The influence of anesthesia type on perioperative maternal glycemic-stress response during elective cesarean section: A prospective cohort study.

BACKGROUND: It has been known that the type of anesthesia can affect the stress response to surgery in form of hyperglycemia. This study aims to evaluate and compare the influence of general anesthesia (GA) and spinal anesthesia (SA) on pregnant women who are scheduled to undergo cesarean section (CS) and to understand the impact of obstetrical factors on the maternal hyperglycemic-stress response during CS. METHODS: Prospectively, we identified, assessed and followed those pregnant women who were scheduled to undergo elective CS surgery. The included group comprises any women who was scheduled to undergo an elective CS. The preoperative and postoperative blood glucose levels were measured and compared between both groups (GA and SA groups). RESULTS: The study included 302 patients who satisfied the inclusion and exclusion criteria of the study. GA was more commonly utilized in cesarean sections (56.6%) compared with SA (43.4%). The average gestational age at time of delivery was 37.4 weeks. The post-operative readings were significantly higher in the GA group with a mean sugar level of 110.1 mg/dL and a mean sugar level in the SA group of 87.7 mg/dL (P = 0.00). After performing multiple regression analysis, it was revealed that the type of anesthesia is the most independent factor affecting the postoperative sugar level. CONCLUSION: GA causes higher blood glucose concentrations than SA, which indicates that the impact of GA on hormonal stress response and metabolic hemostasis is greater than in SA.

Chronic rhinosinusitis due to cyano-acrylic glue after endoscopic transsphenoidal pituitary surgery.

BACKGROUND: To reduce the risk of cerebrospinal fluid leak, clinicians utilize a filling material placed in the sella followed by floor reconstruction with various materials, including glue sealing. Cyano-acrylic glue Glubran®2 glue is commercially available and is generally used as embolizing agent and for the prevention of cerebrospinal fluid leakage. CASE DESCRIPTION: A 25-year-old woman underwent endoscopic endonasal transsphenoidal surgery for pituitary adenoma. After tumor resection, sellar floor reconstruction was performed by mucosal graft and Glubran®2 glue. The early post-operative period was uneventful. However, 2 months after surgery, the patient complained of headache, facial pain and greenish foul-smelling nasal discharge with solid particles dripping from the nose. Medical treatment was unsuccessful. Brain MRI showed inflammation and thickening of the sphenoidal and para-sphenoidal mucosa. The patient underwent endoscopic endonasal surgery and a solid glass-like mass surrounded by inflamed infected mucosa was seen in the inferior and lateral aspects of the sphenoid sinus. Efforts were made to erupt and de-crust the solid mass until total resection was achieved. Early post-operative period was uneventful, and a course of antibiotics was continued until total disappearance of the discharge. CONCLUSION: To the best of our knowledge, this is the first case reporting of acrylic glue (Glubran®2)-related sinusitis. Surgeon should be aware about similar side effects for the glue material that would complicate the surgery.

WITHDRAWN: Mechanical ventilation in COVID-19: Is it due to patient or virology factors?

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Familial and Environmental Risk Predisposition in Tonsillectomy: A Case-Control Study.

BACKGROUND: Tonsillectomy is one of the most commonly performed procedures among children and it is the gold standard management to reduce episodes of tonsillitis and obstructive symptoms. Many studies showed a significantly higher incidence of previous tonsillectomy in the parents and siblings. This study investigated the influence of familial and environmental trends in tonsillectomy. METHODS: Retrospectively, we identified those patients who underwent tonsillectomy (the case group). Also, a control group of participants attending the hospital as visitors who had not undergone tonsillectomy was collected. Both groups are compared using the proper statistical tests. RESULTS: This study included 1,232 participants; 615 underwent tonsillectomy (cases) and 617 did not (controls). It was found that paternal and maternal history of tonsillectomy, childhood asthma, and daycare attendance are independent factors influencing tonsillectomy in the offspring. Of about 85.4% of fathers who underwent tonsillectomy their children will also have tonsillectomy. Also, regarding the maternal history, 72.5% of offspring will have tonsillectomy if the mothers underwent the procedure. CONCLUSION: This study reveals that genetic predisposition factors may have a role for tonsillectomy and its underlying causative indications. Also, it highlights the importance of asthma control in children. Moreover, the role of ethnicity may be minimal due to the similar trend of this study with other studies. Further studies and prospective research are recommended.

Factors that influenced pregnant women with one previous caesarean section regarding their mode of delivery.

BACKGROUND: During the last decades, the rate of caesarean section is increasing and this can increase the mortality and morbidity. Up to one third of the caesarean sections are attributed to the elective repeat caesarean section (ERCS). This study aims to evaluate attitudes and factors affecting the choice of pregnant women with one previous caesarean section regarding their mode of delivery in their second pregnancy. By assessing these attitudes, this study can help the efforts in developing strategies to increase the rates of vaginal delivery. MATERIAL AND METHODS: A cross-sectional design was conducted by a structured questionnaire on 166 pregnant women who had delivered once by caesarean section for their first pregnancy and were in the third trimester of their second pregnancy. Any women with an absolute indication for caesarean section was excluded. The study comprises women who attend the clinic at our center in Northern of Jordan. Proper statistical tests were performed to assess the association between the choice of delivery and selected demographic and clinical factors. RESULTS: About 55.4% responded that they would choose ERCS (n = 92) and the remaining participants chose trial of labour after caesarean section (TOLAC) (n = 74). Fear of pain was the most common reason for choosing caesarean section, accounting for 55.4%. Interestingly, our study did not show a significant association between the mode of delivery and demographic factors, such as age, educational level and occupation. The single independent significant factor influencing patients' choice that our study revealed was "being informed about the complications of TOLAC". The choice of TOLAC was almost four times higher for those participants who had been informed about the complications, compared to those who had not been informed. CONCLUSION: Proper counselling is a main factor that affected the patients' choice toward the mode of delivery. Proper pain management may encourage patients to choose TOLAC because fear of pain was a main reason that patients requested ERCS instead of TOLAC.

Anesthesia During Functional Endoscopic Sinus Surgery for Kartagener's Syndrome: A Case Report and Literature Review.

INTRODUCTION: Kartagener's syndrome (KS) is a ciliopathic, autosomal recessive disorder characterized by the triad of situs inversus, chronic sinusitis, and bronchiectasis. The abnormal ciliary structure and function lead to variable clinical manifestations, including dextrocardia, pneumonia, bronchitis, chronic rhinosinusitis, otitis media, reduced fertility in women, and infertility in men. This article reports our experience on general anesthesia with endotracheal intubation during functional endoscopic sinus surgery (FESS) in a patient with KS. CASE PRESENTATION: A 44-year-old man was admitted to our hospital with chronic nasal obstruction, postnasal drip, chronic sinusitis, and chronic non-productive cough for FESS. The patient's heart was on the right side of his chest. A chest roentgenogram and a high-resolution chest and abdomen computed tomography (CT) scan identified dextrocardia, situs inversus, and chronic bronchitis and bronchiectasis involving both lung bases. CT sinuses showed mucosal thickening of bilateral maxillary and ethmoid and sphenoid sinuses. The patient was prescribed oral medications and nasal spray for crepitations and wheezes heard over bilateral lung fields. Intensive chest physiotherapy and supportive care prior to surgery were provided to prevent worsening of lung function. FESS with bilateral frontal polypectomy was performed. All hemodynamic parameters were stable. The emergence from anesthesia was smooth. After ~20 minutes in the post-anesthesia care unit, the patient was fully awake and pain-free. He was then transferred to the surgical intensive care unit and subsequently to the ward. The postoperative period was uneventful. The patient felt subjectively "very well" and was discharged from the hospital on the 2nd postoperative day. CONCLUSION: Anesthesiologists must be aware of cardiopulmonary inversion that could challenge the management of patients with KS. To avoid respiratory depression caused by long-acting systemic opioids, we suggest using short-acting opioids during general anesthesia and for postoperative pain relief.

Endoscopic dacryocystorhinostomy: A comparison of double-flap and single-flap techniques.

BACKGROUND: Dacryocystorhinostomy (DCR) is a procedure to restore the flow of tears into the nose from the lacrimal sac when the nasolacrimal duct obstructed. This study aimed to compare the success rates of two different techniques in endonasal endoscopic DCR; namely single and double mucosal flap techniques. MATERIAL AND METHODS: A nonequivalent quasi-experiment design was used in this study. Retrospectively, patients underwent endoscopic DCR for primary nasolacrimal duct (NLD) obstruction were included. Patients were divided into the single-flap technique and the double-flap technique groups. Success was defined as the achievement of patency of the NLD throughout the period of follow-up with significant improvement in epiphora. RESULTS: Overall, 77 cases were included in the final analysis. Mean age was 41 years and 60% were female. Forty-six cases underwent the single-flap technique and 31 cases underwent the double-flap technique. Recurrence of NLD obstruction occurred in 11 (23.9%) cases in the single-flap group and in only one case (3.2%) in the double-flap group. CONCLUSION: The modified double-flap technique for primary NLD obstruction resulted in less recurrence compared to the single-flap technique. Creating double flaps to cover any exposed lacrimal bone may reduce the rate of postoperative adhesions over the nasolacrimal duct ostium.

Successful and Complete Recovery of the Ulnar Nerve After Eight Years of Chronic Injury Through Local Steroid Injections: A Case Report.

Peripheral neuropathy is a common neurodegenerative disease, with vastness of inducers and causalities. The acquired form peripheral neuropathy can be caused by traumatic injuries caused by nerve lacerations or compressions. Such injuries are usually followed by Wallerian degeneration, and inflammatory reaction. We present a case of a 33-year-old female with a chronic loss of the ulnar nerve function for 8 years after traumatic laceration. After that, she regained the functions of ulnar nerve after nerve stimulation by peri-ulnar nerve injection of methylprednisolone and lidocaine. The theory behind using steroids is related to the fact that the immune system could induce a secondary injury that interferes with the recovery. Many studies have shown effectiveness in using steroids alone or when combined with other substances on nerve regeneration in animal models. We believe that this is the first report of nerve recovery using local steroidal injections after a traumatic injury.

Effect of Depth of Total Intravenous General Anesthesia on Intraoperative Electrically Evoked Compound Action Potentials in Cochlear Implantation Surgery.

PURPOSE: This study aims to compare the effect of the depth of total intravenous anesthesia (TIVA) on intraoperative electrically evoked compound action potential (e-ECAP) thresholds in cochlear implant operations. METHODS: Prospectively, a total of 39 patients aged between 1 and 48 years who were scheduled to undergo cochlear implantation surgeries were enrolled in this study. Every patient received both light and deep TIVA during the cochlear implant surgery. The e-ECAP thresholds were obtained during the light and deep TIVA. RESULTS: After comparing the e-ECAP means for each electrode (lead) between the light and deep anesthesia, no significant differences were detected between the light and deep anesthesia. CONCLUSION: The depth of TIVA may have no significant influence on the e-ECAP thresholds as there was no statistical difference between the light and deep anesthesia.

A 23-Year-Old Joradanian Woman with a Desmoplastic Small Round Cell Tumor Involving the Ovary.

BACKGROUND Desmoplastic small round cell tumor (DSRCT) is a rare soft tissue sarcoma that usually arises in the abdomen or pelvis in young boys and adolescents. Presenting symptoms include abdominal pain and ascites. However, DSRCT is often disseminated throughout the peritoneal cavity at diagnosis, and the prognosis is poor. This report is of a case of DSRCT in a 23-year-old Jordanian woman who presented with abdominal pain. CASE REPORT An unmarried 23-year-old woman presented with abdominal pain. On examination, she was found to have ascites. A computed tomography (CT) scan of the abdomen and pelvis showed a complex cystic mass in the left ovary, multiple peritoneal deposits, a large amount of ascitic fluid, two hypodense lesions in the liver, and multiple enlarged lymph nodes. Diagnostic laparoscopy was performed, and multiple tumor biopsies were obtained. Histopathology showed a cellular tumor composed nests of small round cells embedded in desmoplastic stroma. Immunohistochemistry showed positive staining of the tumor cells for pan-cytokeratin, desmin, Wilms tumor 1 (WT1) antigen, epithelial membrane antigen (EMA), and CD56, which supported the diagnosis of DSRCT. After the second cycle of the P6 Protocol, which included seven courses of chemotherapy, the patient developed a severe and fatal infection. CONCLUSIONS It is important to consider the diagnosis of DSRCT that may present atypically, particularly in patients who present with abdominal and pelvic masses. DSRCT has a rapid and aggressive course that requires early and definitive diagnosis with prompt treatment that includes systemic chemotherapy.

Effect of Spinal Anesthesia versus General Anesthesia on Blood Glucose Concentration in Patients Undergoing Elective Cesarean Section Surgery: A Prospective Comparative Study.

BACKGROUND: This prospective study compared the blood glucose concentration with spinal anesthesia or general anesthesia in patients undergoing elective cesarean section surgery. METHODS: In total, 58 pregnant women who underwent elective cesarean section surgery were included in this prospective comparative study. Group S (n = 35) included patients who chose spinal anesthesia, and group G (n = 23) included patients who chose general anesthesia. The patients were allocated to the groups upon patients' preference. For the group G, the blood glucose concentration (BGC) was obtained 5 minutes before induction, T1, and 5 minutes after induction T2. For the group S, the BGC was obtained immediately before the injection of the local anesthetic agent T1 and 5 minutes after the complete block T2. For both groups, BGC was measured 5 minutes before the end of surgery T3 and 30 minutes after the end of surgery T4. For BGC measurements, we used a blood glucose monitoring system with a lancet device to prick the finger. RESULTS: There was no statistically significant difference in the mean blood glucose concentration between the groups S and G in T1 (78.3 ± 18.2 vs. 74.3 ± 14.7, p > 0.05) and T2 (79.2 ± 18.3 vs. 84.9 ± 23.7, p > 0.05). The mean BGC was statistically significantly higher in group G in comparison to group S in the times 5 minutes before (80.2 ± 18.1 vs. 108.4 ± 16.7, p < 0.05) and 30 minutes after the end of surgery (80.9 ± 17.7 vs. 121.1 ± 17.4, p < 0.05). CONCLUSION: There is a much lower increase in blood glucose concentration under spinal anesthesia than under general anesthesia. It is reasonable to suggest that the blood sugar concentration must be intraoperatively monitored in patients undergoing general anesthesia.

Accuracy of intraoperative electrophysiological testing in confirming correct cochlear implant electrode positions.

Objective: To investigate the accuracy of intraoperative electrophysiological studies in detecting incorrectly positioned electrodes in cochlear implant surgery. Study design: A retrospective chart review. Setting: Tertiary referral centre. Patients: In total, 104 consecutive patients with a mean age of 5 years underwent cochlear implant surgery at our centre between January 2012 and December 2013. All patients were implanted with Cochlear Nucleus Freedom implants. Method: A retrospective study to compare intraoperative neural response telemetry (NRT), impedance and electrode position using Stenver's transorbital plain X-ray view. Results: Intraoperative electrophysiological tests for patients with Cochlear Nucleus Freedom implants showed 97% sensitivity and 100% specificity compared with postoperative X-ray imaging. Conclusion: NRT results for the position of cochlear implants were very accurate when checked by X-ray imaging showing that this technique is sufficient in most cases. Stenver's plain X-ray view is needed in complicated cases with abnormal NRT testing or difficult electrode insertion.

Intraoperative angioedema induced by angiotensin II receptor blocker: a case report.

BACKGROUND: Angiotensin II receptor blockers are a class of antihypertensive agent that is developed to exclude the adverse effects of angiotensin converting enzyme inhibitors. However, as angiotensin II receptor blockers have begun to be more widely prescribed, cases of angiotensin II receptor blocker-induced angioedema have been reported. Rare cases of angioedema following surgery in patients using angiotensin converting enzyme inhibitors have been published. CASE PRESENTATION: A 38-year-old man with past history of hypertension was admitted for an elective lumbosacral spine surgery. He had been taking Valsartan 160 mg a day for the past 4 years.At the end of the surgical procedure and turning the patient into supine position, we noticed severe swelling in the neck and the face with.an edematous tongue, floor of the mouth, glottis, and supraglottic areas. A diagnosis of drug induced angioedema was made and intravenous dexamethasone, diphenhydramine and ranitidine were given. The patient remained intubated and was transferred to the intensive care unit. The valsartan was suspected to be the precipitating factor for the angioedema and was therefore discontinued.The swelling started to regress after 2 h, and resolved completely by the third day. CONCLUSION: The precise mechanism of angiotensin II receptor blocker-induced angioedema is still unknown and should be thoroughly investigated. This report demonstrates a unique case of intraoperative angiotensin II receptor blocker-induced angioedema. Potential differential diagnoses of postoperative facial edema are discussed in detail, including the prolonged prone positioning for posterior spine surgery. Anesthesiologists should be aware of such rare, but potentially dangerous, perioperative adverse reaction that can occur with angiotensin II receptor blockers use.

Effect of total intravenous vs volatile anesthetics on intraoperatively acquired electrically evoked compound action potential in children undergoing cochlear implant surgery: A randomized prospective study.

OBJECTIVE: The purpose of the present study was to compare the effects of inhalational anesthesia to those of total intravenous anesthesia on intraoperative electrically evoked compound action potential (e-ECAP) thresholds in children undergoing cochlear implantation. STUDY DESIGN: Randomized prospective study. SETTING: Tertiary referral teaching hospital. PATIENTS: Forty children aged 6 months to 17years with bilateral severe-to-profound sensorineural hearing loss and undergoing cochlear implantation were enrolled in the study. INTERVENTION: Patients were randomly assigned (1:1 ratio) into 2 groups to receive inhalational or total intravenous anesthesia. MEASUREMENTS: The e-ECAP measurements were obtained with neural response telemetry software. MAIN RESULTS: All electrodes showed lower e-ECAP thresholds under propofol, and results were statistically significant for the apical electrodes (P<.05). There was no statistical difference in the impedances between the 2 groups. Propofol minimally affected the e-ECAP. In contrast, the impedance was not affected by anesthesia. CONCLUSION: Volatile anesthetics result in higher e-ECAP thresholds in children, suggesting that e-ECAP thresholds acquired during inhalational anesthesia overestimate auditory nerve stimulation levels, which may cause discomfort postoperatively and adversely affect the child's adaptation to the implant. We recommend the use of total intravenous anesthesia for the measurement of the e-ECAP thresholds during cochlear implant surgery.

Comparison of the Disposable Streamlined Liner of the Pharynx Airway and the Disposable I-gel in Anaesthetized, Paralyzed Adults: A Randomized Prospective Study.

Introduction. This study compared streamlined liner of the pharynx airway (SLIPA) and I-gel noninflatable, single-use, supraglottic airway device (SAD) performance in anesthetized, paralyzed adults. Methods. Eighty adults (ASA physical statuses I-III) who were undergoing elective procedures under general anesthesia with an SAD were enrolled in this prospective, randomized, single-blind study. Subjects were randomly and evenly assigned to the SLIPA or I-gel group for intraoperative airway management. Ease and number of insertions, insertion time, oropharyngeal sealing pressure, hemodynamic response, oxygen saturation (SpO2), end-tidal CO2 (EtCO2), and peri- and postoperative complications were examined. Results. The SLIPA and I-gel devices were successfully inserted in 100% and 95% of subjects, respectively. In two I-gel subjects (5%), ventilation was not possible after two attempts, but a size 55 SLIPA was successfully inserted in both cases. Forty-two and 38 patients were ultimately included in the SLIPA and I-gel groups, respectively. Insertion time was significantly shorter with the SLIPA (11.19 ± 3.03 s) than with the I-gel (15.05 ± 6.37 s, P = 0.003). Oropharyngeal sealing pressure was significantly higher in SLIPA (28.76 ± 3.11 cmH2O) than in I-gel (25.9 ± 3.65 cmH2O) subjects (P = 0.001). Blood staining occurred more frequently in SLIPA (n = 8, 19.0%) than in I-gel (n = 5, 13.2%) patients (P < 0.01). Heart rate, mean arterial blood pressure, SpO2, and EtCO2 were not significantly different between groups. Conclusion. Although blood staining incidence was higher, SLIPA insertion was easier and faster than I-gel insertion. The SLIPA provided better airway sealing pressure. Both devices had similar mechanical ventilation and oxygenation characteristics and comparable hemodynamic stability. Both noninflatable SADs are useful, but SLIPA rapid insertion and good airway sealing make it an effective alternative to the I-gel.