Cellular and Molecular Medicine; the Lost World in Postgraduate Medical Education

Cellular and molecular medicine is an integrated part of translational medicine, which endeavors to bridge between the traditional classification of "basic and clinical" medicine; aiming clinician-scientists to use their knowledge in designing and developing novel interventions and other specific tools for prevention, diagnosis and treatment of abnormal health conditions

Problem-Based Learning

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BOTH ORAL PASSIFLORA INCARNATA AND OXAZEPAM CAN REDUCE PRE-OPERATIVE ANXIETY IN AMBULATORY SURGERY PATIENTS: A DOUBLE-BLIND, PLACEBO-CONTROLLED STUDY

Objectives: Pre-operative anxiety control without increased post-operative psychomotor dysfunction is an anesthesia concern especially in ambulatory surgery; so, the development of a strong anxiolytic with minimal psychomotor impairment for premedication is desirable. In this study, it was hypothesized that Passiflora incarnata decreases pre-operative anxiety (PAN) similar to oxazepam.Methods: In this double-blinded placebo controlled study, 128 patients were randomized into Passiflora group (n=68) who received oral P. incarnata and oxazepam group (n=60) who received oxazepam (10 mg) as premedication, 90 minutes before surgery. A numerical rating scale (NRS) was used for each patient to assess anxiety before, and 90 minutes following premedication. Psychomotor function was assessed with the trigger dot test (TDT) and the digit-symbol substitution test at arrival in the operating room, and 90 minutes after tracheal extubation.Results: The 90th minutes NRS anxiety scores were significantly lower in the Passiflora group compared with oxazepam group (p<0.001). There were no significant differences in psychological variables, in groups, in the postanesthesia care unit.Conclusion: In outpatient surgery, administration of oral P. incarnata as a premedication reduces PAN with similar psychomotor function impairment compared with pre-operative oral oxazepam

The Effect of Premedication by Remifentanil and Magnesium Sulfate in Hemodynamic Responses to Tracheal Intubation in Cesarean Section Delivery: 1 A Randomized Double-Blinded Controlled Study

Background: The preventing effects of remifentanil and magnesium sulfate on hemodynamic responses to tracheal intubation were evaluated in a double-blinded controlled trial on pregnant women undergoing cesarean section delivery.Methods: A total of 54 American Society of Anesthesiologists Class I-II women candidate for cesarean section delivery were randomly assigned to one of three groups (n = 18) to receive one of the following premedication: Intravenous (IV) remifentanil 0.75 µg/kg, IV magnesium sulfate 30 mg/kg, or IV normal saline 10 cc as placebo. All hemodynamic profiles were recorded immediately before and after intubation, and 2, 3, 5 minutes after tracheal intubation.Results: Heart rate and systolic and diastolic blood pressures were significantly lower in the remifentanil group than in other groups both before and immediately after intubation. The trend of the changes in homodynamic responses within 5 minutes following intubation in the magnesium sulfate and placebo group was similar, but this trend in the remifentanil group was significant difference. In the same time, 1st and 5th minute Apgar scores were slightly lower in the remifentanil group than others. The measured parameters of umbilical cord blood pH and PO had no significant differences between the groups.Conclusions: Remifentanil can attenuate hemodynamic response to tracheal intubation more effectively than magnesium sulfate, and thus it can be considered safe for a pregnant candidate for cesarean section

EFFECT OF VAGINAL SILDENAFIL ON IN VITRO FERTILIZATION SUCCESS RATES IN WOMEN WITH PREVIOUS FAILED IN VITRO FERTILIZATION ATTEMPTS

Objectives: Endometrial thickness of <9 mm is a predictor of in vitro fertilization (IVF) failure, although neither pregnancy rates nor the pregnancy outcomes are dependent on the endometrial thickness alone. The impact that uterine artery blood flow has on endometrial growth is dependent on nitric oxide which concentrations could be altered by halting a cyclic guanosine monophosphate-mediated pathway with a phosphodiesterase type 5 selective inhibitor such as sildenafil.Methods: In this clinical trial, 72 patients aged below 45 years which have had at least two earlier failed IVF attempts were randomly split into two groups each consisting of 36 patients. Both groups were started on a long IVF protocol. The case group was also administered 100 mg vaginal sildenafil suppositories daily, starting on day 3 of menstruation which was continued until human chorionic gonadotropin administration. Endometrial thickness was measured using ultrasonography in both groups plus pregnancy rates were assessed in both groups.Results: The mean age of the patients in Group A who received sildenafil; in this clinical trial, 72 patients aged below 45 years which have had at least two previous failed IVF attempts were randomly split into two groups each consisting of 36 patients was 33.8±4.8 in contrast to Group B (control group) with the mean age of 33.8±4.8. Mean endometrial thickness of 8.6±0.1 mm was recorded in Group B compared to 9.0±0.7 mm in Group A (p=0.03). Of all the 36 participants who received sildenafil citrate during the IVF cycle, 12 (33.3%) patients had successful pregnancies while 24 (66.7%) failed to get pregnant. In the control group, out of the 36 participants, 10 (27.8%) patients got pregnant while 26 (72.2%) failed the cycle (p=0.9).Conclusion: This study showed that although using vaginal sildenafil during the IVF cycle does improve endometrial thickness before implantation, this does not necessarily lead to higher pregnancy rates

The Effect of Different Combination Doses of Intrathecal Hyperbaric Bupivacaine 0.5% and Sufentanil on the Hemodynamic Profile of Geriatric Patients Undergoing Hip Surgery under Spinal Anesthesia

Background: With the increasing number of elderly patients with fragile hemodynamic profiles undergoing lower limb surgery, avoiding hypotension in this population is of great importance. We intended to study the effect of different combination doses of intrathecal hyperbaric bupivacaine 0.5% and sufentanil on the hemodynamic profile of geriatric patients undergoing lower limb surgery.Methods: A total of 60 patients aged over 70, candidates for lower limb surgery under spinal anesthesia were enrolled in this study. The patients were randomly allocated into three groups. Group 1 (G1: 5 mg bupivacaine plus 10 µg sufentanil intrathecally), Group 2 (G2: 10 mg bupivacaine plus 5 µg sufentanil intrathecally), and Group 3 (G3: 15 mg bupivacaine intrathecally). Non-invasive automated blood pressure was checked every 1 minute for the first 5 minutes, and every 5 minutes for 25 minutes and every 15 minutes for 30 minutes during surgery. Heart rate (HR) was recorded at the same intervals. The quality of the blocks was also compared.Results: A total of 60 patients met the inclusion criteria and were enrolled in the study. Five patients had failed spinal anesthesia whom were replaced with new patients. There was no difference between the groups in their baseline characteristics. Mean arterial pressure after 1 minute in Groups 2 and 3 was significantly lower than Group 1 (86.0 ± 9.0, 87.3 ± 11.0, 92.2 ± 13.0, P = 0.001). No statistically significant difference in HR was observed in between the three groups. The degree of motor and sensory block was adequate in all three groups, and no patients required any additional analgesics. 15 (75%) patients in Group 3 received ephedrine in comparison to 11 (55%) patients in Group 2. 3 (15%) patients in group one needed ephedrine.Conclusions: In conclusion, adding sufentanil as an adjuvant and decreasing the dose of intrathecal hyperbaric bupivacaine may help maintain a stable hemodynamic during lower limb surgery in the elderly

Preoperative Oral Valiflore Reduces Anxiety in Laparoscopic Cholecystectomy: A Double Blind, Placebo Controlled Study

AbstractMany patients undergoing surgical procedures experience preoperative anxiety. Therefore; develop a drug as a premedication with strong anxiolytic effect and minimal psychomotor impairment is desirable. Under ethics committee approval, eighty patients, who met the inclusion criteria, were randomly assigned to two groups to receive either oral Valiflore (600 mg, Niak) or placebo as a premedication, 90 minutes before surgery. A numerical rating scale (NRS) for anxiety and the Ramsay sedation scale were measured at baseline, and 15, 30, 60, 90 minutes after premedication. Psychomotor function recovery was assessed using the Digit Symbol Substitution Test and the Trieger Dot Test on arrival in the operating room, 30 and 90 minutes after tracheal extubation. The duration of anesthesia, surgery and recovery time were recorded for each patient. There were no statistically significant differences in the patients’ demographic characteristics, ASA physical status, basal NRS score, the sedation level at different time intervals, duration of anesthesia, surgery and recovery time in the two groups (P > 0.05).The NRS anxiety scores were significantly lower in the Valiflore group in comparison with the control group (P < 0.001). There was no significant difference in psychomotor function test in both groups. Oral Administration of Valiflore as a premedication reduces anxiety before surgery without inducing sedation. Keywords:Anxiety; Herbal Medicine; Premedication; Preoperative anxiety; Valiflore Trial registry number:IRCT201404115175N13 Short title: Valiflore reduces pre-operative anxiety

Effect of Ephedrine on Pain and Hemodynamic Status on Injection of Propofol

Background: Propofol is one of the drugs most commonly used during induction of anesthesia. The induction dose of propofol can lead to hemodynamic changes such as hypotension and bradycardia. Pain on injection is another side effect of propofol. The purpose of this study was to evaluate the effect of two different doses of ephedrine on hemodynamic status and pain on injection of propofol compared to lidocaine and placebo.Methods: In the present study, 100 patients were enrolled. A 22 gauge cannula was inserted into the veins on the non-dominant hand of all patients. The patients were randomly allocated to 4 groups and 10 ml/kg of saline was administered over 10 minutes from each of the cannulas. Then, patients received either of these pretreatments: 2 ml of Saline (group S); 2 ml lidocaine 2% (40 mg) (group L); Ephedrine (30 ug/kg) (group E1); or Ephedrine (70 ug/kg) (group E2). After 30 seconds all patients were administered 2.5 mg/kg of propofol with a rate of 1 ml per second. The patients were asked to give a score from 0 to 10 (0 = no pain and 10 = most severe pain) every 5 seconds until loss of consciousness. Systolic and diastolic pressures and heart rate were recorded before induction of anesthesia, before intubation, and 1, 3, and 5 minutes after intubation.Results: Systolic, diastolic, and mean arterial pressure and heart rate following induction in E1 and E2 groups were higher than S and L groups (P < 0.001). There were no differences in systolic, diastolic, and mean arterial pressure and heart rate 1, 3, and 5 minutes after intubation between groups. Lidocaine and both doses of ephedrine reduced pain on injection of propofol similarly.Conclusions: Lidocaine and high and low doses of ephedrine reduce the intensity of pain on injection of propofol. Small doses of ephedrine attenuate blood pressure and heart rate reduction after induction of anesthesia with propofol

Plethysmography Variability Index as a Guidance for Intraoperative Fluid Management in Cesarean Section Delivery under Spinal Anesthesia: A Pilot Study

Background: Plethysmography variability index (PVI) is a measure of the dynamic changes in the perfusion index (PI) that occur during one or more complete respiratory cycles. This study was designed to investigate the accuracy of PVI in guidance of fluid management in parturient undergoing cesarean section surgery under spinal anesthesia.Methods: This randomized clinical trial was performed on 21 consecutive patients who were candidate for cesarean section surgery under spinal anesthesia at Shariati Hospital in Tehran, Iran, between April 2015 and April 2016. The patients were randomly assigned to one of the PVI or conventional group. In all patients, serum level of lactate, mean arterial pressure (MAP), total amount of infused intraoperative fluids, urine output, and duration of surgery were recorded.Results: In total, 21 patients (10 in PVI group and 11 in control group) were assessed. The trend of the change in MAP was significantly different between the two groups with a downward trend in PVI group and a fluctuated trend in the conventional group (P = 0.003). The mean amount of infused fluid was 2565.00 ± 563.74 ml in PVI group that was significantly lower than control group (3122.73 ± 321.99 ml) (P = 0.011). Although urine output was numerically higher in PVI than in control group (425.00 ± 274.12 ml vs. 322.00 ± 121.82 ml), it was not statistically significant (P = 0.292). In PVI group, the primary value of PVI was 23.80 ± 6.93 that reached to 12.20 ± 1.75 at the end of surgery indicating a significant reduction (P < 0.001).Conclusions: Regarding clinical and hemodynamic stability as well as fluid therapy responsiveness (less requiring fluids within surgery), PVI monitoring seems to be superior to the conventional method