Tehran University Medical Journal

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Ingestion of fish oil fatty acids (omega - 3 fatty acids ) inhibits the formation of arachidonic acid - derived cytokines and leads to production of compounds with diminished biological activity. Beneficial effects of dietary supplementation with fish oil in rheumatoid arthritis have been shown in many controlled trials.
Methods : 43 patients with active rheumatoid arthritis entered in a prospective, double-blind, placebo-controlled clinical trial to recieve either lOgr fish oil daily (treatment group) or corn oil (placebo group). Baseline drugs and usual diet were continued without any changes. Disease variables were evaluated at baseline and after completion of study period.
The changes in disease variables were compared by paired t-tesl in each group. Comparison of the two groups was done by t-test. Functional capacity was compared by Wilcoxon ranks test.
Results : 19 patients in treatment group and 20 patients in placebo group completed the study which lasted eight weeks . In the treatment group, joint pain index decreased from 30±11 at baseline, to 18±11 at the end of study period (P < 0.01). Joint swelling index decreased from 8 ± 4 to 2 ± 4, (P< 0.01), morning stiffness from 87 ± 41 to 24±16 minutes (P < 0.01). In the placebo group the above variable changes were from 19±14 to 25±14 8±8 to 7±6 and 80±71 to 76±75 minutes respectively, which were not significant . The differences between the treatment and placebo groups were significant in joint swelling index (P < 0.05), morning stiffness (P<0.01) and functioal capacity (p< 0.005), the differences in joint pain index and grip strenght did not quite achieve statstical significance. During study period there were no adverese effects with fish oil consumption.
Conclusion : Fish oil supplemention has anti-inflamatory effects in rheumatoid arthritis. Further studies are needed to recommend its long - term usage concomittant with other drugs in all patients

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Background: Surgical wound infection surveillance is an important facet of hospital infection control processes. There are several surveillance methods for surgical site infections. The objective of this study is to evaluate the accuracy of two different surgical site infection surveillance methods.
Methods: In this prospective cross sectional study 3020 undergoing surgey in general surgical wards of Imam Khomeini hospital were included. Surveillance methods consisted of review of medical records for postoperative fever and review of nursing daily note for prescription of antibiotics postoperatively and during patient’s discharge. Review of patient’s history and daily records and interview with patient’s surgeon and the head-nurse of the ward considered as a gold standard for surveillance.
Results: The postoperative antibiotic consumption especially when considering its duration is a proper method for surgical wound infection surveillance. Accomplishments of a prospective study with postdischarge follow up until 30 days after surgery is recommended.
Conclusion: The result of this study showed that postoperative antibiotic surveillance method specially with consideration of the antibiotic usage duration is a proper method for surgical site infection surveillance in general surgery wards. Accomplishments of a prospective study with post discharge follow up until 30 days after surgery is recommended.

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Background: For patients requiring chronic hemodialysis, the preferred site for vascular access is an autogenous arteriovenous fistula. Although a properly formed fistula is advantageous because it is less susceptible than other types of vascular accesses to infection and clot formation and can last longer than any other types of vascular access, AV fistula has a high rate of early failure that can increase immediate cost and complications. In this study, the prognostic value of physical examination of arteriovenous fistula by the surgeon at the end of the surgery was evaluated.
Methods: In the general surgery ward of Imam Khomeini Hospital in 326 chronic renal failure patients, 354 arteriovenous fistula operations were accomplished by two surgeons from 1377 to 1381 (ca. 1998 to 2002). The performance of each fistula was divided into the following groups by the surgeon at the end of operation: 1) systolic and diastolic thrill, 2) systolic thrill 3) souffle 4) pulse 5) not functional. Clinical function of the fistula was evaluated by the same surgeon in the following days if no souffle or thrill, early failure was detected on initial inspection.
Results: In the 354 cases of arteriovenous fistula, the total early failure rate was 12.7%. The lowest early-failure rate was 3.5% in the systolic and diastolic thrill group. The highest early-failure rate was in the not functional group (P<0.001). There was no correlation between early failure and age, sex, surgeon and location of fistula.
Conclusion: Optimally, an arteriovenous fistula has a thrill with a soft compressible pulse. At the end of each operation, if the surgeon cannot detect a thrill at the fistula site, can find only pulse, or if the function is otherwise unsatisfactory, considering of a new arteriovenous fistula may be required, however it is better to postpone the surgery.

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Background: Cardiac herniation is a fatal post pneumonectomy complication. We report the signs, clinical findings, diagnosis and management of a patient with post pneumonectomy cardiac herniation.

Case report: A 34-year-old man with lung cancer underwent left pneumonectomy with partial pericardiectomy in the right lateral decubitus position. At the end of the surgery, cardiovascular collapse, severe bradycardia, desaturation and elevated airway pressure occurred just after repositioning the patient to the supine position. This patient survived as we returned him to the right lateral decubitus position and avoided the use of positive pressure ventilation.

Conclusions: Attention to the acute complications of pneumonectomy, diagnosis and rapid therapeutic interventions is essential in post pneumonectomy care.

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Background: Total spinal anesthesia is a complication of lumbar epidural anesthesia following undiagnosed subarachnoid or subdural injection of local anesthetic. Although many achondroplastic dwarfs have a normal spine, catheter insertion may be more problematic with a narrow epidural space making a subarachnoid tap more probable.  Other malformations associated with achondroplasia, such as prolapsed intervertebral discs, reduced interpedicular distance, shortened pedicles, and osteophyte formation, combined with a narrow epidural space may make identification of the space difficult and increases the risk of dural puncture. Furthermore, subarachnoid tap or dural puncture may be hard to recognize if a free flow of CSF is difficult to achieve due spinal stenosis. Yet, for those who meet the criteria, epidural regional anesthesia is frequently preferred over other forms, which often have more or more dangerous side effects in this type of patient.

Case report: A 22-year-old achondroplastic male dwarf patient was scheduled for pelvic mass resection and was considered a candidate for continuous epidural anesthesia. The anesthesia became complicated by total spinal anesthesia, which was reversed following supportive management for about two hours.

Conclusion: There is significant debate over the composition and volume of the test dose, especially for patients with achondroplasia. We nevertheless recommend repeated test-doses during the accomplishment of epidural anesthesia to exclude unintended intravascular, intrathecal or subdural injection, keeping in mind that a test dose of local anesthetic does not completely prevent complications.

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Background: post operative pain is an essential problem. Epidural infusion of two different doses of bupivacaine in pain management of post orthopedic surgeries was studied.

Methods: In this double blinded randomized clinical trial we studied two groups of 42 patients undergone knee surgery. Based on block randomization, patients received two different concentration of bupivacaine (0.1% or 0.125%) in combination with fentanyl (1.7µg/ml). The beginning infusion rate was 5ml/h. Pain scores were documented by a blinded researcher 6, 12, 18, 24 and 48 hours after completion of surgery according to VAS tool. Patient satisfaction, complications and treatment failure (when increased volume of epidural infusion or other analgesics were required) were evaluated.

Results: In higher bupivacaine dose group, post operative pain scores were not significantly lower in different hours and during the follow up (both p values less than 0.001). After 48 hours, patients satisfaction were more in the higher bupivacaine group. There were no significant differences in complications. Treatment failure was more significant in lower bupivacaine dose (33.3% versus 11.9%, p=0.03).

Conclusion: continuous epidural infusion of both bupivacaine and fentanyl provide acceptable post operative pain control in orthopedic patients. Although higher concentrations of bupivacaine during first hours are more effective, lower concentrations are as effective as the higher one, during subsequent hours.

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Background: Anal surgeries are prevalent, but they didn't perform as outpatient surgeries because of concerns about postoperative pain. The aim of the present study was to compare the effects of rectal acetaminophen and diclofenac on postoperative analgesia after anal surgeries in adult patients.

Methods: In a randomized, double-blinded, placebo-controlled study 60 ASA class I or II scheduled for haemorrhoidectomy, anal fissure or fistula repair, were randomized (with block randomization method) to receive either a single dose of 650 mg rectal acetaminophen (n=20), 100 mg rectal diclofenac (n=20) or placebo suppositories (n=20) after the operation. The severity of pain, time to first request of analgesic agent after administration of suppositories and complications were compared between three groups. Pain scores were evaluated in patients by Visual Analogue Scale (VAS) in 0 (after complete consciousness in recovery), 2, 4, 12 and 24 hours after surgery. The period between administration of the suppositories and the patients' first request to receive analgesic was compared between groups.

Results: Pain scores were lower significantly in rectal diclofenac than the other groups. The period between administration of the suppositories and the patients' first request to receive analgesic in diclofenac group was 219±73 minutes, was significantly longer compared with placebo (153±47 minutes) and acetaminophen (178±64 minutes) groups. No complications were reported.

Conclusions: Diclofenac suppository is more effective than acetaminophen suppository in post hemorrhoidectomy pain management.

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Normal 0 false false false EN-GB X-NONE AR-SA MicrosoftInternetExplorer4 Background: Successful brachial plexus blocks rely on proper techniques of nerve localization, needle placement, and local anesthetic injection. Standard approaches used today (elicitation of paresthesia or nerve-stimulated muscle contraction), unfortunately, are all "blind" techniques resulting in procedure-related pain and complications. Ultrasound guidance for brachial plexus blocks can potentially improve success and complication rates. This study presents the ultrasound-guided brachial plexus blocks for the first time in Iran in adults and pediatrics.
Methods: In this study ultrasound-guided brachial plexus blocks in 30 patients (25 adults & 5 pediatrics) scheduled for an elective upper extremity surgery, are introduced. Ultrasound imaging was used to identify the brachial plexus before the block, guide the block needle to reach target nerves, and visualize the pattern of local anesthetic spread. Needle position was further confirmed by nerve stimulation before injection. Besides basic variables, block approach, block time, postoperative analgesia duration (VAS<3 was considered as target pain control) opioid consumption during surgery, patient satisfaction and block related complications were reported.
Results: Mean adult age was 35.5±15 and in pediatric group was 5.2±4. Frequency of interscalene, supraclavicular, axillary approaches to brachial plexus in adults was 5, 7, 13 respectively. In pediatrics, only supraclavicular approach was accomplished. Mean postoperative analgesia time in adults was 8.5±4 and in pediatrics was 10.8±2. No block related complication were observed and no supplementary, were needed.

Conclusions: Real-time ultrasound imaging during brachial plexus blocks can facilitate nerve localization and needle placement and examine the pattern and extend of local anesthetic spread.

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Normal 0 false false false EN-GB X-NONE AR-SA MicrosoftInternetExplorer4 Background: Bispectral index (BIS index) shows the depth of anesthesia. The effects of drugs on BIS and amnesia are different. This study was performed to evaluate the association between two different sedative regimens on BIS and amnesia.
Methods: In this clinical trial, 60 patients who needed elective orthopedic surgery under regional anesthesia with intravenous sedation were elected. Patients divided in two equal groups based on sedation protocol by block randomization method: midazolam plus fentanyl group (MF group) or propofol group (P group). Dose of sedative drugs were adjusted according to clinical findings of sedation. Depth of sedation in all patients, preserved in four based on modified Ramsey Sedation Score. Patients questioned about spontaneous recall after full awakening in recovery room. Recall of any event during operation considered as failed amnesia. Correlation of BIS index with recall was measured in two different groups separately.
Results: The frequency of recall was 2 (6.7%) in P group and 10 (33.3%) in MF group (p=0.01). The mean± SD of BIS in P group was 76±5 (68-91) and in MF group was 93.4±5 (77-98) (p<0.001). The difference of BIS in patients without amnesia (p=0.019) and with amnesia (p<0.001) in two groups were significant, respectively. No delay in recovery was observed.
Conclusion: Although the Modified Ramsey Sedation Score and clinical sedation indices were the same, but BIS in patients varied in a wide range. Hypnotic drug was a main determinant of BIS score and amnesia.

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Background: Inadequate ventilation, esophageal intubation and difficult intubation are the most common adverse respiratory outcomes in patient undergoing anesthesia .The aim of this study was to compare Mallampati test in supine and sitting positions in traditional approach and during phonation for predicting difficult laryngoscopy and intubation.
Methods: In this study performed in Imam Khomeini Hospital in Tehran, Iran, Mallampati test was performed on 661 patients who met the inclusion criteria for the study. The test was done in supine and sitting positions with and without phonation by a rater who was blind to Mallampati test. Subsequently, laryngoscopy view and difficult intubation were evaluated in the four aforesaid positions by Mallampati test for predicting difficult laryngoscopy and intubation. For each situations, sensitivity, specificity, positive and negative predictive values and accuracy were calculated.
Results: Overall, 28 (4.2%) patients had difficult laryngoscopy and 9 (1.4%) patients had difficult intubation. The highest sensitivity for Mallampati test in predicting difficult laryngoscopy and intubation was in supine and sitting positions without phonation, and the highest specificity was seen in sitting position with phonation. Negative predictive values were more than 95% in all different positions for Mallampati tests and the highest positive predictive value was seen in supine position with phonation.
Conclusion: According to our findings, the highest correlation between Mallampati test and different positions in predicting difficult laryngoscopy and intubation was seen in supine position with phonation. Phonation improved Mallampati score in supine rather than sitting position.

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Background: Education is the main mission of teaching hospitals, but the residents’ learning in acquiring new techniques does interfere in the overall treatment process of patients. Studies pertaining to the effect of anesthesia residents’ training in operating room on treatment procedures have reported conflicting results. Therefore, this study was performed to investigate the effects of anesthesia residents’ training on start time operative delays. Methods: This cohort study was done in neurosurgical operating room, Imam Khomei-ni Hospital, Tehran, Iran during 2010-2013 on a population study comprising of sec-ond year anesthesia residents. Patients were classified into three groups with 30 cases in each one according to the anesthetic team. Group I: one anesthesiologist in charge of two operating rooms and two anesthesia assistants Group II: one anesthesiologist in charge of one operating room and one assistant Group III: one anesthesiologist with-out an assistant. Patients in these groups were compared in terms of American society of anaesthesiologists (ASA) class, induction difficulties and type of surgery. Studied variables included :1) Interval between the patient lying on the bed to till anesthesia, 2) the time devoted to teaching residents, 3) time from the start of anesthesia until the start of surgery. An observer that was blinded to the type of intervention and the study design, recorded the times. Results: ASA class (P= 0.94), induction difficulties (P= 0.66) and type of surgery (spinal cord or brain operation) (P= 0.41) were not statistically different between patients in groups. Preoperative preparation time for the first group (23.5±8.1 min) was longer than the other two groups (21.5±6.2 min and 15.8±9.1 min), respectively (P= 0.001). Differences between the times from start of anesthesia to surgeries in three groups, based on ASA class and type of surgery were not significant (P> 0.05). There was no re-lationship between the times devoted to teaching residents in the first and second groups (P> 0.05). Conclusion: Anesthesia residents’ training in neurosurgery operating room may in-crease the time required for preparing for surgery, but this time expended is hardly of any significance.