Tehran University Medical Journal

Effective non-opioid drugs for pain control in laparoscopic cholecystectomy surgery: a narrative review study

Background: With the rapid advancement of minimally invasive surgical techniques, laparoscopic cholecystectomy has become one of the most frequently performed procedures worldwide. Despite its benefits, such as reduced postoperative complications and faster recovery, effective pain management remains a critical challenge. Postoperative pain can significantly impact patient recovery, hospital stay duration, and overall satisfaction. Given the limitations and side effects of opioid-based analgesics, there is growing interest in non-opioid alternatives for pain control following laparoscopic cholecystectomy. This narrative review evaluates the efficacy of various non-opioid analgesics in managing postoperative pain in patients undergoing this procedure.
Methods: A comprehensive literature search was conducted across multiple electronic databases, including Scopus, PubMed, Science Direct, SID, Magiran, and Google Scholar, using both Persian and English keywords. English equivalents were "Pain" and "Laparoscopic Cholecystectomy." Studies discussing pharmacological interventions for postoperative pain management in laparoscopic cholecystectomy were included.
Results: The review identified a wide range of non-opioid analgesics used for pain control in laparoscopic cholecystectomy patients. These included: Systemic medications (intravenous/oral) were magnesium sulfate, ketamine, ketorolac, paracetamol, ibuprofen, pregabalin, gabapentin, acetazolamide, N-acetylcysteine, dexamethasone, clonidine, celecoxib, and diclofenac. Local anesthetics & adjuvants were used intraperitoneally like bupivacaine, lidocaine, and hydrocortisone. Administration routes varied, with most drugs given intravenously, intraperitoneally, or preemptively (e.g., celecoxib and clonidine before surgery). Some studies highlighted the benefits of multimodal analgesia, combining different drug classes to enhance pain relief while minimizing side effects.
Conclusion: Despite the availability of numerous non-opioid analgesics, no single drug has been universally endorsed as the gold standard for postoperative pain management in laparoscopic cholecystectomy. Current evidence suggests that the choice of analgesic should be individualized, considering patient factors (e.g., comorbidities, pain tolerance) and the anesthesiologist’s expertise. Multimodal approaches, combining different drug classes, may offer superior pain control with fewer adverse effects compared to monotherapy. Further high-quality randomized trials are needed to establish standardized protocols and optimize pain management strategies for these patients.

The Efficacy of pregabalin and gabapentin in managing headache following subarachnoid hemorrhage: a systematic review

Faezeh Sharifi

Background: Subarachnoid hemorrhage (SAH) is a life-threatening emergency condition often accompanied by severe, sudden-onset headache. The main causes are head trauma and aneurysm rupture. Pain management in these patients remains challenging, typically requiring opioids which carry significant adverse effects. As anti-neuropathic agents, gabapentin and pregabalin may serve as suitable alternatives to opioids. This systematic review aimed to evaluate the efficacy and safety of gabapentin and pregabalin in managing SAH-associated headaches.
Methods: Following PRISMA guidelines, we conducted comprehensive searches in PubMed, SCOPUS, Web of Science, and EMBASE through May 2025. Key search terms included "Gabapentin," "Pregabalin," "Subarachnoid Hemorrhage," and "Headache." After initial screening, we selected English or Persian-language articles investigating these medications' effects on SAH-related headache. After removal of duplicates and screening, four eligible studies (including randomized controlled trials and cohort studies) were included for final analysis. Data on study type, sample size, type of interventions, headache management-related outcomes, as well as safety and tolerability profiles were extracted.
Results: Pregabalin demonstrated significant efficacy, showing a statistically significant reduction in pain intensity compared to placebo before anesthesia induction (P≤0.004) and up to 24 hours post-operatively (P=0.007). Additionally, patients receiving pregabalin required significantly fewer rescue analgesics (P≤0.005). In contrast, gabapentin did not produce a statistically significant reduction in pain intensity or morphine equivalent requirements compared to placebo, although a non-significant trend toward decreased pain was observed. Safety profiles were favorable for both medications; no serious adverse events leading to drug discontinuation were reported.
Conclusion: Pregabalin appears to be an effective, safe, and well-tolerated option for managing SAH-related headache, significantly reducing both pain intensity and opioid requirements. Current evidence for gabapentin remains limited and inconclusive, warranting further large-scale, randomized controlled trials to confirm its potential role in this setting.

Evaluation of the diagnostic value of blood cell count in the diagnosis of subarachnoid hemorrhage

Background: Subarachnoid hemorrhage is a life-threatening neurological emergency that requires rapid diagnosis to reduce morbidity and mortality. Acute headache is the most common presenting symptom of Subarachnoid hemorrhage; however, it overlaps with many benign conditions, making early differentiation difficult in emergency departments. Although brain computed tomography is the diagnostic gold standard, readily available laboratory markers may assist clinicians in early risk stratification. Complete blood count (CBC) derived inflammatory indices are inexpensive, rapidly obtainable, and routinely measured in emergency settings. This study aimed to evaluate the diagnostic value of CBC derived indices in distinguishing Subarachnoid hemorrhage from other causes of acute headache.
Methods: This study is a retrospective study conducted on patients who presented with acute headache to the emergency department of the educational and therapeutic hospital affiliated with Urmia University of Medical Sciences. Medical records of patients presenting with acute headache between January 2018 and December 2022 were reviewed. A total of 1,025 patients were included. Demographic data and initial laboratory parameters, including white blood cell count (WBC), neutrophil percentage, lymphocyte percentage, neutrophil to lymphocyte ratio (NLR), and platelet to lymphocyte ratio (PLR), were collected. Patients were classified into Subarachnoid Hemorrhage and non-Subarachnoid Hemorrhage groups based on brain CT scan findings and complementary diagnostic evaluations when required. Comparative analyses were performed, and the diagnostic performance of CBC derived indices was assessed using Receiver operating characteristic (ROC) curve analysis.
Results: Among the study population, 22 patients (2.1%) were diagnosed with Subarachnoid Hemorrhage. Patients with Subarachnoid Hemorrhage demonstrated significantly higher mean WBC counts and neutrophil percentages, along with significantly lower lymphocyte percentages, compared with non-Subarachnoid Hemorrhage patients (P<0.001). The mean NLR was higher in the Subarachnoid Hemorrhage group (7.23±4.92) than in the non-Subarachnoid Hemorrhage group (3.67±3.51, P<0.001). ROC curve analysis showed that NLR and neutrophil percentage had the highest diagnostic accuracy, each yielding an Area under the curve (AUC) of 0.76, indicating moderate discriminative ability.
Conclusion: CBC derived inflammatory indices, particularly NLR and neutrophil percentage, may serve as useful adjunctive screening tools for early identification of SAH in patients presenting with acute headache. However, these parameters should complement, rather than replace, definitive neuroimaging methods.

Comparison of changes in urodynamic testing after 5 years of deformity correction surgery in patients with idiopathic and congenital scoliosis referred to the neurosurgery clinic of Sina Hospital, Tehran from September 2016 to September 2018

Majid Pourfahraji Fakhrabadi

Background: Congenital scoliosis (CSC) and Idiopathic scoliosis (ISC) are complex spinal disorders that may involve neurological components affecting bladder function. Surgery remains the primary treatment for significant deformity, and in selected cases, correction of an associated tethered cord is also required. Given the potential interaction between spinal pathology and lower urinary tract function, this study examined changes in urodynamic findings before and after treatment in patients with CSC and ISC.
Methods: This retrospective cross-sectional study included patients with scoliosis who were presented to the Neurosurgery Clinic at Sina Hospital between September 2016 and September 2018. Preoperative and postoperative urodynamic study (UDS) results were reviewed, and statistical analyses were performed using SPSS version 24.
Results: Thirty-one patients were analyzed, consisting of 10 males (32.2%) and 21 females (67.7%), with a mean age of 14.18 years (median: 13 years). Among the 12 patients with CSC, 10 (83.3%) showed abnormal UDS prior to surgery. In contrast, 13 of 19 patients with ISC (68.4%) demonstrated normal baseline UDS. Following treatment, normalization occurred in 10 CSC patients (83.3%) and in 14 ISC patients (73.7%) (P=0.008). Before surgery, 15 of the 23 patients without a tethered cord (65.2%) had normal UDS, whereas all 8 patients with a tethered cord exhibited abnormal findings. Of the 12 patients with abnormal preoperative UDS, 3 (25%) showed no postoperative change, while 12 patients demonstrated normalization and 4 continued to show abnormal results (McNemar test, P=0.039). Improvement was also observed in 7 of the 8 patients (87.5%) with a tethered cord (P=0.57).
Conclusion: Scoliosis surgery, particularly when combined with tethered cord release, was associated with meaningful improvement in urodynamic function. Urodynamic abnormalities were more common among CSC patients before intervention, and the presence of a tethered cord contributed to greater urinary dysfunction across both scoliosis types. These findings highlight the importance of thorough preoperative urodynamic assessment to guide management and anticipate postoperative outcomes.

Comparison of hemorrhoidectomy complications in elderly and non-elderly patients: a retrospective longitudinal study

Hosein Shiri

Background: Since multiple factors contribute to the occurrence of postoperative complications and these risk factors are generally more prevalent among elderly individuals compared to younger patients this study was conducted to compare the complications of hemorrhoidectomy between elderly and non-elderly patients.
Methods: For each patient, a data collection form was completed, including demographic characteristics (age, sex, body mass index, ASA class, and comorbidities), as well as laboratory and disease-related information. Postoperative complications assessed were bleeding, anal fissure, rectal stenosis, anal pain, hemorrhoid recurrence, reoperation, postoperative infection, pruritus, and urinary tract infection.
Results: The findings indicated that the lymphocyte-to-monocyte ratio LMR Lymphocite to Monocye Ratio) was associated with a reduced incidence of complications, whereas both the neutrophil-to-lymphocyte ratio (NLR) and C-reactive protein CRP (c_reactive protein) levels were associated with an increased incidence of complications. Furthermore, hemorrhoid grade, disease duration, number of hemorrhoidal nodules, preoperative pain severity, and chronic preoperative pain were all significantly associated with a higher likelihood of postoperative complications in elderly patients.
Conclusion: This study demonstrates that several factors including hematologic ratios (LMR, NLR), CRP (c_reactive protein) levels, hemorrhoid grade, disease duration, number of hemorrhoidal nodules, preoperative pain severity, and chronic preoperative pain are significantly associated with the occurrence of postoperative complications following hemorrhoidectomy in elderly patients.

Prevalence of hypertension in patients with coronary artery disease and its relationship with the severity of pulmonary involvement in patients admitted to Shahid Mostafa Khomeini Hospital in Ilam

Ali Zeinyvand

Background: The COVID-19 epidemic is predicted to cause another NCDs epidemic. The fact that hypertension, as well as other forms of cardiovascular disease, is frequently seen in COVID-19 patients has led to the fact that most patients with SARS-COV-2 are treated with angiotensin converting enzyme inhibitors (ACEIs) and blockers. Angiotensin receptor (ARB) be treated. So far, no study has been conducted on the prevalence of hypertension in patients with coronary heart disease and its relationship with pulmonary involvement. Let's do it.
Methods: This retrospective cross-sectional comparative study is performed on the records of patients admitted to Shahid Mostafa Khomeini Hospital in Ilam with a diagnosis of COVID-19. It was carried out in the summer of 2021 to the summer of 2023. At the time of hospitalization, patients' blood pressure is calculated and recorded according to standard criteria. The degree of hypoxia is also assessed using a pulse oximeter according to the set criteria.
Results: In this study, the mean age of patients aged 54.65 years in the age range of 18-95 years. The correlation coefficient of systolic blood pressure is directly related to pulmonary involvement, but this relationship is not statistically significant. At the age of less than 60 years, the correlation coefficient between systolic blood pressure and pulmonary involvement with age is positive and significant, but at the age of more than 60 years, this relationship is inverse and not significant. The relationship between systolic blood pressure and pulmonary involvement is direct and significant. A linear correlation coefficient was reported between systolic blood pressure and pulmonary involvement with a history of direct hypertension.
Conclusion: In the present study, the prevalence of hypertension was 19.5% and using Pearson linear correlation test, it was shown that there is a direct relationship between blood pressure correlation coefficient with pulmonary involvement, but this relationship was not statistically significant. This relationship was reported to be direct and significant for the age group under 60 years. It was also direct and significant in men.

Addressing concurrent hypoglycemia and thrombocytopenia in a neonate: a case report

Background: Neonatal hypoglycemia is a common metabolic disturbance during the first days of life, particularly in infants with risk factors such as prematurity, perinatal stress, intrauterine growth restriction, or maternal diabetes. Early onset thrombocytopenia within the first 72 hours is often attributed to placental insufficiency and reduced platelet production, whereas persistent hypoglycemia beyond this period may indicate sepsis, necrotizing enterocolitis, or hyperinsulinemic states. Given that perinatal stress and asphyxia can predispose to both hypoglycemia and thrombocytopenia, simultaneous presentation of these conditions may complicate diagnosis and management. This case report describes a neonate with persistent hypoglycemia and thrombocytopenia unresponsive to standard therapies, ultimately attributed to transient hyperinsulinism.
Case Presentation: This case was managed and documented at Valiasr Hospital, Tehran University of Medical Sciences, in April 2023. A late preterm female infant born at 36+2 weeks via emergency cesarean section for intrauterine growth restriction and fetal distress presented with hypotonia and hypoglycemia (38 mg/dL) at 15 hours of life. Despite intravenous dextrose infusion up to 13 mg/kg/min, recurrent hypoglycemia persisted. Concurrently, severe thrombocytopenia (26,000/µL) was noted, unresponsive to platelet transfusion and intravenous immunoglobulin. Maternal platelet count was normal, excluding autoimmune etiologies. On day six, a glucagon stimulation test demonstrated a rise in glucose from 44 to 78 mg/dL, confirming hyperinsulinemic hypoglycemia. Laboratory evaluation revealed elevated insulin levels with absent ketones. Glucagon infusion was initiated, followed by diazoxide therapy (15 mg/kg/day) beginning on day ten. After two doses, glucose levels stabilized above 50 mg/dL, allowing gradual reduction of intravenous fluids. Remarkably, platelet counts normalized within five days of diazoxide initiation. Diazoxide was tapered and discontinued by day 27, and the infant was discharged on day 31 with stable glucose levels and normal platelet counts.
Conclusion: This case highlights the coexistence of transient hyperinsulinemic hypoglycemia and thrombocytopenia in a neonate, both of which responded to diazoxide therapy. The temporal relationship suggests a potential modulatory effect of insulin or diazoxide on platelet dynamics. Further clinical and mechanistic studies are needed to clarify this association.

Correction of severe kyphosis in a patient with high pelvic incidence: a case report

Ahmad Ghorbanpour Barforoshi

Background: Severe spinal kyphosis, particularly in patients with sagittal imbalance and high Pelvic incidence (PI), represents one of the most challenging conditions in spinal surgery. This deformity is commonly associated with chronic pain, functional limitation, and a decreased quality of life.
Case Presentation: A 66 year old woman presented with progressively worsening radicular pain, gait impairment, early fatigue while standing, and a severe kyphotic deformity with marked sagittal imbalance. Her history was significant for an instrumented lumbar fusion from L3 to S1 performed in March 2023, complicated by persistent right foot drop, followed approximately five weeks later by rehospitalization for herpetic encephalitis; concurrent imaging demonstrated inflammatory changes at the L5-S1 disc space suspicious for discitis, although CT guided biopsy cultures were negative. Her medical comorbidities included type 2 diabetes mellitus and prior coronary artery bypass grafting. Radiographic and spinopelvic analysis revealed adjacent segment disease at L2-L3 and severe sagittal malalignment with a pelvic incidence of 88°, lumbar lordosis of 30°, and sagittal vertical axis of 25 cm. Given the significant PI-LL mismatch and progressive postural collapse, revision deformity surgery was indicated. The patient underwent a Smith-Petersen osteotomy at L5-S1 with long segment posterior fixation from T11 to S2, including iliac screw fixation, between August and September 2025. Postoperatively, lumbar lordosis improved to 45°, pelvic incidence decreased to 65°, and global sagittal alignment was restored, resulting in marked pain relief, improved standing tolerance, correction of spinal balance, and stable neurological status during recovery.
Conclusion: Postoperatively, significant improvement in sagittal balance was achieved, with LL increasing to 45° and PI decreasing to 65°, leading to marked functional recovery and pain relief. This case powerfully demonstrates the correlation between a high Pelvic incidence (PI) and prior surgical failure. It serves as an important didactic example in understanding the biomechanical drivers of sagittal deformity, emphasizing the optimization of safer, corrective surgical techniques for high-risk, complex patients to ensure durable global alignment.

Use of propofol before umbilical cord clamping in cesarean surgery un-der spinal anesthesia in mothers with nausea and anxiety: a letter to ed-itor

Farzaneh Jadidi