The Effect of Repeated Direct Observation of Procedural Skills (R-DOPS) Assessment Method on the Clinical Skills of Anesthesiology Residents.

BACKGROUND: The ultimate result of patient care is one of the most important outcomes in medical education. Several methods, including the direct observation of procedural skills (DOPS), have been proposed to assess professional competencies in clinical practice. OBJECTIVES: This study aimed to assess the effects of the Repeated DOPS (R-DOPS) method on the performance of procedural skills in anesthesiology residents. METHODS: The procedural skill performance of anesthesiology residents was assessed using a standard DOPS protocol from May to October 2019. Their scores were then objectively recorded, and the satisfaction rates regarding the 2 DOPS exams were assessed. RESULTS: We found a considerable improvement in anesthesiology residents' procedural skill performance, especially in the anesthesiology residency curriculum's basic items. Besides, anesthesiology residents' satisfaction was significantly improved after the 2nd DOPS. CONCLUSIONS: R-DOPS leads to improved training outcomes, including assessing the procedural skills, time to feedback to trainees, and trainee satisfaction.

Comparison of the Combined Femoral and Lateral Femoral Cutaneous Nerve Block Plus Popliteal Block with Spinal Anesthesia for Thigh Tourniquet Pain During Foot or Ankle Surgery: A Randomized Clinical Trial.

BACKGROUND: A pneumatic thigh tourniquet is routinely used during lower-extremity orthopedic surgeries to provide a bloodless field. When using peripheral nerve blocks, tourniquet-related thigh pain and discomfort limit their routine use as an anesthetic method. OBJECTIVES: The aim of the present prospective, randomized study was to compare the efficacy of combined femoral nerve/lateral femoral cutaneous nerve block technique and spinal anesthesia on intraoperative thigh tourniquet pain. METHODS: We studied 60 American Society of Anesthesiologists physical status I-II patients scheduled for orthopedic surgery on the foot or ankle using a pneumatic thigh tourniquet. They were randomly divided into two equal groups. The peripheral nerve block group received a combined popliteal, femoral, and lateral femoral cutaneous nerve block under ultrasound-guidance. In both groups, the level of sensory blockade was determined by the pinprick test. The block performance time, anesthetic effect time, intraoperative tourniquet pain scores, the amount of fentanyl and ketamine, surgery duration, and patient's satisfaction were recorded. RESULTS: The patients' characteristics were comparable in the two groups. The mean duration of block performance and anesthetic effect, intraoperative tourniquet pain scores, and the amount of intravenous analgesics in the peripheral nerve block group were significantly greater than those in the spinal anesthesia group. Patient satisfaction was similar in both groups. CONCLUSIONS: Spinal anesthesia is significantly more effective than the peripheral nerve block method in reducing thigh tourniquet pain. A combined femoral and lateral femoral cutaneous nerve block with popliteal block can improve thigh tourniquet tolerance if supplemented with intravenous analgesics.

Laser Therapy in Lumbar Disc Surgery - A Narrative Review.

Introduction: Low back pain is one of the most chronic debilitating conditions involving considerable loss of cash, work, and quality time. Lasers are utilized in different fields of drugs, providing unique advantages. They are useful and advantageous in treating lumbar disc disease. In this research, an attempt is made to examine the role and importance of different lasers in lumbar disc surgeries. Methods: We conducted studies about laser therapy in lumbar disc surgery. Our primary search began with reviewing English-language citations from PubMed and Scopus between 1990 and 2019 using the keywords: (laser therapy) OR (lumbar disc AND disc surgery). The initial search yielded 97 articles. However, about 49 articles were selected and used in the present study. Results: Based on the present study, it can be found that there are several methods of using lasers to treat lumbar disc surgery. These methods all have their strengths and weaknesses. Conclusion: The development of laser lumbar disc surgery can be very helpful due to the reduction of surgical risks and the length of the patients' hospital stay. However, the choice of method used for this type of surgery should be made according to the patient's condition and based on the opinion of the treating physician.

Periarticular hypertonic dextrose vs intraarticular hyaluronic acid injections: a comparison of two minimally invasive techniques in the treatment of symptomatic knee osteoarthritis.

BACKGROUND: Knee osteoarthritis (KOA) is the most prevailing form of joint disease. Despite the importance of minimally invasive therapeutic methods of KOA, there is a lack of evidence to compare intraarticular hyaluronic acid injection vs traditional dextrose prolotherapy. OBJECTIVE: The aim was to compare the therapeutic effects of prolotherapy with hypertonic dextrose vs hyaluronic acid on function and pain in KOA cases. MATERIALS AND METHODS: One hundred and four KOA patients were enrolled and randomly assigned into two groups, each containing 52 patients. The hyaluronic acid (HA) group were treated by 2.5 mL of hyaluronic acid intraarticulary, and the hypertonic dextrose (HD) group received 10 mL of 12.5% dextrose periarticulary. Injections were repeated three times with 1-week intervals. Pain intensity, measured by visual analog scale, and knee function, scaled by the Western Ontario and McMaster university arthritis index scores were compared between the two groups before and 3 months after intervention. Pain and function of the knee improved significantly (P<0.001) in all patients. However, significantly more symptom relief was found in the HA over the HD group. Prolotherapy with hypertonic dextrose and intraarticular injection of hyaluronic acid results in the same pain reduction and symptom relief as a noninvasive therapeutic method of KOA. CONCLUSION: These results recommended intraarticular hyaluronic acid rather than prolotherapy by hypertonic dextrose for KOA symptoms relief.

Comparison of Stone Retrieval Basket, Stone Cone and Holmium Laser: Which One Is Better in Retropulsion and Stone-Free Status for Patients with Upper Ureteral Calculi?

Introduction: Transurethral lithotripsy (TUL) is an appropriate treatment for ureteral stones and is usually used for stones in the middle and lower part of the ureter. Different devices such as the Holmium laser, the stone basket, and the stone cone exist to prevent any fragments from retropulsion during TUL. The present study aims to compare the advantages and disadvantages of the Holmium laser, the stone basket, and the stone cone. Methods: A retrospective study was conducted from September 2016 to January 2018 comparing various TUL methods in 88 subjects with proximal ureteral calculi. The study participants were divided into 4 matched groups. The first one included 20 patients undergoing TUL with no device (group 1), the second group included 22 patients undergoing TUL while using the stone retrieval basket, the third group included 18 patients undergoing TUL while utilizing the stone cone and the fourth group included 28 patients undergoing TUL while using the Hol-YAG laser. Results: A residual stone ≥3 mm was recorded in 15.9% of the patients. The stone free rate was seen in 100%, 90.9, 83.3%, and 55% of the Holmium laser group, the retrieval basket group, the stone cone group and the no device group respectively (P=0.001). The lowest rate of surgery complications including ureteral perforation, post-operative fever, and mucosal damage between the 4 groups (P=0.003) and the highest time of surgery (P=0.001) belonged to the laser group. If we want to ignore the laser group, the success rate for lithotripsy was better in both groups with a stone retrieval device compared to the no device group, but no advantage existed between the stone basket and the stone cone. Conclusion: We can safely conclude that lasers significantly help to prevent stone migration during TUL. If we want to ignore the laser group, the success rate for lithotripsy was significantly better in both groups with a stone retrieval device compared to the no device group, but no advantage existed between the stone basket and the stone cone.

The Effect of Percutaneous Laser Disc Decompression on Reducing Pain and Disability in Patients With Lumbar Disc Herniation.

Introduction: As low back pain incidence is increasing, noninvasive modalities are gaining attention for their ability to achieve the best possible outcome with the least complications. Percutaneous laser disc decompression (PLDD) is currently popular for this purpose. This study aims to evaluate the effect of PLDD on disability and pain reduction in patients with lumbar disc herniation. Methods: Thirty patients were enrolled in this study. Spinal nerve blocks were conducted by laser discectomy single stage injection of a needle into the disc space. The nucleus pulposus of herniated discs were irradiated with laser in order to vaporize a small part of the nucleus pulposus of the intervertebral discs and reduce the voluminosity of diseased discs. Patients were treated with 1000 J of 980 nm diode laser with 5 W energy. In order to measure the severity of pain, visual analog scale (VAS) and also ODI (Oswestry Disability Index) were used. Data were analyzed using SPSS version 12. Results: Thirty patients participated in this trial including 11 men and 19 women with a mean age (SD) of 40.8 (10.8) years. The mean patients VAS score and ODI level before and after discectomy showed statistically significant differences. The mean VAS and ODI scores showed no statistical difference between males and females (P<0.05) and percutaneous laser discectomy decreased the VAS and ODI at both groups of patients similarly. Conclusion: We found the use of PLDD reduces pain and disability in patients as a noninvasive procedure.

Effects of Epidural Needle Rotation on Evolution of Unilateral Epidural Block and Patients' Hemodynamics beside Recovery Profile in Patients Undergoing Arthroscopic Knee Surgeries; A Randomized Clinical Trial.

OBJECTIVE: To evaluate the evolution pattern of epidural block after rotating the needle tip 45° to the operative side and evaluate its effects on patients' hemodynamics and recovery profile in those undergoing arthroscopic knee surgery. METHODS: Forty participants were randomly subdivided into control and rotation group (n=20). An 18-gauge, 3.5 inch, Tuohy needle was placed at the level of L4-5 and pushed forward into the epidural space through parasagittal approach, in control group, the needle was pushed forward to the epidural space in cephaldad 90 degrees. For the rotation group, the needle was pushed forward to the epidural space and the tip was rotated 45 degrees to the surgical side.15 mL of bupivacaine 0.5% was injected and evolution of sensory and motor blocks until 2-segment regression of the sensory level below to T10 as well as total duration of motor block and surgery were recorded. Hemodynamic parameters (HR, MAP, and SPO2), hypotension, fluid intake, vasopressors, first ambulation and spontaneous urination were recorded. Statistical analysis was performed using SPSS and P≤0.5 considered significant. RESULTS: Sensory block up to T10 level, Complete motor block and time for 2-segment regression of sensory level were earlier in the 45°-rotation than in the control group (p<0.001). Total duration of motor block in control group was lower than rotation group (p<0.001).Hypotension, N&V, vasopressors and fluid intake showed no statistically difference between the two groups (p=0.219). First spontaneous urination and ambulation were significantly lower in rotation group (p<0.001). CONCLUSION: 45 degrees' needle rotation to the surgical side provides a faster block evolution and hastened recovery profile with no significant difference in hemodynamic fluctuations. CLINICAL TRIAL REGISTRY: IRCT20130518013364N7.

Unilateral Epidural Blockade for Lower Limb Fracture Surgery: Parasagittal Epidural Versus Midline Epidural Anesthesia.

OBJECTIVE: To compare the efficacy of parasagittal interlaminar (PIL) and midline interlaminar (MIL) approaches for epidural block in patients with lower limb orthopedic surgery. METHODS: This double-blind randomized clinical trial was performed on 40 patients undergoing tibial shaft fracture surgery. In PIL group, an 18-gauge, 3.5 inch, Tuohy needle was placed at the level of L2-3 or L3-4 intervertebral spaces and pushed forward in a posteroanterior (PA) direction vertical to the body surface. After determining the most lateral place for needle arrival in an anteroposterior (AP) view, needle was pushed forward into the epidural space. For the MIL group, needle was pushed forward from the midline interspinous space with the same method. After confirmation of needle position, 1 mL of contrast was injected to confirm the epidural space distribution and then 15 ml lidocaine 2% was injected. The sensory and motor block level, onset, duration, heart rate (HR), mean arterial pressure (MAP), and arterial oxygen saturation (SPO2), and success rate were recorded. RESULTS: Mean patients' baseline characteristics showed no statistically significant difference between the two groups.p>0.05). Outcome measures were statistically different and significantly higher in PIL group (p-values for sensory block level <0.001, motor block level <0.001, duration of sensory block: <0.001 and duration of motor block <0.001 and success rate: <0.001). Hemodynamic variables didn't show statistically significant difference between the two groups (p-values for Systolic pressure: 0.997, diastolic pressure:0.579, MAP:0.585, HR:0.710). CONCLUSION: Epidural anesthesia with parasagittal interlaminar approach provide deep motor block, high sensory level block, and hemodynamic stability. CLINICAL TRIAL REGISTRY: IRCT2017041615515N2.

Comparing the results of intradiscal ozone injection to treat different types of intervertebral disc herniation based on MSU classification.

PURPOSE: To evaluate the therapeutic efficacy of intradiscal ozone injection in reducing pain and improving patients' performance in different types of intervertebral disc herniation based on Michigan State University (MSU) classification. PATIENTS AND METHODS: Consecutive patients with low back pain and radiculopathy treated in our center with ozone chemonucleolysis from May 2017 through to January 2018 entered the study. Patients had a disc herniation classified as group 1-A, 2-A, 1-B, 2-B, 1-C, 2-C, 1-AB or 2-AB based on MSU classification in magnetic resonance imaging. In all patients entering the study the severity of pain was recorded according to the visual analog scale criteria before and one and three months after the end of treatment. Oswestry Low Back Pain Disability Index (ODI) was used to compare patients' performance before and after the treatment. RESULTS: In total 128 patients (60 females and 68 males) with mean age of 40.1 ± 10.7 entered the study. The patients were divided into eight groups based on MSU classification each including 16 patients. The reduction of pain severity and ODI score compared to baseline was statistically significant in all groups both in the first month and the third month after treatment. There was also a statistically significant difference between groups regarding the reduction of pain and ODI score indicating significantly worse treatment outcomes in groups 1-C, 2-C and 2-AB. CONCLUSION: Based on our findings it seems that MSU classification can be used in patients' selection to achieve the best treatment outcome after intradiscal ozone injection among patients with lumbar disc herniation.

A comparison of prophylactic use of meperidine, meperidine plus dexamethasone, and ketamine plus midazolam for preventing of shivering during spinal anesthesia: a randomized, double-blind, placebo-controlled study.

STUDY OBJECTIVES: The aim of this study is to compare the efficacy of combination of meperidine and dexamethasone with that of placebo, meperidine alone, and the combination of ketamine and midazolam in preventing shivering during spinal anesthesia. DESIGN: This is a prospective, placebo-controlled study. SETTING: The setting is at an operating room of a university-based teaching hospital. PATIENTS: Two hundred American Society of Anesthesiologists I and II patients undergoing orthopedic and urologic surgery under spinal anesthesia were included. INTERVENTIONS: Subarachnoid anesthesia was performed by using 15mg of 0.5% hyperbaric bupivacaine. Patients were randomly allocated to receive saline (placebo, group C), meperidine 0.4mg/kg (group Me), ketamine 0.25mg/kg plus midazolam 37.5µg/kg (group KMi), and meperidine 0.2mg/kg plus dexamethasone 0.1mg/kg (group MeD). All drugs were given as an intravenous bolus immediately after intrathecal injection. MEASUREMENTS: During surgery and stay in the recovery room, shivering score, blood pressure, and some other adverse effects were recorded at 5-minute intervals. Axillary and tympanic temperatures were recorded at 15-minute intervals during the perioperative period. MAIN RESULTS: The incidence of shivering after 30minutes of spinal anesthesia in groups C, Me, KMi, and MeD was 64%, 20%, 20%, and 4%, respectively, which was significantly higher in group C compared with other groups (P<.0001). Regarding adverse effects, there was no significant difference between groups (P≥.2). Axillary temperature significantly increased in the 15th-120th-minute interval in groups Me, KMi, and MeD (P<.0001) and in group MeD was higher than that in other groups. Core temperature decreased in the 15th-120th-minute interval in group MeD, lower than that in other groups (P<.0001). CONCLUSIONS: Prophylactic use of meperidine 0.2mg/kg plus dexamethasone 0.1mg/kg was more effective than meperidine 0.4mg/kg as a sole agent or the combination of ketamine 0.25mg/kg and midazolam 37.5µg/kg in preventing shivering resulting from spinal anesthesia.

Superficial siderosis: A rare case of ataxia and otoneurological manifestations.

Superficial siderosis (SS) is a rare disease which affects people in all ages and both sexes, but three times more in men. Pathological etiology is deposition of hemosiderin (a product of the breakdown of blood) in leptomeninges, subpial layer, ependymal surface and other parts of central nervous system (CNS) and typically leads to neurological dysfunction and progressive irreversible signs and symptoms. We present a 33-year-old man with complete deafness in left ear, partial hearing loss in right ear, gait imbalance, bilateral frontotemporal throbbing headache and anosmia resulted from superficial siderosis.

A randomized evaluation of intravenous dexamethasone versus oral acetaminophen codeine in pediatric adenotonsillectomy: emergence agitation and analgesia.

BACKGROUND: Adenotonsillectomy is the most frequently performed ambulatory surgical procedure in children. Post operative agitation and inadequate pain control, for children undergoing adenotonsillectomy, can be a challenge. The aim of this study was to assess the effect of intravenous dexamethasone and oral acetaminophen codeine on emergence agitation and pain after adenotonsillectomy in children. METHODS: One hundred and five pediatric patients (3-7 years old), scheduled to undergo adenotonsillectomy under general anesthesia, were enrolled in the study. Thirty minutes before induction, patients were randomized to three groups. Group 1 received 0.2 mg/kg of intravenous dexamethasone and 0.25 ml/kg of oral placebo syrup. Group 2 received 20 mg/kg of oral acetaminophen codeine syrup and 0.05 ml/kg of intravenous saline. Group 3 received 0.25 ml/kg of oral placebo syrup and 0.05 ml/kg of intravenous saline. Emergence agitation and postoperative pain were assessed, recorded and compared. RESULT: Agitation was less frequent in dexamethasone and acetaminophen codeine groups in comparison with placebo group, but there were not significant differences between the two groups. The pain frequencies in the three groups were not significantly different. CONCLUSION: The results of this study suggest that the administration of intravenous dexamethasone (0.2 mg/kg) and oral acetaminophen codeine (20 mg/kg) thirty minutes before anesthesia can significantly decrease the incidence and severity of agitation but does not have an effect on postoperative pain.