¬Transcranial direct current stimulation improves sleep quality in patients with insomnia after traumatic brain injury.

INTRODUCTION: Insomnia is a serious problem after traumatic brain injury (TBI) and partially improves via sleeping pills. We investigated the efficacy of transcranial direct current stimulation (tDCS) with a focus on the role of age and gender. MATERIALS AND METHODS: In a randomized double-blind clinical trial, 60 eligible TBI-induced insomnia patients were assigned to real and sham tDCS groups and were treated for three weeks. Sham but not real tDCS took sleeping pills for the first three weeks of the study and then used the placebo until the end of the study. The placebo was used by the real-tDCS group throughout the study. Sleep quality and insomnia severity were respectively evaluated by Pittsburg Sleep Quality Index (PSQI) and Insomnia Severity Index (ISI) at three time points. RESULTS: Real tDCS group reported lower mean ISI and PSQI scores at 3 weeks post treatment onset and maintained this decline for six weeks post treatment onset (P < 0.001). In younger participants and those identified as men, the treatment-induced attenuation of the mean PSQI score was reported higher and more lasting in real than sham tDCS groups. CONCLUSION: Gender and age-specific tDCS protocols may be warranted to optimize the therapeutic effect of tDCS.

The association of 25 (OH) D3 serum level with ischemic cerebrovascular accident risk, severity and outcome in Iranian population.

OBJECTIVES: The role of combined presence of vitamin D deficiency and other risk factors of stroke in ischemic cerebrovascular accident (CVA) development in Iranian adults has been unclear, so far. The association of vitamin D status at admission with ischemic CVA severity and outcome in this community is not yet well elucidated. This study aimed to clarify these ambiguities. METHODS: In a cross-sectional study 104 hospitalized ischemic CVA patients and 104 healthy controls participated. The serum level of 25 (OH) D3 and baseline biochemical parameters were measured in ischemic patients within the first 24 h of admission, as well as healthy controls. The severity of CVA and clinical outcome were assessed using National Institutes Health Stroke Scale and Modified Rankin Scale, respectively. Data were analyzed using the Chi-square test, independent t-test, and multiple logistic regression. RESULTS: There was a significant difference between patients and controls regarding the presence of vitamin D3 deficiency, hypertension, smoking, and baseline level of LDL and FBS. Vitamin D3 deficiency boosted the risk of ischemic in males and those having family history of CVA. A low serum level of 25 (OH) D3 was associated with more severity and poor outcome of CVA. The CVA severity, vitamin D3 deficiency, and hypertension were predictors of poor outcome. CONCLUSIONS: The study highlights the increased risk of ischemia in Iranians by cooccurrence of vitamin D3 deficiency and other risk factors of CVA. Clinical significance of vitamin D3 deficiency control may be suggested in those at risk of CVA and functional poor outcomes.

Electroconvulsive therapy-related cognitive impairment and choice of anesthesia: the tipping point.

INTRODUCTION: Electroconvulsive therapy (ECT) is among the most effective treatments of several life-threatening psychiatric disorder. Despite effective therapy, ECT-induced seizure could cause several adverse effects including cognitive disorders and memory impairment. Drugs such as thiopental, which have been prescribed for anesthesia required for ECT, are known as drugs with cognitive effects. This pilot randomized clinical trial tried to assess the feasibility of using a lower dose of thiopental in combination with remifentanil instead of a higher challenging dose of a single drug with cognitive side effects such as thiopental. We evaluated post-ECT cognitive impairment in patients who received remifentanil-thiopental compared with thiopental-placebo group. PATIENTS AND METHODS: One hundred twenty patients with psychiatric disorders between the ages of 18 and 60 years were enrolled. The patients were randomized into 2 groups who received either thiopental sodium (4 mg/kg) and remifentanil (1 µg/kg) or thiopental sodium (3 mg/kg, placebo). The psychiatric patients were examined using mini-mental state examination in terms of the cognitive deficits before ECT as well as 5 and 24 hours after ECT. Statistical analyses were done using Statistical Package for the Social Sciences version 16. Unpaired t test, χ2 test, and analysis of variance were used to determine the association of variables. RESULTS: All the patients completed the trial. There were no reports of adverse effects. In terms of depth of anesthesia measured by bispectral index, no significant difference was observed. Regarding mini-mental state examination scores, the difference was not statistically significant. CONCLUSIONS: Depth of anesthesia was similar between the groups.

Efficacy of intranasal ketamine and midazolam for pediatric sedation: A double-blind, randomized clinical trial.

BACKGROUND: Pediatric patients feel significant fear and anxiety when undergoing surgeries. The ideal drug and its administration route have not been found yet. The aim of this study was to compare the efficacy and safety of intranasal (IN) ketamine and midazolam as premedication in children. METHODS: We studied 71 eligible pediatric patients undergoing elective urologic surgeries, aged 2 to 6 years. The degree of sedation and separation scores was compared between the two groups. Additionally, hemodynamic parameters, before premedication, after induction of anesthesia, and during surgery were documented and compared between two groups. Postoperatively, any side effect was recorded as well. RESULTS: Finally, the data from 71 children were analyzed. Recovery time was significantly longer in group K (ketamine) compared to group M (midazolam); 27.86±4.42 vs 38.19± 6.67 minutes respectively (P=0.01). No significant difference was observed in terms of sedation score between two groups of K & M; 3.29±0.78 vs 3 ±0.71 respectively (P=0.17), and not regarding separation score; 2.51±0.61 & 2.31±0.52 respectively (P=0.01). Vital signs were kept within the physiological limits in both groups with no marked fluctuations. CONCLUSION: To produce sedation in young children, both midazolam and ketamine were effective and safe by IN route.

Electroconvulsive Therapy-Related Anxiety: A Survey in an Academic Hospital in the North of Iran.

BACKGROUND: Electroconvulsive therapy (ECT) is a medical treatment most commonly used in the most severe psychiatric diseases; however due to unreal anxiety, it is not widely accepted by patients and their families. OBJECTIVES: The present study aimed to investigate the main causes of ECT-related anxiety (ERA) in an academic hospital in the north of Iran. METHODS: In this study, the participants were hospitalized psychiatric patients with proper communication skills. A 12-item questionnaire encompassing four sections (namely ECT side-effects, procedure factors, medical team communication, and familial, social, and economic factors) were filled out by a responsible psychiatric resident through a face-to-face interview. The participants' demographic information, including gender, age, psychiatry disorder, level of education, and history of ECT, were also recorded. RESULTS: In this study, 353 cases were analyzed, among whom 329 patients (93.2%) reported at least one item for ERA, and 143 patients (85.6 %) had the history of ECT. All the participants (100%) had no experience in this regard (P = 0.0001). The most common cause of ERA was ECT-related side effects (70.7%) such as memory impairment (60.4%), disablement (24.9%), and death (14.7%) followed by procedure factors (27.2%), general anesthesia (GA) (73.2 %), and electric current (26.8 %). A significant relationship was observed between gender and the history of ECT with the patients' anxiety reasons (P = 0.0001); however, the other variables, including age (P = 0.72), type of disease (P = 0.144), and the level of education (P = 0.012) had no impact on the results. CONCLUSIONS: In this paper, the main causes of ERA were general anesthesia, memory impairment, and electric current. Obviously, a multidisciplinary approach is required to help these patients to handle their fear and anxiety successfully.

Effectiveness of spinal anesthesia combined with obturator nerve blockade in preventing adductor muscle contraction during transurethral resection of bladder tumor.

OBJECTIVE: To determine whether spinal anesthesia combined with obturator nerve blockade (SOB) is effective in preventing obturator nerve stimulation, jerking and bladder perforation during transurethral resection of bladder tumor (TURBT). MATERIAL AND METHODS: In this clinical trial, 30 patients were randomly divided into two groups: spinal anesthesia (SA) and SOB. In SA group, 2.5 cc of 0.5% bupivacaine was injected intrathecally using a 25-gauge spinal needle and in SOB after spinal anesthesia, a classic obturator nerve blockade was performed by using nerve stimulation technique. RESULTS: There was a statistically significant difference between jerking in both groups (p=0.006). During the TURBT, surgeon satisfaction was significantly higher in SOB group compared to SA group (p=0.006). There was no significant correlation between sex, patient age and location of bladder tumor between the groups (p>0.05). CONCLUSION: Obturator nerve blockade by using 15 cc lidocaine 1% is effective in preventing adductor muscle spasms during TURBT.

Lidocaine as an Induction Agent for Intracranial Aneurysm Surgery: A Case Series.

INTRODUCTION: Induction of anaesthesia and its associated spikes in blood pressure can cause rupture of an aneurysm during intracranial surgery. Lidocaine can reportedly provide hemodynamic stability when applied before endotracheal intubation. Rapid injection of large doses of lidocaine can cause unconsciousness. CASE PRESENTATION: Lidocaine was applied as the sole anaesthetic for induction and maintenance during aneurysm surgery in four patients undergoing intracranial aneurysm surgery. Blood pressure alteration after induction and during surgery, bleeding, brain laxity, intracranial pressure and extubation time were acceptable. CONCLUSIONS: Although propofol remains a standard agent for such types of surgeries, lidocaine proved equally effective and coupled with its low cost, minimal side effects and omission of other hypnotic agents was a plausible induction agent and a maintenance drug in the selected cases.

Granulomatous mastitis: Presentations, diagnosis, treatment and outcome in 206 patients from the north of Iran.

OBJECTIVES: The aim of this study is to review the clinical presentations, diagnostic methods, treatment options and outcome of patients with Granulomatous Mastitis (GM). MATERIAL AND METHODS: In a retrospective study, we indentified 206 women who met the required histological criteria of (GM). RESULTS: Thirty eight (18%) of these women had taken antibiotics before their diagnosis of GM. The most common symptoms in remaining 168 symptomatic women were breast mass. The most common ultrasonographic and mammographic finding was large irregular hypo echoic masses and an irregular mass, respectively. As a diagnostic tool, fine needle aspiration (FNA) was performed in 33 (19.5%) and core needle biopsy with or without ultrasound was done in 92 (55%) of patients while successful rate was 13 (39%) and 87 (94.5%), respectively. The remaining 43 (25.5%) of women underwent surgical excisions. Only 6 (3%) patients improved with antibiotics and 200 (97%) of women who did not respond to antibiotics, were treated with steroid and among them 144 (72%) improved. Treatment with combination of methotrexate and steroid was done in 56 (28%) patients and was effective in 40 (71%) of them. Sixteen (8%) patients were treated with a combination of steroid and bromocriptine which was effective in 5 (31%) patients. A wide surgical excision was performed in 11 (5.5%) patients who were nonresponsive to steroid and methotrexate and bromocriptine therapy. CONCLUSION: Our findings indicate that clinical and imaging findings of (GM) have overlapped with malignancy. The best diagnostic method is core needle biopsy. Corticosteroids are in the first line of treatment with a good therapeutic response.

Effect of gabapentin on morphine consumption and pain after surgical debridement of burn wounds: a double-blind randomized clinical trial study.

BACKGROUND: Burn pain is recognized as being maximal during therapeutic procedures, and wound debridement can be more painful than the burn injury itself. Uncontrolled acute burn pain increases the stress response and the incidence of chronic pain and associated depression. Although opiates are excellent analgesics, they do not effectively prevent central sensitization to pain. The anticonvulsant gabapentin has been proven effective for treating neuropathic pain in large placebo-controlled clinical trials. Experimental and clinical studies have demonstrated antihyperalgesic effects in models with central neuronal sensitization. It has been suggested that central neuronal sensitization may play an important role in postoperative pain. OBJECTIVES: The aim of this study was to investigate the effect of gabapentin on morphine consumption and postoperative pain in burn patients undergoing resection of burn wounds. PATIENTS AND METHODS: In a randomized, double-blind, placebo-controlled study, 50 burn patients received a single oral dose of gabapentin (1200mg) or placebo 2h before surgery. Anesthesia was induced with propofol and fentanyl and maintained by infusingpropofol, remifentanil, and 50% N2O in O2. All patients received patient-controlled analgesia with morphine at doses of 2.5 mg bolus and a lock-out time of 10 min for 24h before the operation. Pain was assessed on a visual analog scale (VAS) at rest and during movement at 1,4,8,12,16,20, and 24 h before the operation. Heart rate, oxygen saturation, mean arterial blood pressure, respiratory rate, sedation score, and morphine consumption were studied. RESULTS: All the enrolled patients were able to complete the study; therefore, data from 50 patients wereanalyzed. The VAS scores at rest andduring movement at 1,4,8,12,16,20, and 24 h after the operation were significantly lower in the gabapentin group than in the placebo group (P < 0.05). Morphine consumption was significantly lessr in the gabapentin group than in the placebo group (P < 0.05). Sedation scores were similar in the 2 groups at all measured times. There were no differences in adverse effects between the groups. CONCLUSIONS: A single oral dose of 1200mg gabapentin resulted in a substantial reduction in postoperative morphine consumption and pain scores after surgical debridement in burn patients.

Epidemiology of burn injuries at a newly established burn care center in rasht.

BACKGROUND: Advances in the care of burn injuries have resulted from the efforts of regional patient-based specialist teams at burn care centers. OBJECTIVES: We conducted this study to assess the four-year epidemiology of burn injuries in Rasht, Iran. MATERIALS AND METHODS: In this cross-sectional study, medical records of 2274 burn patients, treated at Velayat hospital from January 2007 to December 2010 in Rasht, Iran, were assessed. Age, sex, level of education, occupation, severity and degree of burn, burn surface area, burn cause and outcome of patients were evaluated. RESULTS: In our study the overall mortality rate was 8.7%; 65.7% of patients were men and 34.3% were women. Mean age of patients was 31.47 ± 22.67 years. Mean Total Burn Surface Area (TBSA) was 15.24 ± 18.4. Lowest TBSA was 0.5% and highest TBSA was 100%. Significant associations were observed between age (P = 0.0001), place of residence (P = 0.004), level of education (P = 0.0001), unemployment (P = 0.0001), marital status (P = 0.021), causes of burn (P = 0.0001), TBSA (P = 0.0001) and mortality rate. In our study, no significant difference was observed between age and sex (P = 0.071). CONCLUSIONS: Due to high prevalence of burn injuries in Iran, increasing the level of awareness of the society as well as adhering to safety procedures both at home and workplace is recommended via implementing effective national safety policies.