GDF15 linked to maternal risk of nausea and vomiting during pregnancy.

GDF15, a hormone acting on the brainstem, has been implicated in the nausea and vomiting of pregnancy, including its most severe form, hyperemesis gravidarum (HG), but a full mechanistic understanding is lacking1-4. Here we report that fetal production of GDF15 and maternal sensitivity to it both contribute substantially to the risk of HG. We confirmed that higher GDF15 levels in maternal blood are associated with vomiting in pregnancy and HG. Using mass spectrometry to detect a naturally labelled GDF15 variant, we demonstrate that the vast majority of GDF15 in the maternal plasma is derived from the feto-placental unit. By studying carriers of rare and common genetic variants, we found that low levels of GDF15 in the non-pregnant state increase the risk of developing HG. Conversely, women with ß-thalassaemia, a condition in which GDF15 levels are chronically high5, report very low levels of nausea and vomiting of pregnancy. In mice, the acute food intake response to a bolus of GDF15 is influenced bi-directionally by prior levels of circulating GDF15 in a manner suggesting that this system is susceptible to desensitization. Our findings support a putative causal role for fetally derived GDF15 in the nausea and vomiting of human pregnancy, with maternal sensitivity, at least partly determined by prepregnancy exposure to the hormone, being a major influence on its severity. They also suggest mechanism-based approaches to the treatment and prevention of HG.

The acute vestibular syndrome: prevalence of new hearing loss and its diagnostic value.

OBJECTIVES: To assess the prevalence of new hearing losses in patients with acute vestibular syndrome (AVS) and to start to evaluate its diagnostic value for the differentiation between peripheral and central causes. DESIGN: We performed a cross-sectional prospective study in AVS patients presenting to our Emergency Department (ED) from February 2015 to November 2020. All patients received an MRI, Head-impulse test, Nystagmus test and Test of skew ('HINTS'), caloric testing and a pure-tone audiometry. RESULTS: We assessed 71 AVS patients, 17 of whom had a central and 54 a peripheral cause of dizziness. 12.7% had an objective hearing loss. 'HINTS' had an accuracy of 78.9% to diagnose stroke, whereas 'HINTS' plus audiometry 73.2%. 'HINTS' sensitivity was 82.4% and specificity 77.8% compared to 'HINTS' plus audiometry showing a sensitivity of 82.4% and specificity of 70.4%. The four patients with stroke and minor stroke had all central 'HINTS'. 55% of the patients did not perceive their new unilateral hearing loss. CONCLUSIONS: We found that almost one-eighth of the AVS patients had a new onset of hearing loss and only half had self-reported it. 'HINTS' plus audiometry proved to be less accurate to diagnose a central cause than 'HINTS' alone. Audiometry offered little diagnostic accuracy to detect strokes in the ED but might be useful to objectify a new hearing loss that was underestimated in the acute phase. Complete hearing loss should be considered a red flag, as three in four patients suffered from a central cause.

Impact of Sleep Disturbance on Fatigue, Nausea, and Pain: Mediating Role of Depressive Symptoms Among Youth With Disorders of Gut-Brain Interaction.

OBJECTIVES: A high degree of sleep disturbance is reported among youth with disorders of gut-brain interaction (DGBIs). Given that sleep quality impacts a range of pediatric health outcomes including somatic sensations (eg, pain) and depressive mood occurs relatively frequently among youth with DGBIs, there is a dire need to disentangle the unique contributions of sleep and depressive mood on the somatic sensations experienced by youth with DGBIs. We aimed to examine whether depressive mood mediates the relations among sleep disturbance and pain intensity, nausea, and fatigue among youth with DGBIs. METHODS: One hundred eighteen patients aged 8-17 years ( Mage = 14.05, SD = 2.88; 70.34% female), 83.05% White/non-Hispanic recruited at a pediatric neurogastroenterology clinic completed measures of sleep disturbance, nausea, fatigue, pain intensity, and depressive mood. Three mediation models examined the effect of sleep disturbance on nausea, fatigue, and pain, with depressive mood as a mediator. RESULTS: Participants reported moderate sleep disturbance. Depressive mood partially mediated the significant, respective relations between greater sleep disturbance and more severe nausea and fatigue. Sleep disturbance was significantly associated with higher pain intensity; however, depressive mood was not a significant mediator of this relation. CONCLUSIONS: Sleep quality is a major concern among youth with DGBIs. Low sleep quality may worsen nausea and fatigue via co-occurring increases in depressive mood symptoms. In contrast, sleep disturbance may directly increase pain, regardless of youths' depressive mood symptoms. Future research should explore these relations through prospective studies leveraging a combination of subjective and objective assessment approaches.

Preventing Spinal Hypotension During Cesarean Birth With Two Initial Boluses of Norepinephrine in Chinese Parturients: A Randomized, Double-Blind, Controlled Trial.

BACKGROUND: Norepinephrine is effective in preventing spinal hypotension during cesarean birth; however, an optimal regimen has not been determined. We hypothesized that an initial bolus of norepinephrine improves efficacy of spinal hypotension prophylaxis beyond continuous norepinephrine alone. METHODS: In this double-blind, controlled study, 120 patients scheduled for cesarean birth under spinal anesthesia were randomly allocated to receive a norepinephrine bolus at 0.05 or 0.10 µg/kg, followed by norepinephrine infusion at a rate of 0.05 µg·kg -1 ·min -1 . The primary outcome was the frequency of spinal hypotension during cesarean birth. The doses of the rescue drug (phenylephrine), frequency of nausea or vomiting, duration of hypotension, frequency of intraoperative hypertension, frequency of bradycardia, and fetal outcomes were also compared. RESULTS: One-hundred-fifteen patients were included in the analysis. Compared with the 0.05 µg/kg group, the frequency of spinal hypotension was lower in the 0.10 µg/kg group (20.7% vs 45.6%; odds ratio [OR], 0.31; 95% confidence interval (CI), 0.14-0.71; P = .004). Fewer rescue doses of phenylephrine (0 [0,0] vs 0 [0,80]; 95% CI for the difference, 0 (0-0); P = .006) were required, and the frequency of nausea or vomiting was lower (5.2% vs 17.5%; OR, 0.26; 95% CI, 0.07-0.99; P = .04) in the 0.10 µg/kg group. The duration of hypotension was shorter in the 0.10 µg/kg group than that in the 0.05 µg/kg group (0 [0,0] vs 0 [0,2]; 95% CI for the difference, 0 [0-0]; P = .006). The incidence of intraoperative hypertension, frequency of bradycardia, and fetal outcomes were comparable between the 2 groups. CONCLUSIONS: With a fixed-rate norepinephrine infusion of 0.05 µg·kg -1 ·min -1 , the 0.10 µg/kg initial bolus was more effective in reducing the incidence of spinal hypotension compared with the 0.05 µg/kg initial bolus.

Efficacy of a propofol bolus against placebo to prevent cough at emergence from general anesthesia with desflurane: a randomized controlled trial.

PURPOSE: Emergence from anesthesia is a critical period and cough can result in adverse effects. Propofol inhibits airway reflexes and when infused it reduces cough more than inhalation anesthesia does. We evaluated the effect of a propofol bolus given at emergence on the incidence of coughing following a desflurane-based anesthesia. METHODS: One hundred and fifty-four patients scheduled for elective surgery were prospectively randomized to propofol (0.5 mg·kg-1) or normal saline (NS) administered at the end of the surgery at 1 minimum alveolar concentration (MAC) of desflurane. A "no touch" emergence technique was used until extubation. The primary outcome was the incidence of cough at the discontinuation of desflurane (T0) and reaching a MAC adjusted for age (MACage) of 0.15. Secondary outcomes included incidence and severity of cough until five minutes postextubation (T0-T5), time to extubation, nausea and vomiting, sedation, hemodynamic variations, postoperative hypoventilation, hypoxemia, and sore throat. RESULTS: We could not draw inferences on the incidence of cough between T0 and MACage of 0.15 because only 27/68 (40%) patients in the NS group and 13/73 (18%) patients in the propofol group regained consciousness before reaching a MACage of 0.15. There were no significant differences between the groups in coughing incidence and severity between T0 and T5 (NS group, 57/68 [84%] vs propofol group, 70/73 [96%] ). The mean time to extubation in the propofol group was prolonged by 3 min 27 sec (95% confidence interval, 1 min 7 sec to 4 min 47 sec; P < 0.001) and more vasopressors were used at emergence (P = 0.02). The incidence of respiratory complications, nausea and vomiting, agitation, and sedation were not different between groups. CONCLUSION: In the present trial, a propofol bolus administered at emergence did not reduce the incidence of cough occurring between T0 and T5 following a desflurane-based general anesthesia compared with placebo. TRIAL REGISTRATION: ClinicalTrials.gov (NCT02932397); registered 13 October 2016.

RéSUMé: OBJECTIF: L'émergence de l'anesthésie est une période critique et la toux peut entraîner des effets indésirables. Le propofol inhibe les réflexes des voies aériennes et, lorsqu'il est perfusé, il est plus efficace pour réduire la toux que l'anesthésie inhalée. Nous avons évalué l'effet d'un bolus de propofol administré à l'émergence sur l'incidence de toux après une anesthésie à base de desflurane. MéTHODE: Cent cinquante-quatre patients devant bénéficier d'une chirurgie non urgente ont été randomisés prospectivement à recevoir du propofol (0,5 mg·kg−1) ou une solution physiologique de sérum salé (NS) administrée à la fin de la chirurgie lorsque la concentration alvéolaire minimale (MAC) de desflurane était de 1. Une technique d'émergence « sans contact ¼ a été utilisée jusqu'à l'extubation. Le critère d'évaluation principal était l'incidence de toux à l'arrêt du desflurane (T0) et à l'atteinte d'une MAC ajustée en fonction de l'âge (MACâge) de 0,15. Les critères d'évaluation secondaires comprenaient l'incidence et la gravité de la toux jusqu'à cinq minutes après l'extubation (T0-T5), le délai d'extubation, les nausées et vomissements, la sédation, les variations hémodynamiques, l'hypoventilation postopératoire, l'hypoxémie et les maux de gorge. RéSULTATS: Nous n'avons pas pu tirer de conclusions sur l'incidence de toux entre T0 et à une MACâge de 0,15 parce que seulement 27/68 (40 %) patients du groupe NS et 13/73 (18 %) patients du groupe propofol ont repris conscience avant d'atteindre une MACâge de 0,15. Il n'y avait aucune différence significative entre les groupes dans l'incidence et la gravité de la toux entre T0 et T5 (groupe NS, 57/68 [84 %] vs groupe propofol, 70/73 [96 %]). Le temps moyen d'extubation dans le groupe propofol a été prolongé de 3 min 27 sec (intervalle de confiance à 95 %, 1 min 7 sec à 4 min 47 sec; P < 0,001) et une plus grande quantité de vasopresseurs a été utilisée à l'émergence (P = 0,02). L'incidence de complications respiratoires, de nausées et vomissements, d'agitation, et de sédation n'était pas différente entre les groupes. CONCLUSION: Dans la présente étude, un bolus de propofol administré à l'émergence n'a pas réduit l'incidence de toux survenant entre T0 et T5 après une anesthésie générale à base de desflurane par rapport au placebo. ENREGISTREMENT DE L'éTUDE: ClinicalTrials.gov (NCT02932397); enregistrée le 13 octobre 2016.

Safety and efficacy of combined ropivacaine and sufentanil compared with ropivacaine for cesarean sections: A systematic review and meta-analysis.

Cesarean sections are the most common operations in the United States and one of the most common worldwide. Using the lowest possible dose of anesthetic that provides painless delivery with the lowest adverse events is a major concern. We investigated the efficacy and safety of combined ropivacaine and sufentanil by pooling data from relevant studies. We searched PubMed, Web of sciences, Scopus, and Cochrane Library until the end of December 2021 and included all records with data about combined ropivacaine and sufentanil. We used Review Manager to pool data as a mean difference for continuous outcomes or risk ratio for dichotomous outcomes with a 95% confidence interval. Methodological quality was appraised using version one of the Cochrane risks of bias tool. Seven Randomized clinical trials with a total sample size of 730 women were included; the mean age of enrolled parturients ranged from 28 to 35 years. We found that combined sufentanil and ropivacaine were significantly associated with decreased risk of being aware and nervous during CS (presented by Sedation level 1) (RR: 0.05, 95%CI [0.01,0.33], P=0.002), decreased risk of shivering (RR=0.29, 95%CI [0.19,0.44], P<0.00001), nausea (RR=0.62, 95%CI [0.41, 0.92], P=0.02), and vomiting (RR=0.27, 95% CI [0.12, 0.61], P=0.002). However, combined sufentanil and ropivacaine slightly were associated with late-onset of sensory blockade (MD=0.41, 95%CI [0.13, 0.68], P=0.004) and less motor blockade of leg flexion at hip joint presented by Bromage Scale 0 (RR=7.15 95%CI [2.71, 18.86], P<0.0001). Combined ropivacaine and sufentanil were associated with a reduction in visceral pain and lower risks of hypotension, shivering, nausea, and vomiting, compared to isolated ropivacaine, with no difference regarding the incidence of bradycardia. Although Combined ropivacaine and sufentanil were associated with a higher risk of pruritus, the incidence of pruritus was reportedly proportionate with the used dose of sufentanil. However, combined ropivacaine and sufentanil may slightly delay the onset of the sensory blockade to pinprick at T10 with less motor blockade but with a smaller probability for women to be aware and nervous during CS.

Operative Findings in Pediatric and Adolescent Patients With Presumed Adnexal Torsion.

INTRODUCTION: Clinical and radiographic findings often lead to diagnostic laparoscopy for presumed adnexal torsion (AT). To better understand the preoperative factors leading to AT, we evaluated the clinical course of patients with ultrasound findings concerning for AT to assess intraoperative AT rates and predictive factors for AT. METHODS: An institutional review board-approved retrospective review in two hospital centers over a period of 5 y was performed for females (4-18 y) with ultrasound (US) findings concerning for AT (n = 225). Preoperative clinical, radiographic, and intraoperative findings were assessed for patients with intraoperative AT versus for those without. RESULTS: The median age of patients was 14 y. Of those who went to the operating room (OR) (n = 113), AT was found in 57%. There was no difference between patients taken to the OR with or without AT regarding demographics or presentation. The presence of nausea/vomiting, tenderness, leukocytosis, lack of blood flow, or a mass/cyst >5 cm were found to be more likely in patients with AT than in those without. An ovarian volume ratio >15 was noted to be predictive of AT. Six patients initially discharged from the emergency department returned and went to the OR, two of which had AT, both with ovarian salvage. CONCLUSIONS: Limited data are available when counseling patients with presumed AT. We found the larger mean ovarian volume and an ovarian volume ratio >15 were predictive of AT. Despite this, 43% of patients taken to the OR did not have AT. This relatively high rate of not finding AT intraoperatively may be justified given the sequelae of missing AT.

Effect of niacin supplementation on nausea-like behaviour in an isoniazid-induced mouse model of pellagra.

Niacin deficiency causes pellagra, the symptoms of which include dermatitis, diarrhoea and dementia. Investigating the mechanism underlying these phenotypes has been challenging due to the lack of an appropriate animal model. Here, we report a mouse model of pellagra-related nausea induced by feeding mice a low-niacin diet and administering isoniazid (INH), which is thought to induce pellagra. Mice fed a normal or low-niacin diet received INH (0·3 or 1·0 mg/mg per animal, twice daily, 5 d), and nausea was evaluated based on pica behaviour, which considered the rodent equivalent of the emetic reflex. Furthermore, the effect of therapeutic niacin administration on nausea was evaluated in this model. Urinary and hepatic metabolite levels were analysed by LC coupled with MS. INH-induced pica was observed in mice fed a low-niacin diet but not in those fed a normal diet. Levels of urinary metabolites, such as 1-methyl-2-pyridone-5-carboxamide, kynurenic acid and xanthurenic acid, were significantly reduced in the mice treated with INH compared with those that did not receive INH. Furthermore, niacin supplementation prevented pica and restored the levels of some metabolites in this mouse model. Our findings suggest that INH-related nausea is pellagra-like. We also believe that our newly established method for quantifying pica is a useful tool for investigating the mechanisms of pellagra-related nausea.

Development and content validation of patient-reported outcomes tools for ulcerative colitis and Crohn's disease in adults with moderate-to-severe disease.

BACKGROUND: Ulcerative colitis (UC) and Crohn's disease (CD) are associated with a range of symptoms that adversely affect health-related quality of life. This research aimed to develop and validate two patient-reported outcome (PRO) tools to assess signs and symptoms in patients with moderate-to-severe UC or CD. METHODS: PRO-UC and PRO-CD Diaries were developed in accordance with US Food and Drug Administration (FDA) recommendations. Data were collected from concept elicitation interviews (in which patients described their symptoms and experience of the disease) and further refined through cognitive interviews (in which patients assessed the relevance and clarity of questions in the tools). RESULTS: Interviews were conducted with 12 patients for each indication. Five symptoms (urgent bowel movements, abdominal pain, frequent bowel movements, bloody stools, diarrhea/watery stools) were reported by 83-100% of participants with UC and were included in the final 6-item PRO-UC Diary: stool frequency, rectal bleeding (2 items), diarrhea, rectal urgency, and abdominal pain. For CD, seven symptoms (abdominal pain, diarrhea/loose stools, urgent bowel movements, fatigue/tiredness/weakness, frequent bowel movements, bloody stools, nausea) were reported by 50-100% of participants. These, together with vomiting and incontinence (reported by 42% and 33% of participants, respectively), were included in the final 10-item PRO-CD Diary, covering abdominal pain (2 items), stool frequency, liquid/very soft stool frequency, rectal bleeding, rectal urgency, nausea, vomiting, bowel incontinence, and general well-being. Symptoms were consistently cited across both indications to have an impact on quality of life, with frequent complaints being the need to always be near a toilet and inability to leave home, as well as general pain, discomfort, and nausea. For both tools, questions were accurately interpreted, with at least 67% of participants in both indications stating that items were easy to answer/relevant to their condition and symptoms were easy to recall over the last 24 h. CONCLUSIONS: Both the PRO-UC and PRO-CD Diaries were developed and validated in accordance with FDA recommendations, providing two new tools for use in clinical trials to assess response to treatment in patients with UC or CD. Psychometric analyses are warranted to fully evaluate their properties and value for use in clinical trials.

Lack of catch-up in weight gain may intermediate between pregnancies with hyperemesis gravidarum and reduced fetal growth: the Japan Environment and Children's Study.

BACKGROUND: Women with nausea and vomiting of pregnancy (NVP) have higher birth weight infants, while those with hyperemesis gravidarum, a severe manifestation of NVP, have lower birth weight infants. We aimed to investigate the associations between maternal weight loss (a consequence of hyperemesis gravidarum), NVP, and infant birth weight. METHODS: This study was a secondary analysis of a nationwide birth cohort in Japan. Singleton pregnancies delivered at 28-41 weeks of gestation were included in the analysis. Women were categorized based on their weight change in the 1st trimester (as a proportion to their pre-pregnancy weight: > + 3%, > 0 to + 3%, > -3 to 0%, > -5 to -3%, ≤ -5%) and severity of NVP (no nausea, only nausea, vomiting but able to eat, vomiting and unable to eat). The effects of weight change and severity of NVP on infant birth weight and small for gestational age (SGA) were assessed using regression models. We further examined how these effects could be modified by maternal weight gain up to the 2nd trimester. RESULTS: Among 91,313 women, 5,196 (5.7%) lost ≥ 5% of their pre-pregnancy weight and 9,983 (10.9%) experienced vomiting and were unable to eat in the 1st trimester. Women with weight loss ≥ 5% in the 1st trimester had infants 66 (95% CI: 53, 78) g lighter and higher odds of SGA (aOR: 1.29; 95% CI: 1.14, 1.47) than women who gained > 3% during the same period. However, when adjusting for weight gain up to the 2nd trimester, women with weight loss ≥ 5% in the 1st trimester had infants 150 (95% CI: 135, 165) g heavier and lower odds of SGA (aOR: 0.39; 95% CI: 0.33, 0.46) than those who gained > 3% during the same period. In contrast, women with more severe NVP tended to have infants with larger birth weight and lower odds of SGA compared to women without NVP. These trends were strengthened when adjusting for weight gain up to the 2nd trimester. CONCLUSIONS: Our study suggests the possibility that reduced fetal growth in pregnancies with hyperemesis gravidarum may be caused by the lack of catch-up in gestational weight gain up to the 2nd trimester.

Clinical characteristics and outcomes of pheochromocytoma crisis: a literature review of 200 cases.

PURPOSE: Pheochromocytoma crisis is a life-threatening endocrine emergency that requires prompt diagnosis and treatment. Because of its rarity, sudden onset, and lack of internationally uniform and validated diagnostic criteria, pheochromocytoma crisis remains to be fully clarified. Therefore, we aimed to describe the clinical characteristics and outcomes of pheochromocytoma crisis through a literature review. METHODS: We performed a systematic literature search of PubMed/MEDLINE database, Igaku-Chuo-Zasshi (Japanese database), and Google Scholar to identify case reports of pheochromocytoma crisis published until February 5, 2021. Information was extracted and analyzed from the literature that reported adequate individual patient data of pheochromocytoma crisis in English or Japanese. Cases were also termed as pheochromocytoma multisystem crisis (PMC) if patients had signs of hyperthermia, multiple organ failure, encephalopathy, and labile blood pressure. RESULTS: In the 200 cases of pheochromocytoma crisis identified from 187 articles, the mean patient age was 43.8 ± 15.5 years. The most common symptom was headache (39.5%). The heart was the most commonly damaged organ resulting from a complication of a pheochromocytoma crisis (99.0%), followed by the lungs (44.0%) and the kidney (21.5%). PMC accounted for 19.0% of all pheochromocytoma crisis cases. After excluding 12 cases with unknown survival statuses, the mortality rate was 13.8% (26/188 cases). Multivariable logistic regression analysis revealed that nausea and vomiting were significantly associated with a higher mortality rate. CONCLUSION: Pheochromocytoma can present with different symptomatology, affecting different organ systems. Clinicians should be aware that patients with nausea or vomiting are at a higher risk of death because of pheochromocytoma crisis.

Analgesic effect of ultrasound-guided erector spinae plane block (espb) in general anesthesia for cesarean section: a randomized controlled trial.

BACKGROUND: The analgesic effects of erector spinae plane block in general anesthesia for cesarean section and recovery from puerperae remain unclear. METHODS: Sixty patients with contraindications for spinal anesthesia who required general anesthesia for cesarean section were enrolled and randomly divided into the erector spinal plane block (ESPB) combined with the general anesthesia group (group E) and general anesthesia group (group G). Group E received bilateral ESPB (20 ml of 0.25% ropivacaine on each side) under ultrasound guidance 30 min before general anesthesia. The primary outcomes were the number of patient-controlled intravenous analgesia (PCIA) boluses, and Bruggemann comfort scale (BCS) scores at 2 h, 6 h, 12 h, and 24 h after operation. The second outcome was intraoperative anesthesia dosage, fetal delivery time, puerperae emergence time, visual analog scale (VAS) at 2 h, 6 h, 12 h, and 24 h after operation, and incidence of nausea and vomiting. Heart rate (HR) and mean arterial pressure (MAP) were recorded 10 min before the start of anesthesia (T0), at the induction of anesthesia (T1), at skin incision (T2), and fetal delivery (T3), and immediately after surgery (T4). RESULTS: The number of PCIA boluses was lower in group E than in group G (P < 0.001). The BCS score increased at 2 h and 6 h after the operation in group E (P < 0.05), while the VAS score significantly decreased in group E at the same time (P < 0.05). Compared with group G, the doses of propofol and remifentanil were significantly decreased in group E (P < 0.001), the emergence time of puerperae was shortened (P = 0.003), and the incidence of nausea and vomiting was significantly decreased (P = 0.014). CONCLUSION: Ultrasound-guided ESPB applied to general anesthesia for a cesarean section can significantly reduce the required dose of general anesthetic drugs, shorten the recovery time of the puerperae, and improve postoperative analgesia. TRIAL REGISTRATION: www. CLINICALTRIALS: gov under the number ChiCTR2200056337 (04-02-2022).

Effect of postoperative ultrasound-guided internal superior laryngeal nerve block on sore throat after intubation of double-lumen bronchial tube: a randomized controlled double-blind trial.

BACKGROUND: Postoperative sore throat (POST) is one of the main adverse postoperative outcome after tracheal intubation using double-lumen endobronchial tubes (DLTs). The aim of this study was to investigate the effectiveness and safety of ultrasound (US)-guided block of the internal branch of the superior laryngeal nerve (iSLN) for alleviating POST after intubation of DLTs. METHODS: Patients undergoing thoracic surgery between August 2019 and August 2021 were randomized into two groups depending on whether they received US-guided iSLN block immediately after the operation. In the control group, the patients underwent a thoracic surgery under general anesthesia (GA) with DLTs without any special treatment, while the patients in the experimental group received US-guided iSLN block bilaterally with 2 ml of 0.25% ropivacaine on either side immediately after the operation. The primary outcome was the grading of sore throat at three-time points after the operation, i.e., immediate extubation, 2 h after extubation, and 24 h after extubation. Secondary outcomes included the rate of nausea and vomiting, hoarseness, dyspnea, and choking cough after swallowing saliva at 2 h after extubation. RESULTS: The incidence and severity of sore throat were significantly lower in the experimental group than the control group at all time intervals (all P < 0.01). The rate of nausea and vomiting, hoarseness, dyspnea, and choking cough after swallow saliva at 2 h after extubation had no statistical difference (all P > 0.05). CONCLUSIONS: The use of US-guided iSLN block can be effectively and safely applied to relieve POST after intubation of DLTs on thoracic surgery. TRIAL REGISTRATION: The study protocol was registered at the Chinese Clinical Trial Registry ( http://www.chictr.org.cn , NO. ChiCTR2000032188, 22/04/2020).

Effect of glycopyrrolate on vasopressor requirements for non-elective cesarean section under spinal anesthesia: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: The study aimed to investigate whether prophylactic use of glycopyrrolate decreases the vasopressor requirements to prevent hypotension following spinal anesthesia during non-elective cesarean section. METHOD: In this double-blind randomized clinical trial, 258 patients undergoing non-elective cesarean section were randomly assigned (1:1) to receive intravenous 0.2 mg glycopyrrolate or normal saline (placebo) before spinal anesthesia. The primary outcome was phenylephrine equivalent needed intraoperatively. Secondary outcomes included incidences of maternal hypotension, reactive hypertension, bradycardia, need for atropine, tachycardia, intraoperative nausea/vomiting, shivering, pruritus, dry mouth, dizziness; neonatal APGAR score at 1 min and 5 min, neonatal resuscitation needed, NICU admission and neonatal death. RESULTS: Three patients withdrew from the study due to failed spinal anesthesia. 128 patients in the glycopyrrolate group and 127 patients in the placebo group were analyzed. The mean phenylephrine equivalent needed was 1108.96 µg in the glycopyrrolate group and 1103.64 µg in the placebo group (mean difference, 5.32 µg [95% CI - 67.97 to 78.62]; P = 0.88). Hypotension occurred in 38 patients (30%) in the glycopyrrolate group as compared with 49 patients (39%) in the placebo group (P = 0.13). Tachycardia was reported in 70% of the participants in the glycopyrrolate group and 57% of those in the placebo group (P = 0.04). No statistically significant difference was noted in hypotensive episodes > 1, reactive hypertension, bradycardia, need for atropine, nausea, vomiting, shivering, and dry mouth between the two groups. Neonatal outcomes were similar in the two groups. CONCLUSION: Prophylactic use of glycopyrrolate does not decrease the requirements of vasopressor to prevent hypotension in non-elective cesarean section under spinal anesthesia. TRIAL REGISTRATION: Registration number: NCT04401345. Date of registration: 26/05/2020. Website: https://clinicaltrials.gov.

Medication Prescription, Common Side-effects, and Nutritional Status are Associated in Patients With Chronic Kidney Disease.

OBJECTIVE: Chronic kidney disease (CKD) is associated with metabolic, nutritional, and extra-renal changes, as well as a high rate of comorbidities, which necessitates the prescription of numerous medications. Patients with CKD often experience poor nutritional status related to disease severity and prescribed medication; however, this association has not been investigated in depth. Therefore, this study aimed at investigating the association between prescribed medication and nutritional status in patients with CKD. METHODS: Assessment of nutritional status was performed using anthropometric and functional measurements and by biochemical measures. Patient history and the number and type of currently prescribed medications were collected from patients' records. We evaluated the total number and the number of specific medicines with common or very common side-effects of nausea or xerostomia. RESULTS: Two hundred seventeen patients with CKD were included in this cross-sectional study (n = 112 with pre-dialysis CKD stages 3-5, n = 33 with hemodialysis, and n = 72 with kidney transplant). On average, patients were prescribed nine medications concurrently. The number of prescribed medications was inversely associated with mid-upper arm circumference, skinfold thickness triceps, handgrip strength, serum albumin, and hemoglobin after adjustment for age, sex, and kidney function. Prescription of medications with nausea as a side-effect showed similar associations, whereas prescription of medications with xerostomia as a side-effect was associated with lower handgrip strength. CONCLUSION: Medication prescription was associated with poor nutritional status in patients with CKD, and monitoring of nutritional status in patients with CKD with long medication lists is warranted to identify and treat patients with poor nutritional status.

Peripheral Nerve Block for Hip Arthroscopy Does Not Have any Clinical Advantage Compared With Local Anesthetic Regarding Pain Management: A Meta-analysis of Randomized Controlled Trials.

PURPOSE: To evaluate the efficacy of peripheral nerve block on reduction in opioid consumption and pain control after hip arthroscopy. METHOD: To identify studies evaluating the effects of peripheral nerve block on pain control and reduction in opioid consumption in hip arthroscopy, we searched all records in the PubMed, Embase, and Cochrane Library databases until May 2021. Studies with the following characteristics were considered eligible: 1) patients who underwent a hip arthroscopy (population); 2) patients who received peripheral nerve block (intervention); 3) patients who did not receive peripheral nerve block (comparator); 4) record of total opioid consumption as a primary outcome and pain level at 1, 3 to 6, and 24 hours after surgery, patient satisfaction, and incidence of nausea and vomiting as secondary outcomes (outcomes); and 5) randomized controlled trial (study design). Data were independently extracted by two reviewers and synthesized using a random or fixed-effects model, according to the heterogeneity. RESULTS: Eight RCTs were finally included in the meta-analysis. There were no significant differences in postoperative opioid consumption at 24 hours (standardized mean difference [SMD] = -0.091, 95% confidence interval [CI] [-0.270, 0.089]) or in visual analog scale (VAS) score at 1 (SMD = 0.299, 95% CI [-0.758, 0.160]), 3 to 6 (SMD = -0.304, 95% CI [-0.655, 0.047]), and 24 (SMD = -0.230, 95% CI [-0.520, 0.060]) hours postoperatively between the peripheral nerve block and control groups. Moreover, no significant differences were observed in patient satisfaction (SMD < 0.001, 95% CI [-0.284, 0.284]) or the incidence of nausea and vomiting (SMD = 0.808, 95% CI [0.311, 2.104]) between the two groups. CONCLUSION: Peripheral nerve block for hip arthroscopy has no clinical advantage regarding pain management after surgery when compared with the group that received the local infiltration of analgesics without peripheral nerve block. LEVEL OF EVIDENCE: Level II, meta-analysis of level I and II randomized controlled trials (RCTs).

Comparing the efficacy of peritonsillar injection of bupivacaine and intravenous acetaminophen on post-tonsillectomy pain in children.

INTRODUCTION: In this study we aimed to compare the efficacy of peritonsillar injection of bupivacaine and intravenous acetaminophen on post-tonsillectomy pain in children. MATERIALS AND METHODS: In this randomized double-blind clinical trial study 60 children with ASA = I-II aged 5-12 years undergoing tonsillectomy were involved. The first group received bupivacaine at a dose of 0.1 mg/kg that was injected into the bed and the anterior crease of each tonsil. The second group was given intravenous acetaminophen at a dose of 12.5 mg/kg. The patient's pain score at 10, 30, 60 min after his/her admission to recovery room and 120, 240 and 360 min after the surgery was recorded using CHEOPS. Patient's sedation score, nausea or vomiting, the time of the first request for analgesia and the time of starting oral feeding were recorded and analyzed too. RESULTS: There was no significant differences in mean age (p value = 0.44), gender (p value = 0.79), weight (p value = 0.36), height (p value = 0.17), anesthesia duration (p.value = 0.85) and surgery duration (p.value = 0.73) between two groups. Postoperative pain was significantly less in the bupivacaine group at 240 and 360 min after the surgery. The mean sedation score was higher in the bupivacaine group but not significantly. There was no significant difference between groups regarding the nausea and vomiting, the first analgesics request time and the start time of oral feeding. CONCLUSION: According to the results of the present study, since administration of peritonsillar bupivacaine compared to acetaminophen had a better effect on managing postoperative pain and improving sedation and also since no complications were reported; therefore, peritonsillar infiltration with bupivacaine is suggested for pediatric tonsillectomy.

Effects of throat packs in upper airway surgery under intubation anesthesia: a randomized controlled trial.

INTRODUCTION: Throat packs (TP) are used in upper airway surgery to avoid accumulation and aspiration of blood, foreign bodies, and fluids. But side effects such as sore throat and TP retention have been reported and challenge the standardized use of TP. The aim of this study is to compare benefits and side effects of TP versus no TP for upper airway procedures in intubation anesthesia. MATERIAL AND METHODS: One hundred forty-eight patients with surgical interventions at the upper airway under intubation anesthesia were included. Of those, n = 74 each were treated without (A, control) and with (B) TP. Study group B was subdivided whether TP was placed by the surgeon (B1; n = 37) or by the anesthesiologist (B2; n = 37). TP-related side effects such as sore throat, foreign body sensation, hoarseness, dyspnea, difficulty of swallowing, nausea, retching, nausea, aspiration, and pneumonia as well as the influence of TP design and the applicant (surgeon or anesthetist) were analyzed. RESULTS: A significantly increased rate of difficulty of swallowing (p = 0.045), intensity of sore throat (p = 0.04), and foreign body sensation (p = 0.024) was found in group B when compared to group A. There was no correlation between hoarseness, dyspnea, nausea, retching, and TP. No case of aspiration or pneumonia was seen but one TP was accidentally forgotten in the patient. B2 showed an increased frequency of difficulty swallowing, followed by A and B1. B1 led to the highest incidence of nausea followed by the A and B2. CONCLUSION: The use of TP led to a high rate of side effects without showing the propagated advantages. CLINICAL RELEVANCE: The use of TP must be considered critically and cannot generally be recommended without specific reasons, such as high aspiration risk.

Combined application of adductor canal block and local infiltration anesthesia in primary total knee arthroplasty: an updated meta-analysis of randomized controlled trials.

BACKGROUND: Perioperative pain after total knee arthroplasty (TKA) may seriously affect the rapid recovery of patients. The purpose of this study was to assess whether the combined use of adductor canal block (ACB) and local infiltration anesthesia (LIA) can further reduce postoperative pain and improve early functional recovery. MATERIALS AND METHODS: PubMed, Web of Science, EMBASE, and Cochrane Central Register of Controlled Trials were systematically searched for randomized controlled trials (RCTs) comparing ACB + LIA and LIA alone in primary TKA. The primary outcomes were visual analog scale (VAS) scores at rest and walking, morphine consumption, range of motion (ROM) at 24 and 48 h postoperatively and distance walked. The secondary outcomes were the length of stay, the incidence of nausea and vomiting, and the total complications. Subgroup analyses were performed on the VAS at rest and walking, morphine consumption, and distance walked at 24, 48, and 72 h postoperatively. RESULTS: A total of 10 RCTs involving 797 patients were enrolled in this meta-analysis. The results demonstrated that the combined application of ACB + LIA had a lower resting VAS at 24 h postoperatively (p = 0.02) and the walking score at 24 (p = 0.0002) and 48 h (p = 0.02) postoperatively compared with LIA alone. Similarly, the combined ACB + LIA group also had less morphine consumption at 48 h postoperatively (p = 0.0005) and had a higher ROM score at 24 h (p = 0.01) postoperatively compared to the LIA group. There were no statistical differences in length of stay, distance walked, and incidence of nausea and vomiting. CONCLUSION: The current meta-analysis showed that ACB + LIA significantly reduced postoperative walking pain and morphine consumption and promoted rapid recovery in the early postoperative period. There is no statistical difference in the length of stay and ROM after 72 h in the two groups.