Tadalafil versus tamsulosin as combination therapy with 5-alpha reductase inhibitors in benign prostatic hyperplasia, urinary and sexual outcomes.

PURPOSE: To compare the urological and sexual outcomes of using either tamsulosin/finateride or tadalafil/finasteride as combination therapies in patients with large prostate. PATIENTS AND METHODS: Selection criteria included prostate volume > 40 ml and IPSS > 7. Patients with severe erectile dysfunction (IIEF-erectile functions ≤ 10) were excluded. Patients were randomized into group I (tamsulosin/finasteride) and group II (tadalafil/finasteride). The primary endpoint was to define urinary and sexual function changes (IPSS, IPSS-quality of life, urinary flow rates and IIEF domains) within each group. The secondary endpoint was to compare the treatment induced changes between both groups. RESULTS: At 4th and 12th weeks, 131 and 127 patients were available in both groups, respectively. Both groups showed significant LUTS improvement (IPSS changes: - 4.9 ± 2.7 and - 4.3 ± 2.9 at 4th week and - 6.1 ± 3 and - 5.4 ± 2.8 points by the 12th week in both groups, respectively). Group I had better average flow rates at both follow-up visits. Meanwhile, maximum flow rates were comparable in both groups at 12th week (13.5 ± 3.9vs. 12.6 ± 3.7, p > 0.05). In group I, all IIEF domains were significantly lowered at both visits (p < 0.05). Group II showed significant increase in IIEF-erectile function scores (1.3 ± 1.1 and 1.8 ± 1.2 at the 4th and 12th weeks) with a transient significant reduction of IIEF-orgasm and sexual desire noted only by the 4th week (- 0.8 ± 0.4 and - 0.6 ± 0.4, respectively). CONCLUSION: Within three months, both combinations are comparably effective in improving BPH related LUTS. Tamsulosin/finasteride provided significantly better Qmax only at 4th week. Tadalafil/finasteride had the advantage of improving sexual performance over the other combination.

The ARISCAT Risk Index as a Predictor of Pulmonary Complications After Thoracic Surgeries, Almoosa Specialist Hospital, Saudi Arabia.

Background: Pulmonary complications after thoracic surgery are common and are associated with prolonged hospital stay, higher costs, and increased mortality. This study aimed to evaluate the value of The Assess Respiratory risk in Surgical Patients in Catalonia (ARISCAT) risk index in predicting pulmonary complications after thoracic surgery. Methods: This retrospective study was conducted at Almoosa Specialist Hospital, Saudi Arabia, from August 2016 to August 2019 and included 108 patients who underwent thoracic surgery during the study period. Demographic data, ARISCAT risk index score, length of hospital stay, time of chest tube removal, postoperative complications, and time of discharge were recorded. Results: The study involved 108 patients who met the inclusion criteria. Their mean age was 42.5 ± 18.9 years, and most of them were men (67.6%). Comorbid diseases were present in 53.7%, including mainly type 2 diabetes mellitus and hypertension. FEV1% was measured in 58 patients, with a mean of 71.1 ± 7.3%. The mean ARISCAT score was 39.3 ± 12.4 and ranged from 24 to 76, with more than one-third (35.2%) having a high score grade. The most common surgical procedures were thoracotomy in 47.2%, video-assisted thoracoscopic surgery (VATS) in 28.7%, and mediastinoscopy in 17.6%. Postoperative pulmonary complications (PPCs) occurred in 22 patients (20.4%), mainly pneumonia and atelectasis (9.2%). PPCs occurred most frequently during thoracotomy (68.2%), followed by VATS (13.6%), and mediastinoscopy (9.1%). Multinomial logistic regression of significant risk factors showed that lower FEV1% (OR = 0.88 [0.79-0.98]; p=0.017), longer ICU length of stay (OR = 1.53 [1.04-2.25]; p=0.033), a higher ARISCAT score (OR = 1.22 [1.02-1.47]; p=0.040), and a high ARISCAT grade (OR = 2.77 [1.06-7.21]; p=0.037) were significant predictors of the occurrence of postoperative complications. Conclusion: ARISCAT scoring system, lower FEV1% score, and longer ICU stay were significant predictors of postoperative complications. In addition, thoracotomy was also found to be associated with PPCs.

Common Presentation of Uncommon Disease: Inflammatory myofibroblastic tumor of the lung, case report.

Background: Inflammatory myofibroblastic tumor (IMT) of the lung is a rare lung tumor, accounting for 0.7% of all lung tumors. They are usually benign, but can invade surrounding structures, undergo malignant transformation, recur, or even metastasize. Case report: We report a 44-year-old adult diabetic male from Saudi Arabia who had been suffering from cough with severe sputum and left shoulder pain for 2 weeks. Chest radiography (X-ray and computed tomography (CT)) revealed the presence of a mass lesion in the left lower upper lobe with central cavitation. The diagnosis of inflammatory myofibroblast lung tumor was confirmed by histological and immunohistochemical examination of the CT guided lung biopsy. The patient was successfully treated with surgical resection of the tumor by left limited thoracotomy with safety margin, and IMT was also documented. Conclusion: A high degree of suspicion of a solitary pulmonary mass is required for diagnosis and management of an inflammatory myofibroblastic lung tumor. The clinical and radiologic presentation of an inflammatory myofibroblastic tumor is nonspecific and the diagnosis is rarely made before surgical biopsy. Histologic and immunohistochemical examination is usually required to confirm the diagnosis and prevent recurrence.

Modified Pectoral Nerve Block versus Serratus Block for Analgesia Following Modified Radical Mastectomy: A Randomized Controlled Trial.

BACKGROUND: Modified pectoral nerves (PECSII) and serratus blocks have been recently used for analgesia in breast surgery, but evidence comparing their analgesic benefits is limited. This prospective randomized, controlled study aims to examine the analgesic efficacy and safety profile of ultrasound-guided PECSII versus serratus blocks in patients undergoing modified radical mastectomy (MRM) for breast cancer. PATIENTS AND METHODS: One-hundred and eighty adult females scheduled for MRM were randomly allocated to three groups. PECS group patients received a PECSII block with 30mL of bupivacaine 0.25%, whereas SAPB group received a serratus anterior plane block (SAPB) using the same volume of bupivacaine 0.25% before induction of anesthesia. The control group received general anesthesia alone. Outcomes included 24 hours morphine consumption, intraoperative fentanyl requirements, visual analogue scale (VAS) scores for pain at rest and during movement, time to first rescue analgesia, postoperative nausea and vomiting (PONV), and sedation scores. RESULTS: Both PECSII and serratus blocks were associated with reduced postoperative morphine consumption compared to the control group (p<0.001). Both blocks were associated with reduced intraoperative fentanyl requirements, VAS scores, and PONV as compared with the control group. Also, they were associated with prolonged time to first rescue analgesia and better sedation scores in comparison with the control group. However, there were no differences between both blocks for all outcomes. CONCLUSION: PECSII and serratus blocks provide similarly adequate analgesia following modified radical mastectomy. CLINICAL TRIAL REGISTRATION: NCT02946294.

Comparative study between sugammadex and neostigmine in neurosurgical anesthesia in pediatric patients.

BACKGROUND: Postoperative recurarization remains a risk following the use of the conventional neuromuscular blocking agents. In addition, none of the commonly used reversal agents, such as neostigmine or edrophonium are capable of reliably reversing profound blockade. The present comparative and randomized study investigated the use of sugammadex for reversing profound neuromuscular blockade (NMB) in pediatric neurosurgical patients undergone posterior fossa tumor excision. PATIENTS AND METHODS: Forty pediatric patients undergoing elective craniotomy for posterior fossa tumor excision were randomly divided into either of neostigmine or sugammadex group in which muscle relaxant was reversed at the end of anesthesia either with neostigmine 0.04 mg/kg added to atropine 0.02 mg/kg or sugammadex 4 mg/kg alone, respectively. The primary endpoint was the time from the administration of sugammadex or neostigmine to recovery of the train of four (TOF) ratio to 90% after rocuronium-induced neuromuscular block. Unpaired t-test was used to compare continuous variables between groups. Meanwhile, repeated ANOVA was used to detect intragroup differences. RESULTS: Patients in sugammadex group attained a TOF ratio 90% in statistically shorter time (1.4 ± 1.2 min) than those in neostigmine group (25.16 ± 6.49 min) for reversal of the rocuronium. Mean arterial pressure and heart rate were significantly higher in neostigmine group at 2, 5 and 10 min after administration of the reversal agents and returned nonsignificantly different after that. With no recurarization in any patient throughout the study period. CONCLUSION: Sugammadex rapidly and effectively reverses rocuronium-induced NMB in pediatric patients undergoing neurosurgery when administered at reappearance of T2 of TOF at dose 4 mg/kg.

Splenic abscess associated with infective endocarditis; Case series.

Splenic abscess is a well-described but rare complication of infective endocarditis. Rapid diagnosis and treatment are essential as its course can be fatal. We present three case reports that describe the management of splenic abscesses in patients initially diagnosed with infective endocarditis. In all cases, the diagnosis was based on the findings of abdominal computed tomography (CT) scan or magnetic resonance imaging (MRI). In two of the cases, splenectomy was performed before valve surgery; while in the third case, the spleen was removed after cardiac surgery. All three patients recovered fully, with satisfactory follow-up as outpatients. Immediate splenectomy, combined with appropriate antibiotics and valve replacement surgery alongside multi-disciplinary team work could be the treatment of choice in this clinical scenario.

Awakening properties of isoflurane, sevoflurane, and desflurane in pediatric patients after craniotomy for supratentorial tumours.

BACKGROUND: The aim of this prospective, comparative, randomized study was to compare the inhalational anesthetics isoflurane, sevoflurane, and desflurane in pediatric patients undergoing craniotomy for excision of supratentorial tumors. We assessed early postoperative recovery outcome, intraoperative hemodynamics, and degree of brain swelling, as well as postoperative vomiting and shivering. METHODS: Sixty patients scheduled for supratentorial brain tumor excision, were randomly allocated into 1 of 3 groups (20 patients each); isoflurane, sevoflurane, and desflurane group. After IV induction of anesthesia, maintenance was achieved using the inhalational anesthetic according to the allocated group. Tracheal extubation time was the primary endpoint. The secondary endpoints included: emergence time and the interval time needed to reach Aldrete score ≥9, intraoperative degree of brain swelling, intraoperative heart rate and mean arterial blood pressure, as well as postoperative vomiting and shivering. RESULTS: The mean emergence time, extubation time, and the interval required to reach Aldrete score 9 were significantly shorter in the desflurane and sevoflurane groups than the isoflurane group. No statistically significant changes in the 3 groups regarding intraoperative brain swelling, hemodynamics, and postoperative shivering or vomiting were noted. CONCLUSIONS: Desflurane and sevoflurane can be used to facilitate early emergence from anesthesia in neurosurgical pediatric patients. Emergence times are shorter with desflurane or sevoflurane than with isoflurane. The patients who received desflurane or sevoflurane have similar intraoperative and postoperative incidence of adverse effects compared with those who received isoflurane. Thus, desflurane and sevoflurane can be considered as suitable for emergence in pediatric neurosurgical anesthesia.

Comparative study between computed tomography guided superior hypogastric plexus block and the classic posterior approach: A prospective randomized study.

CONTEXT: The classic posterior approach to superior hypogastric plexus block (SHPB) is sometimes hindered by the iliac crest or a prominent transverse process of L5. The computed tomography (CT) - guided anterior approach might overcome these difficulties. AIMS: This prospective, comparative, randomized study was aimed to compare the CT guided anterior approach versus the classic posterior approach. SETTINGS AND DESIGN: Controlled randomized study. MATERIALS AND METHODS: A total of 30 patients with chronic pelvic cancer pain were randomized into either classic or CT groups where classic posterior approach or CT guided anterior approach were done, respectively. Visual analog score, daily analgesic morphine consumed and patient satisfaction were assessed just before the procedure, then, after 24 h, 1 week and monthly for 2 months after the procedure. Duration of the procedure was also recorded. Adverse effects associated with the procedure were closely observed and recorded. STATISTICAL ANALYSIS USED: Student's t-test was used for comparison between groups. RESULTS: Visual analog scale and morphine consumption decreased significantly in both groups at the measured times after the block compared with the baseline in the same group with no significant difference between both groups. The procedure was carried out in significantly shorter duration in the CT group than that in the classic group. The mean patient satisfaction scale increased significantly in both groups at the measured times after the block compared with the baseline in the same group. The patients in the CT groups were significantly more satisfied than those in classic group from day one after the procedure until the end of the study. CONCLUSIONS: The CT guided approach for SHPB is easier, faster, safer and more effective, with less side-effects than the classic approach.

Hybrid Approach to Repair Type A Aortic Dissection: Combined Endovascular Superior Mesenteric Artery Stenting and Bentall Procedure.

A Stanford Type A aortic dissection is a life-threatening surgical emergency that requires emergent surgery. The mortality after repair is high especially if the aortic dissection is complicated by visceral or peripheral malperfusion. We describe a case of a male patient who presented with an aortic dissection involving the ascending aorta, aortic arch, descending thoracic aorta, and the abdominal aorta down to the iliac bifurcation. The dissection also involved the visceral and renal arteries with evidence of superior mesenteric artery (SMA) occlusion. Successful outcome was achieved by endovascular stenting of the patient's SMA, followed by a Bentall procedure. To the best of our knowledge this is the first case report in the English literature of SMA stenting followed by a Bentall procedure to treat acute Type A aortic dissection complicated by SMA occlusion.

Characterizing game dynamics in two-player strategy games using network motifs.

Many complex systems, whether biological, sociological, or physical ones, can be represented using networks. In these networks, a node represents an entity, and an arc represents a relationship/constraint between two entities. In discrete dynamics, one can construct a series of networks with each network representing a time snapshot of interaction among the different components in the system. Understanding these networks is a key to understand the dynamics of real and artificial systems. Network motifs are small graphs-usually three to four nodes-representing local structures. They have been widely used in studying complex systems and in characterizing features on the system level by analyzing locally how the substructures are formed. Frequencies of different network motifs have been shown in the literature to vary from one network to another, and conclusions hypothesized that these variations are due to the evolution/dynamics of the system. In this paper, we show for the first time that in strategy games, each game (i.e., type of dynamism) has its own signature of motifs and that this signature is maintained during the evolution of the game. We reveal that deterministic strategy games have unique footprints (motifs' count) that can be used to recognize and classify the game's type and that these footprints are consistent along the evolutionary path of the game. The findings of this paper have significance for a wide range of fields in cybernetics.