Peri-anal infiltration versus caudal block for multimodal analgesia in paediatric patients with Hirschsprung's disease undergoing transanal endorectal pull-through procedure: A randomised trial.

Background and Aims: Transanal endorectal pull-through (TERPT) is a standard procedure for managing paediatric patients with Hirschsprung's disease (HD). This study aimed to evaluate peri-anal infiltration versus caudal block as a part of multimodal analgesia for paediatric patients with HD undergoing the TERPT procedure. Methods: This randomised trial included 60 patients of both genders, aged 6 to 18 months who underwent the TERPT procedure under general anaesthesia. The patients were randomly assigned into two groups to receive either peri-anal infiltration or caudal block with 1 ml/kg bupivacaine 0.25% and dexmedetomidine 1 µg/kg in 0.5 ml normal saline. The primary outcome was the time to the first rescue analgesia. The secondary outcomes were the total consumption, the frequency of nalbuphine administration as rescue analgesia within 24 hours and the level of postoperative sedation. Results: The time to first rescue analgesia was significantly shorter in the peri-anal infiltration group versus the caudal block group (median [interquartile range] 10 [7.5-12.5] h versus 16 [13.5-18.5] h, respectively, P = 0.008). The frequency of administration and the total dose of nalbuphine was significantly higher in the peri-anal infiltration group (P = 0.003 and 0.013, respectively). The sedation score was significantly higher in the caudal block group postoperatively. Conclusion: For paediatric patients undergoing the TERPT procedure, peri-anal infiltration was less effective than caudal block in terms of the duration of postoperative analgesia. However, both techniques were comparable during the first 6 hours postoperatively.

Managing adult patients with infectious diseases in emergency departments: international ID-IRI study.

We aimed to explore factors for optimizing antimicrobial treatment in emergency departments. A single-day point prevalence survey was conducted on January 18, 2020, in 53 referral/tertiary hospitals in 22 countries. 1957 (17%) of 11557 patients presenting to EDs had infections. The mean qSOFA score was 0.37 ± 0.74. Sepsis (qSOFA ≥ 2) was recorded in 218 (11.1%) patients. The mean qSOFA score was significantly higher in low-middle (1.48 ± 0.963) compared to upper-middle (0.17 ± 0.482) and high-income (0.36 ± 0.714) countries (P < 0.001). Eight (3.7%) patients with sepsis were treated as outpatients. The most common diagnoses were upper-respiratory (n = 877, 43.3%), lower-respiratory (n = 316, 16.1%), and lower-urinary (n = 201, 10.3%) infections. 1085 (55.4%) patients received antibiotics. The most-commonly used antibiotics were beta-lactam (BL) and BL inhibitors (n = 307, 15.7%), third-generation cephalosporins (n = 251, 12.8%), and quinolones (n = 204, 10.5%). Irrational antibiotic use and inappropriate hospitalization decisions seemed possible. Patients were more septic in countries with limited resources. Hence, a better organizational scheme is required.

Effects of Pulsed Versus Conventional Versus Combined Radiofrequency for the Treatment of Trigeminal Neuralgia: A Prospective Study.

BACKGROUND: During radiofrequency bursts of energy are applied to nervous tissue. The clinical advantages of this treatment remain unclear. OBJECTIVES: We compared the effectiveness and pain relief for idiopathic trigeminal neuralgia (TN) after continuous radiofrequency (CRF), pulsed radiofrequency (PRF), and combined continuous and pulsed radiofrequency (CCPRF) treatment of the Gasserian ganglion (GG). STUDY DESIGN: We conducted a randomized prospective study. Forty-three patients were included. Eleven patients were treated with PRF at 42°C for 10 minutes (PRF group), 12 patients received CRF for 270 seconds at 75 °C (CRF group), and 20 patients received PRF for 10 minutes at 42°C followed by CRF for at 60°C for 270 seconds (CCPRF group). SETTING: Assuit University Hospital, Pain and Neurology outpatient clinics. METHODS: Patients were assessed for pain, satisfaction, and consumption of analgesics at baseline and 7 days, one month, 6 months, 12 months, and 24 months after the procedure. The incidence of complications, anesthesia dolorosa, weakness of muscles of mastication, numbness, and technical complications, was evaluated after the procedure. RESULTS: Excellent pain relief was achieved after 6, 12, and 24 months, respectively in 95%, 85%, and 70% of patients with CCPRF; 75%, 75%, and reduced to 50% among patients with CRF; and 82%, reduced to 9.1%, and 0% of patients with PRF. No complications were recorded in 75% of patients in the CCPRF and PRF groups. There was one case of anesthesia dolorosa, 4 cases of masseter muscle weakness, and 5 cases of severe numbness recorded in the CRF group. LIMITATION: There was a small number of patients in each group. CONCLUSION: The best results were observed in the CCPRF group, followed by the CRF group, and then the PRF group.Key words: Pulsed, continuous, radiofrequency, trigeminal neuralgia, Gasserian ganglion.

A New Look on Adding Dexamethasone as an Adjuvant to Caudal Bupivacaine; Efficacy on Postoperative Pain and Vomiting in Pediatric Patients.

BACKGROUND: Controlling postoperative pain and vomiting in children remains a great challenge. OBJECTIVE: Study the efficacy of adding dexamethasone to caudal bupivacaine on postoperative analgesia and vomiting. STUDY DESIGN: Prospective, randomized double blind controlled clinical trial. SETTING: Assiut University Hospital. PATIENTS: Ninety children ASA I-II, undergoing lower orthopedic surgeries. METHODS: Patients were randomly allocated into 3 equal groups. All received caudal block after induction of anesthesia with 0.5 mL/kg of 0.25% bupivacaine in addition to 5 mL intravenous (IV) normal saline in the control group, IV 0.5 mg/kg dexamethasone in IV dexamethasone group and lastly 0.1 mg/kg dexamethasone in the caudal dexamethasone group. Postoperative pain scores and rescue analgesic consumption were recorded. Blood glucose, postoperative vomiting, and other side effects were evaluated up to 24 hours after extubation. RESULTS: The time of first analgesia and the number of patients requiring rescue analgesics were significantly decreased with intravenous or caudal dexamethasone. No significant increase in postoperative blood glucose levels were observed. A significant increase in B- Endorphin level at 3 and 24 hours postoperative was found in both dexamethasone groups when compared with the preoperative baseline value. The incidence of postoperative vomiting was significantly decreased in both dexamethasone groups in comparison with the control group. No other side effects were detected. LIMITATIONS: Measurement of serum cortisol. CONCLUSION: Analgesic and antiemetic effects of dexamethasone as an adjunct to caudal block with bupivacaine (0.25%) 0.5 mL/kg is similar whether administered intravenously 0.5 mg/kg or caudally 0.1 mg/kg.

Role of CCR5Δ32 mutation in protecting patients with Schistosoma mansoni infection against hepatitis C viral infection or progression.

Schistosomiasis has been incriminated in the significant increase in hepatitis C virus (HCV) infections, although the association has not been adequately explained. We hypothesized that the CCR5Δ32 mutation may be involved in the high prevalence of HCV with schistosomiasis. The aim was to explore the association between the CCR5Δ32 mutation in schistosomiasis patients and protection against HCV infection or progression. We compared 220 schistosomiasis patients (S group) and 190 patients with HCV and schistosomiasis (HCV/S group) for the presence of the CCR5Δ32 mutation. Clinical, biochemical, and radiological assessments were done. HCV infection was diagnosed with anti-HCV antibodies and a recombinant HCV antigen-based rapid immunochromatographic test, and confirmed by HCV reverse transcriptase PCR. HCV genotyping was done by reverse hybridization line probe assay. Schistosomiasis was diagnosed by FAST-ELISA and indirect hemagglutination for Schistosoma mansoni antibodies, and stool analysis for ova. Polymorphisms of the CCR5 receptor gene were assessed by PCR-based genotyping of the 32-bp deletion at the CCR5 locus in whole blood. Of HCV/S patients, 91.6 vs. 91.8 % of S patients had CCR5 WT/WT homozygosity (nonmutants). Heterozygous and homozygous CCR5Δ32 mutation patterns (CCR5Δ32/WT and CCR5Δ32/Δ32) were distributed similarly in the HCV/S and S groups (6.8 vs. 7.2 % and 0.53 vs. 0.90 %, respectively; p > 0.05, OR = 0.97). Genotype 4 was the predominant viral genotype (93 % of cases). No differences were observed in CCR5 gene patterns according to viral genotype, viral RNA count, or ALT level. However, CCR5Δ32 mutants (homozygous and heterozygous) had a lower rate of severe hepatic fibrosis vs. nonmutants (27 vs. 42 %, p = 0.101, OR = 0.51). Moreover, 53.4 % of CCR5Δ32/WT mutants showed spontaneous viral clearance vs. 26.2 % of nonmutants (p = 0.000, OR = 4.1). In conclusion, no association was detected between the CCR5Δ32 mutation and HCV disease susceptibility in schistosomiasis patients. However, patients with the CCR5Δ32 mutation and HCV infection were less prone to severe hepatic fibrosis and more likely to have spontaneous viral clearance than patients with the nonmutant genotype.