The delaying of elective surgeries after COVID-19 infection decreases postoperative complications.

BACKGROUND: Huge controversy surrounds delaying elective surgeries after COVID-19 infection. Although two studies evaluated the issue, several gaps still exist. METHODS: A propensity score matched retrospective single center cohort design was used to evaluate the optimum time of delaying elective surgeries after COVID-19 infection and the validity of the current ASA guidelines in this regard. The exposure of interest was a previous COVID-19 infection. The primary composite included the incidence of death, unplanned Intensive Care Unit admission or postoperative mechanical ventilation. The secondary composite included the occurrence of pneumonia, acute respiratory distress, or venous thromboembolic. RESULTS: The total number of patients was 774, half of them had a history of COVID-19 infection. The analysis revealed that delaying surgeries for 4 weeks was associated with significant reduction in primary composite (AOR = 0.02; 95%CI: 0.00-0.33) and the length of hospital stay (B = 3.05; 95%CI: 0.41-5.70). Furthermore, before implementing the ASA guidelines in our hospital, a significant higher risk for the primary composite (AOR = 15.15; 95%CI: 1.84-124.44; P-value = 0.011) was observed compared to after applying it. CONCLUSION: Our study showed that the optimum period of delaying elective surgery after COVID-19 infection is four weeks, with no further benefits from waiting for longer times. This finding provide further support to the current ASA guidelines about delaying elective surgeries. Further large-scale prospective studies are needed to give more evidence-based support to the appropriateness of the 4-week waiting time for elective surgeries after COVID-19 infection and to investigate the effect of type of surgery on the required delay.

Global series: Complex regional pain syndrome: abstracts from the International Association for the Study of Pain complex regional pain syndrome SIG virtual symposia 2021.

The aim of this IASP complex regional pain syndrome (CRPS) SIG Global Series 2021 was to bring together clinicians including those from developing countries to better understand the clinical presentation of complex regional pain syndrome in countries with less well-published patient populations. The purpose was to learn from each other about the range of treatments, successful outcomes, and challenges experienced. These meeting proceedings comprise abstracts from nine countries that span 4 continents and are summaries of online presentations delivered by speakers representing these countries over the course of 2 symposia. The symposia were attended by a global audience of approximately 360 people. Patients with CRPS were described and treated by clinicians from countries across Asia (Pakistan, Jordan, South Korea, Taiwan, and Singapore), South America (Brazil and Peru), Africa (South Africa), and Europe (Norway). This reflects that CRPS exists across borders, ethnicities, and cultures. These proceedings provide a broader perspective within the international pain community about how we can better understand and treat CRPS across the globe.

Combining Stellate ganglion block and intravenous regional anesthesia to treat complex regional pain syndrome: A 19-years' experience in a tertiary center.

OBJECTIVES: To study reduction in pain score after treatment with intravenous regional anesthesia (IVRA) and Stellate ganglion block (SGB) combination on complex regional pain syndrome (CPRS) patients and to quantify patients' satisfaction with treatment and occurrence of complications. METHODS: This is a record-based retrospective review carried out in 2020, targeting patients treated in the University of Jordan Hospital, Amman, Jordan, over the years 2002-2020. RESULTS: Among 99 patients, a significant drop in pain scores occurred in 88% of the patients' sample. Gender, age, type of CRPS, and duration of symptoms didn't affect statistical results. An average of 8.6 sessions needed to achieve 50% drop in pain score, and 2-3 sessions for first clinical improvement. Patients with previous application of plaster of Paris had increased success rates. CONCLUSION: We find it practical, inexpensive, safe, and straightforward to combine SGB with IVRA for CRPS patients.

Dose-Dependent Effect of Melatonin on BAT Thermogenesis in Zücker Diabetic Fatty Rat: Future Clinical Implications for Obesity.

Experimental data have revealed that melatonin at high doses reduced obesity and improved metabolic outcomes in experimental models of obesity, mainly by enhancing brown adipose tissue (BAT) thermogenesis. A potential dose-response relationship has yet to be performed to translate these promising findings into potential clinical therapy. This study aimed to assess the effects of different doses of melatonin on interscapular BAT (iBAT) thermogenic capacity in Zücker diabetic fatty (ZDF) rats. At 6 wk of age, male ZDF rats were divided into four groups (n = 4 per group): control and those treated with different doses of melatonin (0.1, 1, and 10 mg/kg of body weight) in their drinking water for 6 wk. Body weight (BW) was significantly decreased at doses of 1 and 10 mg/kg of melatonin, but not at 0.1 mg/kg compared with the control, with a similar rate of BW decrease being reached at the dose of 1 mg/kg (by ~11%) and 10 mg/kg (by ~12%). This effect was associated with a dose-dependent increase in the thermal response to the baseline condition or acute cold challenge in the interscapular area measurable by infrared thermography, with the highest thermal response being recorded at the 10 mg/kg dose. Upon histology, melatonin treatment markedly restored the typical brownish appearance of the tissue and promoted a shift in size distribution toward smaller adipocytes in a dose-dependent fashion, with the most pronounced brownish phenotype being observed at 10 mg/kg of melatonin. As a hallmark of thermogenesis, the protein level of uncoupled protein 1 (UCP1) from immunofluorescence and Western blot analysis increased significantly and dose-dependently at all three doses of melatonin, reaching the highest level at the dose of 10 mg/kg. Likewise, all three doses of melatonin modulated iBAT mitochondrial dynamics by increasing protein expression of the optic atrophy protein type 1 (OPA1) fusion marker and decreasing that of the dynamin-related protein1 (DRP1) fission marker, again dose-dependently, with the highest and lowest expression levels, respectively, being reached at the 10 mg/kg dose. These findings highlight for the first time the relevance of the dose-dependency of melatonin toward BW control and BAT thermogenic activation, which may have potential therapeutic implications for the treatment of obesity. To clinically apply the potential therapeutic of melatonin for obesity, we consider that the effective animal doses that should be extrapolated to obese individuals may be within the dose range of 1 to 10 mg/kg.

Preoperative Anxiety among Adult Patients Undergoing Elective Surgeries at a Tertiary Teaching Hospital: A Cross-Sectional Study during the Era of COVID-19 Vaccination.

Anxiety in the perioperative period has significant impact on both the flow of surgery and the post-operative recovery process. The aim of this cross-sectional study is to determine the prevalence of preoperative anxiety among adult patients undergoing elective surgical procedures at a tertiary teaching hospital and the effect of COVID-19 and COVID-19 vaccines on preoperative anxiety. We used the Amsterdam Preoperative Anxiety and Information Scale (APAIS) to assess patients' anxiety toward surgery and their need for more information. Patients with APAIS about anesthesia and surgery (APAIS-A-T) total score <10 were considered as the low preoperative anxiety group, while patients with APAIS-A-T ≥11 were considered as the high preoperative anxiety group. The overall APAIS-A-T score of the 794 included patients was 8.5 ± 4.5. The mean APAIS-A-T score was 7.0 ± 3.8 among males and 9.6 ± 4.6 among female patients (p < 0.001). The APAIS-A-T score for those who had previously underwent surgery under anesthesia was 8.3 ± 4.4, compared to 9.5 ± 4.8 for those who had not (p = 0.002). No significant difference was found between those with a previous history of COVID-19 and those without (p = 0.105), nor between those who were vaccinated and those who were not (p = 0.550). Sixty-four (26.8%) highly anxious patients were afraid of becoming infected with COVID-19 during their hospital stay (p = 0.009). This fear of COVID-19 in-hospital transmission made 19 (7.9%) highly anxious patients and 36 (4.5%) of the total sample hesitant to undergo this surgery (p = 0.002). In conclusion, this study demonstrated that 30.1% of patients had high preoperative anxiety, with fear of pain after surgery being the most common factor related to anxiety on the day of surgery. Controlling the spread of COVID-19 can play a crucial role in decreasing preoperative anxiety during this pandemic.

Perioperative Cardiac Arrest: A 3-Year Prospective Study from a Tertiary Care University Hospital.

PURPOSE: Perioperative cardiac arrests (CAs) are a rare but catastrophic perioperative complication. Much about incidence, risk factors, and outcomes of such events are still unknown. This study investigated anesthesia-related CAs at a tertiary teaching hospital. METHODS: CA incidence within 24 hours of anesthesia administration was prospectively identified from May 1, 2016 to April 31, 2019. Each CA was matched by four other cases without CA receiving anesthesia on the same date and under similar operating conditions. The CA cases were reviewed and assigned to one of three groups: anesthesia-related, anesthesia-contributing, and anesthesia not related. RESULTS: A total of 58,303 patients underwent 73,557 procedures under anesthesia during the study period. In sum, 27 CAs were reported for incidence of 3.7 per 10,000 anesthesia administrations (95% CI 2.3-5.1). Eleven CA were anesthesia-related for incidence of 1.5 per 10,000 anesthesia administrations. Four CA cases were anesthesia-contributing for incidence of 0.5 per 10,000 anesthesia administrations, while 53% of the anesthesia-related and -contributing CAs were due to respiratory problems. American Society of Anesthesiologists (ASA) physical status score, cardiovascular surgery, emergency surgery, and increased duration of surgery were significantly correlated with CA incidents when compared to the control group. ASA physical status score is an independent risk factor of the occurrence of perioperative CA (OR 7.6, 95% CI 2.6-22.4; P<0.001). CONCLUSION: Identifying factors associated with increased risk for anesthesia-related CA is of great importance in risk stratification for surgical patients. ASA physical status score was found to be a major factor in predicting perioperative CA, since patients with higher ASA scores had a statistically significant increased risk of CA. Therefore, extra precautions must be taken when dealing with unprepared patients who have uncontrolled medical illnesses, especially those who will be undergoing emergency surgery.

Pain in Preterm Infants: Different Perspectives.

In the last decades, there has been a tremendous change in approaching and managing neonates' pain. These changes began with rebutting the previous misconception about neonates' , particularly preterm infants' , pain. The development in neuroimaging has revealed that by 24 weeks of gestation the peripheral nervous system is mature and function fully. Researchers now know that neonates experience pain and premature infants have even lower pain thresholds. Since that time, a mounting amount of literature has addressed the issue of neonatal pain. Many pharmacological and non pharmacological pain reduction strategies have been investigated for their safety and analgesic effectiveness. Many interventions such as nonnutritive sucking (NNS), skin-to-skin contact (SSC), and facilitated tucking are effective in controlling neonates pain.

Hesitancy towards COVID-19 Vaccines: An Analytical Cross-Sectional Study.

Vaccination is the most promising strategy to counter the spread of Coronavirus Disease 2019 (COVID-19). Vaccine hesitancy is a serious global phenomenon, and therefore the aim of this cross-sectional study was to explore the effect of educational background, work field, and social media on attitudes towards vaccination in Jordan. We compared between medical personnel who were in direct contact with patients and non-medical individuals at Jordan University Hospital in terms of demographics, knowledge about COVID-19 vaccines, rumors received via social media, their trust in these vaccines, and the encouraging factors for vaccination. 646 individuals were enrolled in this study, of which 287 (44.4%) were from medical field, and 359 (55.6%) from non-medical field. 226 (35%) were planning to take the vaccine once available, with a positive response from 131 (45.6%) medical field workers, compared to 94 (26.2%) non-medical individuals (p < 0.001). The social media rumor that was believed the most was the unsafety of these vaccines (n = 283; 43.8%). Only 163 (56.8%) of medical persons did not believe any of the circulated rumors, compared to 126 (35.1%) of non-medical persons (p < 0.001). The effect of medical personnel advice (OR = 0.83; 95% CI = 0.70 to 0.98; p = 0.026) and social media (OR = 1.21; 95% CI = 1.04 to 1.41; p = 0.012) were significantly associated with the willingness to take COVID-19 vaccine once available. In conclusion, medical personnel and social media play a crucial role in increasing the society's inclination towards vaccination by providing the community with updated evidence-based information about COVID-19 vaccines as an efficient medical countermeasure and by correcting the previously spread misinformation.

The combinatorial use of propofol-fentanyl-ketamine for sedoanalgesia in patients undergoing urological procedures.

OBJECTIVES: To compare sedoanalgesia achieved using propofol-fentanyl-ketamine (PFK) combination with general anesthesia (GA) in terms of safety, hemodynamic stability, and perioperative complications. METHODS: Patients in the GA group were anesthetized using fentanyl (2 µg kg-1) and propofol (2 mg kg-1). The PFK group was anesthetized using a mixture of which each one ml contains 0.005 mg of fentanyl, 5 mg of propofol, 5 mg of ketamine, and 2 mg of lidocaine. Patients received an initial dose of 0.05 ml kg-1, followed by 0.05 mg kg-1 60 seconds later. Maintenance boluses of 0.025 ml kg-1 were administered every 3-5 minutes. Respiration occurred spontaneously through a simple face mask with 3 L min-1 O2. RESULTS: The GA group had 37 (37%) patients develop hypotensive episodes, compared to one (1%) episode in the PFK group (p<0.001). Five (5%) patients in the PFK group had an episode of transient O2 desaturation, compared to one (1%) patient in the GA group (p=0.212). The duration of induction and termination of anesthesia were significantly shorter in the PFK group (p<0.001). CONCLUSION: The PFK combination herein described is safe, effective, and provides intraoperative hemodynamic stability in patients with multiple comorbidities undergoing urological procedures.

The Impact of Spinal Anesthesia and Use of Oxytocin on Fluid Absorption in Patients Undergoing Operative Hysteroscopy: Results from a Prospective Controlled Study.

OBJECTIVE: The aim of this study was to determine if combining intravenous oxytocin infusion and spinal anesthesia will reduce the amount of glycine absorption in patients undergoing operative hysteroscopy. PATIENTS AND METHODS: A prospective controlled study was conducted in premenopausal patients who had hysteroscopic surgery including endometrial resection, endometrial polypectomy, myomectomy resection and uterine septal resection. The effect of combined spinal anesthetic with oxytocin infusion on fluid deficit was studied. RESULTS: A total of 88 patients were studied. Sixty-two cases were done under general anesthesia (control group) and 26 cases were performed with spinal anesthesia and the use of oxytocin infusion (study group). There was a statistically significant less mean fluid deficit in the study group than control group in the endometrial polypectomy patients (220±36 mL vs 392±178 mL, respectively, P value 0.010, 95% C.I.: 163-276) and the myomectomy patients (308±66 mL vs 564±371 mL, respectively, P value 0.003, 95% C.I.: 239-378). In the endometrial resections, there was also a statistically significant less mean fluid deficit in the study than the control group (P value ˂ 0.001). Regarding septal resection, there was no statistically significant difference in the mean fluid deficit between the two groups (P value 0.833). CONCLUSION: Spinal anesthesia combined with intravenous oxytocin infusion in operative hysteroscopy results in a statistically significant reduction in the glycine fluid deficit than the general anesthesia. We also recommend studying the effects of this combination in operative hysteroscopy using bipolar devices with isotonic solutions.

Preparedness of Frontline Doctors in Jordan Healthcare Facilities to COVID-19 Outbreak.

The number of COVID-19 (Coronavirus Disease of 2019) cases in Jordan is rising rapidly. A serious threat to the healthcare system appears on the horizon. Our study aims to evaluate preparedness of Jordanian frontline doctors to the worsening scenario. It has a questionnaire-based cross-sectional structure. The questionnaire was designed to evaluate preparedness according to knowledge about virus transmission and protective measures, adherence to protection guidelines, and psychological impacts affecting doctors. Institutional factors affecting doctors' readiness like adopting approach protocols and making protection equipment available were investigated; 308 doctors from different healthcare facilities participated (response rate: 53.9%). Approximately 25% of doctors (n = 77) previously took care of COVID-19 patients, and 173 (56.2%) have institutional COVID-19 approach protocols. Only 57 doctors (18.5%) reported all PPE (Personal Protective Equipment) available. The self-reported score of preparedness to deal with COVID-19 patients was 4.9 ± 2.4. Doctors having institutional protocols for dealing with COVID-19 cases and those with sustained availability of PPE reported higher scores of preparedness (5.5 ± 2.3 and 6.2 ± 2.1 with p < 0.001, respectively). Correlations with knowledge score, adherence to PPE score, and psychological impacts were investigated. The study revealed multiple challenges and insufficiencies that can affect frontline doctors' preparedness. Policy makers are urged to take these findings into consideration and to act promptly.

Video game distraction and anesthesia mask practice reduces children's preoperative anxiety: A randomized clinical trial.

PURPOSE: The study aims to evaluate the effectiveness of combined video game distraction and anesthesia mask exposure and shaping intervention as compared to conventional preoperative preparation on the preoperative anxiety, anesthesia induction compliance and emergence delirium of children undergoing day-case surgery. DESIGN AND METHODS: The CONSORT guidelines were followed in the current study; a randomized clinical trial, two groups, pre posttest, between subjects design with 1:1 allocation ratio was employed. Children (5-11 years of age; N = 128) admitted for day case surgery were invited to participate in the study. Sixty-four children were assigned to the intervention group receiving combined videogame distraction and anesthesia mask exposure and shaping intervention, and 64 children were assigned to the control group. RESULTS: The results showed that children in the intervention group reported statistically significant lower anxiety scores than the children in the control group at three preoperative points of time: postintervention t = 4.48, p < .001, at the time of transfer to the operation room t = 10.18; p < .001 and during anesthesia induction t = 7.76; p < .001. In addition, compared with the children in the control group, fewer children in the intervention group demonstrated poor anesthesia induction compliance χ2 = 3.91; p = .04. The results, however, did not reveal statistically significant differences in children's emergence delirium scores. PRACTICE IMPLICATION: Combined video game distraction and anesthesia mask exposure and shaping are simple, safe, and time-effective intervention that the nurses can implement at the day of surgery to mitigate children anxiety and to enhance their anesthesia induction compliance.

Corrosion behavior, in vitro and in vivo biocompatibility of a newly developed Ti-16Nb-3Mo-1Sn superelastic alloy.

The biocompatibility of a recently developed Ni-free Ti-16Nb-3Mo-1Sn (at.%) superelastic alloy was investigated both in vitro and in vivo. In addition, static water contact angle (WCA) and electrochemical tests were carried out. Commercial purity Ti (cp-Ti), which is already being used as a clinical material, was used as the control material. The alloy showed a stable corrosion behavior similar to that of the cp-Ti. The WCA measurements showed that the alloy exhibited hydrophilic properties that contributed to cell attachment to implants, as evident by the cytocompatibility tests. According to the in vivo implantation tests conducted on 30 adult BALB/c rats for periods up to 12 weeks, the tissue reaction around the implants was similar for both the cp-Ti and the alloy, and no significant difference was found in almost all parameters analyzed. Due to its stable superelastic properties accompanied with excellent biocompatibility and high corrosion resistance, we believe that this alloy is considered as a promising substitute for the biomedical materials containing Ni or other toxic elements.

A systematic review of the diagnostic accuracy of epidural wave form analysis to identify the epidural space in surgical and labor patients.

INTRODUCTION: Epidural failure due to misidentification of the epidural space is not uncommon. Epidural wave form analysis has been suggested to identify the epidural space. EVIDENCE ACQUISITION: A systematic literature search (Medline, Epub, Embase.com (Embase plus Medline), Cochrane Central, Web of Science, and Google Scholar) was performed to identify studies comparing epidural wave form analysis (index test) to epidural analgesia (reference test). EVIDENCE SYNTHESIS: Eight studies (3901 patients) were retrieved that provided data on diagnostic accuracy. These studies had a low risk of bias and of applicability concerns, as assessed by the quality assessment of diagnostic accuracy studies (QUADAS-2) tool. One study did not observe an epidural wave form in parturients, a finding that was not corroborated in another study. Because the reference test was different across the studies we decided not aggregate the data. The sensitivity values of the individual studies varied between 0.81 and 1.00, for the specificity values between 0.42 and 1.00 were found. CONCLUSIONS: Our study suggests that epidural wave form analysis is a reliable method for identification of the epidural space that could become a useful adjunct especially in anticipated difficult catheter placements or in teaching situations. Further research is warranted to define the role of epidural wave form analysis in pregnant women.

Potential Relevance of Melatonin Against Some Infectious Agents: A Review and Assessment of Recent Research.

Melatonin, a tryptophan-derived neurohormone found in animals, plants, and microbes, participates in various biological and physiological functions. Among other properties, numerous in vitro or in vivo studies have reported its therapeutic potential against many parasites, bacteria and viruses. In this concern, melatonin was found to be effective against many parasites such as Plasmodium, Toxoplasma gondii, and Trypansoma cruzi, via various mechanisms such as modulation of calcium level and/or host immune system. Likewise, a recent investigation has reported in vitro activity of melatonin against Leishmania infantum promastigotes which is the causative agent of fascinating visceral Leishmaniasis. This review was initially undertaken to summarize some facts about certain physiological and therapeutic effects of melatonin. It also reviews the effects and action mechanisms of melatonin in bacterial and viral infection besides biology of different parasites which may provide a promising strategy for control of many diseases of public health importance.

Effect of dexmedetomidine added to spinal bupivacaine for urological procedures.

OBJECTIVES: To determine the effect of adding dexmedetomidine to bupivacaine for neuraxial anesthesia. METHODS: Sixty-six patients were studied between April and May 2008 in the University of Jordan, Amman Jordan. They were randomly assigned into 3 groups, each receiving spinal bupivacaine 12.5mg combined with normal saline (group N) Dexmedetomidine 5 microg (group D5), or dexmedetomidine 10 microg (group D10). The onset times to reach T10 sensory and Bromage 3 motor block, and the regression times to reach S1 sensory level and Bromage 0 motor scale, were recorded. RESULTS: The mean time of sensory block to reach the T10 dermatome was 4.7 +/- 2.0 minutes in D10 group, 6.3 +/- 2.7 minutes in D5, and 9.5 +/- 3.0 minutes in group N. The mean time to reach Bromage 3 scale was 10.4 +/- 3.4 minutes in group D10, 13.0+/-3.4 minutes in D5, and 18.0 +/- 3.3 minutes in group N. The regression time to reach S1 dermatome was 338.9 +/- 44.8 minutes in group D10, 277.1 +/- 23.2 minutes in D5, and 165.5 +/- 32.9 minutes in group N. The regression to Bromage 0 was 302.9 +/- 36.7 minutes in D10, 246.4 +/- 25.7 minutes in D5, and 140.1 +/- 32.3 minutes in group N. Onset and regression of sensory and motor block were highly significant (N vesus D5, N versus D10, and D5 versus D10, p<0.001). CONCLUSION: Dexmedetomidine has a dose dependant effect on the onset and regression of sensory and motor block when used as an adjuvant to bupivacaine in spinal anesthesia.