Novel coronavirus 2019 pneumonia in a kidney transplant recipient.

The COVID-19 pandemic is spreading worldwide and the impact of the disease in transplant patients is evolving. In this case report, we presented a 63-year-old female kidney transplant recipient who presented with dyspnea and cough and was diagnosed with COVID-19 pneumonia. On the fourth day of admission, the patient's condition worsened. Therefore, the immunosuppressive medications were discontinued, and hydrocortisone was started. The patient died on the fifth day.

The Effect of Spinal versus General Anesthesia on Quality of Life in Women Undergoing Cesarean Delivery on Maternal Request.

Introduction The proportion of women electing for cesarean delivery has increased in both developed and developing countries. Cesarean delivery on maternal request (CDMR) refers to a primary cesarean delivery performed because the mother requests this method of delivery in the absence of standard medical/obstetrical indications. Several studies compared anesthesia modalities in cesarean section regarding clinical outcomes such as maternal mortality, post-operative pain and bleeding, but only a few compared health-related quality of life (HRQoL) of women undergoing general anesthesia versus spinal anesthesia. The aim of this study was to determine whether pregnant women who undergo general anesthesia (GA) for cesarean delivery compared with spinal anesthesia (SA) differ regarding their perceived HRQoL. Methodology We enrolled 160 pregnant women with American Society of Anesthesiologists (ASA) class II, scheduled for CDMR with GA or SA. Anesthesia modality was based on patient's preference. Participants assessed their state of health with the EuroQoL-5 Dimensions-3 Levels (EQ-5D-3L) self-administered questionnaire at four time points: six hours before cesarean delivery, 24 hours after cesarean delivery, one week and one month after cesarean delivery. Patients also rated their health on the EQ visual analog scale (EQ-VAS) from 100 mm "best imaginable health state" to 0 mm "worst imaginable health state". Results More women who underwent spinal anesthesia reported "no problem" with regards to "mobility' (64% vs. 30%, p = 0.00), "usual activities" (90% vs. 38%, p = 0.00), and "pain/discomfort" (20% vs. 5%, p = 0.007). Repeated measurement analysis showed that the two groups started off with the same EQ-VAS score, however, both decreased over time with different slope resulting in different scores at 24 hours after CS. Then the scores increased in both groups over time and ended up being rather close at one month after CS. Discussion Unless there is a contraindication, neuraxial anesthesia is the anesthetic technique of choice for cesarean delivery in all parturient in general. This concept is based on more mortality and morbidity that have been seen with general anesthesia in this particular population. Our study demonstrated significant advantages of spinal anesthesia compared to general anesthesia in cesarean section regarding postoperatively perceived HRQoL. We showed that more pregnant women who chose spinal anesthesia as their anesthesia modality reported "no problem" with respect to "mobility" and "Self-care" 24 hours after cesarean section. On the top of that, more women in this group had "no problem" in their "usual activities" at one week and one month after cesarean delivery time points. Moreover, EQ-5D general health score was higher 24 hours after cesarean delivery with regional anesthesia comparing to general anesthesia. Conclusion We determined that compared to general anesthesia, spinal anesthesia is the technique of choice for cesarean section because not only it avoids a general anesthetic and the risk of failed intubation, but also because it provides effective pain control, mobility and fast return back to daily activities for new mothers and increase their quality of life.

The relationship between fasting blood glucose variability and coronary artery collateral formation in type 2 diabetes patients with coronary artery disease.

BACKGROUND: Coronary collaterals are an alternative source of blood supply to ischemic myocardium. Well-developed coronary collateral arteries in patients with coronary artery disease (CAD) limit the size of acute myocardial infarction and improves survival. The aim of this study was to investigate the relationship between glycemic variability and coronary collateral formation in patients with type 2 diabetes mellitus and CAD. METHODS: Consecutive patients undergoing percutaneous coronary intervention or coronary artery bypass grafting procedures were studied. Multivariate logistic regression models were used to examine the association between coronary artery collateral formation graded by Rentrope classification and glycemic variability, measured by coefficient variation of fasting blood glucose. RESULTS: In our study, we retrospectively enrolled 300 patients, of whom 239 were diabetic (age: 70.1±11.9, 56% men) and 61 were nondiabetic (age: 71.5±11.5, 72% men). Diabetic patients were further stratified as follows: those with poor coronary collateral artery development (n=171, age: 69.7±12.4, 55% men) and those with good coronary collateral artery development (n=68, age 71.1±10.8, 59% men) according to the Rentrope classification. Our findings did not show association between glycemic variability and coronary collateral vessels development after controlling for potential confounders (odds ratio: 2.51; 95% confidence interval: 0.57-11.03; P=0.22). The culprit lesion (≥75% stenosis) in the left anterior descending artery and the right coronary artery was more frequent in the good collateral group compared with the poor collateral group (66 vs. 50%, P=0.02; 63 vs. 45%, P=0.01 respectively). CONCLUSION: Glycemic variability is not associated with coronary collateral artery formation in patients with type 2 diabetes mellitus and CAD.

Seven Cases of Zika Virus Infection in South Florida.

INTRODUCTION: Zika virus, an arbovirus of the Flaviviridae family, is a mosquito-borne virus known to cause microcephaly through vertical transmission. Infection presents with mild, self-limiting symptoms. Currently, a Zika virus outbreak has spread across most of South and Central America. Travel-related and sexually transmitted cases have been reported across the United States. However, the vector-borne transmission has been limited to Florida and Texas. We present seven cases of Zika virus infection that presented at a single institution in South Florida. METHODS: Patients were included that had real-time polymerase-chain reaction (RT-PCR) for Zika virus RNA in urine or serum or enzyme-linked immunosorbent assay (ELISA) for Immunoglobulin M (IgM) antibody against Zika virus in serum. RESULTS: All seven patients reported recent travel or employment in areas of active Zika virus transmission and at least two of the four most commonly reported symptoms (fever, arthralgia, rash, and conjunctivitis) with a rash present in all patients. All patients had positive RT-PCR for Zika virus RNA in urine. RT-PCR for Zika virus RNA in serum was negative in four of five patients that were tested, indicating that these patients likely presented one to two weeks after symptom onset. CONCLUSION: The future of Zika virus outbreaks in other cities in the United States is still uncertain. However, it is clear that prevention and control policies are urgently needed. We have presented seven confirmed cases of Zika virus infection in South Florida. In addition to conducting research concerning both the diagnostic and therapeutic aspects of the virus, there is a need for public awareness of its presentation, methods of transmission, and subsequent clinical outcomes.

The Effect of Intravenous Magnesium Sulfate on Post-Operative Analgesia During Laminectomy.

BACKGROUND AND OBJECTIVES: Post-operative pain control is an important concern for both patients and physicians. Magnesium is being used as an adjuvant for anesthesia and analgesia during and after various surgeries. We aimed to investigate the effects of intravenous magnesium sulfate on post-operative analgesia after laminectomy. Methods Materials: In this randomized double-blind controlled clinical trial, we enrolled 40 adult patients aged 18-60 with American Society of Anesthesiologists (ASA)  Class I-II who were candidates for elective laminectomy. The patients were randomly assigned in two control groups and were similarly anesthetized. In the case group, after the induction of anesthesia, a loading dose of magnesium sulfate (30 mg/kg) was administered within five to 10 minutes followed by a maintenance dose of 10 mg/kg/hr up to the end of the surgery; while, the patients in the control group received the same volume of saline. After the surgery, all patients received a patient-controlled intravenous analgesia (PCA) pump containing morphine. The first time of using PCA, the amount of consumed morphine during the first 24 hours, and pain score were recorded at 6,12,18 and 24 hours in the post-operative period. RESULTS: There was no significant difference between the two groups with respect to the amount of morphine consumed in 24 hours after the surgery (P value =0.23), the first time of using of PCA pump (P value =0.79) and pain intensity (P value=0.52). CONCLUSION: The infusion of Magnesium Sulfate during laminectomy had no effect on patients' pain and opioid requirement during the first 24 hours after the surgery.

Efficacy of dexamethasone on postoperative analgesia in children undergoing hypospadias repair.

BACKGROUND AND OBJECTIVE: Management of post operative pain in children undergoing hypospadiasis repair, accounts for optimized surgery outcomes and improved patients' satisfaction. Thus, various studies have widely investigated the best approaches for the pain management. In this study our aim was to determine the effect of dexamethasone in combination with penile nerve block on the postoperative pain and complications in the children undergoing hypospadias surgery. METHODS: In this randomized double-blind placebo controlled trial, after obtaining informed consent from parents or legal guardians, 42 children undergoing surgical treatment of hypospadias were randomized in two groups to receive either IV dexamethasone 0.5 mg/kg (n=23) or placebo (normal saline) (n=19) during the operation. Penile block was performed in both groups using Bupivacaine 0.5% (1mg/kg) at the end of the procedure. By the end of the operation, FLACC (Face, Leg, Activity, Cry, Consolability) pain score was assessed as the primary outcome of the study. Secondary outcomes includes timing and episodes of rescue medication consumption, post operative nausea \vomiting and bleeding. All the outcomes were assessed in the recovery room and after 2, 6, 12, and 24 hours. RESULTS: The median of FLACC pain scores at the recovery room and 2, 6, 12, and 24 hours post operation was 2, 1, 1, 1, and 2 for the dexamethasone group and 8, 8, 7, 7, and 8 for the placebo group respectively. This were significantly different (P<0.000). The median time of first rescue medication consumption was 8 hours post operation for the dexamethasone group and three hours for the placebo group which was significantly different (z= 4.57, p<0.000). The maximum episode of post operative rescue medication consumption in dexamethasone group was 4 episodes in only one patient and the minimum was one episode in 11 patients. In comparison numbers in placebo group were five episodes in seven patients and three episodes in four patients. The result indicated that there was statistically significant difference between two groups in terms of episodes of rescue medication consumption (Chi2= 31.4, p<0.000). CONCLUSION: Single dose of intravenous dexamethasone (0.5 mg/kg) in combination with penile block decreased the post operative pain measures, and total post operative analgesic requirement. It also increased the onset of the first analgesic requirement compared to penile block alone.

Validation of the Persian version of COOP/WONCA functional health status charts in liver transplant candidates.

CONTEXT: Health-related quality of life is a preferred outcome measure for patients with advanced liver disease. The functional health status charts developed by the Dartmouth Primary Care Cooperative Information Project (COOP)/World Organization of National Colleges, Academies and Academic Associations (WONCA) make up a generic instrument for assessing health-related quality of life. OBJECTIVE: To translate and validate the Persian version of COOP/WONCA in liver transplant candidates and to assess the correlation of Child Pugh classification and Model of End Stage Liver Disease (MELD) score with quality of life.Setting-The Shiraz liver transplant center, the most active liver transplant center in the Middle East. PARTICIPANTS: Consecutive adult outpatients waiting for their first liver transplant who attended follow-up visits in the pretransplant clinic.Main Outcome Measures-Patients completed COOP/WONCA along with the Short Form (SF)-36. Data on the underlying cause of cirrhosis, Child-Pugh classification, and MELD scores were collected from medical records. RESULTS: A Persian version of the COOP/WONCA was accepted by liver transplant candidates and showed adequate reliability and validity. Similar domains in COOP/WONCA charts and the SF-36 were highly correlated, indicating that construct validity of the COOP/WONCA in relation to the SF-36 was good (77% of correlations were as expected). Moreover, the exploratory factor analysis could not extract 2 different quality-of-life factors. These findings provide sufficient evidence to conclude that the Persian versions of COOP/WONCA charts and the SF-36 measure the same constructs of health-related quality of life and can be used interchangeably. Four of the 6 COOP/WONCA charts did not allow discrimination between groups of patients according to Child Pugh classification, indicating poor known group validity.

The effects of Aminophylline on clinical recovery and bispectral index in patients anesthetized with total intravenous anaesthesia.

OBJECTIVE: Aminophylline, which is clinically used as a bronchodilator, antagonizes the action of adenosine, so it can be used to shorten the recovery time after general anesthesia. Therefore, we wanted to test the hypothesis that the administration of aminophylline leads to an increase in bispectral index (BIS) and clinical recovery in patients anesthetized with total intravenous anesthesia (TIVA). Methods : Ninety two patients who were scheduled for elective inguinal herniorrhaphy were enrolled in this study. All patients were premedicated with midazolam and morphine. Anesthesia was induced with propofol 2.5 mg /kg and remifentanil 2.5 µg/kg without muscle relaxant. For maintenance of anesthesia we used propofol 100µg/kg/min, remifentanil 0.2µg/kg/min and 100% oxygen with stable BIS readings in the range 40-60. After skin closure, aminophylline 4mg/ kg was given to Group A and an equivalent volume of normal saline to Group P. BIS values, heart rate, blood pressure, oxygen saturation and End tidal CO2(ETco2) were determined. Time to eye opening, extubation time and response to command were measured. Results : There were no significant differences in SpO2, ETco2 and anesthesia time. Heart rate and systolic blood pressure were found to be statistically higher (p<0.001) in Group A. Time to eye opening, hand grip and extubation were significantly shorter (p<0.001) in Group A. Bispectral index scores were significantly higher in group A. CONCLUSIONS: Injection of aminophylline at emergence time led to significant increase in BIS and shortening recovery time from anesthesia.

Music can effectively reduce pain perception in women rather than men.

OBJECTIVE: Nowadays music is used to decrease pain and increase relaxation in clinical settings. It is hypothesized that music can affect women more easily than men. We assessed the effect of two types of music (Iranian folkloric and preferred music) on pain tolerance and pain rating in cold pressor test. METHODOLOGY: A consecutive sample of 50 healthy Iranian medical students was enrolled. They reported pain tolerance and pain rating in cold pressor test in three different musical conditions served as the outcome measures. The results were analyzed with repeated measurement analysis of variance. RESULT: Mean tolerance time was significantly higher in preferred music compared to Iranian folkloric music (F (1,48) =25.44, p=0.0001) and no music (F(1,48)=3.51, p=0.0001) conditions. There was a significant interaction when tolerance time in no music condition was compared to preferred music condition, regarding sex; Tolerance time increased more in females (F(1,48)=5.53, p=0.023). The results also indicated that pain ratings, regardless of sex, were different in three musical conditions (F(1.7,81.34)=15.37, p=0.0001). CONCLUSION: Music distracted attention from pain and Women can be impressed and distracted more easily by music.

Incidence of Nosocomial Infections in a Big University Affiliated Hospital in Shiraz, Iran: A Six-month Experience.

BACKGROUND: Nosocomial infections (NIs) are one of the most important health issues, particularly in developing countries, because these infections cause high mortality and morbidity, and economic and human resource loss as a consequence. To date, most surveillance studies have been conducted in developed countries, and only a few have been performed in Iran. All of the few Iranian studies have been performed using paper-based collection forms, and none was conducted with the aid of an electronic patient data retrieving and collecting tool. The aim of this study is to determine the incidence of NIs in a big university hospital of Shiraz, with the help of specifically programmed surveillance software merging electronically the available patient data and the infection results input manually. METHODS: The study was conducted prospectively through 6 months from 21(st) March up to 22(nd) September 2006, in a 374-bedded educational hospital. All patients admitted during this period were included in the study and examined everyday for detecting four types of NIs: surgical site infection (SSI), urinary tract infection (UTI), pneumonia (PNEU), and blood stream infection (BSI). Centres for Disease Control and Prevention National Nosocomial Infection Surveillance system criteria were applied. RESULTS: 4013 patients were admitted in the hospital. The overall infection rate was 4.14, and UTI, SSI, BSI, and PNEU rates were 1.82, 1.22, 0.5, and 0.5, respectively, per 1000 patient days of admission. CONCLUSIONS: The results of this study showed that the frequency of NI in the investigated hospital was not higher than in many other reported surveillance results from other countries. This, however, might be a bias as the administration of antibiotics was very high in this study and the quality of microbiological investigation might have influenced significantly, resulting in more false-negative results than expected. Overall, the use of the Iranian National Nosocomial Infection Surveillance System Software proved to be useful and allowed both rapid data collection and detailed data analysis.

Validity and reliability of Persian version of Chronic Liver Disease Questionnaire (CLDQ).

PURPOSE: The aim of this study is to test the psychometric properties of the Persian version of the Chronic Liver Disease Questionnaire (CLDQ) in Iranian candidates for liver transplantation. METHOD: One hundred and fifty-five consecutive adult patients awaiting liver transplantation completed the Persian version of CLDQ and the short-form health survey (SF-36). The etiology of cirrhosis, Child Pugh classification and Model for End stage Liver Disease (MELD) scores were taken from medical records. RESULTS: The scaling success rate for convergent validity was 100% for all domains, and the success rate for item discriminant validity was 95.8% (139/145). The internal consistency (Cronbach α) for the domains ranged from 0.65 to 0.89. Multitrait-multimethod correlation matrix and factor analysis revealed that the CLDQ and SF-36 measure different constructs of quality of life. CONCLUSION: The Persian version of the CLDQ, a disease-specific questionnaire for measuring health-related quality of life, is accepted by liver transplantation candidates with adequate reliability and validity. There is no significant correlation of Child Pugh classification and MELD score with quality of life.

Preoperative factors as predictors of blood product transfusion requirements in orthotopic liver transplantation.

CONTEXT: Intraoperative transfusion can affect the chance of graft survival in liver transplantation, a complicated operation with massive blood loss. Verification of factors that are predictive of intraoperative blood loss and transfusion increases the quality of anesthesia management. OBJECTIVE: To assess use of blood and blood products between 2002 and 2008 and to evaluate factors associated with blood loss and requirement for blood products in adult patients undergoing orthotopic liver transplantation via piggyback technique. DESIGN: Medical charts and anesthesia records from 261 eligible adult recipients of an orthotopic liver transplant between March 2002 and May 2008 were reviewed. SETTING: Shiraz Liver Transplantation Center, the only active liver transplantation center in Iran. MAIN OUTCOME MEASURES: Potential influencing factors in blood loss and transfusion, including sex, preoperative hemoglobin level, international normalized ratio, primary diagnosis, platelet count, creatinine level, Model for End-Stage Liver Disease (MELD) score, central venous pressure, and total anesthesia time, were measured and subjected to multivariable analysis. RESULTS: Mean blood loss was 54.2 (SD, 47.9) mL/kg, the mean (SD) for amounts of blood products transfused was 25.3 (19.5) mL/kg for packed red blood cells, 2.6 (3.3) units for fresh frozen plasma, and 1.7 (3.1) units for platelets. Seven recipients (2.7%) underwent transplantation without intraoperative transfusion of red blood cells, whereas 25 patients (9.6%) received more than 10 units of red blood cells intraoperatively. Multivariable analysis showed that no preoperative factor was a predictor of blood loss or requirement for intraoperative transfusion. Transfusion of fresh frozen plasma and packed red blood cells was significantly lower in 2005, 2006, 2007, and 2008 than in 2003 to 2004 (P < .001).

Perceived barriers to information access among medical residents in Iran: obstacles to answering clinical queries in settings with limited Internet accessibility.

Studies performed in the US and other Western countries have documented that physicians generate many clinical questions during a typical day and rely on various information sources for answers. Little is known about the information seeking behaviors of physicians practicing in other countries, particularly those with limited Internet connectivity. We conducted this study to document the perceived barriers to information resources used by medical residents in Iran. Our findings reveal that different perceived barriers exist for electronic versus paper-based resources. Notably, paper-based resources are perceived to be limited by resident time-constraints and availability of resources, whereas electronic resources are limited by cost decentralized resources (such as PDAs) and accessibility of centralized, Internet access. These findings add to the limited literature regarding health information-seeking activities in international healthcare settings, particularly those with limited Internet connectivity, and will supplement future studies of and interventions in such settings.

The relief of anxiety: comparative study--air plane flying vs anesthesia.

BACKGROUND: Airplane Flying and anesthesia are both not entirely safe. Passengers and patients have the right not to be endangered during flight or anesthesia. Flying and anesthesia has always been associated with anxiety in passengers and patients. OBJECTIVE: This study was undertaken to compare the anxiety between passengers to fly and patients to receive anesthesia. METHODS: One hundred and eighty persons were randomly selected and divided into six equal groups. Pilots and flight crew; anesthetist, resident of anesthesiology and nurse anesthetists; people who had flown but without any history of anesthesia; people without any experience of flight or anesthesia; people with previous experiences of both the flight and anesthesia and finally people with a previous history of anesthesia but without any experience of flight as Groups 1 to 6 respectively. A questionnaire was used to evaluate the level of anxiety during both the flight and anesthesia. RESULTS: All six groups had significantly more anxiety from anesthesia than flying (p < 0.05) except in group 5 (p = 0.460). Anxiety of flying was significantly less in pilots and flight crews (group 1) when compared with other groups (p < 0.004). The anxiety of anesthesia was significantly less in anesthetist team when compared with those who has not experienced general anesthesia. People who had not experienced anesthesia showed more fear about anesthesia than those who had experienced general anesthesia (p < 0.002). CONCLUSION: The results showed that having enough information about flying causes less anxiety just as preoperative visits help the patient to undergo a more comfortable anesthesia.