Prospective case-control study on pain intensity after the use of promethazine in patients undergoing videothoracoscopy.

Objective: Effective and secure pain management following video-assisted thoracoscopic surgery (VATS) is crucial for rapid postoperative recovery. This study evaluated analgesic and sedative effects of sufentanil and promethazine in patient-controlled intravenous analgesia (PCIA) post-thoracic surgery, along with potential adverse reactions. Methods: In this prospective, randomized, controlled, double-blind, clinical study, 60 patients (American Society of Anesthesiologists status I-III) undergoing VATS were enrolled. The patients were randomized into experimental (Group P) or control (Group C) groups. PCIA was administered post-general anesthesia using a double-blind method. Group P received sufentanil (3 µg/kg) + promethazine (1 mg/kg) + 0.9% sodium chloride solution (100 mL total), while Group C received sufentanil (3 µg/kg) + 0.9% sodium chloride solution (100 mL total). PCIA settings included a 1-mL bolus and 15-min locking time. The primary outcomes were the visual analog scale (VAS) at rest and during coughing and sedation (Ramsay) scores at 6, 12, 24, and 48 h. The secondary outcomes were rescue drug use rate, hemodynamic parameters (mean arterial pressure and heart rate), percutaneous oxygen saturation, respiratory rate, and occurrence of adverse reactions. Results: Group P exhibited lower resting and coughing VAS scores at 6, 12, 24, and 48 h, plus decreased incidence of nausea and vomiting within 48 h post-surgery compared with Group C (p < 0.05). No significant differences were observed in pruritus, sedation (Ramsay) scores, mean arterial pressure, heart rate, oxygen saturation, or respiratory rate between the two groups (p > 0.05). Discussion: The combination of sufentanil and promethazine for postoperative intravenous analgesia could effectively reduce adverse effects such as nausea and vomiting, contributing to postoperative pain relief.

Pain and immune function in patients undergoing gastric cancer surgery following stellate ganglion block with total intravenous anesthesia.

BACKGROUND: Stellate ganglion block is a commonly used sympathetic nerve block technique that restores the balance of the sympathetic and vagal nervous systems of the body and inhibits sympathetic nerve activity. AIM: To analyze the effect of a stellate ganglion block combined with total diploma intravenous anesthesia on postoperative pain and immune function in patients undergoing laparoscopic radical gastric cancer (GC) surgery to provide a reference basis for the formulation of anesthesia protocols for radical GC surgery. METHODS: This study included 112 patients who underwent laparoscopic radical surgery for GC between January 2022 and March 2024. There was no restriction on sex. The patient grouping method used was a digital random table method, and the number of cases in each group was 56. The control group was administered total intravenous anesthesia, and the observation group compounded the stellate ganglion block according to the total intravenous anesthesia protocol. Postoperative hemodynamics, pain levels, and immune indices were compared between the groups. RESULTS: The heart rate and mean arterial pressure in the observation group after intubation were lower than those in the control group (P < 0.05). Pain levels were compared between the two groups at 2 hours, 12 hours, 24 hours, and 48 hours after surgery (P > 0.05). The number of CD3+, CD4+, and CD4+/CD8+ cells at the end of surgery was higher in the observation group than in the control group, and the number of CD8+ cells was lower in the observation group than in the control group (P < 0.05). There were no significant differences between the two groups in terms of propofol dosage, awakening time, extubation time, or postoperative adverse reactions (P > 0.05). CONCLUSION: The application of a stellate ganglion block combined with total intravenous anesthesia had no significant effect on postoperative pain levels in patients undergoing laparoscopic radical GC surgery. However, it can safely reduce the effect of surgery on the immune function of patients and is worth applying in clinical practice.

Timing of intravenous immunoglobulin treatment and outcome in Guillain-Barré syndrome: Is time nerve?

INTRODUCTION/AIMS: Despite treatment, a considerable proportion of patients with Guillain-Barré syndrome (GBS) experience poor recovery, highlighting a therapeutic need. There is a lack of evidence that treatment timing affects recovery. This study aims to investigate the effects of intravenous immunoglobulin (IVIg) timing on disability and speed of recovery in GBS. METHODS: We performed a retrospective study of 136 IVIg-treated GBS patients admitted to two Korean centers between 2010 and 2021. We analyzed the effect of time to IVIg on the GBS disability scale (GBS-DS) and the degree of improvement from nadir (∆GBS-DS) at 1, 3, 6, and 12 months, as well as the time to regain the ability to walk or run unaided. Time to IVIg was treated either as a continuous variable or categorized into 1-week intervals to explore critical time windows. Known prognostic factors, the modified Erasmus GBS Outcome Scores on admission and pre-treatment serum albumin levels were adjusted as covariates. RESULTS: Shorter time to IVIg was independently associated with better GBS-DS, greater ∆GBS-DS, and shorter time to walk or run unaided at all time points. The therapeutic effect of IVIg was notably diminished when administered beyond the first 2 weeks of onset. DISCUSSION: Our study highlights the timing of IVIg as a modifiable prognostic factor in GBS. The earlier IVIg is initiated, the better the outcomes, with the ideal time window being within the first 2 weeks. These findings underscore the importance of prompt diagnosis and early intervention to optimize recovery in GBS patients.

Cytokine landscape in hospitalized children with multisystem inflammatory syndrome.

The etiology of multisystem inflammatory syndrome in children (MIS-C), frequently observed following COVID-19 infection, remains elusive. This study unveils insights derived from cytokine analysis in the sera of MIS-C patients, both before and after the administration of intravenous immunoglobulin (IVIG) and glucocorticosteroids (GCS). In this study, we employed a comprehensive 45-cytokine profile encompassing a spectrum of widely recognized proinflammatory and antiinflammatory cytokines, as well as growth factors, along with other soluble mediators. The analysis delineates three principal cytokine-concentration patterns evident in the patients' sera. Pattern no.1 predominantly features proinflammatory cytokines (IL-6, IL-15, IL-1ra, granulocyte-macrophage colony-stimulating factor (GM-CSF), tumor necrosis factor α (TNFα), C-X-C motif chemokine ligand 10 (CXCL10/ IP-10), and IL-10) exhibiting elevated concentrations upon admission, swiftly normalizing post-hospital treatment. Pattern no. 2 includes cytokines (IL-17 A, IL-33, IFNγ, vascular endothelial growth factor (VEGF), and programmed death ligand (PD-L1)) with moderately elevated levels at admission, persisting over 7-10 days of hospitalization despite the treatment. Pattern no. 3 comprises cytokines which concentrations escalated after 7-10 days of hospitalization and therapy, including IL-1α, IL-1ß, IL-2, IL-13, platelet-derived growth factor AA/BB (PDGF AA/BB). The observed in cytokine profile of MIS-C patients showed a transition from acute inflammation to sustaining inflammation which turned into induction of humoral memory mechanisms and various defense mechanisms, contributing to recovery.

Intravenous Tranexamic Acid for Control of Bleeding during External Dacryocystorhinostomy under General Anesthesia: A Randomized Clinical Trial.

Purpose: To investigate the effect of intravenous tranexamic acid administered prior to external dacryocystorhinostomy (DCR) surgery to decrease intraoperative bleeding under general anesthesia. Methods: This was a double-blinded randomized placebo-controlled trial. A total of 70 patients (35 intervention and 35 control) with nasolacrimal duct obstruction (NLDO) who were selected for DCR surgery between September 2021 and September 2022 were included. After clinical examinations and laboratory tests, patients were randomly classified into intervention and control groups. The intervention group received 10 mg/kg intravenous tranexamic acid to a maximum dose of 1 gr 30 minutes before the surgery. Controls received normal saline solution as a placebo. The amount of intraoperative bleeding and surgical time were compared between the two groups. Results: The intervention group included 21 men (60%) and 14 women (40%), while the control group included 19 men (54.3%) and 16 women (45.7%). The mean ages of the participants were 55.46 ± 10.8 years and 58.06 ± 11.28 years in the intervention and control groups, respectively. A significant difference was observed between the two groups in the surgical time analysis (control group: 37.74 ± 9.52 minutes vs intervention: 26.03 ± 10.5 minutes; P < 0.001). Additionally, there was a significant difference in the bleeding volume between the intervention (70.66 ± 48.19 ml) and control (47.74 ± 60 ml) groups (P < 0.001). Conclusion: Intravenous tranexamic acid administration before the DCR procedure can successfully control bleeding during the surgery.

Treatment Challenges and Controversies in the Management of Critically Ill Diabetic Ketoacidosis (DKA) Patients in Intensive Care Units.

This review discusses the challenges and controversies in the treatment of diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). Key areas include the selection of intravenous (IV) fluids, insulin therapy, strategies for preventing and monitoring cerebral edema (CE) by managing hyperglycemia overcorrection, electrolyte replacement, timing of nutrition, use of IV sodium bicarbonate, and airway management in critically ill DKA patients. Isotonic normal saline remains the standard for initial fluid resuscitation, though balanced solutions have been shown to have faster DKA resolution. Current guidelines recommend using continuous IV insulin for DKA management after fluid status has been restored potassium levels have been achieved and subcutaneous (SQ) insulin is started only after the resolution of metabolic acidosis. In comparison, the British guidelines recommend using SQ insulin glargine along with continuous regular IV insulin, which has shown faster DKA resolution and shorter hospital stays compared to continuous IV insulin alone. Although rare, rapid overcorrection of hyperglycemia with fluids and insulin can lead to CE, seizures, and death. Clinicians should be aware of risk factors and preventive strategies for CE. DKA frequently involves multiple electrolyte abnormalities, such as hypokalemia, hypophosphatemia, and hypomagnesemia and regular monitoring is essential for DKA management. Early initiation of oral nutrition has been shown to reduce intensive care unit and overall hospital length of stay. For impending respiratory failure, Bilevel positive airway pressure is not recommended due to aspiration risks. Instead, intubation and mechanical ventilation, with monitoring and management of acid-base and fluid status, are recommended. The use of sodium bicarbonate is discouraged due to the potential for worsening ketosis, hypokalemia, and risk of CE. However, IV sodium bicarbonate can be considered if the serum pH falls below 6.9, or when serum pH is less than 7.2 and/or serum bicarbonate levels are below 10 mEq/L, pre-and post-intubation, to prevent metabolic acidosis and hemodynamic collapse that occurs from apnea during intubation. Managing DKA and HHS in critically ill patients includes using balanced IV fluid solutions to restore volume status, followed by continuous IV insulin, early use of SQ glargine insulin, electrolyte replacement, and monitoring, CE preventive strategies by avoiding hyperglycemia overcorrection, early nutritional support, and appropriate airway management.

Optimizing Microfluidic Channel Design with High-Performance Materials for Safe Neonatal Drug Delivery.

INTRODUCTION: Designing the microfluidic channel for neonatal drug delivery requires proper considerations to enhance the efficiency and safety of drug substances when used in neonates. Thus, this research aims to evaluate high-performance materials and optimize the channel design by modeling and simulation using COMSOL multiphysics in order to deliver an optimum flow rate between 0. 3 and 1 mL/hr. METHOD: Some of the materials used in the study included PDMS, glass, COC, PMMA, PC, TPE, and hydrogels, and the evaluation criterion involved biocompatibility, mechanical properties, chemical resistance, and ease of fabrication. The simulation was carried out in the COMSOL multiphysics platform and demonstrated the fog fluid behavior in different channel geometries, including laminar flow and turbulence. The study then used systematic changes in design parameters with the aim of establishing the best implementation models that can improve the efficiency and reliability of the drug delivery system. The comparison was based mostly on each material and its appropriateness in microfluidic usage, primarily in neonatal drug delivery. The biocompatibility of the developed materials was verified using the literature analysis and adherence to the ISO 10993 standard, thus providing safety for the use of neonatal devices. Tensile strength was included to check the strength of each material to withstand its operation conditions. Chemical resistance was also tested in order to determine the compatibility of the materials with various drugs, and the possibility of fabrication was also taken into consideration to identify appropriate materials that could be used in the rapid manufacturing of the product. RESULTS: The results we obtained show that PDMS, due to its flexibility and simplicity in simulation coupled with more efficient channel designs which have been extracted from COMSOL, present a feasible solution to neonatal drug delivery. CONCLUSION: The present comparative study serves as a guide on the choice of materials and design of microfluidic devices to help achieve safer and enhanced drug delivery systems suitable for the delicate reception of fragile neonates.

Effect of coastal and island geographic environments on patients with acute ischemic stroke in southeastern China.

OBJECTIVE: To analyze the geographic variation in characteristics and treatment processes of patients with acute ischemic stroke (AIS) in coastal, island, and inland regions. METHODS: We conducted a retrospective, cross-sectional analysis of data from patients with AIS in southeastern China. We collected demographic and clinical information, including the time from stroke onset to treatment for those receiving reperfusion therapy, using a time-tracking table. RESULTS: Among 8069 patients with AIS, 26.6% received reperfusion therapy, with a higher proportion undergoing endovascular therapy in maritime hospitals than in inland hospitals (14.2% vs. 6.7%). Maritime hospitals had a higher prevalence of atrial fibrillation (15.1% vs. 11.9%) and cardioembolism (17.2% vs. 13.6%) than inland hospitals. Patients in maritime hospitals had shorter in-hospital processing times than those in inland hospitals (39 vs. 46 minutes). Island hospitals showed different patterns, with a shorter time from stroke onset to emergency room arrival (80 vs. 120 minutes) but a longer in-hospital process time (51 vs. 36 minutes), than coastline hospitals. CONCLUSIONS: Our study suggests geographic variation in AIS characteristics and treatment processes across southeastern China, emphasizing the need for region-specific strategies. These findings are essential for tailoring public health policies and guidelines to improve stroke outcomes in various regions.

Use of tissue adhesive for neonatal intravenous access devices: A scoping review.

Neonates often require vascular access devices for medication or fluid therapy, but a third of devices fail before treatment completion or end with a complication. For adults and children, securing these devices with tissue adhesive (TA) increases the dwell and reduces complications. However, there is a lack of evidence for the neonatal population. This scoping review aimed to assess the evidence of TA for vascular access devices in neonates. The Arksey and O'Malley's (2005) framework was used. The inclusion criteria covered studies published from 2007 (when TA was first reported for use in vascular access devices) to June 2024, available in English, Portuguese, and Spanish, across six databases. Two independent reviewers assessed the studies using Covidence software, with a third reviewer resolving conflicts. Quality assessment was performed using the Mixed Methods Appraisal Tool. From 981 identified studies, 12 were included. Most studies (n = 5, 41.7%) enrolled between 100 and 500 neonates with vascular access devices. Publications originated from four regions and were observational studies (n = 6, 50%), quasi-experimental (n = 3, 25%), and case series (n = 2, 16.7%) with one randomized controlled trial (8.3%) focusing on umbilical venous catheters (UVC). The most common TA composition used was a combination of n-butyl- and 2-octyl- cyanoacrylate (n = 4, 33.3%). The amount of TA applied varied across studies, and often TA was part of a bundle (n = 7, 58.3%). Most studies applied TA to central venous access devices (n = 10, 83.3%) and 2 (16.7%) in peripheral devices. Although there was variation in device failure, the studies generally indicated a reduction in complications such as dislodgment (central catheter: 11.3% [peripherally inserted central catheter {PICC}] to 24.6% [UVC] in non-TA group vs 0.7% [PICC] to 7.7% [UVC] in TA group), device-associated bloodstream infections (central: 7.7% [UVC] and incidence of 2.76/1000 catheter days [PICC] in non-TA group vs 3.1% [UVC] and incidence of 0.99/1000 catheter day [PICC] in TA group), and phlebitis (13% in non-TA group vs 3% in TA-group), as well as increased dwell time in peripheral catheters. Most studies included both term and preterm neonates but did not differentiate between them in their analyses. Skin assessment, life of first dressing, and follow-up of catheters and patients were not reported in most studies. CONCLUSION: TA may reduce complications in vascular access devices, but the evidence in neonates is limited and varied. Many studies include TA as part of bundle, making it difficult to isolate its effects. Additionally, the current evidence lacks robustness due to the design limitations of the studies. Future research should focus on randomized controlled trials to evaluate TA's effectiveness and safety in preventing device failures and complications in neonates, considering different subgroups, to ensure the safety of TA in these nuanced populations. WHAT IS KNOWN: • Research in adults and pediatrics provides evidence supporting the use of tissue adhesive (TA) for vascular access devices, showing a positive impact in reducing failures and complications. • The use of TA in neonates needs to be carefully considered due to their unique characteristics. WHAT IS NEW: • There is a gap in the literature on the use of TA for securing vascular access devices in neonates, particularly regarding its safety and effectiveness in preventing failures and complications. • Further studies are needed to provide robust evidence verifying the effectiveness and safety of TA in this population.

Lung ultrasound assessment of atelectasis following different anesthesia induction techniques in pediatric patients: a propensity score-matched, observational study.

INTRODUCTION: Atelectasis is a well-documented complication in pediatric patients undergoing general anesthesia. Its incidence varies significantly based on surgical procedures and anesthesia techniques. Inhalation induction, commonly used to avoid the discomfort of venipuncture, is suspected to cause higher rates of respiratory complications, including atelectasis, compared to intravenous induction. This study aimed to evaluate the impact of inhalation versus intravenous anesthesia induction on atelectasis formation in pediatric patients, as assessed by lung ultrasound (LUS). METHODS: This propensity score-matched observational study was conducted at a tertiary pediatric hospital in Milan, Italy. Inclusion criteria were children ≤ 18 years undergoing elective surgery with general anesthesia. Patients were divided into inhalation and intravenous induction groups. LUS was performed before and after anesthesia induction to assess lung aeration. The primary endpoint was the global LUS score post-induction, with secondary endpoints including the incidence and distribution of atelectasis. RESULTS: Of the 326 patients included, 65% underwent inhalation induction and 35% intravenous induction. The global LUS score was significantly higher in the inhalation group (12.0 vs. 4.0, p < 0.001). After propensity score matching (for age, presence of upper respiratory tract infection, duration of induction, and PEEP levels at induction), average treatment effect (ATE) of mask induction was 5.89 (95% CI, 3.21-8.58; p < 0.001) point on LUS global score and a coefficient of 0.35 (OR 1.41) for atelectasis. DISCUSSION: Inhalation induction is associated with a higher incidence of atelectasis in pediatric patients also when we adjusted for clinically relevant covariates. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT06069414.

Neonatal Sepsis: Aetiology, Pathophysiology, Diagnostic Advances and Management Strategies.

Neonatal sepsis, a bloodstream infection in the first 28 days of life, is a leading cause of morbidity and mortality among infants in both developing and developed countries. Additionally, sepsis is distinguished in neonates by unique pathophysiological and presentational factors relating to its development in immature neonatal immune systems. This review focuses on the current understanding of the mechanics and implications of neonatal sepsis, providing a comprehensive overview of the epidemiology, aetiology, pathophysiology, major risk factors, signs and symptoms and recent consensus on the diagnosis and management of both early-onset and late-onset neonatal sepsis. It also includes a discussion on novel biomarkers and upcoming treatment strategies for the condition as well as the potential of COVID-19 infection to progress to sepsis in infants.

Efficacy and Safety of Intravenous Diltiazem Versus Metoprolol in the Management of Atrial Fibrillation with Rapid Ventricular Response in the Emergency Department: A Comprehensive Umbrella Review of Systematic Reviews and Meta-analyses.

Atrial fibrillation (AF) is the most common cardiac arrhythmia in the United States, affecting 2.7-6.1 million people. AF can cause symptoms, but when it triggers a rapid ventricular response (RVR), most patients suffer from decompensation. Therefore, we performed an umbrella review of systematic reviews and meta-analyses comparing intravenous (IV) metoprolol and diltiazem to identify discrepancies, fill in knowledge gaps, and develop standardized decision-making guidelines for physicians to manage AF with RVR. A comprehensive search was conducted in PubMed, the Cochrane Library, and Scopus to identify studies for this umbrella review. The overall certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation method, while the quality of the included reviews was evaluated using AMSTAR 2, the Cochrane Collaboration tool, and the Newcastle-Ottawa scale. This study comprehensively analyzed four meta-analyses covering 11 randomized controlled trials and 19 observational studies. The analysis showed that IV diltiazem treatment was significantly more successful in rate control for AF with rapid ventricular response (RVR) than IV metoprolol (risk ratio [RR], 1.30; 95% confidence interval [CI], 1.09-1.56; I 2 = 0%; P = .003). IV diltiazem also led to a significantly greater reduction in ventricular rate (mean difference, -14.55; 95% CI, -16.93 to -12.16; I 2 = 72%; P < .00001), particularly at 10 min. The analysis also revealed a significantly increased risk of hypotension associated with treatment with IV diltiazem (RR, 1.43; 95% CI, 1.14-1.79; I 2 = 0%; P = .002). In conclusion, IV diltiazem therapy achieved better rate control and ventricular rate decrease than metoprolol therapy in AF with RVR. Future clinical trials should compare calcium channel blockers and ß-blockers for heart rate control efficacy and safety, considering adverse events.

Comparative Analysis of Intravenous Immunoglobulins (IVIg) vs Plasmapheresis (PLEX) in the Management of Myasthenic Crisis.

Myasthenia gravis (MG) is an autoimmune disorder affecting postsynaptic membranes in neuromuscular junctions, presenting as fatigable muscle weakness. Myasthenic crisis is a life-threatening complication characterized by severe respiratory insufficiency necessitating invasive or noninvasive ventilation. Two rapid therapies used to manage myasthenic crises are intravenous immunoglobulins (IVIg) and plasmapheresis (PLEX). Their comparative effectiveness remains equivocal. Our article examines evidence from several clinical trials and observational studies, in order to determine the superiority of one treatment over the other. Multiple factors can complicate the choices between two treatments. We concluded that the choice between PLEX and IVIg is multifaceted, guided by individual patient characteristics, institutional resources, and clinician preference. While PLEX can be considered as first-line for rapid clinical outcomes, it is hard to pick one treatment over the other, and careful consideration of comorbidities and resource availability is crucial. Our article highlights the need for further research to establish definitive guidelines and enhance patient outcomes in myasthenic crisis patients.

Which Intravenous Isotonic Fluid Offers Better Outcomes for Patients with a Brain Injury?

Administering intravenous fluids is a common therapy for critically ill patients. Isotonic crystalloid solutions, such as saline or balanced solutions, are frequently used for intravenous fluid therapy. The choice between saline or a balanced crystalloid has been a significant question in critical care medicine. Recent large randomized controlled trials (RCTs) have investigated whether balanced crystalloids yield better outcomes in general or specific critical care populations, and many of them have confirmed this hypothesis. Although the broad eligibility criteria of these RCTs suggest applicability to neurocritical care patients, it is important to discuss whether using balanced crystalloids, as opposed to saline, would benefit patients who primarily have neurological disorders or diseases. This review considers the relevance of this question, weighs the pros and cons of the two fluid types, examines available data, and anticipates results from ongoing RCTs to guide clinicians in selecting the optimal fluid for patients with brain injury.

Peripheral intravenous therapy infiltration and extravasation (PIVIE) risks in 11 006 paediatric surgery inpatients in China: a retrospective observational study.

OBJECTIVE: To determine the risk factors associated with peripheral intravenous therapy infiltration and extravasation (PIVIE) in paediatric surgery inpatients. METHODS: This retrospective observational study was conducted at a tertiary general hospital in Sichuan, China. Logistic regression was employed to identify independent risk factors predictive of PIVIE. Kaplan-Meier survival analysis was undertaken to determine the relationship between the occurrence of PIVIE and the duration of that event (survival time). RESULTS: This study included 11 006 paediatric surgery inpatients and 19 771 peripheral intravenous catheters (PIVCs). The incidence of PIVIE was 16.93% (3347 of 19 771). The following were significant predictors of PIVIE: sex (odds ratio [OR] 0.834; 95% confidence interval [CI] 0.772, 0.900); age (OR 0.945; 95% CI, 0.934, 0.956); disease classification (OR 0.962, 95% CI 0.950, 0.976); puncture site (OR 1.061; 95% CI 1.044, 1.078); and indwelling time (OR 1.257; 95% CI 1.215, 1.300). CONCLUSIONS: Sex, age, type of disease, puncture site and indwelling time were risk factors for PIVIE. The puncture site should be effectively assessed and accurately selected. Informed judgements should be based on the child's sex, age and medical condition, so that the appropriate preventive measures to minimize the risk of PIVIE can be implemented.

The impact of intravenous versus submucosal dexamethasone on short-term patient response: A randomized controlled trial.

BACKGROUND: The purpose of this randomized, cross-over trial was to determine if a preoperative dose of dexamethasone administered submucosally is as effective as intravenous (IV) dexamethasone in reducing pain, swelling, and analgesic consumption after periodontal flap surgery. METHODS: Thirty-nine patients planned for two similar flap surgeries under IV sedation were included. Before the first surgery, patients were randomized to receive 8 mg of IV or submucosal dexamethasone. Via the alternate route, 0.9% sodium chloride (placebo) was administered. Dexamethasone was administered via the opposite route during the second surgery. A standardized regimen of 600 mg ibuprofen and 325 mg acetaminophen was used to manage postoperative pain. Patients recorded pain and swelling levels on a 21-point numerical rating scale (NRS-21) and a four-point visual rating scale (VRS-4), as well as analgesic usage via a phone application at 12, 24, 48, 72, and 168 h postoperatively. RESULTS: While NRS-21 and VRS-4 data suggest a trend toward decreased pain and swelling with IV administration, there were no significant differences in analgesic usage or pain at any time and a significant difference in swelling only at 72 h in favor of IV administration (p = 0.047). CONCLUSIONS: There was no significant difference in pain or analgesic usage following periodontal flap surgery comparing IV and submucosal dexamethasone. A statistically significant difference in swelling between groups at 72 h is likely of limited clinical relevance. Submucosal dexamethasone is an effective way to mitigate pain following periodontal surgery, particularly when IV access for sedation is not required.

Successful Treatment of Refractory Cutaneous Manifestations of Dermatomyositis With Intravenous Immunoglobulin: A Case Report.

Dermatomyositis is a connective tissue disorder with dermatological and extracutaneous manifestations. Multiple treatment modalities have been used to treat dermatomyositis, and there have been cases with resistant disease refractory to conventional therapies. Corticosteroids are usually used to achieve remission, and from then, steroid-sparing agents such as azathioprine are used to maintain remission. However, in this report, we present a case of dermatomyositis with refractory cutaneous manifestation. The patient's muscular pain had subsided with the use of corticosteroids, but the dermatological lesions did not respond to multiple treatment modalities, responding only to intravenous immunoglobulins (IVIG).

Atypical Infective Endocarditis Presenting With Euthermia and Right Lower Quadrant Abdominal Pain.

Infectious endocarditis (IE) is an infection of the heart's endothelial lining, often stemming from an underlying bacteremia. High-risk populations include intravenous substance users, individuals with structural heart disease, those with intravascular devices, and those with prosthetic heart valves. In the emergency department, IE is often suspected in patients with a fever, known risk factors, and unexplained systemic symptoms due to systemic thromboemboli. We present a case of atypical IE occurring in an afebrile 38-year-old woman with a remote history of intravenous drug use. The patient's clinical presentation was characterized by systemic inflammatory response syndrome, stabbing-like right lower quadrant abdominal pain radiating to the right lower back and the rest of the abdomen, malaise, fatigue, and an absence of a fever. A CT scan revealed a right renal embolism and an infarcted right kidney, prompting a bedside point-of-care echocardiogram that showed a large vegetation on the mitral valve, suggestive of IE with systemic thromboembolic disease. The patient received broad-spectrum antibiotics and antipyretics and ultimately underwent mitral valve replacement, with good recovery upon discharge. Patients with IE are at high risk for life-threatening complications due to tissue damage from systemic microemboli and sepsis. It is important to identify IE's atypical presentation and risk factors for early recognition, prompt point-of-care echocardiogram, and initiation of treatment. This is particularly important in the era of increased opioid use among our patient population which could potentially conceal an underlying fever.

Intravenous lidocaine infusion therapy and intraoperative neurophysiological monitoring in adolescents undergoing idiopathic scoliosis correction: A retrospective study.

BACKGROUND: Posterior spinal instrumentation and fusion is an established surgical procedure for the correction of adolescent idiopathic scoliosis. Intraoperative neurophysiological monitoring is standard practice for this procedure. Anesthetic agents can have different, but significant, effects on neurophysiological monitoring outcomes. AIM: To determine if intravenous lidocaine infusion therapy has an impact on the intraoperative neurophysiological monitoring during posterior spinal instrumentation and fusion for adolescent idiopathic scoliosis. METHODS: Following ethical approval, we conducted a retrospective review of charts and the archived intraoperative neurophysiological data of adolescents undergoing posterior spinal instrumentation and fusion for adolescent idiopathic scoliosis. Intraoperative neurophysiological monitoring data included the amplitude of motor evoked potentials and the amplitude and latency of somatosensory evoked potentials. A cohort who received intraoperative lidocaine infusion were compared to those who did not. RESULTS: Eighty-one patients were included in this analysis, who had surgery between February 4, 2016 and April 22, 2021: 39 had intraoperative intravenous lidocaine infusion and 42 did not. Based on hourly snapshot data, there was no evidence that lidocaine infusion had a detrimental effect on the measured change from baseline for MEP amplitudes in either lower (mean difference 41.9; 95% confidence interval -304.5 to 388.3; p = .182) or upper limbs (MD -279.0; 95% CI -562.5 to 4.4; p = .054). There was also no evidence of any effect on the measured change from baseline for SSEP amplitudes in either lower (MD 16.4; 95% CI -17.7 to 50.5; p = .345) or upper limbs (MD -2.4; 95% CI -14.5 to 9.8; p = .701). Finally, there was no evidence of a difference in time to first reportable neurophysiological event (hazard ratio 1.13; 95% CI 0.61 to 2.09; p = .680). CONCLUSIONS: Data from these two cohorts provide preliminary evidence that intravenous lidocaine infusion has no negative impact on intraoperative neurophysiological monitoring during PSIF for adolescent idiopathic scoliosis.

The use of lipid emulsion therapy in severe hydroxychloroquine overdose - a narrative review of case reports.

INTRODUCTION: Hydroxychloroquine has cardiac and cerebral sodium channel- and human ether-à-go-go-related gene (HERG) potassium channel-blocking effects. This causes depolarization delays, resulting in cardiovascular toxicity with potentially fatal consequences. Despite several supportive care options, hydroxychloroquine poisoning remains difficult to treat. Its high lipid solubility suggests that lipid emulsion therapy might be beneficial; however, no clear evidence regarding its efficacy is available. The aim of this review is to assess the evidence, the outcomes, and adverse events regarding the use of intravascular lipid emulsion therapy as a treatment for hydroxychloroquine poisoning. METHODS: We conducted a systematic search in PubMed, Embase.com, Cochrane Central Register of Controlled Trials (CENTRAL)/Wiley, Web of Science Core Collection/Clarivate Analytics, and Scopus/Scopus.com from inception until 1 November 2023. We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria encompassed original observational or interventional studies, case series and case reports describing patients receiving lipid emulsion therapy for hydroxychloroquine toxicity. We extracted clinical data and performed a quality assessment of the included cases. We present the results as a narrative synthesis. RESULTS: Of 157 identified articles, 16 case reports met the inclusion criteria, reporting on 18 patients. Lipid emulsion therapy was always associated with additional treatments, and detailed information on the circumstances regarding the administration of intravenous lipid emulsion and its presumed effect was often lacking. Fifteen of 18 patients survived to hospital discharge. Some reports described clear and almost immediate clinical improvement after intravenous lipid emulsion administration. No clear adverse effects were reported. DISCUSSION: A limitation is the reliance on case reports, which varied in the degree of reported details. The administration of multiple therapeutic drugs in most cases made it difficult to attribute survival primarily to lipid emulsion. Publication bias may favour cases with successful outcomes. CONCLUSION: Among published case reports, most patients who received lipid emulsion for treatment of hydroxychloroquine poisoning survived. The risk of bias, the small number of reports, and the lack of systematic reporting of both favourable and adverse effects limit any conclusions about the effectiveness of lipid emulsion for hydroxychloroquine poisoning.