, palm print was of highest specificity (96.46%) and modified Mallampati of highest sensitivity (98.40%). In a combination of the tests, the highest specificity, sensitivity and Youden index were observed when using all three tests together. CONCLUSIONS: Palm print has a high specificity for prediction of difficult intubation, but the best way for prediction of difficult intubation is using all three tests together.

Modified cricothyroidotomy in skill laboratory.

INTRODUCTION: Unsuccessful tracheal intubation is considered the most common cause of anesthesia death or brain damage. This study delineates our experience recommending modifications in the cricothyroidotomy technique. METHODS: Thirty emergency medicine residents of participated in a study performed on the human simulator moulage in Skill Laboratory of Tabriz University of Medical Science. The cricothyroid membrane was punctured using a 16-gauge cannula. Later, J guide wire was advanced into trachea and standard 16-gauge intravenous cannula with a removable needle stylet withdrawn after the puncture being dilated by a dilator. Consequently, a cuffed tracheal tube (ID= 6) was introduced from the foramen. RESULTS: From 30 residents, 18 residents performed cricothyroidotomy within 1 minute, 7 residents in 2 minutes and 5 residents failed to fulfill the procedure. CONCLUSION: Several studies using cadavers and human simulators have demonstrated the pre-hospital feasibility of this technique. However, descriptions of clinical pre-hospital experience with percutaneous cricothyroidotomy are limited. This study shows that skill lab may help residents to acquire techniques required in management of difficult airway.

Role of anesthesiology curriculum in improving bag-mask ventilation and intubation success rates of emergency medicine residents: a prospective descriptive study.

BACKGROUND: Rapid and safe airway management has always been of paramount importance in successful management of critically ill and injured patients in the emergency department. The purpose of our study was to determine success rates of bag-mask ventilation and tracheal intubation performed by emergency medicine residents before and after completing their anesthesiology curriculum. METHODS: A prospective descriptive study was conducted at Nikoukari Hospital, a teaching hospital located in Tabriz, Iran. In a skills lab, a total number of 18 emergency medicine residents (post graduate year 1) were given traditional intubation and bag-mask ventilation instructions in a 36 hour course combined with mannequin practice. Later the residents were given the opportunity of receiving training on airway management in an operating room for a period of one month which was considered as an additional training program added to their Anesthesiology Curriculum. Residents were asked to ventilate and intubate 18 patients (Mallampati class I and ASA class I and II) in the operating room; both before and after completing this additional training program. Intubation achieved at first attempt within 20 seconds was considered successful. Successful bag-mask ventilation was defined as increase in ETCo2 to 20 mm Hg and back to baseline with a 3 L/min fresh gas-flow and the adjustable pressure limiting valve at 20 cm H2O. An attending anesthesiologist who was always present in the operating room during the induction of anesthesia confirmed the endotracheal intubation by direct laryngoscopy and capnography. Success rates were recorded and compared using McNemar, marginal homogeneity and paired t-Test tests in SPSS 15 software. RESULTS: Before the additional training program in the operating room, the participants had intubation and bag-mask ventilation success rates of 27.7% (CI 0.07-0.49) and 16.6% (CI 0-0.34) respectively. After the additional training program in the operating room the success rates increased to 83.3% (CI 0.66-1) and 88.8% (CI 0.73-1), respectively. The differences in success rates were statistically significant (P = 0.002 and P = 0.0004, respectively). CONCLUSIONS: The success rate of emergency medicine residents in airway management improved significantly after completing anesthesiology rotation. Anesthesiology rotations should be considered as an essential component of emergency medicine training programs. A collateral curriculum of this nature should also focus on the acquisition of skills in airway management.