Propofol-induced hippocampal Neurotoxicity: A mitochondrial perspective

Propofol is a frequently used anesthetic. It can induce neurodegeneration and inhibit neurogenesis in the hippocampus. This effect may be temporary. It can, however, become permanent in vulnerable populations, such as the elderly, who are more susceptible to Alzheimer's disease, and neonates and children, whose brains are still developing and require neurogenesis. Current clinical practice strategies have failed to provide an effective solution to this problem. In addition, the molecular mechanism of this toxicity is not fully understood. Recent advances in molecular research have revealed that apoptosis, in close association with mitochondria, is a crucial mechanism through which propofol contributes to hippocampal toxicity. Preventing the toxicity of propofol on the hippocampus has shown promise in in-vivo, in-vitro, and to a lesser extent human studies. This study seeks to provide a comprehensive literature review of the effects of propofol toxicity on the hippocampus via mitochondria and to suggest translational suggestions based on these molecular results.

Falsely prolonged prothrombin time test in a patient with erythrocytosis: a case report

The prothrombin time (PT) test is commonly used to monitor deficiencies in coagulation factors. A prolonged PT may indicate a deficiency of factors II, V, VII, X, and fibrinogen, or the presence of an inhibitor. However, further tests are required to differentiate between a true factor deficiency and the presence of an inhibitor. It is important to note that falsely prolonged PT can lead to misdiagnosis and inappropriate clinical intervention that can have life-threatening consequences. A 19-year-old woman with elevated hematocrit levels and prolonged PT was diagnosed with secondary erythrocytosis due to cyanotic congenital heart disease with ventricular septal defect (VSD). However, further investigation revealed that the prolonged PT result was false. Excess citrate in the blood sample, caused by polycythemia, led to this misleading outcome, resulting in unnecessary and potentially harmful treatment. This incident emphasizes the importance of laboratory personnel and clinicians being aware of the test's limitations. Not only should specialists in thrombosis and hemostasis possess this knowledge, but it is also pertinent for general laboratory staff, as well as laboratory directors and specialists. The significance of accurate laboratory testing for the proper diagnosis and treatment of patients is highlighted in this case.

Congenital Bleeding Disorders and COVID-19-A Systematic Literature Review

Hypercoagulability is a prominent feature of coronavirus disease 2019 (COVID-19) and can lead to fatal consequences. Although the impact of COVID-19 on several disorders is well-established, its effect on congenital bleeding disorders (CBDs) is not well-documented. To address this ambiguity, a systematic review was conducted on the available studies to determine the impact of COVID-19 and vaccination aimed to prevent COVID-19 on patients with CBDs. We performed a systematic literature review using relevant keywords and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) protocol. We conducted our search on the PubMed, Scopus, and Web of Science databases until July 2023. Out of 31 included studies, 12 case series covering 770 patients with CBD and COVID-19 were further analyzed. The majority of the patients had hemophilia A (n = 352, ∼46%) or hemophilia B (n = 74, ∼10%), while the remaining patients had von Willebrand disease (n = 43, 5.6%) or rare bleeding disorders (n = 27, 3.5%). A total of 25 deaths (3.2%) and 22 intensive care unit admissions (2.8%) were recorded. Bleeding complications were reported in the majority of the 12 case series (n = 7, 58.3%) and in most of the case reports (n = 8, ∼57%), while thrombotic complications were only reported in two studies (16.6%). The mortality rate ranged from 0% in five studies (41.6%) to 5.7% and the rate of hospitalization ranged from 0 to 40%. Bleeding complications were reported in a range of 0 to 81%, while the thrombotic complication rate in one study was 6.9%. The mortality rate varied from 0 to 5.7%, and the hospitalization rate ranged from 0 to 40%. Bleeding complications were reported in a range of 0 to 81%, while the rate of thrombotic complications in one study was 6.9%. Vaccination was reported in five case series, which included 821 patients with CBDs with the majority having hemophilia A (n = 479; 67.2%) and hemophilia B (n = 85; ∼12%). The most frequently reported side effects were myalgia (6.5%), flu-like symptoms (4.8%), fever (4.7%), and headache (4%). COVID-19 in patients with CBDs appears to provoke thrombotic complications and bleeding events more frequently, as well as a higher rate of hospitalization, which may be partially due to the increased risk of bleeding events. Although it seems that patients with CBD have lower mortality rates, further studies are necessary to fully understand this, especially considering comorbidities and low number of available studies.

Attitudes of Anesthesiology Postgraduate Residents Toward the Influential Factors in Their Success in the Iranian National Board Exam

Background

One of the prominent indicators of academic success in postgraduate medical education is the "Residents' Pass Rate" in the "National Board Exam."

Objectives

This study was designed and implemented to assess the attitudes of the anesthesiology residents toward factors affecting their success in the National Board Exam.

Methods

After the Institutional Review Board (IRB) approval, in an attitude assessment study, 20 of the 21 recently graduated anesthesiology residents were asked about the factors affecting their success quantitatively and qualitatively. A self-administered questionnaire with 19 closed questions and a personal virtual WhatsApp Messenger® interview were used for the study.

Results

The respondents' viewpoints demonstrated that a step-by-step multifaceted integrative program in combination with psychological support (both from the family and the department) and individual motivation positively affected their success and their endurance to overcome the high load of the mandatory texts. In contrast, unplanned stressors leading to program shifts (mainly due to COVID-19) had adverse effects on their success.

Conclusions

Anesthesiology residents believed that a well-designed and appropriately implemented study plan with psychological support and personal motivating factors could facilitate passing the National Board Exam, and unplanned external stressors could hinder it.

Porosity Effects on Static Performance of Carbon Nanotube-Reinforced Meta-Nanocomposite Structures

A mixture of outstanding merits of polymer nanocomposites (PNCs) and metamaterials can lead to the development of ultra-light meta-nanomaterials whose high sensitivity can be efficiently used in wearable strain sensors. Thus, reliable data about the performance of structural elements manufactured from such meta-nanomaterials are needed before implementing their design. Motivated by this issue, the negative impacts of pores in the microstructure and carbon nanotubes' (CNTs') wavy configuration on the nonlinear bending features of thick beams consisted of auxetic CNT-reinforced (CNTR) polymers are probed for the first time. The impacts of distinct porosity distributions on the mechanical reaction of the system are covered in this article. In addition, a very low computationally cost homogenization is implemented herein to consider the waviness' influence on the reinforcement mechanism in the auxetic PNC material. Moreover, higher-order shear deformation theory (HSDT) is followed and merged with non-linear definition of strain tensor with the aid of von Kármán's theory to gather the equations describing the problem. Thereafter, the famous Navier's exact solution is employed towards solving the problem for thick beams with simple supports at both ends. A comparison of our data with those existing in the literature certifies the accuracy of the presented modeling. The outcomes indicate on the remarkable rise in the flexural deformation of the auxetic PNC beam while the coefficient of porosity is raised. It is also shown that utilization of thick-walled cells in the re-entrant lattice can help to control the system's total deflection. In addition, if the non-ideal shape of the nanofillers is ignored, the deflection of the meta-nanomaterial beam will be much larger than that of ideal calculations.

Atorvastatin versus Placebo in ICU Patients with COVID-19: Ninety-day Results of the INSPIRATION-S Trial

BACKGROUNDS

In the INSPIRATION-S trial, atorvastatin versus placebo was associated with a non-significant 16% reduction in 30-day composite of venous/arterial thrombosis or death in ICU patients with COVID-19. Thrombo-inflammatory response in COVID-19 may last beyond the first 30 days.

METHODS

This article reports the effects of atorvastatin 20 mg daily versus placebo on 90-day clinical and functional outcomes from INSPIRATION-S, a double-blind multicenter randomized trial of adult ICU patients with COVID-19. The main outcome for this pre-specified study was a composite of adjudicated venous/arterial thrombosis, treatment with extracorporeal membrane oxygenation (ECMO), or all-cause mortality. Functional status was assessed with Post-COVID-19 Functional Scale (PCFS).

RESULTS

In the primary analysis, 587 patients were included (age: 57 (Q1, Q3: 45, 68) years; 44% women). By 90-day follow-up, the main outcome occurred in 96 (33.1%) patients assigned to atorvastatin and 113 (38.0%) assigned to placebo (hazard ratio, HR: 0.80, 95% confidence interval, CI: 0.60-1.05, P=0.11). Atorvastatin in patients who presented within 7 days of symptom onset was associated with reduced 90-day hazard for the main outcome (HR: 0.60, 95% CI: 0.42-0.86, Pinteraction=0.02). Atorvastatin use was associated with improved 90-day functional status, although the upper bound CI crossed 1.0 (ORordinal, 0.64, 95% CI: 0.41 to 1.01, P=0.05).

CONCLUSIONS

Atorvastatin 20 mg compared with placebo did not significantly reduce the 90-day composite of death, treatment with ECMO, or venous/arterial thrombosis. However, the point estimates do not exclude a potential clinically meaningful treatment effect, especially among patients who presented within 7 days of symptom onset. (NCT04486508).

Wave Dispersion Behaviors of Multi-Scale CNT/Glass Fiber/Polymer Nanocomposite Laminated Plates

In this paper, wave propagation in multi-scale hybrid glass fiber (GF)/carbon nanotube (CNT)/polymer nanocomposite plates is studied for the first time by means of refined higher-order plate theory. The hybrid nanocomposite consists of CNTs and glass fibers (GF) as reinforcing components distributed within a polymeric matrix. A hierarchical micromechanical approach is used to predict the effective mechanical properties of the hybrid nanocomposite, including the three-dimensional (3D) Mori-Tanaka method and the rule of mixture. Moreover, a refined-type higher-order shear deformation theory (HSDT) is implemented to take into account the influence of the shear deformation on the motion equations of the system. Then, the governing equations are achieved on the basis of the energy-based Hamilton's principle. Finally, the derived equations will be solved analytically for the purpose of extracting the natural frequency of the continuous system. A set of numerical examples are provided to cover the effects of various parameters on the wave dispersion characteristics of the plate. It can be declared that the hybrid nanocomposite system can achieve higher wave frequencies compared with other types of composite structures. Additionally, it is found that the selection of the lay-ups and length-to-diameter ratio plays a significant role in the determination of the sandwich plate's acoustic response.

Comparative Assessment of Propofol and Ketamine on Hemodynamic Indices and Cerebral Oximetry of Pediatric Patients Undergoing Cardiac Catheterization

Background

Propofol and ketamine are widely used in the induction and maintenance of anesthesia and sedation with different cardiovascular and respiratory effects. In cardiac anesthesia (including pediatric cardiac catheterization), due to the high risk of neurologic complications, cerebral oximetry can effectively monitor cerebral blood oxygen saturation to prevent neurological and respiratory complications.

Objectives

This study aimed to compare the effect of propofol and ketamine on hemodynamic indices and cerebral oxygenation results in children undergoing cardiac catheterization.

Methods

This clinical trial study was performed on 48 patients who were candidates for cardiac catheterization by easy and continuous sampling. Patients were randomly divided into 2 groups: ketamine and propofol. In the ketamine group, ketamine was injected at a dose of 1 - 2 mg/kg, and in the propofol group, propofol was injected at a dose of 0.5 - 1.5 mg/kg. In both groups, incremental doses were repeated as needed. The hemodynamic indices, including blood pressure, heart rate, and peripheral SpO₂, were recorded. Cerebral regional oxygen saturation (RSO₂) was recorded using infrared spectroscopic sensors. Data were analyzed using chi-square, independent t-test, paired t-test, and 1-way analysis of variance (ANOVA).

Results

The results showed that all demographic characteristics of patients and also the mean duration of catheterization were homogeneous between the 2 groups. Hemodynamic indices (such as systolic, diastolic, and mean arterial blood pressure) did not show a significant difference between the 2 groups; however, in the ketamine group compared to the propofol group, the heart rate was significantly higher, and mean RSO₂ was lower (P = 0.023).

Conclusions

Propofol has fewer complications than ketamine and is a good drug for sedating children undergoing cardiac catheterization.

Molecular basis of rare congenital bleeding disorders

Rare bleeding disorders (RBDs), including factor (F) I, FII, FV, FVII, combined FV and FVIII (CF5F8), FXI, FXIII and vitamin-K dependent coagulation factors (VKCF) deficiencies, are a heterogeneous group of hemorrhagic disorder with a variable bleeding tendency. RBDs are due to mutation in underlying coagulation factors genes, except for CF5F8 and VKCF deficiencies. FVII deficiency is the most common RBD with >330 variants in the F7 gene, while only 63 variants have been identified in the F2 gene. Most detected variants in the affected genes are missense (>50% of all RBDs), while large deletions are the rarest, having been reported in FVII, FX, FXI and FXIII deficiencies. Most were located in the catalytic and activated domains of FXI, FX, FXIII and prothrombin deficiencies. Understanding the proper molecular basis of RBDs not only can help achieve a timely and cost-effective diagnosis, but also can help to phenotype properties of the disorders.

Inhibitory Effects of Dutasteride on TLR4: An In vitro Pain Study

Dutasteride was potentially proposed to control chronic pain by Toll-Like Receptor 4 (TLR4) inhibition through its effect on TLR4 expression, Myeloid differentiation primary response 88 (MyD88), Nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB), secretory Interleukin-1β (IL-1β), and nitric oxide (NO) in the Lipopolysaccharides (LPS)-stimulated U-87 MG cell line. The human astrocytoma U-87 MG cell line was cultured and incubated with 10 μg/mL of LPS for 24 hours to create a neuro-inflammation model, using two different treatment approaches. The first approach included LPS treatment for 24 hours, followed by dutasteride (20 μg/mL) incubation for the next 72 hours. In the second treatment approach, the cells were co-incubated with LPS and dutasteride for 72 hours. Expression of TLR4, MyD88, NF-κBp65, and secretory IL-1 was evaluated by Western blotting while expression of NO was assessed by NO assay. TLR4, MyD88, NF-κBp65, and secretory IL-1β levels increased in LPS-treated cells after 24 hours. Dutasteride significantly decreased the secretion of NO and also, the levels of TLR4, MyD88, and NF-κBp65 in both treatment approaches. No difference in IL-1β level was seen with the second treatment approach. Dutasteride has anti-inflammatory properties and probably analgesic effects, by mechanisms different from conventional analgesics.

The Role of Entrustable Professional Activities in Competency-based Medical Education for Anesthesiology Residents: A Pilot Phase

Background

After graduation, physicians should be able to provide professional and safe services without the need for supervision by their clinical professors, mandating a competency-based medical education (CBME) approach.

Objectives

This study aimed to develop a national model of entrustable professional activities (EPAs) based on our experiences in the Department of Anesthesiology and Critical Care (DACC), Shahid Beheshti University of Medical Sciences (SBMU).

Methods

The primary EPA design plan was designed in a 10-step model as a career roadmap for the project. The texts were prepared according to a consensus-based approach. On the other hand, the texts were reviewed and revised by a broad team of faculty in a daily workshop.

Results

The final product included 14 topics for EPA as the first round of targeting topics for anesthesiology residents. The texts were developed using previous studies and were standardized considering national standards.

Conclusions

We described a clear path toward designing and implementing EPAs in anesthesiology residency programs to improve the quality of the graduated residents. Though the basic theory is the same, each country needs its formula for implementing the process.

The effectiveness of whole-body vibration on the attenuation of delayed-onset muscle soreness in healthy untrained individuals: a randomised controlled trial

Delayed onset muscle soreness (DOMS) is a condition that happens following eccentric or intensive exercises. Whole-body vibration (WBV) is a potential treatment for DOMS; however, there is a lack of studies assessing its effectiveness in the untrained population. Our study objective was to test the efficacy of WBV compared with no treatment on pain and knee strength in healthy adults with DOMS. We randomly allocated 52 participants, 12 men and 40 women, aged 18 to 28 years, into WBV (n=26) and control (n=26) groups. The eligibility criteria included no history of injury, strengthening or aerobic exercises within the past six months. The participants walked on a treadmill to introduce DOMS. 24 h later, the WBV group received one session of WBV treatment, with their knees bent to 60° for 1 min (frequency, 30 Hz; amplitude 2-5 mm). We assessed pressure pain threshold (PPT), visual analogue scale (VAS), and knee maximum isometric force (MIF) at four time points. We did a one-way repeated measures ANOVA of each outcome measure, followed by a t-test and Bonferroni post-hoc test. The between-group differences were not significant at the baseline and 24 h post-DOMS (P>0.05). Statistical analyses revealed significant differences between the two groups for all variables at 96 h post-DOMS inducement (P<0.05), with mean differences for PPT, MIF and VAS being 1.19 kilo Pascals (95%CI = 0.78-1.32), 42.87 Newtons (95%CI = 28.53-56.98), and -2.39 (95%CI = -3.13- -1.98), respectively. Moreover, differences between the two groups were statistically significant for MIF 168 h post-DOMS (P<0.05). WBV can effectively improve pain and muscle strength; therefore, beneficial treatment for recovery of DOMS symptoms. However, determining the exact dose, frequency, and best time of application is pending future research.

Iranian Registry of Clinical Trials registration number: IRCT2016092429958N1

Prediction of Acute Kidney Injury After Cardiac Surgery Using Interpretable Machine Learning

Background

Acute kidney injury (AKI) is a complication that occurs for various reasons after surgery, especially cardiac surgery. This complication can lead to a prolonged treatment process, increased costs, and sometimes death. Prediction of postoperative AKI can help anesthesiologists to implement preventive and early treatment strategies to reduce the risk of AKI.

Objectives

This study tries to predict postoperative AKI using interpretable machine learning models.

Methods

For this study, the information of 1435 patients was collected from multiple centers. The gathered data are in six categories: demographic characteristics and type of surgery, past medical history (PMH), drug history (DH), laboratory information, anesthesia and surgery information, and postoperative variables. Machine learning methods, including support vector machine (SVM), multilayer perceptron (MLP), decision tree (DT), random forest (RF), logistic regression, XGBoost, and AdaBoost, were used to predict postoperative AKI. Local interpretable model-agnostic explanations (LIME) and the Shapley methods were then leveraged to check the interpretability of models.

Results

Comparing the area under the curves (AUCs) obtained for different machine learning models show that the RF and XGBoost methods with values of 0.81 and 0.80 best predict postoperative AKI. The interpretations obtained for the machine learning models show that creatinine (Cr), cardiopulmonary bypass time (CPB time), blood sugar (BS), and albumin (Alb) have the most significant impact on predictions.

Conclusions

The treatment team can be informed about the possibility of postoperative AKI before cardiac surgery using machine learning models such as RF and XGBoost and adjust the treatment procedure accordingly. Interpretability of predictions for each patient ensures the validity of obtained predictions.

Effects of Acute Potassium Chloride Administration on Ventricular Dysrhythmias after Myocardial Infarction in a Rat Model of Ischemia/Reperfusion

Background: Acute myocardial infarction is an important cause of morbidity. This study aimed to investigate the effects of the administration of potassium chloride (KCl) on reperfusion-induced injuries in a rat model of myocardial ischemia/reperfusion. Methods: Thirty-six male Wistar rats, weighing 200 to 250 g, were randomly assigned to 3 experimental groups: control, K1 (10 µg/kg of KCl), and K2 (20 µg/kg of KCl). Twenty minutes before ischemia, a single dose of 10 and 20 µg/kg of KCl was intraperitoneally administered in the K1 and K2 groups, respectively. The coronary artery was occluded for 30 minutes (ischemia); thereafter, it was opened for 60 minutes (reperfusion) to measure hemodynamic parameters and ventricular arrhythmias. Blood sampling was performed after the reperfusion period to determine the serum levels of lactate dehydrogenase, troponin I, creatine kinase (CK)-MB, malondialdehyde, and pro-oxidant-antioxidant balance. Results: Serological parameters significantly decreased in the potassium groups compared with the control group. In particular, the decline was more pronounced for the serum levels of lactate dehydrogenase (1180.25±69.48 vs 1556.67±77.02 U/L; P=0.011), troponin I (21.98±0.61 vs 28.76±1.65 ng/mL; P=0.020), and pro-oxidant-antioxidant balance (15.51±0.72 vs 20.63±1.42 HK; P=0.041) in the K2 group compared with the K1 group. Moreover, the administration of 20 µg/kg of KCl significantly decreased the incidence of ventricular tachycardias and fibrillations compared with the control group (P=0.002). Additionally, no considerable differences were observed between the control group and the groups with 10 µg/kg and 20 µg/kg of KCl regarding the number of ventricular ectopic beats.  Conclusion: The administration of KCl before ischemia could reduce ventricular arrhythmias and reperfusion-induced injuries by reducing oxidative stress.

The Predictive Power of Near-Infrared Spectroscopy in Improving Cognitive Problems in Patients Undergoing Brain Surgeries: A Systematic Review

One of the main objectives in neurosurgical procedures is the prevention of cerebral ischemia and hypoxia leading to secondary brain injury. Different methods for early detection of intraoperative cerebral ischemia and hypoxia have been used. Near-infrared spectroscopy (NIRS) is a simple, non-invasive method for monitoring cerebral oxygenation increasingly used today. The aim of this study was to systematically review the brain monitoring with NIRS in neurosurgery. The search process resulted in the detection of 324 articles using valid keywords on the electronic databases, including Embase, PubMed, Scopus, Web of Science, and Cochrane Library. Subsequently, the full texts of 34 studies were reviewed, and finally 11 articles (seven prospective studies, three retrospective studies, and one randomized controlled trial) published from 2005 to 2020 were identified as eligible for systematic review. Meta-analysis was not possible due to high heterogeneity in neurological and neurosurgical conditions of patients, expression of different clinical outcomes, and different standard reference tests in the studies reviewed. The results showed that NIRS is a non-invasive cerebral oximetry that provides continuous and measurable cerebral oxygenation information and can be used in a variety of clinical settings.

Pulmonary Artery Sling Associated with Stridor from Early Infancy: A Case Report

Background

Pulmonary artery sling is a rare condition in which the left pulmonary artery anomalously originates from a normally positioned right pulmonary artery. The left pulmonary artery arises anterior to the right main bronchus, courses between the trachea and esophagus then enters the left hilum. Respiratory symptoms such as wheezing, stridor, cough, and dysphasia are common in this anomaly.

Case presentation

We describe a 16-month-old male infant presenting recurrent cough, stridor, and wheezing from early infancy. He underwent computed tomography angiography, bronchoscopy, and transthoracic echocardiography, confirming the left pulmonary artery sling diagnosis. Surgical correction of pulmonary artery sling was successfully performed as a new anastomosis between the main pulmonary artery and the left pulmonary artery, as well as tracheoplasty. The infant was discharged without any complications. Follow-up after two years revealed no respiratory symptoms and feeding difficulty.

Conclusion

In the presence of chronic cough, stridor, recurrent wheezing, and other prolonged respiratory symptoms, investigation for possible detection of pulmonary artery sling is recommended.

Controlled temperature-mediated curcumin release from magneto-thermal nanocarriers to kill bone tumors

Systemic chemotherapy has lost its position to treat cancer over the past years mainly due to drug resistance, side effects, and limited survival ratio. Among a plethora of local drug delivery systems to solve this issue, the combinatorial strategy of chemo-hyperthermia has recently received attention. Herein we developed a magneto-thermal nanocarrier consisted of superparamagnetic iron oxide nanoparticles (SPIONs) coated by a blend formulation of a three-block copolymer Pluronic F127 and F68 on the oleic acid (OA) in which Curcumin as a natural and chemical anti-cancer agent was loaded. The subsequent nanocarrier SPION@OA-F127/F68-Cur was designed with a controlled gelation temperature of the shell, which could consequently control the release of curcumin. The release was systematically studied as a function of temperature and pH, via response surface methodology (RSM). The bone tumor killing efficacy of the released curcumin from the carrier in combination with the hyperthermia was studied on MG-63 osteosarcoma cells through Alamar blue assay, live-dead staining and apoptosis caspase 3/7 activation kit. It was found that the shrinkage of the F127/F68 layer stimulated by elevated temperature in an alternative magnetic field caused the curcumin release. Although the maximum release concentration and cell death took place at 45 °C, treatment at 41 °C was chosen as the optimum condition due to considerable cell apoptosis and lower side effects of mild hyperthermia. The cell metabolic activity results confirmed the synergistic effects of curcumin and hyperthermia in killing MG-63 osteosarcoma cells.

Residency Education Reform Program in Department of Anesthesiology and Critical Care: An Academic Reform Model

Background

Reform in medical education is a basic process in every academic department, especially in residency programs.

Objectives

This study was designed to assess the indices of education and research as part of the Medical Education Reform program (MERP) in the Department of Anesthesiology and Critical Care (DACC), Shahid Beheshti University of Medical Sciences (SBMU) for four years.

Methods

MERP in DACC, SBMU was designed and implemented as a modern academic reform model; different outcome measures in education and research were assessed to demonstrate the effects of the reform plan in academic improvements.

Results

there were significant improvements regarding education indices (i.e., teaching methods, passing comprehensive exams, mentorship, assessment methods, faculty development, professionalism in medical education, integration in education, and crisis management) and research indices (targeted research activities, innovation in research approaches, increasing the impact of research).

Conclusions

Based on the experiences of DACC, SBMU regarding clinical anesthesiology residency, reform could be achieved using painstaking plans and continuous efforts with tangible documented outcomes. Often, the management period is not durable, and these reforms require meticulous care to sustain.

The Relationship between Inflammatory Cytokines and Coagulopathy in Patients with COVID-19

Coronavirus disease 2019 (COVID-19), with a broad range of clinical and laboratory findings, is currently the most prevalent medical challenge worldwide. In this disease, hypercoagulability and hyperinflammation, two common features, are accompanied by a higher rate of morbidity and mortality. We assessed the association between baseline inflammatory cytokine levels and coagulopathy and disease outcome in COVID-19. One hundred and thirty-seven consecutive patients hospitalized with COVID-19 were selected for the study. Baseline interleukin-1 (IL-1), IL-6, and tumor necrosis factor alpha (TNF-α) level were measured at time of admission. At the same time, baseline coagulation parameters were also assessed during the patient’s hospitalization. Clinical findings, including development of thrombosis and clinical outcome, were recorded prospectively. Out of 136 patients, 87 (~64%) had increased cytokine levels (one or more cytokines) or abnormal coagulation parameters. Among them, 58 (~67%) had only increased inflammatory cytokines, 12 (~14%) had only coagulation abnormalities, and 17 (19.5%) had concomitant abnormalities in both systems. It seems that a high level of inflammatory cytokines at admission points to an increased risk of developing coagulopathy, thrombotic events, even death, over the course of COVID-19. Early measurement of these cytokines, and timely co-administration of anti-inflammatories with anticoagulants could decrease thrombotic events and related fatal consequences.

The Effect of Bioactive Glass and Sintering Conditions on the Properties of Titanium-Hydroxyapatite Composites

Titanium-hydroxyapatite (Ti-HA) based composites have been widely investigated as viable materials to be used in dentistry. However, sintering of these composites is very challenging due to decomposition of HA and oxidation of Ti. The objective of this study was to investigate the effect of incorporating a bioactive glass in Ti-HA composites sintered in different atmospheric conditions. The bioactive glass was prepared and added to different percentages of Ti-HA mixtures and divided into two groups. Samples in Group 1 were sintered with air atmosphere, while samples in Group 2 were sintered with vacuum furnace. All samples were later subjected to XRD, SEM, density, micro-hardness, and compression strength tests. XRD results showed that in Group 1, the major phases were assigned to Ti and HA while the minor phases were assigned to oxidised Ti. Whereas, Group 2 showed that the major phases were assigned to HA and the minor phases showed decomposition of HA to Ca3(PO4)2(TCP) and Ca4(PO4)2O (TTCP). Oxidized Ti was also present in this group. In terms of density, micro-hardness and compression strength, statistical analyses showed that samples in Group 1 have a significant difference (p = 0.000) as compared to those in Group 2. Sintering Ti-HA composites incorporated with BGby using air atmosphere furnace could reduce the decomposition of HA and oxidation of Ti, thus improve the density, micro-hardness and compression strength of the composites.

Effect of Intermediate-Dose vs Standard-Dose Prophylactic Anticoagulation on Thrombotic Events, Extracorporeal Membrane Oxygenation Treatment, or Mortality Among Patients With COVID-19 Admitted to the Intensive Care Unit: The INSPIRATION Randomized Clinical Trial

IMPORTANCE

Thrombotic events are commonly reported in critically ill patients with COVID-19. Limited data exist to guide the intensity of antithrombotic prophylaxis.

OBJECTIVE

To evaluate the effects of intermediate-dose vs standard-dose prophylactic anticoagulation among patients with COVID-19 admitted to the intensive care unit (ICU).

DESIGN, SETTING, AND PARTICIPANTS

Multicenter randomized trial with a 2 × 2 factorial design performed in 10 academic centers in Iran comparing intermediate-dose vs standard-dose prophylactic anticoagulation (first hypothesis) and statin therapy vs matching placebo (second hypothesis; not reported in this article) among adult patients admitted to the ICU with COVID-19. Patients were recruited between July 29, 2020, and November 19, 2020. The final follow-up date for the 30-day primary outcome was December 19, 2020.

INTERVENTIONS

Intermediate-dose (enoxaparin, 1 mg/kg daily) (n = 276) vs standard prophylactic anticoagulation (enoxaparin, 40 mg daily) (n = 286), with modification according to body weight and creatinine clearance. The assigned treatments were planned to be continued until completion of 30-day follow-up.

MAIN OUTCOMES AND MEASURES

The primary efficacy outcome was a composite of venous or arterial thrombosis, treatment with extracorporeal membrane oxygenation, or mortality within 30 days, assessed in randomized patients who met the eligibility criteria and received at least 1 dose of the assigned treatment. Prespecified safety outcomes included major bleeding according to the Bleeding Academic Research Consortium (type 3 or 5 definition), powered for noninferiority (a noninferiority margin of 1.8 based on odds ratio), and severe thrombocytopenia (platelet count <20 ×103/µL). All outcomes were blindly adjudicated.

RESULTS

Among 600 randomized patients, 562 (93.7%) were included in the primary analysis (median [interquartile range] age, 62 [50-71] years; 237 [42.2%] women). The primary efficacy outcome occurred in 126 patients (45.7%) in the intermediate-dose group and 126 patients (44.1%) in the standard-dose prophylaxis group (absolute risk difference, 1.5% [95% CI, -6.6% to 9.8%]; odds ratio, 1.06 [95% CI, 0.76-1.48]; P = .70). Major bleeding occurred in 7 patients (2.5%) in the intermediate-dose group and 4 patients (1.4%) in the standard-dose prophylaxis group (risk difference, 1.1% [1-sided 97.5% CI, -∞ to 3.4%]; odds ratio, 1.83 [1-sided 97.5% CI, 0.00-5.93]), not meeting the noninferiority criteria (P for noninferiority >.99). Severe thrombocytopenia occurred only in patients assigned to the intermediate-dose group (6 vs 0 patients; risk difference, 2.2% [95% CI, 0.4%-3.8%]; P = .01).

CONCLUSIONS AND RELEVANCE

Among patients admitted to the ICU with COVID-19, intermediate-dose prophylactic anticoagulation, compared with standard-dose prophylactic anticoagulation, did not result in a significant difference in the primary outcome of a composite of adjudicated venous or arterial thrombosis, treatment with extracorporeal membrane oxygenation, or mortality within 30 days. These results do not support the routine empirical use of intermediate-dose prophylactic anticoagulation in unselected patients admitted to the ICU with COVID-19.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04486508.

Intermediate-Dose versus Standard-Dose Prophylactic Anticoagulation in Patients with COVID-19 Admitted to the Intensive Care Unit: 90-Day Results from the INSPIRATION Randomized Trial

BACKGROUND

 Thrombotic complications are considered among the main extrapulmonary manifestations of coronavirus disease 2019 (COVID-19). The optimal type and duration of prophylactic antithrombotic therapy in these patients remain unknown.

METHODS

 This article reports the final (90-day) results of the Intermediate versus Standard-dose Prophylactic anticoagulation In cRitically-ill pATIents with COVID-19: An opeN label randomized controlled trial (INSPIRATION) study. Patients with COVID-19 admitted to intensive care were randomized to intermediate-dose versus standard-dose prophylactic anticoagulation for 30 days, irrespective of hospital discharge status. The primary efficacy outcome was a composite of adjudicated venous or arterial thrombosis, treatment with extracorporeal membrane oxygenation (ECMO), or all-cause death. The main safety outcome was major bleeding.

RESULTS

 Of 600 randomized patients, 562 entered the modified intention-to-treat analysis (median age [Q1, Q3]: 62 [50, 71] years; 237 [42.2%] women), of whom 336 (59.8%) survived to hospital discharge. The primary outcome occurred in 132 (47.8%) of patients assigned to intermediate dose and 130 (45.4%) patients assigned to standard-dose prophylactic anticoagulation (hazard ratio [HR]: 1.21, 95% confidence interval [CI]: 0.95-1.55, p = 0.11). Findings were similar for other efficacy outcomes, and in the landmark analysis from days 31 to 90 (HR: 1.59, 95% CI: 0.45-5.06). There were 7 (2.5%) major bleeding events in the intermediate-dose group (including 3 fatal events) and 4 (1.4%) major bleeding events in the standard-dose group (none fatal) (HR: 1.82, 95% CI: 0.53-6.24).

CONCLUSION

 Intermediate-dose compared with standard-dose prophylactic anticoagulation did not reduce a composite of death, treatment with ECMO, or venous or arterial thrombosis at 90-day follow-up.

The Effect of Repeated Direct Observation of Procedural Skills (R-DOPS) Assessment Method on the Clinical Skills of Anesthesiology Residents

Background

The ultimate result of patient care is one of the most important outcomes in medical education. Several methods, including the direct observation of procedural skills (DOPS), have been proposed to assess professional competencies in clinical practice.

Objectives

This study aimed to assess the effects of the Repeated DOPS (R-DOPS) method on the performance of procedural skills in anesthesiology residents.

Methods

The procedural skill performance of anesthesiology residents was assessed using a standard DOPS protocol from May to October 2019. Their scores were then objectively recorded, and the satisfaction rates regarding the 2 DOPS exams were assessed.

Results

We found a considerable improvement in anesthesiology residents’ procedural skill performance, especially in the anesthesiology residency curriculum’s basic items. Besides, anesthesiology residents’ satisfaction was significantly improved after the 2nd DOPS.

Conclusions

R-DOPS leads to improved training outcomes, including assessing the procedural skills, time to feedback to trainees, and trainee satisfaction.

The Effect of Exogenous Surfactant on Moderate and Severe Stages of COVID-19 Induced ARDS: the Pilot Study of a Clinical Trial

COVID-19 pandemic has created a global health challenge. Many pharmaceuticals have been repurposed as potential treatments, though many have not been promising. Due to the inflammatory and destructive effects of the virus on alveolar cells, the effect of exogenous surfactant was assessed as a potential treatment of lung dysfunction in COVID-19 patients. In this pilot study of the clinical trial, 49 patients aged 35-80 years with COVID-19 admitted in ICU entered the study (22 patients intubated and 23 had face masks; 4 patients in the control arm). The treatment arm patients received two consecutive doses of surfactant. P/F ratio (based on serial blood gas analyses before and 12 hours after 2 doses of surfactant) and also, clinical outcomes were assessed.in COVID-19 adult patients, surfactant significantly improved pulmonary P/F ratio both in intubated and face mask COVID-19 patients (increasing from 119.2 ± 51.7 to 179.4 ± 115.5). The rate of extubation was much better than similar country-wide studies. Surfactant significantly alleviates the respiratory status in moderate to severe COVID-19 ARDS with two consecutive 100 mg doses of surfactant (with 6 hours' interval) though previous studies have been controversial, regarding the effect of surfactant in general forms of ARDS. Higher doses might have better effects, mandating more trials.

A review on chitosan and its development as pulmonary particulate anti-infective and anti-cancer drug carriers

Chitosan, as a biodegradable and biocompatible polymer, is characterized by anti-microbial and anti-cancer properties. It lately has received a widespread interest for use as the pulmonary particulate backbone materials of drug carrier for the treatment of infectious disease and cancer. The success of chitosan as pulmonary particulate drug carrier is a critical interplay of their mucoadhesive, permeation enhancement and site/cell-specific attributes. In the case of nanocarriers, various microencapsulation and micro-nano blending systems have been devised to equip them with an appropriate aerodynamic character to enable efficient pulmonary aerosolization and inhalation. The late COVID-19 infection is met with acute respiratory distress syndrome and cancer. Chitosan and its derivatives are found useful in combating HCoV and cancer as a function of their molecular weight, substituent type and its degree of substitution. The interest in chitosan is expected to rise in the next decade from the perspectives of drug delivery in combination with its therapeutic performance.

Evaluation of One-Day Multiple-Choice Question Workshop for Anesthesiology Faculty Members

BACKGROUND

Multiple-choice questions (MCQs) are used commonly to evaluate medical health students. Most novice educators tend to create poor quality, flawed, and low-cognitive-level questions. Therefore, there is a need for educating the assessors to maximize the quality of MCQs and evaluations.

OBJECTIVES

The current study aimed to evaluate the effect of a one-day MCQ workshop on anesthesiology faculty members.

METHODS

Faculty members were invited to participate in a four-hour, one-day MCQ workshop. At the beginning of the workshop, the participants were questioned about their knowledge about MCQ quality indexes and also were asked about MCQ general principles (pre-test). Participants were again asked about the questions which they had in the pre-test as their post-test and were questioned about their expectations and the influence of this workshop.

RESULTS

The participants declared that their expectations were fulfilled (9.4 ± 0.6 out of 10), and the course was applicable (9.7 ± 0.7 out of 10). Before the workshop, only 12.5% of the participants know MCQ indicators. This rate increased to 41% after the workshop (P < 0.05). Also, they were questioned about Millman's checklist for the MCQ examination. Participants' correct answers were increased from 2.75 to 3.05 out of four (P < 0.05).

CONCLUSIONS

Although previous participation in MCQ training courses did not demonstrate an increase in knowledge and attitude, it could be theorized that short-term repetition would yield better results.

Attitudes of the Third-Year Clinical Anesthesiology Residents Toward an Independent Clinical Practice Rotation in COVID-19 Pandemic in Iran

BACKGROUND

COVID-19 was a worldwide pandemic with international health emergencies and great challenges; health care personnel shortage and physician burnout is a potential major challenge that should be planned and managed; especially in those countries with a high COVID-19 occurrence.

OBJECTIVES

This study was designed to assess the attitudes of 3rd-year anesthesiology residents toward an independent one month-length clinical care course for patients with COVID-19.

METHODS

A closed self-administered questionnaire was developed to assess the attitudes of 3rd-year clinical anesthesiology residents. A self-administered closed questionnaire was developed. Cronbach's alpha was calculated to measure the reliability of the questionnaire; added with a factor analysis process.

RESULTS

All 19 clinical anesthesiology residents took part in the study, with a 100% response rate. Cronbach's alpha for the reliability of the questionnaire was 0.678. The eigenvalue for 8 factors was equal to 1; however, further assessment led us to 7 factors.

CONCLUSIONS

This one-month period could improve the competencies of the 3rd year clinical anesthesiology residents based on their viewpoints. Since the COVID-19 pandemic is ongoing health and social problem worldwide, 3rd-year anesthesiology residents could help the health system to recover health care delivery faults regarding manpower; a promising point for crisis preparedness in the COVID-19 pandemic. Besides, there were many constructive results for the clinical anesthesiology residents regarding their training and clinical service delivery.

The effect of surfactant on clinical outcome of patients with COVID-19 under mechanical ventilation: A structured summary of a study protocol for a randomised controlled trial

Objectives

Assessing the effect of surfactant on clinical outcome in patients with COVID-19 under mechanical ventilation

Trial design

Single centre, two arm, parallel group (1:1 allocation ratio), randomised superiority trial with blinded care and outcome assessment.

Participants

Inclusion criteria: Adult COVID-19 patients admitted to the ICU in Modarres hospital, Tehran, Iran (age range of 18 to 99 years) with moderate to severe ARDS (based on definition of P/F ratio) requiring auxiliary respiratory devices (either intubation or face mask).

Exclusion criteria:

● Existence of a major underlying pulmonary disease in addition to COVID-19

● Underlying congenital heart disease

● Patients needing extracorporeal membrane oxygenation (ECMO)

● ARDS primarily due to any other reason rather than COVID-19

● The primary source of pulmonary involvement was bacterial pneumonia or any other etiology except for COVID-10 induced lung involvement

● Those who refused to continue the study (either the patient or their family)

● any patient had any sign of healing before entering the study leading to discharge from ICU in less than 12 hours

Intervention and comparator

In the intervention group, the dose of the drug is a vial containing 4 ml, equivalent to 100 mg, which is prescribed for an adult weighing about 70 kg each time, and if the patient's weight is much lower or higher, it will be adjusted accordingly. Surfactant is prescribed inside the trachea in two doses, starting on the day of intubation with a second dose 6 hours later. The control group will receive the same volume of normal saline, based on weight, administered into the trachea with the same time schedule.

Main outcomes

30 days mortality; patient mortality during stay in ICU up to 30 days; ICU length of stay up to 30 days; Time under mechanical ventilation up to 30 days.

Randomisation

After the participant enters the study, i.e. after the qualification of the patients in the trial is confirmed and their informed written consent is taken, we will use a simple randomisation method using a table of random numbers. In order to hide the random allocation process, a central randomisation approach will be used and the random sequence will be at the disposal of one of the researchers, excluding the principal investigator.

Blinding (masking)

Participants, healthcare providers and the principal investigator assessing the outcomes will all be blinded to the group assignment.

Numbers to be randomised (sample size)

A total of 60 participants will be randomised in a 1:1 allocation ratio (30 patients allocated to the intervention group and 30 patients allocated to the control group).

Trial Status

The protocol is Version 1.0, May 31, 2020. Recruitment began July 30, 2020, and is anticipated to be completed by October 30, 2020.

Trial registration

IRCT registration number: IRCT20091201002804N12

Registration date: 1st June 2020, 1399/03/12

Full protocol

The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.

Supplementary Information

Supplementary information accompanies this paper at 10.1186/s13063-020-04815-z.

Pitfalls in Ventilation Devices

Adequate ventilation is the greatest concern of all the anaesthesiologists. Any disturbance in the ventilation process could result in serious hazards: hypoxemia or barotrauma. Deficient devices are one of many causes of such derangements. Some of the typical complications of airway/ventilation tools are described extensively in textbooks, but many other uncommon events can still occur. We described two interesting cases of device-related ventilation inadequacy, hoping that acquaintance with such jeopardizes would be helpful in emergency situations for other colleagues.

Relationship Between "Simulated Patient Scenarios and Role-Playing" Method and OSCE Performance in Senior Anesthesiology Residents: A Correlation Assessment Study

BACKGROUND

"Simulated-patient scenarios and role-playing" and OSCE are among the many non-traditional education methods with variable results in different clinical settings.

OBJECTIVES

This cross-sectional study was performed to assess the correlation between the results of these two methods in senior anesthesiology residents, with a special focus on four of the six ACGME core competencies.

METHODS

During two years, senior anesthesiology residents were subject to "simulated patient scenario and role-playing" sessions. Two faculty members took the role of the patient and one of the relatives. An objective checklist with 15 items was prepared to be rated by other department faculty members. Meanwhile, an ordered pattern of OSCE was prepared to cover four core competencies that were more related to this academic process (from a total of six core competencies). The mean and standard deviation of the score of each of the 15 items in the checklist were calculated. The correlation between cumulative checklist scoring results and OSCE exam results was assessed. A P value of less than 0.05 was considered significant.

RESULTS

A total of 40 senior anesthesiology residents, with 344 assessments by faculty members in 40 sessions, were enrolled in the study. The questionnaire's Cronbach's alpha reliability was 0.74. No statistically significant disparity was detected between the results of the two assessment methods, while the results of the two assessments had a significant correlation (two-tailed correlation coefficient = 0.886; P value < 0.001).

CONCLUSIONS

There was an objective relationship between the results of "simulated patient scenario and role-playing" strategies and the results of OSCE exams using an observer-based rating method. Thus, they could be used as surrogates in the assessment of core clinical competencies of senior anesthesiology residents.

Intermediate versus standard-dose prophylactic anticoagulation and statin therapy versus placebo in critically-ill patients with COVID-19: Rationale and design of the INSPIRATION/INSPIRATION-S studies

BACKGROUND

Microvascular and macrovascular thrombotic events are among the hallmarks of coronavirus disease 2019 (COVID-19). Furthermore, the exuberant immune response is considered an important driver of pulmonary and extrapulmonary manifestations of COVID-19. The optimal management strategy to prevent thrombosis in critically-ill patients with COVID-19 remains unknown.

METHODS

The Intermediate versus Standard-dose Prophylactic anticoagulation In cRitically-ill pATIents with COVID-19: An opeN label randomized controlled trial (INSPIRATION) and INSPIRATION-statin (INSPIRATION-S) studies test two independent hypotheses within a randomized controlled trial with 2 × 2 factorial design. Hospitalized critically-ill patients with reverse transcription polymerase chain reaction confirmed COVID-19 will be randomized to intermediate-dose versus standard dose prophylactic anticoagulation. The 600 patients undergoing this randomization will be screened and if meeting the eligibility criteria, will undergo an additional double-blind stratified randomization to atorvastatin 20 mg daily versus matching placebo. The primary endpoint, for both hypotheses will be tested for superiority and includes a composite of adjudicated acute arterial thrombosis, venous thromboembolism (VTE), use of extracorporeal membrane oxygenation, or all-cause death within 30 days from enrollment. Key secondary endpoints include all-cause mortality, adjudicated VTE, and ventilator-free days. Key safety endpoints include major bleeding according to the Bleeding Academic Research Consortium definition and severe thrombocytopenia (platelet count <20,000/fL) for the anticoagulation hypothesis. In a prespecified secondary analysis for non-inferiority, the study will test for the non-inferiority of intermediate intensity versus standard dose anticoagulation for major bleeding, considering a non-inferiority margin of 1.8 based on odds ratio. Key safety endpoints for the statin hypothesis include rise in liver enzymes >3 times upper normal limit and clinically-diagnosed myopathy. The primary analyses will be performed in the modified intention-to-treat population. Results will be tested in exploratory analyses across key subgroups and in the intention-to-treat and per-protocol cohorts.

CONCLUSIONS

INSPIRATION and INSPIRATON-S studies will help address clinically-relevant questions for antithrombotic therapy and thromboinflammatory therapy in critically-ill patients with COVID-19.

Mortality Risk Factors among Hospitalized COVID-19 Patients in a Major Referral Center in Iran

The Coronavirus Disease 2019 (COVID-19) pandemic has killed many people worldwide since December 2019, and Iran has been among the most affected countries. In this retrospective study, we aimed to determine the prognostic factors associated with mortality in COVID-19 patients by analyzing 396 survived and 63 non-survived patients in Shahid Modarres Hospital, Tehran, Iran, from January 30^th until April 5^th, 2020. As the results, the BMI > 35 (p = 0.0003), lung cancer (p = 0.007), chronic kidney disease (p = 0.002), Immunocompromised condition (p = 0.003), and diabetes (p = 0.018) were more frequently observed in the expired group. The history of statins use was more common in the discharged group (p = 0.002), while there was no significant difference in the drug history of angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, nonsteroidal anti-inflammatory drugs, aspirin, and/or steroids, and in the past-year influenza vaccination. Multivariable regression demonstrated rising odds of in-hospital death related with age (odds ratio (OR) = 1.055, p = 0.002), levels of C-reactive protein (CRP) (OR = 2.915, p < 0.001), creatinine (OR = 1.740, p = 0.023), lymphocyte count (OR = 0.999, p = 0.008), and magnesium level (OR = 0.032, p < 0.001) on admission. In conclusion, the patients with older age and higher BMI with lymphopenia, hypomagnesemia, elevated CRP and/or raised creatinine on admission are at higher risk of mortality due to the COVID-19 infection, which requires the physicians to use timely and strong therapeutic measures for such patients.

Extracorporeal Hemoperfusion as a Potential Therapeutic Option for Severe COVID-19 patients; a Narrative Review

The 2019 novel coronavirus (officially known as severe acute respiratory syndrome coronavirus 2, SARS-CoV2) was first found in Wuhan, China. On February 11, 2020, the World Health Organization (WHO) has declared the outbreak of the disease caused by SARS-CoV2, named coronavirus disease 2019 (COVID-19), as an emergency of international concern. Based on the current epidemiological surveys, some COVID-19 patients with severe infection gradually develop impairment of the respiratory system, acute kidney injury (AKI), multiple organ failure, and ultimately, death. Currently, there is no established pharmacotherapy available for COVID-19. As seen in influenza, immune damage mediated by excessive production of inflammatory mediators contributes to high incidence of complications and poor prognosis. Thus, removal or blocking the overproduction of these mediators potentially aids in reducing the deleterious cytokine storm and improving critically ill patients' outcomes. Based on previous experience of blood purification to treat cytokine storm syndrome (CSS) in severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), here we aimed to review the current literature on extracorporeal hemoperfusion as a potential therapeutic option for CSS-associated conditions, with a focus on severe COVID-19.

Lifestyle and reproductive health: the aetiology of ovarian cancer in Pakistan

Ovarian cancer is a fatal gynaecological cancer and eighth most common cancer in women globally. Lifestyle, reproductive and sociodemographic factors are among the influential parameters that may significantly affect the risk of ovarian cancer and its mortality rate. However, the epidemiological investigations have shown that the risk of ovarian cancers associated with these factors is different in varied geographical distributions. Lifestyle and reproductive factors have not been investigated thoroughly across a wide cultural diversity. The objective of this study is to investigate the association of these factors with ovarian cancer in Pakistan. This investigation will focus on the lifestyle effects of fat intake, intake of tea, habitual exercise, use of talc, personal hygiene, habit of holding urine for long time, obesity on ovarian cancer among Pakistani women.  Reproductive variables will include age at menarche, natural menopausal age, parity, nulliparity (miscarriages, abortion, stillbirths), infertility, fertility treatment, tubal ligation, oral contraceptive use, and family history of breast or ovarian cancer. Sociodemographic variables will include effect of age, income, education, and geographical location. A case-control study will be conducted in the major cancer hospitals of Pakistan and the patients will also be interviewed. The controls will be recruited outside the hospital. For controls the same age limit and residency requirements will be applied. The information gained from this research will be an important contribution to develop programs for health promotion, with a focus on ovarian cancer prevention and women's health. The findings could be used for health policies and planning to prevent ovarian cancer. The research will pave the way for a public policy and interventions to reduce the burden of ovarian cancer in Pakistan.

Attitudes of Anesthesiology Residents Toward a Small Group Blended Learning Class

BACKGROUND

Accreditation Council for Graduate Medical Education (ACGME) has been used to evaluate the residents' competency; however, the thriving of residents needs especial training methods and techniques. Small group learning has been used for this propose.

OBJECTIVES

This study assessed the attitudes of CA-1 to CA-3 anesthesiology residents toward level-specific small-group blended learning.

METHODS

Anesthesiology residents from Department of Anesthesiology, Shahid Beheshti University of Medical Sciences (SBMU), Tehran, Iran participated in this cross-sectional attitude assessment descriptive-analytical study throughout the 2nd academic semester (May-October 2019). They took part in a level-specific small-group blended learning program and filled out an attitude assessment questionnaire. The questionnaire included eight closed questions and was filled out anonymously.

RESULTS

The residents believed that this program made important contributions to their theory training and clinical skills of anesthesia; while created a greater sense of solidarity. In addition, nearly the majority of the respondents did not believe that participating in the classes made interference in their clinical duties or was a difficult task. Instead, the majority of residents believed that these classes were in favor of reducing their burnout. The reliability of the questionnaire based on Cronbach's Alpha was 0.885.

CONCLUSIONS

Anesthesiology residents are in favor of small-group learning, especially when considering their clinical setting and the degree of burnout they tolerate.

The Role of Integrative Educational Intervention Package (Monthly ITE, Mentoring, Mocked OSCE) in Improving Successfulness for Anesthesiology Residents in the National Board Exam

BACKGROUND

National Board of Anesthesiology (NBA) pass rate is an important and critical step in clinical residency programs.

OBJECTIVES

This study was designed to assess the relationship between an integrative educational intervention (IEI) and the relative annual pass rate (RAPR). RAPR is defined as ratio of NBA pass rate of Shahid Beheshti University of Medical Sciences (SBMU) to the NBA pass rate of all the anesthesiology residency programs across Iran.

METHODS

In a descriptive-analytic retrospective study from 2012 to 2019, RAPR was calculated. IEI was implanted in the latter 4years period of this time interval includes: (1) individualized mentorship for residents by faculty members; (2) monthly in-training examination (ITE) in written; and (3) periodical mocked OSCE exam. Spearman's correlation coefficient was used to assess correlation between integrative educational intervention and RAPR results. P value less than 0.05 was considered statistically significant.

RESULTS

There was a statistically significant relationship between "integrative educational intervention program" and the RAPR results: Spearman's correlation coefficient = 0.655 (P value = 0.039).

CONCLUSIONS

The IEI package of Anesthesiology Department, SBMU showed a significant relationship with improvements in successfulness for anesthesiology residents in the National Board Exam (RAPR trend). More prolonged studies could prevail further aspects of these interventions.

Comparing the Frequency of CD4+T Cells in Recurrent Spontaneous Abortion Women with and without Anti-thyroid Peroxidase (TPO)

Thyroid autoimmunity, being recognized by the presence of auto-antibodies against thyroid peroxidase (TPO) and thyroglobulin, has known to be associated with increased risk of recurrent spontaneous abortion (RSA), even in euthyroid subjects. There was no robust evidence regarding T cell deviations in anti-TPO positive RSA patients. The aim of this study was to investigate if the numbers of different CD4+T  subsets were different in women who experienced RSA and have an anti-TPO antibody from those without autoantibody and normal fertile women or not. In this study, peripheral blood samples were obtained from three groups of women (age: 20-35 years) including RSA anti-TPO positive (n=17), RSA anti-TPO negative (n=27), and fertile (n=29) groups. The frequency of T helper (Th) 1, Th2, Th17, and regulatory T cells (Tregs) and also, the proportions of Th1/Th2 and Th17/Treg were measured by flow cytometry and compared between groups in different menstrual phases. The findings indicated elevated levels of Th1 in anti-TPO+ RSA in comparison with those without anti-TPO (p-value: 0.004), exclusively in the luteal phase. Other T cell subsets were different only between RSA and control groups. Also, the Th1/Th2 and Th17/Treg ratios were increased in both RSA groups compared to fertile women. The only subset of CD4+ T cell different between RSA groups (i.e. with and without anti-TPO) was Th1 cells. Other CD4+ T cells' deviations including Th2, Th17, and Treg cells could be related to the presence of abortion, regardless of the underlying thyroid autoimmunity state.

Synthesis of magnesium-based Janus micromotors capable of magnetic navigation and antibiotic drug incorporation

Fe₃O₄ superparamagnetic nanoparticles were used in magnesium based Janus micromotors for the first time and the bactericidal activity of the micromotors reached nearly 100%.

Hemostasis critical values among Iranian clinical laboratories "National Survey of 157 Clinical Laboratories"

BACKGROUND

Immediate reporting of critical values or test results significantly outside the normal range has a growing role in the management of patients, especially in life-threatening conditions. Due to the lack of international consensus, diverse approaches are used for determination of thresholds, reporting, documentation, and follow-up. In this study, we assessed how Iranian laboratories manage critical values for hemostasis.

METHODS

We designed a standard questionnaire to assess different aspects of hemostasis critical values, including the number of coagulation tests with a defined critical value, critical values reporting, documentation, and follow-up policies. All results were self-reported and correctness of the data was not assessed by the authors.

RESULTS

A total of 166 (66.4%) out of 250 laboratories completed the questionnaire; most (52.4%) were private. About 97% of responding laboratories had a critical values policy. These were defined for 64.3% (n: 27) of all coagulation tests (n: 42) performed in Iranian laboratories. Activated partial thromboplastin time (APTT), prothrombin time/international normalized ratio (PT/INR), platelet count, factor XI, and factor XIII assays had defined critical values among all laboratories performing these tests. Almost all laboratories reported critical values within 1 hour, after confirmation of the result on the same sample (70% of the laboratories) or a new one (13.4% of the laboratories). State and private laboratories had the same critical value reporting policy for in and outpatients, with laboratory technicians reporting critical results to nurses, for the most part.

CONCLUSION

Although critical value policy is widely used among Iranian laboratories, there is no consensus policy for the reporting of hemostasis critical values, or documentation, threshold determination, and follow-up processes. It is impossible to determine whether non-responding laboratories had any critical values reporting policy. Results thus are biased toward laboratories that did.

14-3-3ζ protein protects against brain ischemia/reperfusion injury and induces BDNF transcription after MCAO in rat

Brain ischemia is a leading cause of death and disability worldwide that occurs when blood supply of the brain is disrupted. Brain-derived neurotrophic factor (BDNF) is a protective factor in neurodegenerative conditions. Nevertheless, there are some problems when exogenous BDNF is to be used in the clinic. 14-3-3ζ is a pro-survival highly-expressed protein in the brain that protects neurons against death. This study evaluates 14-3-3ζ effects on BDNF transcription at early time point after ischemia and its possible protective effects against ischemia damage. Human 14-3-3ζ protein was purified after expression. Rats were assigned into four groups, including sham, ischemia, and two treatment groups. Stereotaxic cannula implantation was carried out in the right cerebral ventricle. After one week, rats underwent middle cerebral artery occlusion (MCAO) surgery and received 14-3-3ζ (produced in our laboratory or standard form as control) in the middle of ischemia time. At 6 h of reperfusion after ischemia, brain parts containing the hippocampus, the cortex, the piriform cortex-amygdala and the striatum were collected for real time PCR analysis. At 24 h of reperfusion after ischemia, neurological function evaluation and infarction volume measurement were performed. The present study showed that 14-3-3ζ could up-regulate BDNF mRNA at early time point after ischemia in the hippocampus, in the cortex and in the piriform cortex-amygdala and could also improve neurological outcome and reduce infarct volume. It seems that 14-3-3ζ could be a candidate factor for increasing endogenous BDNF in the brain and a potential therapeutic factor against brain ischemia.