A comparative study of respiratory effects of erector spinae plane block versus paravertebral plane block for women undergoing modified radical mastectomy.

BACKGROUND: Inadequate acute postoperative pain control after modified radical mastectomy (MRM) can compromise pulmonary function. This work aimed to assess the postoperative pulmonary effects of a single-shot thoracic paravertebral block (TPVB) and erector spinae plane block (ESPB) in female patients undergoing MRM. METHODS: This prospective, randomized comparative trial was conducted on 40 female American Society of Anesthesiologists (ASA) II-III, aged 18 to 50 years undergoing MRM under general anesthesia (GA). Patients were divided into two equal groups (20 in each group): Group I received ESPB and Group II received TPVB. Each group received a single shot with 20 ml volume of 0.5% bupivacaine. RESULTS: Respiratory function tests showed a comparable decrease in forced vital capacity (FVC) and forced expiratory volume (FEV1) from the baseline in the two groups. Group I had a lower FEV1/FVC ratio than Group II after 6 h. Both groups were comparable regarding duration for the first postoperative analgesic request (P value = 0.088), comparable postoperative analgesic consumption (P value = 0.855), and stable hemodynamics with no reported side effects. CONCLUSION: Both ultrasound guided ESPB and TPVB appeared to be effective in preserving pulmonary function during the first 24 h after MRM. This is thought to be due to their pain-relieving effects, as evidenced by decreased postoperative analgesic consumption and prolonged time to postoperative analgesic request in both groups. GOV ID: NCT03614091 registration date on 13/7/2018.

Ultrasonographic assessment of metoclopramide effect on gastric volume in parturients females undergoing Caesarean section: a randomized double blind study.

BACKGROUND: The prokinetic effect of metoclopramide promotes gastric emptying and decreases stomach capacity. The aim of the present study was to assess the efficacy of metoclopramide in reducing gastric contents and volume using gastric point-of-care ultrasonography (PoCUS) in parturients females prepared for elective Cesarean section under general anesthesia. METHODS: A total of 111 parturient females were randomly allocated to one of two groups. The intervention group (Group M; N.=56) received 10 mg metoclopramide diluted in 10 mL 0.9% normal saline. The control group (Group C; N.=55): received 10 mL 0.9% normal saline. The cross-sectional area and volume of stomach contents were measured using ultrasound before and one hour after the administration of metoclopramide or saline. RESULTS: Statistically significant differences in mean antral cross-sectional area and gastric volume were observed between the two groups (P<0.001). Group M had significantly lower rates of nausea and vomiting compared to the control group. CONCLUSIONS: Metoclopramide decreases gastric volume, reduces postoperative nausea and vomiting, and may lower the risk of aspiration when used as premedication before obstetric surgery. Preoperative gastric PoCUS has utility in objectively assessing stomach volume and contents.

Measuring the Systemic Inflammatory Response to On- and Off-Pump Coronary Artery Bypass Graft (CABG) Surgeries Using the Tryptophan/Kynurenine Pathway.

Background: Cardiac surgeries induce many inflammatory responses with remarkable clinical implications. Tryptophan (Trp) is a precursor for serotonin, melatonin and kynurenine (Kyn). Plasma kynurenic acid (Kyna) and Kyn concentrations are thought to be related to the severity of inflammation. Plasma Trp/Kyn ratio is used to measure inflammatory cytokine activity.Methods: We performed the current longitudinal study in a tertiary care center and included 62 patients divided into two groups; group A (on-pump CABG patients) and group B (off-pump CABG patients). Plasma Trp and Kyn were measured using the high-performance liquid chromatography (HPLC) technique. Serum interlukin-6 (IL-6) and white blood cells (WBCs) were measured using ELISA and routine blood count, respectively.Results: The present study revealed that the intraoperative levels of plasma Kyn, IL-6 and WBCs were significantly increased while the plasma Trp/Kyn ratio was significantly decreased in both the groups; however, the changes were more significant in the on-pump CABG group. Moreover, the levels in both the groups returned to preoperative levels 72 h postoperative. Our study has shown that WBCs is positively correlated with IL-6, but has negative correlation with Trp/Kyn ratio.Conclusions: Kyn and Trp/Kyn ratio might be utilized as markers of the severity of inflammation in major surgery. In addition, off-pump CABG might be more preferable than on-pump CABG regarding stress and release of inflammatory markers.

Effects of transcranial direct current stimulation in pain and opioid consumption after spine surgery.

BACKGROUND: Transcranial direct current stimulation (tDCS) has shown promising results in alleviating different types of pain. The present study compares the efficacy of three sessions of anodal tDCS applied over primary motor area (M1) or the left dorsolateral prefrontal cortex (DLPFC) or sham on reducing pain and the total opioid consumption in postoperative spine surgery patients. MATERIALS: Sixty-seven out of 75 eligible patients for postoperative spine surgery were randomly allocated into one of the three experimental groups. Group A received anodal tDCS applied over M1 cortex, group B over left DLPF cortex (2 mA, 20 min) and group C received sham tDCS, all for 3 consecutive postoperative days. Patients were evaluated using a visual analogue scale (VAS) and adynamic visual analogue scale (DVAS) at baseline, and on each of the treatment days. The total morphine consumption over the 3 postoperative days was assessed. RESULTS: Two-way repeated measures ANOVA showed no statistically significant difference in resting VAS between the three groups. However, there was significant pain improvement (P < 0.001) in DVAS in both active groups (group A and B) compared to the sham group (group C) in the postoperative period, with no significant difference between the active groups. Morphine consumption was significantly reduced in both active groups compared with the sham group, but there was no difference in consumption between the active groups. CONCLUSION: There was a significant postoperative reduction in morphine consumption and DVAS scores after three sessions of active tDCS. SIGNIFICANCE: tDCS is a promising tool for alleviating pain in the field of postoperative spine surgery.

Amino acids versus magnesium sulfate infusion for controlling postoperative shivering in patients undergoing percutaneous nephrolithotomy surgery: a randomized clinical trial.

BACKGROUND: General anesthetics disrupt the thermoregulatory mechanisms by reducing vasoconstriction and shivering thresholds. Postoperative shivering is a challenging anesthesia-related complication with an incidence range of 20-70%. Amino acids that induce thermogenesis and magnesium sulfate are centrally acting mechanisms that could minimize shivering. Thus, this trial was designed to compare the effect of amino acid versus magnesium sulfate infusion on postoperative shivering in patients undergoing elective percutaneous nephrolithotomy (PCNL) surgery under general anesthesia. METHODS: Eighty adults, American Society of Anesthesiologists I and II patients, were randomly assigned into one of two groups. Group A received general anesthesia and perioperative IV amino acid infusion. Group M received general anesthesia and perioperative IV magnesium sulfate infusion. RESULTS: There was a statistically significant difference in shivering score, which was lower in group A than M (0.8±1.1 versus 1.5±1.3; P value=0.01). The incidence of postoperative shivering was lower in group A (4 [10%]) versus (11 [27.5%]) in group M. A less decrease in the core intraoperative temperature (Celsius) was observed in group A than in group M (35.5±0.2 versus 35.1±0.2; respectively, P<0.001) and at the end of surgery (36.1±0.3 versus 35.7±0.3; respectively, P<0.001). CONCLUSIONS: Perioperative amino acids infusion is more effective and better tolerated than magnesium sulfate in preventing postoperative shivering in patients undergoing percutaneous nephrolithotomy surgery. Cost effectiveness should be kept in mind, and amino acids infusion should be reserved in high-risk surgeries for shivering.

Fentanyl versus dexamethasone or both as adjuvants to bupivacaine in an ultrasound-guided paravertebral block in patients undergoing modified radical mastectomy: a randomized double-blind clinical study.

BACKGROUND: This study aimed to compare the effect of dexamethasone added to fentanyl and bupivacaine with the effect of either dexamethasone or fentanyl alone when combined with bupivacaine in the thoracic paravertebral block (TPVB). METHODS: Sixty female patients (aged 18-60 years), scheduled for modified radical mastectomy were enrolled. Patients received preoperative unilateral paravertebral block using 0.3 mL/kg of 0.5% bupivacaine combined with 8 mg dexamethasone (group 1), 1 µg/kg fentanyl (group 2), or 8 mg dexamethasone + 1 µg/kg fentanyl (group 3). The study drugs were diluted with normal saline 0.9% up to 25 mL volume. The primary outcome was the time to first postoperative analgesics request, Secondary outcomes were total analgesic consumption, verbal rating pain scale (VRS) over the first 24 hours postoperatively, hemodynamic parameters, and adverse effects. RESULTS: The time to first analgesic request for intravenous (IV) nalbuphine was longer in group 2 (15.75±0.9 h, P<0.001) than group 1 (10.45±1.1 h, P<0.001), while no patients requested it in group 3 (P<0.001). The total analgesic consumption of IV nalbuphine was lower in group 2 (8.6±3.5mg, P=0.04) than group 1 (11.3±2.1 mg), with a significant difference between group 2 and 3 (P<0.001). From the 8th till the 24th hours postoperatively, patients in group 3 showed the significantly lowest median VAS scores, followed by patients in group 2 (P<0.001) and lastly patients in group 1. There were no significant adverse effects. CONCLUSIONS: Dexamethasone and fentanyl combination enhances the analgesic effect of bupivacaine in TPVB.

Effect of fentanyle versus dexamethasone on shoulder tip pain during laparoscopic ovarian cystectomy under spinal anaesthesia / Omalgia luego de quistectomía ovárica laparoscópica, efecto de fentanyl comparado con dexametasona

BACKGROUND: General anesthesia (GA) was the usual anesthetic technique used for laparoscopic interventions, however regional anesthesia in the laparoscopic field started to gain familiarity. Shoulder pain is a major intraoperative problem that might hinder facilitation of laparoscopic interventions under spinal anesthesia. AIM OF THE STUDY: Evaluate the effect of intrathecal addition of dexamethasone versus fentanyl on incidence and severity of intraoperative shoulder tip pain during gynecological laparoscopic asurgeries. Methods: 120 patients, were randomly assigned into three groups. Group D: 40 patients received 15 mg bupivacaine and 8 mg dexamethasone intrathecally. Group F: 40 patients received 15 mg bupivacaine and 25 pg fentanyle intrathecally. Group C: 40 patients received 15 mg bupivacaine and normal saline intrathecally. RESULTS: Number of patients who experienced intraoperative shoulder pain was significantly lower in Group F (17) and Group D (19) than Group C (31); P = 0.008. with no ststistical difference detected between Group D and C (p value 1). Only 2 patients in Group D and F suffered moderate pain intensity in comparison to 9 patients in Group C; P =0.02. Incidence of postspinal shivering was lower in Group D and F in comparison to Group C; P 0.02. CONCLUSION: Intrathecal dexamethasone is as effective as intrathecal fentanyle in reducing incidence and severity of shoulder tip pain during laparoscopic ovarian cystectomy under spinal anesthesia.

INTRODUCCIÓN: La anestesia general (AG) era la técnica anestésica habitual utilizada para las intervenciones laparoscópicas, sin embargo, la anestesia regional en el campo laparoscópico comenzó a ganar familiaridad. El dolor de hombro es un problema intraoperatorio importante que podría dificultar la facilitación de las intervenciones laparoscópicas bajo anestesia espinal. OBJETIVO DEL ESTUDIO: Evaluar el efecto de la adición intratecal de dexametasona versus fentanilo sobre la incidencia y severidad del dolor intraoperatorio en la punta del hombro durante cirugías laparoscópicas ginecológicas. MÉTODOS: 120 pacientes, fueron asignados aleatoriamente en tres grupos. Grupo D: 40 pacientes recibieron 15 mg de bupivacaína y 8 mg de dexametasona por vía intratecal. Grupo F: 40 pacientes recibieron 15 mg de bupivacaína y 25 pg de fentanilo por vía intratecal. Grupo C: 40 pacientes recibieron 15 mg de bupivacaína y solución salina normal por vía intratecal. RESULTADOS: El número de pacientes que experimentaron dolor de hombro intraoperatorio fue significativamente menor en el Grupo F (17) y el Grupo D (19) que en el Grupo C (31); P = 0,008. sin diferencia estadística detectada entre el Grupo D y C (valor de p 1). Solo 2 pacientes del Grupo D y F sufrieron dolor de intensidad moderada en comparación con 9 pacientes del Grupo C; P = 0,02. La incidencia de escalofríos posespinales fue menor en el Grupo D y F en comparación con el Grupo C; P 0,02. CONCLUSIÓN: La dexametasona intratecal es tan eficaz como el fentanilo intratecal para reducir la incidencia y la gravedad del dolor en la punta del hombro durante la cistectomía ovárica laparoscópica bajo anestesia espinal.

Effect of silver nanoparticles on vancomycin resistant Staphylococcus aureus infection in critically ill patients.

A prevalent increase in antimicrobial resistance represents a universal obstacle for the treatment of Staphylococcus aureus (S. aureus) infection, especially in critically ill patients. Silver nanoparticles are defined as broad spectrum bactericidal agents, which might be effective against vancomycin resistant S. aureus (VRSA). In this study, we examined the bactericidal efficacy of silver nanoparticles on VRSA in 150 blood and sputum samples isolated from intensive care patients. Methicillin resistant S. aureus (MRSA) isolates were identified in 83 samples, with an incidence of 55.3%. Meanwhile, VRSA isolates were found in 11 and 8 isolates (a total of 19 isolates out of 150) from sputum and blood samples, with an incidence of 14.67% and 10.67%, respectively, with a total incidence of 12.67%. Vancomycin intermediate S. aureus (VISA) isolates had an inhibitory zone ranging from 9 to 13 mm, which was found in 13 out of 19 isolates, whereas VRSA isolates had an inhibitory zone ranging from 0 to 6 mm, which was detected in 6 out of 19 isolates. The findings of this study confirm that silver nanoparticles are an effective treatment against VRSA.

Topical use of tranexamic acid versus epinephrine to optimise surgical field during exploratory tympanotomy.

OBJECTIVE: To explore the effect of diluting tranexamic acid as 1000 mg versus epinephrine as 1 mg in a volume of 200 mL of normal saline used for local washing and rinsing of the used gauze at the surgical bleeding sites during microscopic ear surgeries. METHODS: In a randomised, double-blind trial, sixty patients scheduled for elective microscopic exploratory tympanotomy consented to participate after meeting the inclusion criteria. Patients assigned using the balanced block randomisation method into two similar groups; one received tranexamic acid (TXA), and the other received epinephrine. The outcome of the study focused on blood pressure, heart rate, quality of surgical field assessed via Boezaart score, the volume of bleeding, and the incidence of complications. RESULTS: The more prominent findings were the statistically significant and favourable surgical field assessment according to the Boezaart score, and lower estimates of bleeding demonstrated in the TXA group compared to the epinephrine group, along the time of the study P-value was < 0.05. The haemodynamic monitoring showed promising changes in the TXA group compared with the epinephrine group in terms of lower mean blood pressure and lower heart rate that reached the level of statistical significance during the time of the study. CONCLUSION: the use of topical tranexamic acid during microscopic ear surgeries is associated with a better surgical field, less bleeding, and favourable haemodynamic parameters compared to epinephrine.

Prognostic significance of cyclin D1 and E-cadherin expression in laryngeal squamous cell carcinoma.

Cyclin D1 and E-cadherin are important factors in the progression and metastasis of cancers. Their role in laryngeal carcinoma has been studied with conflicting results. To define the frequency of cyclin D1 and E-cadherin expression and its correlation with both the clinicopathological characteristics and prognosis of patients with laryngeal squamous cell carcinoma (LSCC). Tumor tissue samples from 75 patients with laryngeal squamous cell carcinoma were examined for cyclin D1 and E-cadherin expression by immunohistochemistry. The relationship between the expression of both molecules and the age and sex of the patient, tumor site, tumor differentiation, lymph node metastasis, tumor invasiveness, TNM stages, tumor recurrence and overall survival was analyzed. Cyclin D1 was found to be a significant independent prognostic factor of lymph node metastasis (p = 0.000). The multivariate analysis revealed that cyclin D1 and E-cadherin expression wasn't an independent prognostic factor of local recurrence free survival (LRFS) in patients with LSCC (P = 0.56 and 0.28) respectively. However, the univariate analysis revealed a significant association between them and LRFS (p = 0.003 and 0.000) respectively. Also, the group of high cyclin D1 /low E-cadherin expression had the poorest prognosis, so they might serve as potential predictors of the prognosis of the patients with LSCC. E-cadherin was found to affect the overall survival (OAS) significantly by the univariate analysis (p = 0.01). However, by the multivariate analysis the TNM stage was the only independent prognostic factor of OAS (p < 0.05). Cyclin D1 can be used as an independent prognostic marker of lymph node metastasis in patients with LSCC and can help to identify those patients with clinically negative lymph nodes but with considerable risk for occult metastasis. Detection of cyclin D1 and E-cadherin status in LSCC may contribute to the identification of patients with high risk factors of local recurrence. However, they don't appear to be better prognostic predictors than other established markers in LSCC.

Clinical outcome of docetaxel in advanced or metastatic endometrial cancer.

BACKGROUND AND OBJECTIVES: The aim of this study was to evaluate the efficacy, safety and toxicity of docetaxel as first-line chemotherapy or in previously treated patients (one regimen) with recurrent or metastatic endometrial cancer. DESIGN AND SETTING: Prospective phase II study in patients referred to the Department of Clinical Oncology and Nuclear Medicine, Faculty of Medicine, Mansoura University, Egypt. PATIENTS AND METHODS: Fifty patients with advanced or metastatic endometrial cancer were enrolled to receive docetaxel 70 mg/m(2) administered intravenously on day 1 of a 3-week cycle. If patients responded well to docetaxel, additional cycles were administered until progressive disease or unacceptable toxicity occurred. Therapy response was evaluated every 6 weeks. RESULTS: Of 50 patients with a median age of 60 years (range, 40-70 years) who entered the study, 17 patients (34%) had received one prior chemotherapy regimen. All patients were evaluable for efficacy, yielding an overall response rate of 34% (95% confidence interval, 14.8%-55.6%); complete response and partial response (PR) were 4% and 30%, respectively. Of 17 pretreated patients, 5 (29%) had a PR. The median duration of response was 2 months. The median time-to-progression was 4 months and the median survival time was 18 months. The predominant toxicity was grade 3-4 neutropenia, occurring in 92% of the patients, although febrile neutropenia arose in 10% of the patients. Edema was mild and infrequent. CONCLUSION: The study clearly demonstrated that docetaxel is active in the treatment of endometrial cancer. Toxicity was manageable and predominantly hematologic.

Squamous cell carcinoma metastatic to cervical lymph nodes from unknown primary origin: the impact of chemoradiotherapy.

The management of cervical lymph node metastases of squamous cell carcinoma from an unknown primary site is still a therapeutic challenge. We report here our experience in treating these patients with chemoradiotherapy as a curative approach. Data from 40 patients were reviewed. In total, 20 (50%) patients underwent excisional biopsy. All patients underwent radiotherapy, which was delivered to both sides of the neck and pharyngeal mucosa (extensive field), and concurrent chemotherapy consisting of weekly cisplatin at a dose of 40 mg/m(2). The clinical stage of the cervical nodes at presentation was N1 in 25%, N2 in 60%, and N3 in 15%. Most patients (75%) developed at least grade 3 mucositis. Eight patients (20%) had grade 3 xerostomia and 18 patients (45%) required esophageal dilation for stricture. The 5-year overall survival(OS) rate of all patients was 67.5%. The 5-year OS rates of patients with N1, N2, and N3 lesions were 100%, 67%, and 41%, respectively (P = 0.046). The 5-year progression-free survival rate was 62.5%. In multivariate analysis, only N stage significantly affected OS(P = 0.022). Emergence of the occult primary was very limited (1 patient only). Our results suggest that extensive irradiation of both sides of the neck and pharyngeal mucosa with concurrent chemotherapy results in a lower emergence of primary tumor. Because the survival of patients with unknown primary is comparable to that of patients with known primary, an attempt at cure should always be made.