Consensus guidelines for the management of pineal region tumours for low- and middle-income countries.

Pineal region tumours are rare and mainly arise at a younger age. They can be categorized into various types: germ cell tumours (GCT), pineal parenchymal tumours (PPT), meningiomas, gliomas, pineoblastoma, pineal parenchymal tumours of intermediate differentiation, papillary tumours of the pineal region, and SMARCB1- mutant desmoplastic myxoid tumour. Within GCT, germinomas are the most prevalent, comprising the majority of tumours in this region, while nongerminomatous GCTs are also present. In rare instances, metastases from other sites may manifest. These tumours often lead to obstructive hydrocephalus and commonly exhibit symptoms related to mass effect, including headache, nausea, vomiting, and impaired gait stability. Different subtypes of pineal region tumours exhibit distinct radiological characteristics, thus imaging remains the primary diagnostic tool. Histologic diagnosis necessitates biopsy, unless in cases of germ cell tumours, particularly germinomas, which can be identified through elevated levels of tumour markers like alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG) in both cerebrospinal fluid (CSF) and serum. While benign tumours might be effectively treated with radical resection alone, malignant tumours demand additional chemotherapy and radiotherapy following surgical removal.

Endocannabinoid signaling in stress, nausea, and vomiting.

BACKGROUND: Classical antiemetics that target the serotonin system may not be effective in treating certain nausea and vomiting conditions like cyclic vomiting syndrome (CVS) and cannabinoid hyperemesis syndrome (CHS). As a result, there is a need for better therapies to manage the symptoms of these disorders, including nausea, vomiting, and anxiety. Cannabis is often used for its purported antiemetic and anxiolytic effects, given regulation of these processes by the endocannabinoid system (ECS). However, there is considerable evidence that cannabinoids can also produce nausea and vomiting and increase anxiety in certain instances, especially at higher doses. This paradoxical effect of cannabinoids on nausea, vomiting, and anxiety may be due to the dysregulation of the ECS, altering how it maintains these processes and contributing to the pathophysiology of CVS or CHS. PURPOSE: The purpose of this review is to highlight the involvement of the ECS in the regulation of stress, nausea, and vomiting. We discuss how prolonged cannabis use, such as in the case of CHS or heightened stress, can dysregulate the ECS and affect its modulation of these functions. The review also examines the evidence for the roles of ECS and stress systems' dysfunction in CVS and CHS to better understand the underlying mechanisms of these conditions.

Effectiveness of tranexamic acid on intra- and postoperative bleeding in Bimaxillary osteotomies: a retrospective study.

PURPOSE: Perioperative bleeding is a serious concern during orthognathic surgery. Tranexamic acid (TXA), a synthetic lysine analog with antifibrinolytic properties, reduces blood loss across various surgical fields. This study aimed to investigate the effectiveness of preoperative TXA administration in reducing intraoperative and postoperative blood loss following combined Le Fort I and sagittal split ramus osteotomies at our hospital. METHODS: This single-center, retrospective cohort study included patients who underwent combined Le Fort I and sagittal split ramus osteotomies between November 2017 and October 2022. The primary outcome was the volume of intraoperative blood loss. RESULTS: Among 1,329 eligible patients, 87 were included in the analysis (32 in the TXA group and 55 in the control group, where no TXA was administered). The median (interquartile range) intraoperative blood loss was 200.0 (157.5-237.5) mL in the TXA group and 260.0 (180.0-350.0) mL in the control group, showing a significant difference between the groups (p = 0.0365). However, postoperative blood drainage within 24 h and 24-48 h did not differ significantly between the two groups. CONCLUSION: A single intravenous administration of TXA was associated with a decrease in intraoperative bleeding without severe adverse events during combined Le Fort I and sagittal split ramus osteotomies. However, postoperative blood loss, nausea, vomiting, and autologous blood transfusion were not significantly associated with this administration.

Investigation of serum spexin concentrations in pregnant women diagnosed with hyperemesis gravidarum.

OBJECTIVE: We aimed to investigate the serum concentration of the spexin, which has been shown to have an anorexic effect in animal models, in pregnant women with hyperemesis gravidarum (HG). METHODS: This case-control study was conducted with 80 pregnant women who applied to the Umraniye Training and Research Hospital Gynecology and Obstetrics Clinic between April 2022 and September 2022. The HG group consisted of 40 pregnant women who were diagnosed with HG in the first 14 weeks of pregnancy, and the control group consisted of 40 healthy pregnant women matched with the HG group in terms of age, BMI, and gestational week. RESULTS: Both groups were similar in terms of demographic characteristics and gestational age at blood sampling for spexin (p > 0.05). While maternal serum spexin concentration was 342.4 pg/ml in the HG group, it was 272.8 pg/ml in the control group (p = 0.003). ROC analysis was performed to determine the value of maternal serum spexin concentration in terms of predicting HG. AUC analysis of maternal serum spexin for HG estimation was 0.693 (p = 0.003, 95% CI =0.577 - 0.809). The optimal cutoff value for maternal serum spexin concentration was determined as 305.90 pg/ml with 65% sensitivity and 65% specificity. CONCLUSIONS: High serum spexin concentration is thought to play a role in the etiopathogenesis of HG, and this should be supported by demonstrating changes in serum spexin concentrations in pregnant women with HG whose symptoms alleviated and weight regain started after treatment.

Brain mitochondrial damage attenuation by quercetin and N-acetyl cysteine: peripheral and central antiemetic effects.

Nausea serves as a protective mechanism in organisms to prevent excessive consumption of toxic substances. Due to the adverse effects of chemical anti-nausea drugs, there is a growing interest in using herbal remedies and natural antioxidants. In this study, we evaluated the neuroprotective effects of quercetin (QU) and N-acetylcysteine (NAC) against oxidative damage induced by nausea. Emesis was induced in chickens using ipecac and copper sulfate (600 and 60 mg/kg, orally, respectively). QU and NAC (with doses of 50, 100, 200 mg/kg), and their combination were administered, along with a standard therapy (metoclopramide; MET 2 mg/kg) for one-time. Mitochondrial function, lipid peroxidation (LPO), protein carbonyl (PC), glutathione level (GSH), and reactive oxygen species (ROS) as oxidative damage biomarkers were evaluated in the chicken's brain mitochondria. QU and NAC significantly reduced emesis induced by copper sulfate and ipecac compared to the control group (P < 0.001). Significant differences in oxidative damage were observed in the groups received of copper sulfate and ipecac compared with control group. Levels of LPO, ROS, and PC were significantly decreased after the administration of QU and NAC in emesis induced by copper sulfate and ipecac. While, mitochondrial function and GSH levels were increased after the administration of QU and NAC. Combination therapy with QU and NAC yielded the most effective results. This study suggests that QU and NAC possess antiemetic effects through both peripheral and central mechanisms and exhibit neuroprotective effects against oxidative brain damage induced by emesis by increasing plasma antioxidants or scavenging free radicals.

The Effect of Opioid-Free Anesthesia with Transversus Abdominis Plane Block on Patients Undergoing Laparoscopic Sleeve Gastrectomy: Randomized Controlled Study.

Purpose: Anesthesia for metabolic-bariatric surgery is challenging due to the increased risk of opioid-related adverse events. The purpose of the investigation was to assess the feasibility and efficacy of multimodal opioid-free general anesthesia with transversus abdominis plane (TAP) block for laparoscopic sleeve gastrectomy in contrast with conventional opioid-based general anesthesia. Patients and Methods: Eighty patients who underwent laparoscopic sleeve gastrectomy and eventually 71 patients included in the analysis. They were randomly divided into an opioid-based anesthesia group (control group) with sufentanil or opioid-free anesthesia (OFA) group. Esketamine, dexmedetomidine, and TAP were as part of the OFA. Sevoflurane, dexamethasone, and muscle relaxants were administered intraoperatively to all patients. The primary outcome was antiemetic rescue within 24 hours after surgery. The secondary outcomes included pain scores, analgesic needs, extubation time, complications, the hemodynamic changes, and duration of hospital stay. Results: In contrast with the control group, the need for antiemetic rescue was significantly reduced (p= 0.035). Furthermore, the visual Analog Scale (VAS) for postoperative pain was considerably lower in the OFA group (p <0.01) than it was in the control group. There was no significant difference in the need for analgesic rescue in both groups (p= 0.155). Extubation time and post-anesthesia care unit (PACU) stay duration were equal between the two groups (p =0.328 and p =0.54). At the end of the surgery and after extubation, hemodynamic changes was more pronounced in the OFA group (p =0.027) than the control group. The length of the hospital stay was significantly shorter compared with the control group (p =0.002). Conclusion: OFA with TAP results in a significant decrease in the need for antiemetic rescue, a lower level of pain after the surgery, and a shorter hospital stay in contrast with anesthesia based on opioids.

Droperidol administration among emergency department patients with abdominal pain, nausea, and vomiting.

STUDY OBJECTIVE: The primary objective of this study was to examine the common usage patterns of droperidol in the relatively unrestricted environment of an urban, academic medical center. We focused specifically on the most common use of droperidol in our department: patients with a chief complaint of abdominal pain, nausea, and/or vomiting. METHODS: For this retrospective, observational, single-center study, we extracted records of all administrations of droperidol from August 2019 to August 2020. Patients with a chief complaint of abdominal pain, nausea, or vomiting, or any combination thereof, were included in data analysis. RESULTS: Between April 2019 to August 2020, 830 discrete patient visits involving droperidol administration were identified, comprising 706 patients. The average age was 39 years old with a range of 15 to 80. Seven patients (0.08%) were younger than 18, and 35 (4%) were older than 65. Five hundred sixty-five patients (68%) were female. Droperidol doses ranged from 0.625 mg to 5 mg intravenous (IV), with a median dose of 0.625 mg (interquartile range 0.625-1.25 mg), with 590 patients (71%) receiving a dose of 0.625 mg. Only 19 patients (2.3%) had a documented adverse event. Seven had akathisia or restlessness, 7 had anxiety or agitation, 3 had dystonia or stiffness, 1 had fatigue, and 1 had dizziness. For the entire cohort, there were no cardiac dysrhythmias, syncope, seizures, other major adverse events, or fatalities recorded. CONCLUSION: At one institution, droperidol is being used commonly for the chief complaints of abdominal pain, nausea, and/or vomiting. The preferred dosing is nearly universally below the 2.5 mg IV dose for which the FDA warning applies. Similar to previous studies, identification of adverse events was rare, and no major adverse outcomes such as dysrhythmia or death were identified.

Defining the clinical benefits of adding a neurokinin-1 receptor antagonist to control chemotherapy-induced nausea and vomiting in moderately emetogenic chemotherapy: a systematic review and meta-analysis of the clinical practice guidelines for antiemesis 2023 from the Japan society of clinical oncology.

BACKGROUND: Chemotherapy-induced nausea and vomiting (CINV) commonly affects patient quality of life and the overall effectiveness of chemotherapy. This study aimed to evaluate whether adding neurokinin-1 receptor antagonists (NK1RAs) to 5-hydroxytryptamine-3 receptor antagonists (5-HT3RAs) and corticosteroids provides clinically meaningful benefits in preventing CINV in patients receiving moderately emetogenic chemotherapy (MEC). METHODS: We conducted a systematic review of PubMed, Cochrane Library, and Ichushi-Web to identify clinical studies evaluating NK1RAs combined with 5-HT3RAs and dexamethasone for managing CINV in MEC. The endpoints were complete response (CR), complete control (CC), total control (TC), adverse events, and costs. The data were analyzed using a random effects model. RESULTS: From 142 articles identified, 15 randomized controlled trials (RCTs), involving 4,405 patients, were included in the meta-analysis. Approximately 60% of the patients received carboplatin (CBDCA)-based chemotherapy. The meta-analysis showed that triplet antiemetic prophylaxis with NK1RA was significantly more effective for achieving CR than doublet prophylaxis in each phase. Regarding CC, the triplet antiemetic prophylaxis was significantly more effective than the doublet in the overall (risk difference [RD]: 0.11, 95% confidence interval [CI]: 0.06-0.17) and delayed (RD: 0.08, 95% CI: 0.02-0.13) phases. For TC, no significant differences were observed in any phase. Adding NK1RA did not cause adverse events. CONCLUSIONS: Adding NK1RA to CBDCA-based chemotherapy has shown clinical benefits. However, the clinical benefits of NK1RA-containing regimens for overall MEC have not yet been established and require RCTs that exclusively evaluate MEC regimens other than CBDCA-based chemotherapy.

The efficacy of buprenorphine compared with dexmedetomidine in spinal anesthesia: a systematic review and meta-analysis.

BACKGROUND: This study compares dexmedetomidine and buprenorphine as potential adjuvants for spinal anesthesia. Dexmedetomidine enhances sensory block and minimizes the need for pain medication, while buprenorphine, a long-acting opioid, exhibits a favorable safety profile compared to traditional opioids. METHODS: PubMed, Cochrane and EMBASE were systematically searched in December 2023. ELIGIBILITY CRITERIA: RCTs with patients scheduled for lower abdominal, pelvic, or lower limb surgeries; undergoing spinal anesthesia with a local anesthetic and buprenorphine or dexmedetomidine. RESULTS: Eight RCTs involving 604 patients were included. Compared with dexmedetomidine, buprenorphine significantly reduced time for sensory regression to S1 (Risk Ratio [RR = -131.28]; 95% CI -187.47 to -75.08; I2 = 99%) and motor block duration (RR = -118.58; 95% CI -170.08 to -67.09; I2 = 99%). Moreover, buprenorphine increased the onset time of sensory block (RR = 0.42; 95% CI 0.03 to 0.81; I2 = 93%) and increased the incidence of postoperative nausea and vomiting (RR = 4.06; 95% CI 1.80 to 9.18; I²â€¯= 0%). No significant differences were observed in the duration of analgesia, onset time of motor block, time to achieve the highest sensory level, shivering, hypotension, or bradycardia. CONCLUSIONS: The intrathecal administration of buprenorphine, when compared to dexmedetomidine, is linked to reduction in the duration of both sensory and motor blocks following spinal anesthesia. Conversely, buprenorphine was associated with an increased risk of postoperative nausea and vomiting and a longer onset time of sensory block. Further high-quality RCTs are essential for a comprehensive understanding of buprenorphine's effects compared with dexmedetomidine in spinal anesthesia.

Examining Factors in the Decision to Sperm Bank by Adolescent and Young Adult Males Diagnosed With Cancer: A Review of the Literature.

Background: Despite American Society of Clinical Oncology and Children's Oncology Group recommendations, the rate of sperm-banking for newly diagnosed adolescent and young adult males with cancer remains between 18% and 35%. The purpose of this study was to examine recent literature regarding decision-making and fertility preservation prior to the initiation of therapy for adolescents and young adults diagnosed with cancer. Method: A search of multiple online databases was undertaken for peer-reviewed studies between the years of 2010 and 2022. The databases CINAHL, PubMed, PsycInfo, Scopus, Google Scholar, and forward citation search was employed using the same Boolean search phrases in each database. Some 402 articles were then screened for relevance by title, abstract, and full review based on inclusion/exclusion criteria for synthesis. Results: Ten articles met criteria to be included in this review. Three themes were identified as impacting the decision to cryopreserve sperm prior to the initiation of therapy. Provider recommendation, parent recommendation, and referral for fertility specialist consult emerged as statistically significant factors in the decision to attempt sperm banking. Discussion: While the most significant factor impacting the decision to preserve fertility, parents reported they were more likely to recommend this to their child if they received clear recommendations from the medical team. Pediatric oncology physicians and nurses are in a unique position to positively impact quality of life and psychosocial outcomes in survivors of pediatric cancer by providing up-to-date evidence-based information, risk assessment, recommendations, and/or referral to fertility preservation specialists to families and patients.

Dexamethasone-sparing strategies in anthracycline and cyclophosphamide-based chemotherapy with a focus on 5-HT3 receptor antagonists: a network meta-analysis.

Background: The effectiveness of a dexamethasone-sparing strategy in the treatment of breast cancer with anthracycline-cyclophosphamide therapy when combined with first-generation 5-HT3 receptor antagonists (RAs) and neurokinin-1 RAs is unclear. This is attributable to a lack of evidence from direct comparison of multiple doses of DEX to a single dose of DEX in combination with first-generation 5-HT3 RAs in anthracycline-cyclophosphamide therapy. Our goal was to clarify the impact of dexamethasone-sparing strategies that involve both first-generation 5-HT3 RAs and palonosetron when combined with neurokinin-1 RAs, using a network meta-analysis. Materials and methods: A literature search was conducted on PubMed/Medline for articles published up to July 4, 2023. We included randomized controlled trials which assessed the efficacy of antiemetic regimens which combined 5-HT3 RAs and dexamethasone, with or without neurokinin-1 RAs, for the initial dose in anthracycline-cyclophosphamide therapy for patients with breast cancer. The primary outcome was the proportion of patients achieving a complete response during the delayed phase (CR-DP). Results: The difference in the proportion of patients achieving CR-DP between multiple and single doses of dexamethasone was 0.1% (95%CI: -12.4 to 12.5) with palonosetron and neurokinin-1 RAs, compared to 5.3% (95%CI: -13.4 to 23.0) with a single dose of a first-generation 5-HT3 receptor antagonist. Additionally, the difference was 12.7% (95% CI: -2.8 to 28.2) when comparing palonosetron against first-generation 5-HT3 RAs in combination with a single dose of dexamethasone and neurokinin-1 RAs. Conclusion: Palonosetron is recommended rather than a single dose of first-generation 5-HT3 RAs in dexamethasone-sparing strategies for anthracycline-cyclophosphamide therapy.

Case Report: Acute Pancreatitis in an Uncontrolled Diabetic Patient Presenting With a Skin Rash Later Found to Be Eruptive Xanthoma, a Dermatological Manifestation and Diagnostic Clue to Recognizing Hypertriglyceridemia as the Cause of Disease.

Acute pancreatitis results from any insult that leads to inflammation of the organ. Hypertriglyceridemia is one of the risk factors associated with acute pancreatitis. The typical presentation is abdominal pain, nausea, and vomiting. We present a unique case in which the patient's condition was further complicated by diabetic ketoacidosis. Consequently, he presented somnolent to the emergency room, providing a limited history only pertaining to generalized weakness and a skin rash. The patient was found to have hypertriglyceridemia-induced pancreatitis, which was appropriately managed in the intensive care unit. The skin lesions were diagnosed as xanthomas, which are associated with hypertriglyceridemia and acute pancreatitis secondary to hypertriglyceridemia. The patient was discharged on fibrate therapy, dietary counseling, and strict monitoring by his primary care physician. This unique case highlights the importance of recognizing dermatological conditions and their associated diseases to allow for prompt diagnosis and treatment in the face of limited history.

Comparative Analysis of the Modified Aldrete Score and Fast-Track Criteria for Post-general Anaesthesia Recovery: A Narrative Review.

There are two commonly used scoring systems to evaluate recovery from general anaesthesia (GA): the Modified Aldrete Score (MAS) and the Fast-Track Criteria (FTC). Recently, concerns have been expressed about the safety and effectiveness of the Aldrete scoring system due to its exclusion of an assessment for pain or nausea, which can exacerbate recovery from surgery and anaesthesia and cause many patients to experience these side effects. FTC was created to evaluate post-operative nausea vomiting, and pain in order to assess recovery from GA. More data are needed to compare these scoring criteria in low-income countries like India. Understanding how these scores can be effectively utilised in our settings is crucial for ensuring the timely transfer of patients from the operating theatre to the Post-anaesthesia Care Unit and, subsequently, to the ward. This review aims to evaluate the available literature on MAS and FTC and compare their effectiveness. It was found that FTC is more appropriate for outpatient or day surgery procedures where rapid throughput and patient comfort are a priority. MAS, in itself, is very good for a low-income country like India. However, the addition of FTC can only enhance patient care if resources are made available. MAS can ensure consistency and efficiency in the discharge process, while using FTC can address broader recovery-related indicators and improve patient care. More research and modifications are further necessary.

Central mechanisms of emesis: A role for GDF15.

BACKGROUND: Nausea and emesis are ubiquitously reported medical conditions and often present as treatment side effects along with polymorbidities contributing to detrimental life-threatening outcomes, such as poor nutrition, lower quality of life, and unfavorable patient prognosis. Growth differentiation factor 15 (GDF15) is a stress response cytokine secreted by a wide variety of cell types in response to a broad range of stressors. Circulating GDF15 levels are elevated in a range of medical conditions characterized by cachexia and malaise. In recent years, GDF15 has gained scientific and translational prominence with the discovery that its receptor, GDNF family receptor α-like (GFRAL), is expressed exclusively in the hindbrain. GFRAL activation may results in profound anorexia and body weight loss, effects which have attracted interest for the pharmacological treatment of obesity. PURPOSE: This review highlights compelling emerging evidence indicating that GDF15 causes anorexia through the induction of nausea, emesis, and food aversions, which encourage a perspective on GDF15 system function in physiology and behavior beyond homeostatic energy regulation contexts. This highlights the potential role of GDF15 in the central mediation of nausea and emesis following a variety of physiological, and pathophysiological conditions such as chemotherapy-induced emesis, hyperemesis gravidarum, and cyclic vomiting syndrome.

Predictive value of preoperative ultrasonographic measurement of gastric morphology for the occurrence of postoperative nausea and vomiting among patients undergoing gynecological laparoscopic surgery.

Background: Pre-operative prediction of postoperative nausea and vomiting (PONV) is primarily based on the patient's medical history. The predictive value of gastric morphological parameters observed on ultrasonography has not been comprehensively assessed. Methods: A prospective observational study was conducted to evaluate the pre-operative ultrasonographic measurement of gastric morphology for predicting PONV. The gastric antrum of the participants was assessed using ultrasound before anesthesia, and the occurrence of PONV in the first 6 hours and during the 6-24 hours after surgery was reported. The main indicators included the thickness of the muscularis propria (TMP) and the cross-sectional area of the inner side of the muscularis propria (CSA-ISMP). These were recorded and analyzed. Logistic regression analysis was applied to identify factors for PONV. Results: A total of 72 patients scheduled for elective gynecological laparoscopic surgery were investigated in the study. The pre-operative CSA-ISMP of patients with PONV in the first 6 hours was significantly greater than that of those without PONV (2.765 ± 0.865 cm² vs 2.349 ± 0.881 cm², P=0.0308), with an area under the curve of 0.648 (95% CI, 0.518 to 0.778, P=0.031). Conversely, the pre-operative TMP of patients with PONV during the 6-24 hours was significantly smaller than that of those without PONV (1.530 ± 0.473 mm vs 2.038 ± 0.707 mm, P=0.0021), with an area under the curve of 0.722 (95% CI, 0.602 to 0.842, P=0.003). Logistic regression analysis confirmed that CSA-ISMP was an independent risk factor for PONV in the first 6 hours (OR=2.986, P=0.038), and TMP was an independent protective factor for PONV during the 6-24 hours after surgery (OR=0.115, P=0.006). Conclusion: Patients with a larger pre-operative CSA-ISMP or a thinner TMP are prone to develop PONV in the first 6 hours or during the 6-24 hours after surgery, respectively. China clinical trial registration center: http://www.chictr.org.cn (ChiCTR2100055068).

Relationship between nausea and vomiting and physical activity in patients with lung cancer undergoing first chemotherapy.

Objective: Nausea and vomiting are the distressing and debilitating side effects of chemotherapy. This study explores the relationship between the degree of nausea and vomiting and physical activity in patients with lung cancer during the first chemotherapy cycle. Design: A total of 107 patients with lung cancer who received platinum drugs during chemotherapy in a hospital in Shanghai, China, in 2023 were involved in this study. Data were collected with medical record system and self-reported questionnaires.Questionnaires included the International Physical Activity Questionnaire (IPAQ) and Index of Nausea, Vomiting, and Retching (INVR). IPAQ was used before chemotherapy; INVR was used on the second and sixth day of chemotherapy, followed by the analysis of the correlation between physical activity status and degree of nausea and vomiting during chemotherapy. The influencing factors of nausea and vomiting during chemotherapy in patients with lung cancer were analyzed using logistic regression analysis. Results: More than half of the patients experienced nausea, vomiting or retching related symptoms after chemotherapy, and the proportion of moderate to high physical activity was 50.5%. Univariate analysis showed that the degree of nausea and vomiting was influenced by factors such as age, gender, and history of drinking (P < 0.05). The degree of nausea and vomiting was negatively correlated with physical activity (P < 0.05). The multivariate linear analysis showed that gender, history of drinking, and moderate and high physical activity are contributing factors to nausea and vomiting during chemotherapy (P < 0.05). Conclusion: Moderate and high physical activity before chemotherapy is a protective factor for nausea and vomiting in patients with lung cancer. Physical activity can not only improve the degree of nausea and vomiting in patients with lung cancer but also reduce the incidence in these patients during the first chemotherapy cycle.

Efficacy of Gastric-Stimulator as an Adjunct to Pyloroplasty for Gastroparesis: Characterizing Patients Suitable for Single Procedure versus Dual Procedure Approach.

BACKGROUND: Pyloroplasty is an effective surgery for gastroparesis. However, some patients fail to improve after pyloric drainage and may require subsequent gastric electric stimulation. There is a paucity of data on the efficacy of gastric stimulator as an adjunct to failed pyloroplasty. This study aimed to describe our experience with pyloroplasty, determine the efficacy of gastric-stimulator for failed pyloroplasty, and compare the final outcomes of those who required pyloroplasty with and without gastric stimulator for gastroparesis. METHODS: Records of patients who underwent primary pyloroplasty for gastroparesis at our institution were reviewed. Patients with poor symptomatic improvement after pyloroplasty underwent subsequent gastric-stimulator. Symptoms were assessed using the gastroparesis cardinal symptom index (GCSI) preoperatively and after each surgery. Severe gastroparesis was defined as GSCI total score ≥3. Outcomes were assessed after pyloroplasty in all patients and after stimulator in patients who failed pyloroplasty. Final outcomes were then compared between those who did and did not require adjunct gastric-stimulator. RESULTS: The study population consisted of 104 patients (89.4% female) with a mean (SD) age of 42.2(11) and BMI of 26.9(7). Gastroparesis etiologies were 71.2% idiopathic, 17.3% diabetic, and 11.5% postsurgical. At 18.7(12) months after pyloroplasty there was a decrease in the GCSI total score [3.5(1) to 2.7(1.2), p=0.0012] and the rate of severe gastroparesis (71.9% to 29.3%, p<0.0001). Gastric emptying scintigraphy (GES) 4-hr retention decreased [36.5(24) to 15.3(18), p=0.0003]. Adjunct gastric-stimulator was required by 30 (28.8%) patients due to suboptimal outcomes with no improvement in GCSI (p=0.201) or GES (p=0.320). These patients were younger [40.5(10.6) vs 49.6(15.2), p=0.0016)], with higher baseline GSCI-Total scores [4.3(0.7)-vs-3.7(1.1), p<0.001] and more severe gastroparesis (100%-vs-55.6%, p<0.001). All other preoperative characteristics were similar. At 21.7(15) months after gastric-stimulator there was improvement in GCSI [4.1(0.7) to 2.6(1.1), p<0.0001], severe gastroparesis (100% to 33.3%, p<0.0001), and GES 4-hr retention [21.2(22) to 7.6(10), p=0.054]. Prior to gastric stimulator, those who failed pyloroplasty had significantly worse GCSI (p=0.0009) and GES (p=0.048). However, after gastric stimulator, GCSI and GES improved, and were comparable to those who only required pyloroplasty (p>0.05). CONCLUSION: Pyloroplasty improved gastroparesis symptoms and gastric emptying, yet 28% failed, requiring gastric stimulator. Younger patients and those with preoperative GCSI scores ≥3 were more likely to fail. Gastric stimulator improved outcomes after failed pyloroplasty, with comparable final GCSI and GES to those who did not fail.

The effect of self-care education with smart phone applications on the severity of nausea and vomiting after stem cell transplantation in leukemia patients.

INTRODUCTION: Common side effects after stem cell transplantation (SCT), such as anorexia, nausea, and vomiting, can disrupt the quality of life of patients. Therefore, this study aimed to determine the effect of self-care education with smart phone applications on the severity of nausea and vomiting after SCT in leukemia patients. MATERIALS AND METHODS: In this clinical trial study, using the blocked randomization method 104 leukemia patients undergoing SCT were assigned to two groups, intervention and control. The patients of the Control Group received routine care, and the Intervention Group received self-care education with a smart mobile phone application, in addition to routine care. Two weeks, one month, and three months after the start of the intervention, the severity of nausea and vomiting was evaluated using the visual analog scale (VAS) and the Khavar Oncology scale, both of which were completed by both Control and Intervention Groups. Data were analyzed using chi-square, Fisher's exact, Mann-Whitney, and Friedman tests using the Statistical Package for Social Sciences version 25 software. RESULTS: The severity of nausea and vomiting in leukemia patients undergoing SCT was significantly different in the two groups at all three timepoints (two weeks, one month, and three months) after transplantation (p-value = 0.000). CONCLUSION: The severity of nausea and vomiting after SCT in leukemia patients was improved by self-care education with a smart phone application. Therefore, this method is recommended to reduce the severity of nausea and vomiting in leukemia patients who undergo transplantation.

Non-pulmonary complications of intrathecal morphine administration: a systematic review and meta-analysis with meta-regression.

BACKGROUND: Intrathecal morphine provides effective analgesia for a range of operations. However, widespread implementation into clinical practice is hampered by concerns for potential side-effects. We undertook a systematic review, meta-analysis, and meta-regression with the primary objective of determining whether a threshold dose for non-pulmonary complications could be defined and whether an association could be established between dose and complication rates when intrathecal morphine is administered for perioperative or obstetric analgesia. METHODS: We systematically searched the literature for randomised controlled trials comparing intrathecal morphine vs control in patients undergoing any type of surgery under general or spinal anaesthesia, or women in labour. Primary outcomes were rates of postoperative nausea and vomiting, pruritus, and urinary retention within the first 24 postoperative hours, analysed according to doses (1-100 µg; 101-200 µg; 201-500 µg; >500 µg), type of surgery, and anaesthetic strategy. Trials were excluded if doses were not specified. RESULTS: Our analysis included 168 trials with 9917 patients. The rates of postoperative nausea and vomiting, pruritus, and urinary retention were significantly increased in the intrathecal morphine group, with an odds ratio (95% confidence interval) of 1.52 (1.29-1.79), P<0.0001; 6.11 (5.25-7.10), P<0.0001; and 1.73 (1.17-2.56), P=0.005, respectively. Meta-regression could not establish an association between dose and rates of non-pulmonary complications. There was no subgroup difference according to surgery for any outcome. The quality of evidence was low (Grading of Recommendations Assessment, Development, and Evaluation [GRADE] system). CONCLUSIONS: Intrathecal morphine significantly increased postoperative nausea and vomiting, pruritus, and urinary retention after surgery or labour in a dose-independent manner. SYSTEMATIC REVIEW PROTOCOL: PROSPERO (CRD42023387838).

Impact of preoperative anxiety on postoperative outcomes in patients undergoing minimally invasive thoracoscopic surgery: A prospective cohort study.

BACKGROUND: Preoperative anxiety is a common preoperative psychological state in patients with cancer and associated with worsening perioperative outcomes. However, high-quality prospective studies on preoperative anxiety in patients undergoing lung surgery are scarce. METHODS: We conducted a prospective cohort study, enrolling a total of 540 patients. Preoperative anxiety in patients undergoing thoracic surgery was measured using the Hospitalization Anxiety Scale. Patients were grouped according to the Hospitalization Anxiety Scale scores as follows: no anxiety (score <8) and anxiety (score ≥8). The association of preoperative anxiety with postoperative complications and non-complicated adverse events was determined by univariate regression and polynomial regression analyses. RESULTS: A total of 121 patients (22.4 %) experienced preoperative anxiety. The anxiety group had a longer average hospital stay (4.33 vs. 3.85 days). Postoperative complications were similar between groups, but the anxiety group reported worse sleep quality (measured by the Athens Insomnia Scale). Regarding postoperative pain, both groups had comparable rates of mild and severe pain on postoperative day 1. However, the anxiety group experienced significantly higher rates of severe pain on postoperative day 2 and mild pain on postoperative day 3. Additionally, the incidence of postoperative nausea and vomiting was significantly higher in the anxiety group on postoperative day 1. CONCLUSIONS: Preoperative anxiety may not increase the rates of postoperative complications in patients undergoing lung surgery. However, it may be associated with postoperative sleep disturbances, pain, nausea, and vomiting, as well as prolong the length of postoperative hospitalization.