The Effect of Gabapentin on Delayed Discharge from the Postanesthesia Care Unit: A Retrospective Analysis.

BACKGROUND: Enhanced recovery after surgery programs has incorporated gabapentin as part of a multimodal analgesia protocol. The preemptive use of gabapentin was found to be beneficial due to its opioid-sparing effect. However, excessive sedation and delayed discharge from postanesthesia recovery units are of concern. The aim of this study was to investigate whether preoperative gabapentin increased the length of stay in the recovery unit. METHODS: This retrospective cross-sectional study was carried out over a period of 2 months in the postanesthesia care unit (PACU) of a tertiary care hospital in Canada. Two hundred and twenty-eight consecutive patients who underwent elective surgical procedures and who required a longer than 2-hour stay in the PACU were included. Prolonged stays caused by respiratory inadequacy, hemodynamic instability, nausea, vomiting, pain, and loss of consciousness were recorded. The data were collected from patients' charts and nursing flow sheets. RESULTS: All patients were grouped into those who received 300 mg gabapentin (n = 108), 600 mg gabapentin (n = 41), and no gabapentin (n = 139). No significant difference was observed between the groups in terms of opioid consumption, respiratory inadequacy, nausea, vomiting, and hemodynamic parameters. Gabapentin administration groups had significantly lower postoperative pain scores (P < 0.001). Decreased level of consciousness occurred significantly more often in a dose-dependent fashion in the gabapentin groups and led to a longer stay in the PACU (P < 0.001). CONCLUSION: In the setting of enhanced recovery after surgery, gabapentin did reduce pain scores, but at the cost of delayed discharge from the recovery room. Future studies are needed to evaluate the efficacy of gabapentin in this setting.

Smoking Cessation: The Role of the Anesthesiologist.

Smoking increases the risk of postoperative morbidity and mortality. Smoking cessation before surgery reduces the risk of complications. The perioperative period may be a "teachable moment" for smoking cessation and provides smokers an opportunity to engage in long-term smoking cessation. Anesthesiologists as the perioperative physicians are well-positioned to take the lead in this area and improve not only short-term surgical outcomes but also long-term health outcomes and costs. Preoperative interventions for tobacco use are effective to reduce postoperative complications and increase the likelihood of long-term abstinence. If intensive interventions (counseling, pharmacotherapy, and follow-up) are impractical, brief interventions should be implemented in preoperative clinics as a routine practice. The "Ask, Advise, Connect" is a practical strategy to be incorporated in the surgical setting. All anesthesiologists should ask their patients about smoking and strongly advise smokers to quit at every visit. Directly connecting patients to existing counseling resources, such as telephone quitlines, family physicians, or pharmacists using fax or electronic referrals, greatly increases the reach and the impact of the intervention.

Yield of mycobacteriological study in diagnosis of pleural tuberculosis among Human immune deficiency virus-infected patients.

BACKGROUND: Pleural tuberculosis (TB) is common among HIV-infected patients. In the absence of HIV infection, the yield of mycobacteriological study is low and usually invasive procedures, including pleural fluid analysis and pleural biopsy, are necessary. The present study aimed to determine the yield of mycobacteriological study of sputum and pleural fluid among HIV-infected patients. METHODS: This retrospective case-control study involved HIV-positive and HIV-negative patients with new pleural TB admitted to the National Research Institute of Tuberculosis and Lung Disease, Tehran, Iran, for 5years. The results of sputum and pleural fluid smear for acid-fast bacilli (AFB) and mycobacterium culture were extracted and compared between the two groups. RESULTS: In the study period, 343 patients were admitted due to pleural TB, of which 42 were HIV-positive patients. We randomly selected 132 HIV-negative patients as controls. In total, 57.1% of HIV-infected patients had positive sputum smear for AFB compared with 38.6% of controls (p=0.04). Positive culture of pleural fluid was more frequent among the HIV-positive patients than among the controls (63.6% vs. 29.5%, p=0.001). There was no significant correlation between CD4 cell count and sputum or pleural fluid results. Mycobacteriological assay was enough for diagnosis in 66.6% of HIV-positive patients compared with 49.2% in controls. After adjusting for other factors and multivariate analysis, HIV remained independently and significantly associated with positive culture of pleural fluid. CONCLUSION: The diagnostic yield of mycobacteriological studies is higher among HIV-infected patients with pleural TB than among HIV-negative patients. This may decrease the need for pleural biopsy among them. Therefore, a diagnostic approach to pleural TB may be different among HIV-infected patients. In this group of patients, it is prudent to perform sputum and pleural analysis for the detection of AFB before pleural biopsy.

Impact of HIV infection on tuberculous pleural effusion.

The nature of tuberculosis (TB), being one of the most common opportunistic infections, is different among HIV-infected patients than HIV-negative patients. A retrospective study was conducted on HIV-positive and HIV-negative patients with new TB pleural effusion who were admitted to the National Research Institute of Tuberculosis and Lung Diseases in Tehran, Iran from 2005 to 2012. The two groups were compared with respect to clinical, imaging, mycobacteriologic and histopathologic characteristics of TB pleural effusion. In all, 42 HIV-positive and 132 HIV-negative cases of TB pleural effusion were included. Bilateral pleural effusion was statistically more common in the HIV-positive group (p = 0.004, OR = 3.81, 95% CI: 1.46-9.94) without any correlation with CD4 cell count. Pulmonary infiltration was found in 81% of HIV-positive and 49.2% of HIV-negative patients (p = 0.001, OR = 4.38, 95% CI: 1.88-10.1). Mycobacteriologic studies led to the diagnosis of TB in 66.6% of HIV-infected and 49.2% of HIV-negative patients. In 23.8% of HIV-positive and 50.7% of HIV-negative patients TB was ultimately diagnosed by pleural biopsy. HIV remained significantly associated with positive culture of pleural fluid in multivariate analysis. The diagnostic approach to TB pleural effusion in HIV-infected patients may be different. The diagnostic yield of mycobacteriologic studies was higher among HIV-positive patients, which may help in reducing the need for invasive procedures like pleural biopsy.

Mycobacterial infection and the impact of rifabutin treatment in organ transplant recipients: a single-center study.

Tuberculosis (TB) is a frequently encountered infection among organ transplant recipients in developing countries, and the incidence of infection after the first year of transplantation is considerably high. In this study, the impact of rifabutin treatment on organ transplant recipients with TB infection was evaluated with respect to the trend of infection, management and outcome. The medical records of 26 post-transplant patients who received an organ transplant between 2004 and 2012 and later diagnosed with TB of different organs were reviewed retrospectively. We retrieved data regarding clinical features as well as treatment and outcomes. The median time interval between transplantation and TB was 36 months (IQR 12-101 months). The most common form of infection was pulmonary/pleural TB. All our subjects received rifabutin instead of rifampin in the anti-TB treatment regime as rifabutin is a less-potent inducer of cytochrome P-450. All patients responded satisfactorily to the treatment and maintained excellent allograft function. Moreover, we did not have any mortality among our recipients. Drug-induced hepatitis was observed in nine (35%) patients. Rifabutin is an excellent alternative medication to rifampin in the setting of TB management. Hepatotoxicity is a potential risk for treatment because of the potential additive toxicity of immunosuppressive drugs.

Performance of QuantiFERON TB Gold test in detecting latent tuberculosis infection in brain-dead organ donors in Iran: a brief report.

With regard to the significant morbidity and mortality due to tuberculosis in lung transplant recipients, the identification of brain-dead organ donors with latent tuberculosis by use of the QuantiFERON TB Gold (QFT-G) test may be of help to reduce the risk of TB reactivation and mortality in lung recipients. This study was conducted in the National Research Institute of Tuber-culosis and Lung Diseases (NRITLD) in Iran, from January to March 2013. A total of 38 conse-cutive brain-dead donors, not currently infected with active tuberculosis, were recruited. The medi-cal records of all the study enrollees were reviewed. A whole-blood IFN- release assay (IGRA) in reaction to early secreted antigenic target 6 (ESAT-6), culture filtrate protein 10 (CFP-10), and TB7.7 antigens, was performed and the released Interferon- was measured via enzyme-linked immunosorbent assay (ELISA). The data was analyzed with QFT-G software which was provided by the company. The demographic, characteristics and other variables were entered into SPSS version 11.5. The QFT-G test results of three donors (7.9%) turned out to be positive, negative for 24 donors (63.1%), and indeterminate for 11 cases (28.9%). Our study revealed the potential advantages of QFT-G in lowering the incidence of donor-derived post-transplant tuberculosis among lung recipients. However, a high rate of indeterminate results restricted the performance of QFT-G in this study.

Human papillomavirus (HPV) prevalence and types among women attending regular gynecological visit in Tehran, Iran.

BACKGROUND: Persistent infection by HPV is now recognized as the main cause of cervical cancer. HPV prevalence data is not yet available in Iran. This study is organized to evaluate type-specific HPV prevalence and to compare it with Pap smear results among Iranian women attending regular gynecological visits. METHODS: A total of 851 women aged 18 - 65 years, attending regular gynecological visits, were retrospectively evaluated. HPV detection and genotyping was performed by use of Polymerase Chain Reaction (PCR) and Restriction Fragment Length Polymorphism (RFLP). Cytological evaluation was done by Papanicolaou method and the association between cytological results and HPV status was analyzed. RESULTS: 19 different HPV types were detected in 265 of the 851 specimens (31.1%). Overall HPV infection as well as infection with High Risk (HR) HPV types was highest in women aged 18 - 25 years and decreased with age. Type-specific prevalence of HPV-16 and 18 was 7.3% and 2.8%, respectively, and a large number of women (20.2%) were infected by HR HPV types other than HPV-16 and/or HPV-18. There was also an upward trend in the prevalence of HR HPV infections as the abnormality in cytology increased. The prevalence of HPV co-infection was 29.1% of HPV positive patients and declined from LSIL (18.2%) to HSIL (3.9%). CONCLUSIONS: Our study indicated that the burden of HPV infection among Iranian females was higher in comparison with previous estimates reported from Iran. Furthermore, higher prevalence of premalignant changes in Iranian women infected with HR HPV types, other than vaccine types, should be considered in immunization programs and development of population-specific HPV vaccines. This remarkable difference in prevalence of HPV types among previous studies, confirms our need to further investigations on epidemiology of HPV infection in Iran.

A novel PCBD gene mutation in an Iranian patient with hyperphenylalaninemia.

BACKGROUND: Neonatal screening for PKU is carried out nationally and our center is one of the referral centers for molecular analysis of PKU in Iran. Hyperphenylalaninemias are common disorders of phenyalanine catabolism. Six genes, including PAH, PTPS, DHPR, GTPCH, SR, and PCBD, independently play a role in this disorder. METHODS: A 2-year-old boy was referred to our center for genetic diagnosis of PKU. PAH gene was sequenced but no mutation was found. Using the STR based linkage mapping approach, BH4-metabolizing genes were screened. RESULT: A pattern of autozygosity by descent (ABD) suggested that the PCBD gene may be involved in this family. The PCBD gene was sequenced and a homozygous T > C substitution (X105Q) was found in the termination codon. CONCLUSIONS: Although most of the reported mutations in PCBD gene are single substitutions or premature stop codons causing a benign or transient form of BH4 deficiency, this novel mutation was found in the stop codon.