A qualitative study on barriers and strategies to hospital preparedness against chemical, biological, radiological, and nuclear incidents.

BACKGROUND: The effects of chemical, biological, radiological, and nuclear (CBRN) incidents on human society can be irreparable. Preparing the health system for these incidents is essential. This study aims to identify obstacles to hospital preparedness against CBRN incidents and provide solutions. MATERIALS AND METHODS: This qualitative study was conducted using semi-structured interview method in 2022. The research community included experts in the fields of CBRN, and 17 persons were included in the study through purposive sampling. The interviews were collected by interview guide and recorded face-to-face and online and were analyzed using thematic content analysis method in MS Word 2016. RESULTS: The interviews' analysis was classified into two main categories and 34 sub-categories. Some of the most important obstacles to the hospital preparedness against CBRN incidents were the lack of proper crisis management, the lack of specialist staff, the stress of employees, the lack of turnover and sufficient rest for employees, legal gaps, and so on. The main strategies were determining the type and extent of the risk factor, strong crisis management, the lack of parallelism, continuous monitoring, having a protocol and road map, appropriate training programs, having skilled personnel, rapid response of personnel, positive attitude of the staff, and the favorable condition of the building. CONCLUSION: The appointment of an expert in the field of CBRN and having a specialized unit, the existence of specialized and trained staff along with access to the required facilities, clear instructions, and intra-departmental and inter-departmental cooperation affect the readiness of hospitals against CBRN incidents.

Potential drug-drug interactions in a multi-center study of death cases of COVID-19: The significance of appropriate drug choice.

OBJECTIVES: The prevalence, types, severity, risk ratings, and common pairs of involved drugs, and the most important potential drug-drug interactions (pDDIs) in coronavirus disease 2019 (-COVID-19) deceased cases were evaluated. MATERIALS AND METHODS: We reviewed the medical records of 157 confirmed COVID-19 deceased cases hospitalized in 27 province-wide hospitals. Patients' demographics and clinical data (including comorbidities, vital signs, length of in-hospital survival, electrocardiograms (ECGs), medications, and lab test results) were extracted. The online Lexi-interact database and Stockley's drug interactions reference were used to detect pDDIs retrospectively. The QTc interval and total Tisdale risk score were also calculated. Descriptive analysis, analysis of variance, Fisher exact test, and multivariate analysis were conducted for data analysis. RESULTS: Of 157 study cases, 63% were male, had a mean age of 68 years, and 55.7% had one or more underlying diseases. All patients had polypharmacy, with 69.2% having ≥ 15 drugs/day. We detected 2,416 pDDIs in patients' records, of which 658 (27.2%) were interactions with COVID drugs. Lopinavir/ritonavir among -COVID drugs and fentanyl among non-COVID drugs were commonly involved in the interactions. pDDIs was significantly higher in the polypharmacy group of ≥ 15 medications (p < 0.001). A majority (83%) had received drug(s) with the QTc prolongation effect, of whom 67% had actual QTc prolongations in their ECGs. The regression analysis showed that by increasing 6.7% in polypharmacy, one day increase in-hospital survival can be expected. Moreover, an increase of 2.3% in white blood cells or 10.5% in serum potassium level decreased in-hospital survival by 1%. CONCLUSION: The findings underscored the importance of careful drug choice, especially in the hectic search for early treatments in pandemics of novel diseases. Close monitoring of patients' drug choice is warranted for reducing pDDIs and their adverse effects in any new disease outbreak.

The Effect of Chronic Consumption of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Antagonists on Blood Pressure and Inotrope Consumption After Separation from Cardiopulmonary Bypass.

BACKGROUND: Chronic use of renin-angiotensin system (RAS) antagonists (angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor antagonists (ARAS)) can cause hypotension during anesthesia. In some studies hemodynamic instability, including hypotension and its effects on the clinical outcome in patients treated with these drugs during coronary artery bypass graft (CABG) and need to excessive vasoactive drugs in these patient population, has been described. The aim of this study was to evaluate the effect of chronic consumption of ACEIs and ARAS on blood pressure and inotrope consumption during coronary artery bypass graft under cardiopulmonary bypass. METHODS: A total of 200 patients undergoing coronary artery bypass graft surgery, who were treated with either ARAS or ACEIs (n = 100) over at least 2 months, or who were not treated with any RAS antagonists (control group, n = 100) were enrolled. The mean arterial blood pressure, central venous pressure, and need for vasoactive drugs, were measured after induction of anesthesia (T1) before cardiopulmonary bypass (T2) and after separation from (CPB), (T3). RESULTS: There were no significant differences regarding the mean arterial pressure (case group: T1: 84 ± 7 mmHg, T2: 77 ± 6 mmHg, T3: 83 ± 8 mmHg), (control group: T1: 85 ± 7 mmHg, T2: 81 ± 7 mmHg, T3:84 ± 6 mmHg) between two groups (P > 0.05). Also there were no significant differences regarding mean central venous pressure, mean heart rate, and vasoactive drug consumption between the two groups during the time of intervals. CONCLUSIONS: We found that preoperative (RAS) antagonist's continuation have not profound hemodynamic changes during coronary artery bypass graft under cardiopulmonary bypass and so we conclude that omitting these drugs before surgery did not have a sufficient advantage to be recommended routinely.

Relationship Between Anthropometric Findings and Results of Corticosteroid Injections Treatment in Chronic Plantar Heel Pain.

BACKGROUND: Chronic plantar heel pain (CPHP) is one of the common, disabling, and painful problems in the foot. Obesity is one of the known causes of CPHP. The aim of this study is to investigate the relationship between the body mass and the treatment of chronic plantar heel pain. METHODS: In a cohort study, 80 CPHP patients, including 16 men and 64 women, who referred to orthopedic clinic from 2014 to 2016, were investigated. All the patients were initially treated by corticosteroid injections. A total of 80 studied patients were classified according to their body mass index (BMI) in 3 groups: obese, overweight, and ideal weight. Their pain severity, symptoms recurrence, and foot performance were examined. RESULTS: The severity of morning pain was 6.6 ± 1.2 in the obese patients while it was 5.6 ± 1.7 and 5.9 ± 1.7 in overweight and ideal weight patients, respectively, which had significant difference (P = 0.005). In 57% of obese patients, symptoms recurrence was observed; this rate was 12% and 5.3% in overweight and ideal-weight patients, which showed significant difference (P = 0.001). Obese people had higher relative risk of CPHP recurrence (OR = 7.52, 95% CI = 4.28 to 16.53, P < 0.001). CONCLUSIONS: High BMI is a strong risk factor in recurrence of chronic plantar heel pain. There is a strong relationship between the BMI of the patients and the severity of pain in the morning.

Hematoma Block Versus General Anesthesia in Distal Radius Fractures in Patients Over 60 Years in Trauma Emergency.

BACKGROUND: Distal radius fractures are among common fractures in the elderly. Regarding the age, background diseases, and possible risks, analgesia method is of great importance in this group. OBJECTIVES: The aim of this study was to compare two analgesia methods including hematoma block and general anesthesia in people over 60 years in the orthopedic emergency department. METHODS: 68 elderly patients referring to the emergency department of a medical teaching center were selected based on the inclusion criteria for a non-randomized clinical trial. The patients were placed in two groups of 34, which were matched for age and sex. Hematoma block was used as the analgesic method in one group and general anesthesia was used in the other group. These two groups were compared for pain intensity, analgesia duration, and anesthesia side effects. The SPSS software (Statistical Package for the Social Sciences, version 17.0, SPSS Inc., Chicago, Ill, USA) was used for data analysis. RESULTS: 68 elderly patients (mean age of 70.3 ± 6.6) with a dislocated distal radius fracture which required closed reduction were examined. The duration of manipulation and surgery and discharging time were significantly different between two groups and they were all lower in the hematoma blocked group. Pain intensity evaluation indicated a statistically significant difference during initial hours after fracture reduction and fixation so that pain intensity was less in elderly patients under hematoma block than patients who underwent general anesthesia in one and six hours after surgery. Need for narcotic was 35.2% in the general anesthesia group which also showed a significant between-group difference. CONCLUSIONS: Hematoma block analgesia used in distal radius fractures of the elderly is a very safe and effective method that seems preferable to general anesthesia in emergency departments.

Association between SNPs at IL-17A and IL-17F and susceptibility to accelerated silicosis.

The association between single nucleotide polymorphisms (SNPs) in the interleukin (IL)-17 gene and silicosis has been evaluated in different populations. The aim of the present study was to analyze the association between SNPs at IL-17A (-832A/G) and IL-17F (+7488A/G) and susceptibility to accelerated silicosis in the Iranian Kurdish population. We studied 48 patients with accelerated silicosis and 62 controls. Genomic DNA was isolated using the "salting out" method. PCR-RFLP was performed for all SNPs typing. The frequencies of A/A, A/G, and G/G genotypes at IL-17A (-832A/G) were 4 (8.33%), 23 (47.92%), and 21 (43.75%) in patients and 5 (8.06%), 35 (56.45%), and 22 (35.48%) in controls, respectively. The frequencies of A and G alleles at IL-17 (-832A/G) were 31 (32.29%) and 65 (67.71%) in patients, and 45 (36.29%) and 79 (63.71%) in the controls, respectively. The frequencies of A/A, A/G, and G/G genotypes at IL-17F (+7488A/G) were 1 (2.08%), 47 (97.92%), and 0 (0%) in patients, and 11 (17.74%), 51 (82.26%), and 0 (0%) in the controls, respectively. The frequencies of A and G alleles at IL-17F (+7488A/G) were 49 (51.04%) and 47 (48.96%) in patients, and 73 (58.87%) and 51 (41.13%) in the controls, respectively. IL-17F (+7488A/G) genotype was more frequent among the cases compared with controls (97.92% vs. 82.26%). The frequency of the IL-17F (+7488A/G) genotype was significantly greater in patients with accelerated silicosis (odds ratio = 10.13 95%; confidence interval = 1.2-81.5; p = 0.008). The IL-17F (+7488A/G) genotype revealed a significantly increased risk of accelerated silicosis ( p < 0.05). The IL-17F (+7488 G) allele was associated with an increased risk of accelerated silicosis, but in the case of the IL-17A (-832A/G) polymorphism, a significant association was not observed.

Evaluating the quality of intravenous regional anesthesia following adding dexamethasone to lidocaine.

OBJECTIVES: The quality of anesthesia in intravenous regional anesthesia (IVRA) has been evaluated in many studies so far. This study was designed to evaluate the effects of adding the dexamethasone to lidocaine on the quality of IVRA. MATERIALS AND METHODS: A double-blind clinical trial was set up involving 50 hand surgery candidates, 20 to 55 years old, and with American Society of Anesthesiologists class of I and II. Patients were randomly allocated into two groups of 25 cases and received either 3 mg/kg of lidocaine (control group) or 3 mg/kg of lidocaine plus 8 mg of dexamethasone (study group). The onset and recovery times from sensory and motor blocks, the starting time of tourniquet pain, the amount of narcotics needed during patients' recovery, and probable side-effects were all compared between the two groups. RESULTS: No significant differences were detected concerning age, gender, length of surgery and the mean time of starting of tourniquet pain between the two groups. The mean times of both sensory (P = 0.002) and motor (P = 0.004) blocks onset were significantly shorter in the study group. The mean time of recovery from sensory block was significantly longer in the study group (P = 0.01). The average amount of narcotics needed during the recovery was significantly lower in the study group (P = 0.01). No side-effect was detected. CONCLUSION: We conclude that adding the dexamethasone to lidocaine can improve the quality of anesthesia in IVRA.

Comparison the effects of paracetamol with sufentanil infusion on postoperative pain control after craniotomy in patients with brain tumor.

BACKGROUND: Patients experience severe pain after craniotomy surgery that leads to discomfort. Our target in this study that performed in interventional method is an evaluation of sufentanil and paracetamol effect on postoperative pain control in patients undergone craniotomy surgery at Urmia Imam Khomeini Hospital. MATERIALS AND METHODS: Totally, 45 patients between the ages 18 and 65 were studied. The effect of sufentanil and paracetamol medicines in pain management, hemodynamic stability, and side effects compared with control group that were receiving morphine (subcutaneous [SC]) in 3 groups of 15 people at time 0, 2, 4, 12 and 24-h were evaluated. Collected data were included and monitoring blood pressure, O2 Sat, heart rate (HR) and pain, nausea, vomiting and use of morphine. RESULTS: According to the analysis of results, there was a significant difference between 3 groups on postoperative pain (P < 0.05). In patients that used sufentanil, pain score of visual analog scale (VAS) is lowest and in the paracetamol group the highest VAS score was seen. There was a significant difference in HR between 3 groups (P < 0.05). Maximum average of HR was observed in the paracetamol group. There was a significant difference in mean arterial pressure between 3 groups (P < 0.05). In paracetamol group, there was the highest value (99.3). There was no significant difference in Glasgow Coma scale and SPO2 between 3 groups (P > 0.05). CONCLUSION: Sufentanil compared to morphine (which is routinely used for patients pain control after craniotomy surgery) has better pain control, less nausea and vomiting, and better hemodynamic stability. Although paracetamol has the least nausea and vomiting, it has the lowest quality of pain relief.

Vertical infraclavicular block with local anesthetic injections at different currents.

Injecting local anesthetic at the seeking current would be appealing.It would save time and avoid potentially dangerous manipulations of the needle. This study aimed to test the hypotheses that in vertical infraclavicular block, injecting local anesthetic at a seeking current of 0.8 mA would produce the same quality of block as injecting at ≤0.5mA. A total of sixty ASA I -III adult patients scheduled for elective surgery on the hand, wrist and forearm in two equal groups of 30 patients, were enrolled in this study. The technique described by Kilka & Geiger used in both groups. After eliciting a clear and visible motor response of all fingers in either extension or flexion, injection was performed at a current of 0.8 mA and ≤0.5 mA in study and control groups respectively. Duration of time to analgesia and to anesthesia was evaluated. The mean duration of onset of analgesia in radial, median and ulnar nerves in both groups, were similar. The onset of anesthesia took a mean of 13.5 minutes in the control group and 15.6 minutes in study group (P=0.064).  The onset of analgesia was 4.2 minutes in the control group and 4.3 minutes in study group. (P=0.508). The success rate in both groups was 100%. We had patients in both groups who developed complete anesthesia of the hand within 25 minutes. We conclude that the injection at 0.8 mA would result in a similar quality of block to one injected at ≤0.5 mA. The difference between two groups was not statistically significant.

Theophylline versus acetaminophen in the treatment of post-dural puncture headache (PDPH).

BACKGROUND: Post-dural puncture headache (PDPH) is the most frequent complication of procedures associated with dural puncture for spinal anesthesia or following accidental dural puncture during epidural anesthesia. Since invasive treatments have known complications, pharmacologic management may be preferable. The aim of this study was to evaluate and compare the efficacy of theophylline and Acetaminophen in treatment of PDPH. METHODS: In this single-blind randomized clinical trial, 60 patients with Class I physical status according to ASA classification system, who suffered from PDPH were enrolled. Patients in Theophylline group were received theophylline tablet 250 mg three times per day, and in the other group acetaminophen 500 mg three times per day was administered. Pain intensity was assessed 2, 6, and 12 hour after drug administration using 0-10 cm Visual Analog Scale. RESULTS: The main VAS values is significantly lower in theophylline group in comparison with the acetaminophen group at 2 (5 +/- 1.57 vs. 5.97 +/- 1.27), 6 (3.43 +/- 1.73 vs. 4.33 +/- 1.49), and 12 (2.67 +/- 2.35 vs. 4.24 +/- 1.97) hours after drug administration (p < 0.05). No adverse effects were reported. DISCUSSION: Theophylline is a safe and effective treatment for PDPH. It may be tried in PDPH patients before using any invasive technique. Further investigations studying other Methylxanthines are recommended as well.

The effect of nitroglycerin as an adjuvant to lidocaine in intravenous regional anesthesia.

PURPOSE: The disadvantages of intravenous regional anesthesia (IVRA) include slow onset, poor muscle relaxation, tourniquet pain, and rapid onset of pain after tourniquet deflation. In this randomized, double-blind study, we evaluated the effect of nitroglycerin (NTG) in quality improvement when added to lidocaine in IVRA. METHODS: Forty-six patients (20-50 yrs), were randomly allocated in two equal groups. Under identical condition, the control group received a total dose of 3 mg/kg of lidocaine 1% diluted with saline, and the study group received an additional 200 microg NTG. Vital signs and tourniquet pain, based on visual analog scale (VAS) score were measured and recorded before and 5, 10, 15, 20, and 30 min after anesthetic solution administration. The onset times of sensory and motor block were measured and recorded in all patients. After the tourniquet deflation, at 30 min and 2, 4, 6, 12 and 24 h, VAS score, time to first analgesic requirement, total analgesic consumption in the first 24 h after operation, and side effects were noted. RESULTS: The sensory and motor block onset time were shortened in study group (2.61 vs. 5.09 and 4.22 vs. 7.04 min, respectively) (p < 0.05). The recovery time of sensory and motor block and onset of tourniquet pain were also prolonged (7.26 vs. 3.43, 9.70 vs. 3.74 and 25 vs. 16.65 min., respectively) (p < 0.05). Analgesia time after tourniquet deflation was prolonged and tourniquet pain intensity was lowered in study group (p < 0.05). Intraoperative fentanyl and meperedine requirement during first postoperative day and pain intensity at 4, 6, 12 and 24 hr postoperatively were lower in the study group (p < 0.05). There were no significant side effects. CONCLUSION: The NTG adding to lidocaine in intravenous regional anesthesia shortens onset times of sensory and motor block and decreases the tourniquet and postoperative pain, without any side effect.

Do bullae and emphysema increase risk of pneumothorax in silicosis?

BACKGROUND: The occurrence of occupational lung diseases is decreasing due to improvements in occupational health in recent years; however, silicosis and its complications remain important occupational health problems. We have studied the role of emphysema and bullae as predictive factors of secondary spontaneous pneumothorax in acute and accelerated silicosis. METHODS: This study was carried out using questionnaire items on occupational history and conventional computed tomography of lungs. Differences between two groups (silicosis with and without secondary spontaneous pneumothorax) in terms of age, interval of exposure-diagnosis and therefore silica exposure duration were assessed by independent t-test. Fisher's exact test was used to determine the association between secondary spontaneous pneumothorax and both emphysema and bullae. RESULTS: We found a significant association between secondary spontaneous pneumothorax and bullae in acute and accelerated silicosis. CONCLUSION: Pneumothorax in silicosis could be attributed to previous bullae.

Do bullae and emphysema increase risk of pneumothorax in silicosis?

BACKGROUND: The occurrence of occupational lung diseases is decreasing due to improvements in occupational health in recent years; however, silicosis and its complications remain important occupational health problems. We have studied the role of emphysema and bullae as predictive factors of secondary spontaneous pneumothorax in acute and accelerated silicosis. MATERIALS AND METHODS: This study was carried out using questionnaire items on occupational history and conventional computed tomography of lungs. Differences between two groups (silicosis with and without secondary spontaneous pneumothorax) in terms of age, interval of exposure-diagnosis and therefore silica exposure duration were assessed by independentt -test. Fisher's exact test was used to determine the association between secondary spontaneous pneumothorax and both emphysema and bullae. RESULTS: We found a significant association between secondary spontaneous pneumothorax and bullae in acute and accelerated silicosis. CONCLUSION: Pneumothorax in silicosis could be attributed to previous bullae.