Attention-deficit/hyperactive disorder updates.

Background: Attention-deficit/hyperactive disorder (ADHD) is a neurodevelopmental disorder that commonly occurs in children with a prevalence ranging from 3.4 to 7.2%. It profoundly affects academic achievement, well-being, and social interactions. As a result, this disorder is of high cost to both individuals and society. Despite the availability of knowledge regarding the mechanisms of ADHD, the pathogenesis is not clear, hence, the existence of many challenges especially in making correct early diagnosis and provision of accurate management. Objectives: We aimed to review the pathogenic pathways of ADHD in children. The major focus was to provide an update on the reported etiologies in humans, animal models, modulators, therapies, mechanisms, epigenetic changes, and the interaction between genetic and environmental factors. Methods: References for this review were identified through a systematic search in PubMed by using special keywords for all years until January 2022. Results: Several genes have been reported to associate with ADHD: DRD1, DRD2, DRD4, DAT1, TPH2, HTR1A, HTR1B, SLC6A4, HTR2A, DBH, NET1, ADRA2A, ADRA2C, CHRNA4, CHRNA7, GAD1, GRM1, GRM5, GRM7, GRM8, TARBP1, ADGRL3, FGF1, MAOA, BDNF, SNAP25, STX1A, ATXN7, and SORCS2. Some of these genes have evidence both from human beings and animal models, while others have evidence in either humans or animal models only. Notably, most of these animal models are knockout and do not generate the genetic alteration of the patients. Besides, some of the gene polymorphisms reported differ according to the ethnic groups. The majority of the available animal models are related to the dopaminergic pathway. Epigenetic changes including SUMOylation, methylation, and acetylation have been reported in genes related to the dopaminergic pathway. Conclusion: The dopaminergic pathway remains to be crucial in the pathogenesis of ADHD. It can be affected by environmental factors and other pathways. Nevertheless, it is still unclear how environmental factors relate to all neurotransmitter pathways; thus, more studies are needed. Although several genes have been related to ADHD, there are few animal model studies on the majority of the genes, and they do not generate the genetic alteration of the patients. More animal models and epigenetic studies are required.

The Contribution of HCN Channelopathies in Different Epileptic Syndromes, Mechanisms, Modulators, and Potential Treatment Targets: A Systematic Review.

Background: Hyperpolarization-activated cyclic nucleotide-gated (HCN) current reduces dendritic summation, suppresses dendritic calcium spikes, and enables inhibitory GABA-mediated postsynaptic potentials, thereby suppressing epilepsy. However, it is unclear whether increased HCN current can produce epilepsy. We hypothesized that gain-of-function (GOF) and loss-of-function (LOF) variants of HCN channel genes may cause epilepsy. Objectives: This systematic review aims to summarize the role of HCN channelopathies in epilepsy, update genetic findings in patients, create genotype-phenotype correlations, and discuss animal models, GOF and LOF mechanisms, and potential treatment targets. Methods: The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, for all years until August 2021. Results: We identified pathogenic variants of HCN1 (n = 24), HCN2 (n = 8), HCN3 (n = 2), and HCN4 (n = 6) that were associated with epilepsy in 74 cases (43 HCN1, 20 HCN2, 2 HCN3, and 9 HCN4). Epilepsy was associated with GOF and LOF variants, and the mechanisms were indeterminate. Less than half of the cases became seizure-free and some developed drug-resistant epilepsy. Of the 74 cases, 12 (16.2%) died, comprising HCN1 (n = 4), HCN2 (n = 2), HCN3 (n = 2), and HCN4 (n = 4). Of the deceased cases, 10 (83%) had a sudden unexpected death in epilepsy (SUDEP) and 2 (16.7%) due to cardiopulmonary failure. SUDEP affected more adults (n = 10) than children (n = 2). HCN1 variants p.M234R, p.C329S, p.V414M, p.M153I, and p.M305L, as well as HCN2 variants p.S632W and delPPP (p.719-721), were associated with different phenotypes. HCN1 p.L157V and HCN4 p.R550C were associated with genetic generalized epilepsy. There are several HCN animal models, pharmacological targets, and modulators, but precise drugs have not been developed. Currently, there are no HCN channel openers. Conclusion: We recommend clinicians to include HCN genes in epilepsy gene panels. Researchers should explore the possible underlying mechanisms for GOF and LOF variants by identifying the specific neuronal subtypes and neuroanatomical locations of each identified pathogenic variant. Researchers should identify specific HCN channel openers and blockers with high binding affinity. Such information will give clarity to the involvement of HCN channelopathies in epilepsy and provide the opportunity to develop targeted treatments.

Facial topical cream promotes facemask tolerability and compliance during COVID-19 pandemic.

Objectives: Facemask use is essential for managing the COVID-19 pandemic, but may cause facial dermopathy. Topical creams may minimise facemask complications. This clinical study explores the impact of different topical creams on facemask tolerability and complications. Methods: This was a prospective observational study involving 80 adults. Participants voluntarily chose and used topical creams during facemask use. Data were collected using validated scales before and after topical cream application. Results: About 23.8% of the participants used lidocaine gel, 17.5% used petrolatum, 16.2% used hydrocortisone cream, 16.2% used diphenhydramine cream, 13.8% used arnica cream, and 12.5% used zinc oxide cream. Duration of facemask use was 6 h amongst staff and 4 h amongst patients, and was similar both with and without topical cream. Facial temperature rise was lower with all creams (p = 0.033), as was facial redness (p = 0.037) and facial pain (p = 0.025). Facemask compliance was better for all creams (p = 0.015). The facial temperature rise was the lowest with topical lidocaine (p = 0.021). Early facial redness was lowest with topical hydrocortisone or diphenhydramine (p = 0.042). Severe redness was lowest with topical hydrocortisone or zinc oxide (p = 0.044). Facemask pain was lowest with topical lidocaine (p = 0.035), and facemask compliance was best with topical lidocaine (p = 0.001). Petrolatum had the best user satisfaction and odour ratings (p = 0.041). Conclusion: Topical creams minimise facemask complications, thereby promoting compliance; topical lidocaine was the most effective in reducing pain and enabling facemask compliance. Topical hydrocortisone, diphenhydramine, and zinc oxide were effective in reducing facial redness, and topical petrolatum produced the best user satisfaction.

Clonidine is better than zopiclone for insomnia treatment in chronic pain patients.

STUDY OBJECTIVES: Chronic pain is associated with insomnia. The objective of this clinical study was to compare the efficacy and safety of different prescribed doses of zopiclone and clonidine for the management of insomnia in patients with chronic pain. METHODS: This prospective observational crossover study included 160 consenting adult patients receiving pain management treatment. For insomnia treatment, each patient ingested different prescribed doses of zopiclone or clonidine on alternate nights. Each patient used a special validated sleep diary to collect data including pain score, sleep scores, sleep duration, sleep medication dose, and adverse effects. Each patient completed the diary for 3 continuous weeks. Pain was measured using a numeric pain rating scale. Sleep score was measured using the Likert Sleep Scale. A change in the pain or sleep scores by 2 points was considered significant. Of the 160 study participants, 150 (93.8%) completed the study successfully, and their data were analyzed with IBM SPSS Statistics 25 (IBM Corporation, Armonk, NY) using Student's t test, analysis of variance, Pearson chi-square test, and regression analysis. A P value < .05 was considered significant. RESULTS: Pain score was lower with clonidine than zopiclone (P = .025). Time to fall asleep was shorter with clonidine than zopiclone (P = .001). Feeling rested on waking in the morning was better with clonidine than zopiclone (P = .015). Overall sleep quality was better with clonidine than zopiclone (P = .015). Total Likert sleep score was better with clonidine than zopiclone (P = .005). Total sleep duration was better with clonidine than zopiclone (P = .013). Adverse effects were commoner with zopiclone, including collapse, fall, confusion, amnesia, mood disorder, hallucination, nightmare, nocturnal restlessness, locomotor dysfunction, nausea and headache. A minor adverse effect of dry mouth was commoner with clonidine. CONCLUSIONS: Clonidine is significantly better than zopiclone with respect to sleep quality, analgesia, tolerability profile, and patient safety. Further studies comparing clonidine with other insomnia medications will be beneficial. CITATION: Bamgbade OA, Tai-Osagbemi J, Bamgbade DO, et al. Clonidine is better than zopiclone for insomnia treatment in chronic pain patients. J Clin Sleep Med. 2022;18(6):1565-1571.

Delayed surgical diagnosis and treatment of severe sickle cell arthropathy: The need to raise clinicians' awareness.

OBJECTIVES: Sickle cell disease (SCD) is associated with femoral head osteonecrosis and is treated with hip arthroplasty 18 weeks after presentation. However, there is inadequate data regarding the timing of surgical management of severe hip arthropathy. This study explores the problem of delayed diagnosis and surgical management of severe SCD hip arthropathy by comparing the clinical outcomes of patients from Nigeria, Canada and Britain. METHODS: This is a prospective clinical audit of the routine care of 30 adult SCD patients who underwent hip arthroplasty for femoral head osteonecrosis. The clinical data are collected from five medical centers in Britain, Canada and Nigeria and compared. RESULTS: Hip arthroplasty was delayed beyond 18 weeks in 3 of 14 Nigerian patients (21%), 7 of 10 British patients (70%) and all 6 Canadian patients (100%). The majority of Nigerian patients (79%) and only 30% of British patients had diagnostic imaging and surgical management without delay. CONCLUSION: Inadequate physician awareness and delayed surgical management of SCD hip arthropathy can be mitigated by improving the education of physicians who manage patients with SCD. It is essential to recruit, train and support physicians with an interest in SCD. As this primarily affects young patients, it is necessary to set an international standard for the timing of surgical management of SCD hip arthropathy.

Perioperative care of obstructive sleep apnea patients: A survey of European anesthesiologists.

BACKGROUND: Obstructive sleep apnea (OSA) is prevalent in the surgical patient population and is associated with high risk of perioperative complications. There are limited guidelines and wide practice variations regarding the perioperative care of obese and OSA patients. This is a study of European anesthesiologists' clinical practice of perioperative care of OSA patients. METHODS: This survey evaluated United Kingdom anesthesiologists' clinical practice of the perioperative care of OSA patients. Outcomes and variables were compared between 4100 anesthesiologists of different clinical experience and hospital settings. RESULTS: Approximately 45% of respondents manage OSA patients rarely, 42% occasionally, and 13% regularly. Most respondents order OSA screening tests if patients have tonsillar hypertrophy, head/neck tumor, BMI >35, increased neck circumference, craniofacial anomaly, and right-sided electrocardiography (ECG) anomaly. Majority request preoperative polysomnography, ECG, overnight pulse oximetry, and arterial blood gas analysis. Majority recommend preoperative weight loss, optimisation, smoking cessation, reduction of substance use, and regular mask-CPAP use. Majority consider endoscopy, and ophthalmology as appropriate day case procedures, but not laparoscopy. Majority postpone elective airway, laparoscopic, laparotomy, and head/neck surgery; if patients are not optimized preoperatively. For major surgery, combined general + neuraxial anesthesia was ranked as 3rd option. For major limb surgery, neuraxial anesthesia without sedation was ranked as 1st option, nerve block without sedation was ranked 2nd, and general anesthesia + nerve block was ranked 3rd or 4th. At anesthesia emergence, majority ensure that patients have normal consciousness, respiration and neuromuscular function. Majority ensure postoperative oximetry, telemetry, and oxygen supplementation. CONCLUSION: This study highlights variations in anesthesiologists' perioperative care of OSA patients; even in developed countries with advanced medical training and standards. The study outcomes will improve perioperative care of OSA patients.

Difficult tracheal extubation due to endotracheal tube malfunction: A challenge during the COVID-19 pandemic.

Tracheal extubation is an aerosol-generating medical procedure. Difficult tracheal extubation is a serious complication that increases the risk of respiratory aerosol and pathogen spread, especially during the COVID-19 pandemic. The management of difficult extubation is potentially even more challenging during the pandemic. We report two cases of difficult extubation due to endotracheal tube cuff malfunction during the COVID-19 pandemic. Special airway maneuvers and infection control measures were employed to successfully manage the unexpected dilemma. This case series highlights the risk of COVID-19 virus transmission during difficult extubation. This report describes the preventive and reactive management of difficult extubation.

Modified vertical infraclavicular block: An evaluation of two methods.

The vertical infraclavicular block (VIB) of the brachial plexus is commonly used to provide local anesthesia (LA) of the upper limb. The original method involves LA injection at the mid-point of an infraclavicular line between acromion and jugular fossa. However, this method is ineffective in adult patients with variant anatomy. Two modified VIB methods have been previously suggested. This prospective observational, clinical study compared both modified VIB approaches. The study showed that modified VIB is easy, efficacious, and applicable to all adult patients; including those with small stature, extreme tallness, or variant anatomy.

Anesthesiologist preference for postoperative analgesia in major surgery patients with obstructive sleep apnea.

Obstructive sleep apnea (OSA) is prevalent and presents perioperative challenges. There are guidelines regarding perioperative care of OSA, but analgesia management of OSA patients is inconsistent or inadequate. This is a study of the United Kingdom anesthesiologists' postoperative analgesia preferences for OSA patients. Overall, the 1st choice of main analgesia was continuous epidural local anesthetic (LA) without opioid, at 30% rate; P = 0.001. The 2nd choice was continuous epidural LA plus fentanyl, at 21% rate; P = 0.001. The 3rd choice was intrathecal diamorphine, at 19% rate; P = 0.001. The 4th choice was nerve block catheter LA infusion, at 13% rate; P = 0.001. The 5th choice was wound infiltration with LA ± epinephrine, at 8% rate; P = 0.001. The 6th choice was systemic opioid, at 7% rate; P = 0.007. The 7th choice was systemic nonsteroidal anti-inflammatory drugs, at 2% rate; P = 0.001. The hospital setting or anesthesiologists' experience did not significantly impact analgesia choice: P =0.411. This study shows that current practice by anesthesiologists has a preference for regional or opioid-sparing analgesia for OSA patients. This safe approach conforms to guidelines and should be encouraged.

Magnesium interscalene nerve block for the management of painful shoulder disorders.

Shoulder pain is a common and distressing disorder. Systemic multimodal analgesia may be ineffective, but interscalene nerve block provides effective therapy. Magnesium may increase the efficacy and duration of systemic or regional analgesia. This case series examines the utility of magnesium interscalene nerve block for the management of painful shoulder disorders. Six elderly patients with shoulder pain and dysfunction received interscalene nerve block with injection of bupivacaine and magnesium. The patients subsequently reported significant improvement in sleep, shoulder pain, and physical function for 16 weeks. This report highlights that magnesium interscalene nerve block provides safe, effective, and prolonged shoulder analgesia.

Perioperative Antiemetic Therapy for Fast-Track Laparoscopic Bariatric Surgery.

BACKGROUND: Postoperative nausea and vomiting (PONV) is problematic in bariatric surgery patients and has negative impacts on perioperative outcome. Antiemetic prophylaxis may reduce PONV. Perioperative antiemetic prophylaxis or therapy is crucial and may enhance fast-track bariatric surgery. This study examined the impact of intraoperative multimodal antiemetic prophylaxis on fast-track bariatric surgery. METHODS: This prospective observational clinical study explored the perioperative data of 400 consecutive laparoscopic bariatric surgery patients, over a 6-year period. Perioperative outcomes and variables were analyzed and compared between different intraoperative antiemetic modes. RESULTS: The mean BMI was 49, mean age was 42, and male:female ratio was 1:4. About 70% of patients received intraoperative multimodal antiemetic, comprising combinations of prochlorperazine, dexamethasone, ondansetron, or cyclizine. PONV occurred in 19.5% of patients. Intraoperative multimodal antiemetic was associated with significantly less PONV, shorter post-anesthesia care unit duration, earlier postoperative drinking, and shorter hospital stay (p = 0.001). Compared to other multimodal antiemetic modes, dexamethasone + cyclizine + prochlorperazine provided the best prophylaxis and outcome: p = 0.002. CONCLUSION: PONV is a common and peculiar problem in bariatric surgery patients. However, intraoperative multimodal antiemetic prophylaxis effectively minimizes PONV. Intraoperative multimodal antiemetic enhances fast-track bariatric surgical care, patient satisfaction, and perioperative outcomes.

The use of intubating lightwand in difficult airway patients with limited management options.

The intubating lightwand is a recommended airway management tool in patients with failed direct laryngoscopy or intubation; but the device is under-utilised. This study reports successful lightwand intubation in a cohort of 22 consecutive adult patients with difficult airway; who required endotracheal general anaesthesia, in the presence of limited management options. Patients underwent different procedures: tonsillectomy (2), pharyngeal biopsy (6), abdominal surgery (5), thoracoscopy (3) and maxillofacial surgery (6). All the patients had a difficult airway, reduced mouth opening, neck anomalies and airway scores of Mallampati 3 or 4. They were all intubated easily, promptly and safely with the lightwand. This study shows the utility of lightwand intubation in patients with difficult airway and limited airway management options. The study highlights that the lightwand is durable, portable, cost-effective, easy to use and easy to maintain; compared to other devices for difficult intubation.

Obstructive sleep apnea and postoperative complications among patients undergoing gynecologic oncology surgery.

OBJECTIVE: To investigate the prevalence of obstructive sleep apnea (OSA), physiological or risk factors associated with OSA, and OSA-associated postoperative complications among patients undergoing gynecologic oncology surgery. METHODS: A prospective observational study enrolled gynecologic oncology patients undergoing abdominal surgery at a center in the UK between August 2009 and January 2013. All patients underwent perioperative sleep oximetry for the diagnosis of OSA. Data assessed included the body mass index, the STOP-Bang score, the Epworth Sleepiness Scale score, the apnea-hypopnea index, and postoperative complications. Associations were determined between preoperative OSA and postoperative OSA, postoperative complications, and risk factors such as body mass index, age, STOP-Bang score, and Epworth score. RESULTS: Among 160 participants, 72 (45.0%) were obese and 80 (50.0%) had OSA. Obesity, older age (more than 65 years), and a neck circumference of 40 cm or more were significantly associated with OSA. Overall, 58 (36.3%) patients had postoperative complications; 21 (13.1%) had surgical complications and 37 (23.1%) had medical complications. Complications were not associated with OSA (P=0.612). Four (2.5%) patients died; mortality was not associated with OSA (P=0.810). CONCLUSION: OSA is common among gynecologic oncology patients. Portable sleep oximetry identifies gynecology patients who have OSA or require postoperative critical care. Obesity is associated with OSA, but OSA is not associated with postoperative complications in gynecologic oncology patients.

Perioperative Analgesia for Fast-Track Laparoscopic Bariatric Surgery.

BACKGROUND: Postoperative pain and analgesia present challenges in bariatric surgery patients. Multimodal analgesia may provide better efficacy, less complications and expedite fast-track bariatric surgical care. There are no studies of the broader topic of perioperative analgesia and the overall impact. This study highlights the impact of multimodal intraoperative analgesia on fast-track bariatric surgery. METHODS: This observational study examined the perioperative outcome data of 412 consecutive laparoscopic bariatric surgery patients over a 6-year period. Perioperative outcome and variables were analysed and compared between different intraoperative analgesia types. RESULTS: Mean BMI was 49, mean age was 42 and male:female ratio was 1:4. About 82% of patients received multimodal intraoperative analgesia, comprising various combinations of bupivacaine infiltration and intravenous acetaminophen, morphine, tramadol, parecoxib or diclofenac. Morphine was administered in 83% of patients and tramadol in 17%. Multimodal intraoperative analgesia provided better postoperative analgesia, shorter postanaesthesia care unit (PACU) duration, lower postoperative opioid requirement, less postoperative vomiting, earlier postoperative oral intake, earlier ambulation and shorter hospital stay compared to unimodal intraoperative morphine analgesia (p = 0.0001). Multimodal analgesia comprising tramadol + acetaminophen + diclofenac provided better postoperative analgesia, shorter PACU duration, lower postoperative opioid requirement, earlier ambulation, shorter hospital stay and less postoperative hypopnoea compared to patients who received morphine (p = 0.0001). CONCLUSIONS: Multimodal intraoperative analgesia provides better postoperative analgesia, less complications and better perioperative outcomes and facilitates fast-track bariatric surgical care. Tramadol is suitable, efficacious and safe and associated with the best perioperative outcomes in bariatric surgery patients.

Preoperative bowel preparation complicated by lethal hypermagnesaemia and acute nephropathy.

Hypermagnesaemia is an uncommon but serious disorder. An elderly woman presented with severe cardiovascular collapse, neurologic depression and acute nephropathy, following bowel preparation. Urgent laboratory tests revealed serum magnesium level of 7.5 mmol/L (normal = 0.75-1.05 mmol/L). Prompt resuscitation and treatment of the hypermagnesaemia included intravenous calcium chloride as a physiological antagonist, fluid infusion and frusemide to aid renal excretion of magnesium. There are few case reports of patients who survived hypermagnesaemia levels >7 mmol/L. This is a case report of near-fatal hypermagnesaemia which resolved following early diagnosis and treatment. Hypermagnesaemia may be difficult to diagnose because serum magnesium is not checked routinely and many clinicians are unfamiliar with this uncommon condition. It is a diagnosis of exclusion and may not be recognised as a cause of neurologic or cardiorespiratory depression. Hypermagnesaemia should be considered as a possible diagnosis in elderly or high-risk patients presenting with such symptomatology.