Effect of Ondansetron on Maternal Hypotension During Spinal Anesthesia With Ropivacaine for Cesarean Sections: A Randomized, Double-Blind Trial.

INTRODUCTION: Ondansetron, a selective 5-hydroxytryptamine 3 (5-HT3) receptor antagonist, has been proven to be effective in the prevention of spinal-induced hypotension for elective cesarean section. METHODS: A total of 138 primigravida parturients scheduled for elective cesarean section were randomly assigned to three groups. Groups ONDA4 and ONDA8, respectively, received 4 and 8 mg of ondansetron in 100 mL normal saline, before spinal anesthesia with 1.7 mL ropivacaine 0.75% and 15 mcg of fentanyl, whereas the CONTROL group received an equal volume of normal saline. Noninvasive blood pressure and heart rate were recorded upon arrival, before and after spinal injection, and thereafter every minute for a time period of 10 minutes along with total doses of phenylephrine (mcg) or ephedrine (mg). Time required for the spinal anesthesia to achieve a sensory and motor block at the T4 level and Bromage 3 scale respectively, as well as to regress to the T7 level and a Bromage 1 scale were noted. Maternal nausea/vomiting or shivering, umbilical artery pH, and neonatal Apgar score at 1 and 5 min were also recorded. RESULTS: There were no differences between groups in systolic, diastolic blood pressure, heart rate (p=0.355, p=0.550, p=0.474 respectively), doses of phenylephrine or ephedrine, (p=0.920, p=0.142 respectively), time for the block to reach T4 (p=0.889) and Bromage scale 3 (p=0.269), or to regress to T7 (p=0.273) and Bromage scale 1 (p=0.392), the incidence of nausea/vomiting (p=0.898/p=0.365), umbilical artery pH (p=0.739), neonatal Apgar score at 1 and 5 min (p=0.936 and p=0.907 respectively). CONCLUSION: Our results showed no significant effect of two different doses of ondansetron, in preventing maternal hypotension, following spinal anesthesia with ropivacaine for cesarean section.

Training Requirements in Point-of-Care Ultrasonography of the Upper Airway: A Feasibility Study.

OBJECTIVES: Point-of-care ultrasonography of the upper airway can be a useful supplement to conventional pre-anesthetic clinical evaluations. However, the reliability of such examinations is highly operator-dependent and proper training in sonoanatomy and ultrasound operational skills are required. The objective of this study aims to assess the minimum training requirements for applying a predefined upper airway scanning protocol in healthy volunteers by anesthesia trainees. METHODS: Twenty-two healthy volunteer members of the Operating Room staff participated in the study. A predefined scanning protocol that included the identification of specific structures (hyoid bone, vocal cords, thyrohyoid membrane/epiglottis/pre-epiglottic space, cricothyroid membrane, and thyroid gland), as well as the performance of specific measurements (distance from the hyoid bone to skin, anterior commissure to skin, epiglottis to skin, and thyroid isthmus to skin) was taught in a single-day training course. The trainees' competence was assessed after multiple scanning repetitions performed over a week. Mixed effects regression models were applied for the trainee-instructor differences in all ultrasound measurements. RESULTS: Cricothyroid membrane visualization had the lowest success rate (88%). Trainee-instructor differences were statistically significant for hyoid bone-to-skin (P < .001) and epiglottis-to-skin distances (P = .016). Measurement of the distance from the epiglottis to the skin required more scanning repetitions to achieve minimum deviance compared with other measurements. Ten or fewer scanning repetitions were sufficient to achieve minimum deviance for all four measurements. CONCLUSIONS: At least 10 scanning repetitions of a pre-defined upper airway scanning protocol can be used as the minimum standard for training.

Researching the Phenomenon of Poor Ovarian Responders and Management Strategies in IVF: A Narrative Review.

This narrative review aims to summarize all the latest studies published between 2015-2021 concerning the management protocols adopted for poor ovarian response (POR) cases. Patients defined as "poor responders" show minimal response to controlled ovarian hyperstimulation, although there is no standard definition for POR. Although infertility specialists are endeavoring to improve cycle outcomes in poor responders by adopting multiple management strategies, still the estimated risk of cycle cancellation is about 20%. All the studies performed during this study period were evaluated and their results were recorded. The latest published protocols to improve oocyte retrieval in poor responders include: anti-Mϋllerian hormone, clomiphene citrate, co-enzyme Q10, corifollitropin, dehydroepiandrosterone, double stimulation, Follicle Stimulation Hormone, Growth Hormone, Gonadotropin-releasing hormone agonists, letrozole, human chorionic gonadotropin, Luteinizing Hormone, progesterone and testosterone. CONCLUSION: Although many strategies have been suggested to manage POR, none has been proven superior to the others. Further large-scale randomized studies are needed to validate experimental techniques leading towards successful individualized treatment regimens.

Unusual Case of a Parasitic Extra-Uterine Leiomyoma Presenting With Lower Abdominal Pain.

Parasitic fibroids are a rare type of extrauterine benign tumors that may be spontaneous or iatrogenic in origin and often difficult to diagnose due to their various presentations. We report an unusual case of a parasitic leiomyoma in a 33-year-old nulliparous woman with remote pelvic history who presented to our institution with sudden-onset lower abdominal pain. We performed an exploratory laparotomy, which revealed a 6.3x4.6 cm mass in the space of the adnexa of the right parametrium. Histopathological examination revealed features compatible with a leiomyoma. It is clear that physicians need to assess clinical findings and imaging techniques in order to establish a correct diagnosis of parasitic myomas, even when a history of myomectomy or a laparoscopic morcellation is absent.

Currarino Syndrome: A Rare Case Report of Sepsis and Its Management.

Currarino syndrome (CS) is characterized by a triad of anomalies consisting of: a sacral bone defect, anorectal malformations and a pre-sacral mass. We present the case of an adult patient with a medical history of CS who presented with septic shock and was subjected to an emergency laparotomy due to severe abdominal distension. In this particular case, we underline the importance of immediate surgery on the patient's outcome as well as the considerable role of landiolol in controlling the heart rate with no further deterioration of blood pressure in this patient presenting with atrial fibrillation and sepsis.

Prevalence of postpartum depression and antenatal anxiety symptoms during COVID-19 pandemic: An observational prospective cohort study in Greece.

INTRODUCTION: A significant proportion of pregnant women and women in the early postpartum period suffer from mental health problems. The COVID-19 pandemic represents a unique stressor during this period and many studies across the world have shown elevated rates of postpartum depression (PPD). METHODS: In this multicenter two-phase observational prospective cohort study, we aim to assess the prevalence of anxiety prior to labor (Generalized Anxiety Disorder-7), as well as PPD at 6-8 weeks postpartum using the Edinburgh Postnatal Depression Scale (EPDS). RESULTS: Of the 330 women analyzed, 13.2% reported symptoms of depression using EPDS cut-off score ≥13. High antenatal levels of anxiety (24.8% scored ≥10 in GAD-7) were documented. A significant proportion of postpartum women reported a decrease in willingness to attend antenatal education courses (36%) and fewer antenatal visits to their obstetrician (34%) due to pandemic. Higher antenatal anxiety increased the odds of being depressed at 6-8 weeks postpartum (EPDS ≥13). CONCLUSIONS: Compared to reported prevalence of PPD from previous studies before the COVID-19 era in Greece, we did not find elevated rates during the first wave of the pandemic. High anxiety levels were observed indicating that there is a need for close monitoring in pregnancy during the pandemic and anxiety screening to identify women who need support in the pandemic era. A well-planned maternity program should be employed by all the associated care providers to maintain the proper antenatal care adjusted to the pandemic strains as well as a follow-up after labor.

The Greek Neuropathic Pain Registry: The structure and objectives of the sole NPR in Greece.

OBJECTIVES: Neuropathic pain (NP) is a complex condition that impairs the patients' quality of life. Registries are useful tools, increasingly used as they provide high-quality data. This article aims to describe the Greek Neuropathic Pain Registry (Gr.NP.R.) design, the patients' baseline data, and real-world treatment outcomes. METHODS: The Gr.NP.R. collects electronically, stores, and shares real-world clinical data from Pain and Palliative Care centers in Greece. It is a web-based application, which ensures security, simplicity, and transparency. VAS, DN4, and Pain Detect were used for pain and NP assessment. RESULTS: From 2016 to 2020, 5980 patients with chronic pain, of cancer or non-cancer origin, were examined and 2334 fulfilled the NP inclusion criteria (VAS > 5, DN4 > 4, and Pain Detect ≥ 19). At the first visit, the mean age was 64.8 years, 65.5% were female patients, and 97.9% were Greek. The mean (SD) time from pain initiation to visiting the pain clinics was 1.5 (3.8) years. Most patients were undertreated. Following the patients' registration, the national guidelines were implemented. The majority of the prescribed medications were gabapentinoids (70.2%), especially pregabalin (62.6%), and opioids (tramadol, 55.3%). At visits 1 and 6, mean VAS was 7.1 and 5, and mean DN4 score was 5.6 and 3.5, respectively. CONCLUSIONS: The Gr.NP.R. provides information on the demographics, clinical progress, treatment history, treatment responses, and the drugs of choice for patients with cancer and non-cancer NP. The collected data may help physicians plan the management of their patients.

Paracentesis of an Ovarian Cyst During Second-Trimester Pregnancy.

A common issue is that modern obstetricians are required to manage ovarian cysts during pregnancy. Most lesions are benign and will spontaneously resolve, with a few exceptions. Management practices include conservative observation or surgery. Asymptomatic women with an ovarian cyst larger than 5 cm should undergo serial ultrasounds up to 16 weeks of pregnancy and, if the mass does not regress, further management with imaging or surgery is to be considered. This article presents a case of an ovarian cyst sized 21 cm in a second-trimester pregnancy and its management. Paracentesis was performed due to persisting symptoms. The procedure was performed with no complications for the mother and no adverse effects for the fetus. The patient was discharged in good health.

Peripartum Management of Gitelman Syndrome for Vaginal Delivery: A Case Report and Review of Literature.

We describe the anesthetic management of a spontaneous vaginal delivery at 38 weeks' gestation in a 36-year-old patient with Gitelman syndrome (GS). GS is a rare autosomal recessive renal tubulopathy characterized by hypomagnesemia, hypocalciuria, and secondary aldosteronism, which results in hypokalemia and metabolic alkalosis. To minimize any increase in catecholamine levels and consequent risk of ventricular arrhythmias, a labor epidural analgesia was administered using ropivacaine and fentanyl, along with intravenous magnesium and potassium supplementation. Ropivacaine was substituted for routine bupivacaine to decrease the risk of drug-induced cardiotoxicity. In the event of a cesarean section, the anesthetic plan was to continue with top-up epidural anesthesia and in case of failure, to convert to general anesthesia using propofol and rocuronium for induction. Delivery outcome was successful and uneventful.

Acute and Chronic Pain after Cesarean Delivery under Subarachnoid Anaesthesia. Is Postoperative Analgesia Adequate? A Cohort Observational Study.

Objectives: Uncontrolled pain after cesarean delivery is associated with women's dissatisfaction and limited ability to take care of the neonate. Materials and methods:This prospective observational study included 173 women scheduled for elective cesarean delivery under spinal anesthesia. Postoperative analgesia included subcutaneous morphine 0.1 mg/kg in the post-anesthesia care unit, followed by intravenous paracetamol 1000 mg every eight hours and intravenous diclofenac 75 mg every 12 hours in the ward. Subcutaneous morphine was repeated on demand. Pain intensity at rest, pain intensity after movement and cumulative morphine consumption were recorded at 2, 4, 8, and 24 hours postoperatively. Acute pain intensity was assessed on a 100 mm visual analogue scale (VAS, score 0-100 mm). Three and six months postoperatively, women were interviewed by phone for the presence of persisting pain, abnormal sensation in the wound area and analgesic consumption. Results:Our results showed that 24 hours postoperatively the mean dose of morphine was 16±7.1 mg and VAS scores at rest and after movement were 23±17.3 mm and 40±20.9 mm, respectively. The mean VAS scores at rest remained below 31 mm at all times, while after movement they were over 40 mm at both four and eight hours postoperatively (45±23.8 mm and 43±23.2 mm, respectively). Three months postoperatively, 15% of women reported the presence of continuous or intermittent pain, 72% loss of sensation or numbness at the site of surgery and 32% occasional analgesic consumption at home. Six months after surgery, 5% of women reported pain, 44% loss of sensation or numbness in the wound area and none of them (0%) consumed analgesics due to persistent post-cesarean delivery pain. Conclusion:Based on the above-mentioned findings, we concluded that the amount of morphine consumed in the ward was low and possibly inadequate to alleviate early post-cesarean delivery pain. The overall incidence of persisting pain was low and consistent with previous studies.

Intraoperative Myomectomy during Caesarean Section.

OBJECTIVE: The aim of this article is to support intracaesarian myomectomy as an alternative method of treatment. CASE REPORT: This article presents a case of myomectomy during a caesarean section at 38+1 weeks' gestation, with a subserosal myoma on the left wall of the uterus. CONCLUSION: The postoperative period was free of complications, lending credit to the possibility that intracaesarean myomectomy can have a favourable outcome.

Impact of Altmetrics in evaluation of scientific journals, research outputs and scientists' careers: Views of editors of high impact anaesthesia, critical care and pain medicine journals.

BACKGROUND AND AIMS: Altmetrics represent the attention of an article drawn from social and mainstream media. The aim of this survey was to investigate the views of editors of high-impact journals on the Altmetric Attention Score (AAS), the number derived from an automated algorithm including a weighted count of mainstream news and social media sources. METHODS: A questionnaire related to the AAS was sent to the editors of high-impact journals, namely Anaesthesia, Critical Care Medicine (CCM) and Pain Medicine (PM). Eleven questions were related to the possible benefits and flaws of Altmetrics. RESULTS: Of the 1,381 editors asked, 126 answered. The overall answers showed that 76% of the editors were familiar with Altmetrics, 28% knew how AAS is calculated, 12% believed that AAS should replace traditional bibliometrics, 34% favoured AAS for journal ranking, 40% believed that AAS should be used to assess an article, 44% felt that AAS should be included in researchers' curriculum vitae and 22% felt that it should be considered for grants. Sixty-two percent of editors believed that AAS is vulnerable to manipulations, 60% proposed improvement and 16% abandonment. Positive answers were similar across the fields, except for journal ranking. Fifty-four percent of editors of the CCM journals favoured journal ranking using AAS versus 28% and 26% editors of anaesthesia and PM journals (P = 0.025 and P = 0.006, respectively). CONCLUSION: A high percentage of editors believed that AAS should be used to assess scholarly output and that it should be included in the researchers' curriculum vitae. Sixty percent of responders supported the improvement of AAS.

Comparison of the laparoscopic versus open surgery in patients aged over 75 years old with colorectal cancer. Short- and Mid-term outcomes.

PURPOSE: The benefit of minimally invasive surgery in colorectal cancer patients has been established, however it is not clear whether these advantages apply to older patients as well. The aim of this study was to review short- and mid-term outcomes in elderly patients, over the age of 75 years, with colorectal cancer. METHODS: This was a retrospective study of selected patients over the age of 75 who underwent laparoscopic and open surgery for colorectal cancer between February 2013 and January 2018 in a tertiary referral center. All patients were categorized in two groups: Group 1 included patients who had open procedure (OP) and Group 2 those who underwent laparoscopic procedure (LP). Demographic, clinical, short- and midterm postoperative data were collected and analyzed between the two study groups. RESULTS: A total of 78 patients were included in our cohort; 39 (50%) were operated with LP. The LP was equally safe in comparison with the OP, considering the similar postoperative complications [9 patients (34.6%) in LP and 5 patients (18.5%) in OP (p=0.224)], including anastomotic leakage in 2 patients (7.7%) in LP and 1 patient (3.7%) in OP group (p=0.61). The median postoperative hospital stay favored the laparoscopic approach (6 days in LP group and 8 days in OP group; p=0.001). The number of harvested lymph nodes were without statistically significant differences [LP group retrieved 20.0 nodes in comparison with 20.5 nodes in OP group (p= 0.816)]. The overall survival analysis showed no difference between the two approaches in 12 and 24 postoperative months (p=0.098 and 0.387, respectively).