Comparison of the effects of spinal anesthesia, paracervical block and general anesthesia on pain, nausea and vomiting, and analgesic requirements in diagnostic hysteroscopy: A non-randomized clinical trial.

Background: The aim of this study was to compare the effect of spinal anesthesia (SPA), paracervical block (PB), and general anesthesia (GA), on pain, the frequency of nausea and vomiting and analgesic requirements in diagnostic hysteroscopy. Methods: This single-center, non-randomized, parallel-group, clinical trial was conducted on 66 diagnostic hysteroscopy candidates who were selected by convenience sampling at Fatemieh Hospital, in Hamadan, Iran, in 2021. Results: The mean pain score during recovery and the need for analgesic injections was found to be significantly higher in the GA group compared to that in the SPA group (pain: 3.77 ± 2.25 vs. 0.10 ± 0.30, P < 0.001), (analgesic: 50 vs. 0%, P < 0.001) and PB group (pain: 3.77 ± 2.25 vs. 0.90 ± 1.37, P < 0.001), (analgesic 50 vs. 10%, P < 0.001), respectively. However, no statistically significant difference was observed between the mean pain score between SPA and PB groups (0.10 ± 0.30 vs. 0.90 ± 1.3, P = 0.661). In addition, there were no significant differences between groups on nausea/vomiting after operation (P = 0.382). In adjusted regression analysis (adjusting for age, weight, gravid, abortion, and cause of hysteroscopy), the odds ratio (OR) of pain score during recovery was increased in PB (OR: 4.471, 95% CI: 1.527-6.156, P = 0.018) and GA (OR: 8.406, 95% CI: 2.421-9.195, P = 0.001) groups compared with the SPA group. However, in adjusting based on times of surgery duration, anesthesia duration, recovery and return of motor function, the ORs of pain score between groups was not statistically significant. Conclusion: Despite reduced pain during recovery in patients receiving SPA, duration of anesthesia, recovery period, and return of motor function were significantly prolonged compared to those receiving PB or GA. It seems that PB with less recovery time and faster return of motor function than SPA and also mild pain during recovery compared to GA can be a good option for hysteroscopy. Clinical trial registration: http://www.irct.ir, identifier IRCT20120915010841N26.

Comparison between 10 and 12 mg doses of intrathecal hyperbaric (0.5%) bupivacaine on sensory block level after first spinal failure in cesarean section: A double-blind, randomized clinical trial.

Background: Reducing adverse effects during cesarean delivery and improving the quality of sensory blocks with appropriate doses of intrathecal hyperbaric bupivacaine can play an important role in the safe management of cesarean delivery. The aim of this study was to compare the doses of 10 and 12 mg of intrathecal hyperbaric bupivacaine 0.5% on sensory block level after first spinal failure in cesarean section (CS). Methods: In this double-blind, randomized clinical trial, 40 candidates of CS after first spinal failure with class I-II based on American Society of Anesthesiologists (ASA) were randomly assigned into two equal groups (n = 20). Group A and B received the spinal anesthesia with 10 mg and 12 mg of hyperbaric bupivacaine (0.5%), respectively. Maximum levels of sensory block, motor block quality, and vital signs were measured in two groups by 60 min after SPA. Incidence of SPA complications during surgery were also recorded. Data were analyzed by SPSS ver.21 software using repeated measures analysis of variance at 95% confidence interval (CI) level. Results: Excellent quality of sensory blocks and complete quality of motor blocks were achieved in all participants (100%). However, the mean time to onset of anesthesia (4.47 ± 0.69 vs. 3.38 ± 0.47, P < 0.001) and time to reach T10 level (60.73 ± 11.92 vs. 79.00 ± 19.21, P < 0.001) in the Group A, were significantly shorter than in the patients of Group B. The incidence of hypotension (P = 0.001), nausea/vomiting (P = 0.007) and bradycardia (P = 0.012) as well as administration of ephedrine and atropine were significantly higher in Group B compared to Group A. Conclusion: Spinal anesthesia can be safely repeated with a 10 mg of hyperbaric bupivacaine 0.5% in a caesarean section after the initial spinal failure. Clinical trial registration: [https://en.irct.ir/trial/40714], identifier [IRCT20120915010841N20].

Effectiveness of Curcumin on Outcomes of Hospitalized COVID-19 Patients: A Systematic Review of Clinical Trials.

Despite the ongoing vaccination efforts, there is still an urgent need for safe and effective treatments to help curb the debilitating effects of COVID-19 disease. This systematic review aimed to investigate the efficacy of supplemental curcumin treatment on clinical outcomes and inflammation-related biomarker profiles in COVID-19 patients. We searched PubMed, Scopus, Web of Science, EMBASE, ProQuest, and Ovid databases up to 30 June 2021 to find studies that assessed the effects of curcumin-related compounds in mild to severe COVID-19 patients. Six studies were identified which showed that curcumin supplementation led to a significant decrease in common symptoms, duration of hospitalization and deaths. In addition, all of these studies showed that the intervention led to amelioration of cytokine storm effects thought to be a driving force in severe COVID-19 cases. This was seen as a significant (p < 0.05) decrease in proinflammatory cytokines such as IL1ß and IL6, with a concomitant significant (p < 0.05) increase in anti-inflammatory cytokines, including IL-10, IL-35 and TGF-α. Taken together, these findings suggested that curcumin exerts its beneficial effects through at least partial restoration of pro-inflammatory/anti-inflammatory balance. In conclusion, curcumin supplementation may offer an efficacious and safe option for improving COVID-19 disease outcomes. We highlight the point that future clinical studies of COVID-19 disease should employ larger cohorts of patients in different clinical settings with standardized preparations of curcumin-related compounds.

A pilot study on intravenous N-Acetylcysteine treatment in patients with mild-to-moderate COVID19-associated acute respiratory distress syndrome.

BACKGROUND: We designed this single-centre clinical trial to assess the potential benefits of N-Acetylcysteine (NAC) in patients with COVID19-associated acute respiratory distress syndrome (ARDS). METHODS: Ninety-two patients with mild-to-moderate COVID19-associated ARDS were allocated to the placebo (45-cases) or NAC groups (47-cases). Besides standard-of-care treatment, the patients received either intravenous NAC at a dose of 40 mg/kg/day or the placebo for three consecutive days. The efficacy outcomes were overall mortality over 28-day, clinical status on day 28, based on the WHO Master Protocol, the proportion of patients requiring mechanical ventilation, changes in ARDS-severity (based on the PaO2/FiO2 ratio), and Sequential Organ Failure Assessment (SOFA) scores 48 and 96 h after intervention, RESULTS: No differences were found in the 28-day mortality rate between the two groups (25.5% vs. 31.1% in the NAC and placebo groups, respectively). Although the distribution of the clinical status at day 28 shifted towards better outcomes in the NAC-treated group, it did not reach a statistical significance level (p value = 0.83). Similar results were achieved in terms of the proportion of patients who required invasive ventilator support (38.3% vs. 44.4%), the number of ventilator-free days (17.4 vs. 16.6), and median time of ICU and hospital stay. Results regarding the change in PaO2/FiO2 ratio and SOFA scores also showed no significant differences between the groups. CONCLUSIONS: Our pilot study did not support the potential benefits of intravenous NAC in treating patients with COVID-19-associated ARDS. More studies are needed to determine which COVID-19 patients benefit from the NAC administration. TRIAL REGISTRATION: The trial was registered at Clinicaltrials.gov (identifier code: IRCT20120215009014N355). Registration date: 2020-05-18.

The Level of Procalcitonin in Severe COVID-19 Patients: A Systematic Review and Meta-Analysis.

There is data from individual clinical trials suggesting that procalcitonin (PCT) may be a prognostic factor in the severity of COVID-19 disease. Therefore, this systematic review and meta-analysis was performed to investigate PCT levels in severe COVID-19 patients. We searched Embase, ProQuest, MEDLINE/PubMed, Scopus, and ISI/Web of Science for studies that reported the level of PCT of patient with severe COVID-19. We included all studies regardless of design that reported the level of PCT in patients with severe COVID-19. We excluded articles not regarding COVID-19 or not reporting PCT level, studies not in severe patients, review articles, editorials or letters, expert opinions, comments, and animal studies. Nine studies were included in the analysis. The odds of having more severe COVID-19 disease was higher in subjects with elevated PCT (≥0.05 ng/mL) compared with those having low procalcitonin (<0.05 ng/mL) [n = 6, OR(95% CI) = 2.91(1.14, 7.42), p = 0.025). After estimating the mean and standard deviation values from the sample size, median, and interquartile range, a pooled effect analysis indicated higher serum PCT concentrations in patients with severe versus less severe disease [n = 6, SMD(95% CI) = 0.64(0.02, 1.26), p = 0.042]. The results of this study showed that PCT is increased in patients with severe COVID-19 infection.

Cardiac Injury in COVID-19: A Systematic Review.

Coronavirus 2019 (COVID-19) is responsible for the current pandemic which has already resulted in considerable mortality worldwide. This systematic review was conducted to summarize the results of the published articles assessing the incidence of heart diseases in patients infected with COVID-19. The electronic databases Scopus, Web of Science, Pubmed, Science Direct, and ProQuest were used to search for potentially relevant articles. Articles published from Dec 2019 to April 2020 were included. All cross-sectional, retrospective or prospective observational cohort and case-control studies were selected which reported the incidence or prevalence of myocardial injury, myocardial infarction, or cardiovascular disease in patients with confirmed COVID-19 infection. Based on the inclusion criteria, 12 articles were selected. The incidence of cardiac injury was reported in 8 articles and 8 articles focused on the cardiovascular outcomes of COVID-19 infection. The incidence of new cardiac injury was reported to be 7.2-77% in live and dead patients, respectively. The results showed that patients with cardiac injury had worse outcomes including higher mortality than those without cardiac injury. The most common cardiac injury outcomes were shock and malignant arrhythmias. The most common radiographic findings in patients with cardiac injury were multiple mottling and ground-glass opacities in the lungs (64.6%). A significant number of patients with cardiac injury required noninvasive mechanical ventilation (46.3%) or invasive mechanical ventilation (22.0%). Acute respiratory distress syndrome was seen in 58.5%, acute kidney injury in 8.5%, electrolyte disturbances in 15.9%, hypoproteinemia in 13.4%, and coagulation disorders in 7.3% of patients with cardiac injuries. In addition, survival days were negatively correlated with cardiac troponin I levels (r = -0.42, 95%, p = 0.005). The results of this review showed that myocardial injury in patients with COVID 19 has a poor prognosis. Hence, cardiac investigation and management in these patients are crucial.

Effect of the Specific Training Course for Competency in Doing Arterial Blood Gas Sampling in the Intensive Care Unit: Developing a Standardized Learning Curve according to the Procedure's Time and Socioprofessional Predictors.

BACKGROUND: Standardization of clinical practices is an essential part of continuing education of newly registered nurses in the intensive care unit (ICU). The development of educational standards based on evidence can help improve the quality of educational programs and ultimately clinical skills and practices. OBJECTIVES: The objectives of the study were to develop a standardized learning curve of arterial blood gas (ABG) sampling competency, to design a checklist for the assessment of competency, to assess the relative importance of predictors and learning patterns of competency, and to determine how many times it is essential to reach a specific level of ABG sampling competency according to the learning curve. DESIGN: A quasi-experimental, nonrandomized, single-group trial with time series design. Participants. All newly registered nurses in the ICU of a teaching hospital of Tehran University of Medical Sciences were selected from July 2016 to April 2018. Altogether, 65 nurses participated in the study; however, at the end, only nine nurses had dropped out due to shift displacement. METHODS: At first, the primary checklist was prepared to assess the nurses' ABG sampling practices and it was finalized after three sessions of the expert panel. The checklist had three domains, including presampling, during sampling, and postsampling of ABG competency. Then, 56 nurses practiced ABG sampling step by step under the supervision of three observers who controlled the processes and they filled the checklists. The endpoint was considered reaching a 95 score on the learning curve. The Poisson regression model was used in order to verify the effective factors of ABG sampling competency. The importance of variables in the prediction of practice scores had been calculated in a linear regression of R software by using the relaimpo package. RESULTS: According to the results, in order to reach a skill level of 55, 65, 75, 85, and 95, nurses, respectively, would need average ABG practice times of 6, 6, 7, 7, and 7. In the linear regression model, demographic variables predict 47.65 percent of changes related to scores in practices but the extent of prediction of these variables totally decreased till 7 practice times, and in each practice, nurses who had the higher primary skill levels gained 1 to 2 skill scores more than those with low primary skills. CONCLUSIONS: Utilization of the learning curve could be helpful in the standardization of clinical practices in nursing training and optimization of the frequency of skills training, thus improving the training quality in this field. This trial is registered with NCT02830971.

Incidence and Risk Factors of Delirium in the Intensive Care Unit: A Prospective Cohort.

PURPOSE: The purpose of this study was to determine the incidence, risk factors, and impact of delirium on outcomes in ICU patients. In addition, the scoring systems were measured consecutively to characterize how these scores changed with time in patients with and without delirium. Material and Methods. A prospective cohort study enrolling 400 consecutive patients admitted to the ICU between 2018 and 2019 due to trauma or surgery. Patients were followed up for the development of delirium over ICU days using the Confusion Assessment Method (CAM) for the ICU and Intensive Care Delirium Screening Checklist (ICDSC). Cox model logistic regression analysis was used to explore delirium risk factors. RESULTS: Delirium occurred in 108 (27%) patients during their ICU stay, and the median onset of delirium was 4 (IQR 3-4) days after admission. According to multivariate cox regression, the expected hazard for delirium was 1.523 times higher in patients who used mechanical ventilator as compared to those who did not (HR: 1.523, 95% CI: 1.197-2.388, P < 0.001). CONCLUSION: Our findings suggest that an important opportunity for improving the care of critically ill patients may be the determination of modifiable risk factors for delirium in the ICU. In addition, the scoring systems (APACHE IV, SOFA, and RASS) are useful for the prediction of delirium in critically ill patients.

Hazard Ratio of 90-Day Mortality in ICU Patients with Abdominal Injuries Compared with Head Injuries.

BACKGROUND: Despite advances in the treatment of abdominal injuries in patients with trauma, it remains a major public health problem worldwide. Evaluation of hazard ratio (HR) of 90-day mortality in intensive care unit (ICU) patients with abdominal injuries compare with head injuries in trauma patients and non-trauma surgical ICU patients. METHODS: This single-center, prospective cohort study was conducted on 400 patients admitted to the ICU between 2018 and 2019 due to trauma or surgery in Hamadan, Iran. The main outcome was mortality at 90-day after ICU admission. Cox proportional hazards models were used to determine the HR and 95% confidence interval (CI) for 90-day mortality. RESULTS: The 90-day mortality was 21.9% in abdominal injuries patients. According to multivariate Cox regression, the expected hazard mortality was 2.758 times higher in patients with abdominal injuries compared to non-trauma patients (HR: 2.758, 95% CI: 1.077-7.063, P=0.034). About more than 50% of all deaths in the abdominal and head trauma groups occurred within 20 days after admission. Mean time to death was 27.85±20.1, 30.27±18.22 and 31.43±26.24 days for abdominal-trauma, surgical-ICU, and head-trauma groups, respectively. CONCLUSION: Difficulty in accurate diagnosis due to the complex physiological variability of abdominal trauma, less obvious clinical symptoms in blunt abdominal injuries, multi-organ dysfunction in abdominal injuries, failure to provide timely acute care, as well as different treatment methods all account for the high 90-day mortality rate in abdominal-trauma patients. Therefore, these patients need a multidisciplinary team to care for them both in the ICU and afterwards in the general ward.

Topical Almond Oil for Prevention of Pressure Injuries: A Single-Blinded Comparison Study.

PURPOSE: The aim of our study was to determine the effect of topical almond oil for prevention of pressure injuries. DESIGN: Single-blind randomized clinical trial. SAMPLE AND SETTING: Patients admitted to an intensive care unit in Besat Hospital, Hamadan, Iran, were invited to participate in the trial. Data were collected over an 8-month period. METHODS: A convenience sample of 108 patients, using a permuted block randomization method was assigned to 3 equal groups that received the intervention almond oil, placebo (liquid paraffin), or control (standard of care). Data included demographic information, Braden Scale score, and National Pressure Ulcer Advisory Panel-European Pressure Ulcer Advisory Panel (NPUAP-EPUAP) pressure injury staging system classification score. The intervention and placebo groups received daily application of 6.5 cc of topical almond oil or paraffin to the sacrum, heels, and shoulders for 7 consecutive days. The skin was evaluated for pressure injuries by an expert nurse who was blinded to groups. Chi-square test, analysis of variance, and regression analyses were used to evaluate relationships within and between groups for study variables, incidence of pressure injuries, and duration of time of onset of pressure injuries. P values less than .05 were deemed statistically significant. RESULTS: The incidence of pressure injury in the almond oil group (n = 2; 5.6%) was lower than that in the placebo (n = 5; 13.9%, P = .189) or control groups (n = 9; 25.1%, P = .024). The incidence of pressure injuries in the control group was 6.8 and 2.12 (P = .227) times higher than that in the almond and placebo groups, respectively. The onset day of a pressure injury occurred 5.4 days after initiation of the protocol in the almond oil group compared to 4.22 days in the control group (P = .023) and 5 days in the placebo group (P = .196). CONCLUSION: The topical application of almond oil was associated with a lower incidence of pressure injuries and that developed later during the study compared to participants who received paraffin or standard of care only. Further study is recommended to advance this work in populations at risk for pressure injury.

Association between passive smoking and cardiovascular disease: A systematic review and meta-analysis.

BACKGROUND: The association between passive smoking (PS) and cardiovascular disease (CVD) has not yet been fully clarified. OBJECTIVE: This meta-analysis was performed to evaluate the association between PS and the incidence of CVDs and mortality due to CVD. METHODS: PubMed/Medicine, Science Direct, Scopus, Web of Knowledge, and ProQuest were searched to identify observational studies that met the inclusion criteria without time, language, age, gender, ethnicity, and design restrictions until July 30, 2018. In case-control studies, relative risk (RR) with 95% confidence interval (CI) was calculated for the relationship between PS and CVD incidence. Also, in cohort studies, hazard ratio (HR) with 95% CI was calculated for the relationship between PS and CVD mortality. RESULTS: Eighteen studies (10 cohort and 8 case-control studies) were included with 10,672 participants (2,542 cases and 8,130 controls) in case-control studies and 2,313,935 participants in cohort studies. This meta-analysis in case-control studies revealed that the PS could increase the risk of CVD incidence by 28% (adjusted RR = 1.28 [95% CI 1.09, 1.50]), where the highest risk was associated with those who were exposed to second-hand smoke at home and at work (Adjusted RR = 1.41 [95% CI 0.73, 2.70]). Also, the meta-analysis in cohort studies indicated that PS was associated with a 12% higher increase in the risk of CVD mortality (Adjusted HR = 1.12 [95% CI 1.06, 1.20]) with the highest risk of mortality being observed for those who were exposed to second-hand smoking at home, work, and public places (Adjusted HR = 1.26 [95% CI 1.13, 1.40]). CONCLUSIONS: PS is significantly associated with an increased risk of incidence and mortality of CVD.

The role of ventilation mode using a laryngeal mask airway during gynecological laparoscopy on lung mechanics, hemodynamic response and blood gas analysis.

BACKGROUND: There are two methods for ventilation in gynecological laparoscopy: volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV). OBJECTIVE: To compare the lung mechanics, hemodynamic response and arterial blood gas analysis and gas exchange of two modes of VCV and PCV using laryngeal mask airway (LMA) at different time intervals. MATERIALS AND METHODS: Sixty infertile women referred for diagnostic laparoscopy, based on ventilation mode, were randomly divided into two groups of VCV (tidal volume: 10 ml/kg) and PCV. In the PCV group, ventilation was initiated with a peak airway pressure (tidal volume: 10 ml/kg, upper limit: 35 cm H2O). In both groups, the arterial blood samples were taken in several time intervals (5, 10 and 15 min after LMA insertion) for blood gas evaluation. Also the lung mechanics parameters were continuously monitored and were recorded at different time intervals. RESULTS: There were no significant differences for patient's age, weight, height and BMI in two groups. The peak and plateau airway pressure were significantly higher in VCV group compared to PCV group 5 and 10 min after insertion of LMA. PaO2 was significantly higher after 10 and 15 min in VCV group compared to PCV group (p=0.005 and p=0.03, respectively). PaCO2 showed significant increase after 5 min in PCV group, but the differences were not significant after 10 and 15 min in two groups. The end tidal CO2 showed significant increase after 10 and 15 min in VCV compared to PCV group. CONCLUSION: Both VCV and PCV seem to be suitable for gynecological laparoscopy. However, airway pressures are significantly lower in PCV compared to VCV.