Analgesic Effect of Addition of Pectointercostal Block to Serratus Anterior Plane Block in Breast Surgeries: A Randomized, Controlled Trial.

BACKGROUND: Ultrasound-guided serratus anterior plane block (SAPB) is an efficient perioperative analgesic modality for breast surgeries. SAPB does not block the anterior cutaneous branches of the intercostal nerves; thus, it does not provide adequate analgesia for the parasternal region and the medial side of the breast. A new parasternal block, the pectointercostal fascial plane block (PIFB) has been developed to overcome this issue. OBJECTIVES: The study aimed to evaluate the perioperative analgesic effect of using PIFB in addition to SAPB. The primary outcome was to evaluate the postoperative pain score. The secondary outcomes were to assess perioperative opioid requirements, hemodynamic stability, and the satisfaction of the patient and surgeon. STUDY DESIGN: The current study was a prospective, double-blinded, randomized controlled study. The current study was registered at the Pan-African Clinical Trials Registry (PACTR202001789968542) and was designed after obtaining ethical institutional approval (Institutional Review Board No 00012098, Federalwide Assurance No 00018699). SETTING: The study involved 60 women between 21 and 69 years old with breast cancer who were scheduled for modified radical mastectomy or conservative breast surgeries in a university hospital. METHODS: After verbal and informed written consent, the patients were allocated to Group 1, which received SAPB, and Group 2, which received SAPB with PIFB. We assessed the Visual Analog Scale (VAS), perioperative opioid requirements, intraoperative hemodynamic stability, rescue analgesia, and complications. Patient and surgeon satisfaction were surveyed using a questionnaire where one is very dissatisfied and 5 is very satisfied. RESULTS: Intraoperative mean arterial blood pressure (MABP) and heart rate were significantly lower in Group 2 (SAPB+PIFB). The number of patients who needed intraoperative fentanyl was also significantly lower in Group 2 (SAPB+PIFB) (P value = 0.010). Postoperative VAS showed no significant difference in both groups. The number of patients who needed postoperative rescue morphine, time for the first rescue analgesia, first morphine dose (mg), and total opioid consumption were also comparable for both groups. Patient satisfaction and surgeon satisfaction were comparable for both groups (P values = 1.000 and 0.496, respectively). LIMITATIONS: VAS was not recorded during movements and no follow-up was done to detect the potential effect on chronic postmastectomy pain. Moreover, after reviewing the literature, there was no efficient data about adding PIFB with different regional blocks for breast surgery. CONCLUSIONS: The number of patients who needed intraoperative fentanyl, as well as the MABP and heart rate were significantly lower in Group 2 (SAPB+PIFB). Postoperative vital signs, VAS, postoperative analgesic requirements, and opioid consumption were comparable for both groups. Patient satisfaction was comparable for both groups, while surgeon satisfaction was higher in Group 2 (SAPB+PIFB) but statistically not significant.

Effects of obstructive sleep apnea on non-alcoholic fatty liver disease in patients with obesity: a systematic review.

INTRODUCTION: Obesity has been linked to non-alcoholic fatty liver disease (NAFLD), a widespread chronic liver ailment, as well as obstructive sleep apnea (OSA). The development of NAFLD is influenced by repeated intermittent hypoxia, a feature of OSA. METHODS: This systematic review (SR) investigated CENTRAL, PubMed, and EMBASE databases. The endpoint of this SR was to assess which OSA-related indicators could predict the presence of NAFLD and the effect of bariatric metabolic surgery (BMS) on improving OSA and NAFLD over time. RESULTS: Compared to previous SRs published in 2013, 14 new publications were added to our SR, alongside studies conducted prior to 2013. The SR ultimately included 28 studies (18 cross-sectional and 10 cohort trials). In the majority of studies, significant correlations were observed between OSA, OSA-related outcomes, and NAFLD. However, the apnea-hypopnea index (AHI) alone proved to be an inadequate predictor of NAFLD. Instead, respiratory and metabolic changes were found to alleviate oxidative stress induced by hypoxemia. Six studies involved patients who underwent BMS, with one evaluating patients before and after BMS, revealing associations between increased OSA and NAFLD improvement following BMS. Six months after surgery, 100% of patients in the mild-to-moderate OSA group were free from fatty liver, and an 89% reduction was observed in the severe OSA group. CONCLUSION: For the first time, BMS has been tested in treating both OSA and NAFLD pre and postoperative with positive results. Further research, ideally with histological and functional data, is needed to confirm these findings. The SR identified 14 distinct liver outcome tests; however, high heterogeneity and incomplete data precluded a meta-analysis. It is imperative to pay greater attention to the influence of OSA-related factors and uniformity in liver outcomes testing concerning NAFLD. To accomplish this, study designs should be enhanced by incorporating more comprehensive pre- and postoperative evaluations, extending follow-up periods, and employing a more consistent methodology for liver diagnosis in patients with obesity.

Ultrasound-guided Shoulder Intraarticular Ozone Injection Versus Pulsed Radiofrequency Application for Shoulder Adhesive Capsulitis: A Randomized Controlled Trial.

BACKGROUND: A diseased shoulder due to pain, stiffness, or weakness negatively affects patients' quality of life and their ability to carry out activities of daily living. Adhesive capsulitis is a disease characterized by shoulder pain and global limitation of movement in the shoulder joint. Many interventions have been proposed for the treatment of primary adhesive capsulitis. The current study compares the effect of ultrasound-guided intraarticular injection of ozone versus steroid versus intraarticular application of pulsed radiofrequency. OBJECTIVES: The primary outcome of the current study was to compare the improvement in the Visual Analog Scale (VAS) after the 3 treatment modalities. The secondary outcomes included functional improvement measured by the Shoulder Pain and Disability Index (SPADI) and level of inflammatory biomarkers measured by serum intercellular adhesion molecule (ICAM-1) and high-sensitivity C-reactive protein(hs-CRP). STUDY DESIGN: The current study is a prospective, double blinded, randomized controlled trial. We employed a double blinding technique for both the patients and the outcome assessors. SETTING: Our study was carried out at the Medical Research Institute, Alexandria University, Egypt, after approval of the local ethical committee (IORG0008812). The study was registered in the "clinical trials library for protocol registration and results system" with number NCT04724317.The study included 45 patients with a diagnosis of primary adhesive capsulitis. METHODS: Patients were randomly assigned to 3 equal groups: steroid group, ozone group, and pulsed radiofrequency group. Pain and global shoulder functions were assessed using the VAS at rest and with movement, range of motion (ROM), and the SPADI. Moreover, ICAM-1 and hs-CRP were measured as inflammatory markers. RESULTS: The results of the current study reveal that all patients in all groups have had a statistically significant improvement after their intervention regarding pain, disability, ROM, and inflammatory markers. Pairwise comparisons revealed that improvement of the VAS during movement had a statistically significant improvement starting from the second week and continuing to the fourth and eighth week. VAS during rest had a significant improvement starting from follow-up week one in the steroid group. Moreover, improvement in the ROM and SPADI scores started from the second week follow-up. Percent improvement was calculated for each group and there was a statistically significant difference between groups in VAS at rest and ROM in the pulsed radiofrequency group compared to the steroid group.Regarding inflammatory markers, both ICAM-1 and hs-CRP had a significant improvement after all 3 interventions with no statistically significant difference among the groups. LIMITATIONS: This study is a single-center study. A shortage of previously published data, and heterogeneity in the published methodology of the 3 interventions limited our discussion data for comparison with the previous literature. CONCLUSION: Ultrasound-guided shoulder joint intraarticular injection of steroid, ozone, or pulsed radiofrequency application all result in a significant improvement in pain, disability, and ROM in primary adhesive capsulitis. They can be used as an effective treatment modality for this condition. Comparing groups statistically, the pulsed radiofrequency group had a more delayed, but statistically better long-term improvement compared to the other 2 groups.