Warm Cupping of the Posterior Thorax in Combination with Standard Conventional Therapy for ARDS in COVID-19 Patients in ICU: a Case Series

Acute respiratory distress syndrome (ARDS) is commonly found in critically ill patients with coronavirus disease 2019 (COVID-19). As a non-pharmacological treatment of complementary and alternative medicine (CAM), cupping has been clinically used for respiratory symptoms. We sequentially identified a series of patients with COVID-19 with ARDS who were admitted to the intensive care unit (ICU). Warm cupping of the posterior thorax was performed for seven days. We collected longitudinal severity scores on cough, breathlessness, chest tightness, type of oxygen therapy, and oxygen saturation (SpO₂). We hereby report the changes in the severity scores in a series of eight patients who received 21 sessions of cupping in addition to conventional treatments. All patients reported improvement in symptom scores that was matched by an increase in SpO₂ by as much as 3.16%. All patients were discharged and did not require the use of a mechanical ventilator. The results suggest that combining cupping with conventional treatment may provide a good prognosis for patients with COVID-19 with ARDS.

The Iranian Study of Opium and Cancer (IROPICAN): Rationale, Design, and Initial Findings

BACKGROUND

The International Agency for Research on Cancer (IARC) recently classified opium use as a Group 1 carcinogen. However, much remains to be studied on the relation between opium and cancer. We designed the Iranian Opium and Cancer (IROPICAN) study to further investigate the association of opium use and cancers of the head and neck, bladder, lung, and colon and rectum. In this paper, we describe the rationale, design, and some initial results of the IROPICAN Study.

METHODS

The IROPICAN is a multi-center case-control study conducted in 10 provinces of Iran. The cases were all histologically confirmed and the controls were selected from hospital visitors who were free of cancer, were not family members or friends of the cancer patients, and were visiting the hospital for reasons other than their own ailment. The questionnaires included detailed questions on opium use (including age at initiation, duration, frequency, typical amount, and route), and potential confounders, such as tobacco use (e.g., cigarettes, nass and water-pipe), and dietary factors. Biological samples, including blood and saliva, were also collected.

RESULTS

The validation and pilot phases showed reasonably good validity, with sensitivities of 70% and 69% for the cases and controls, respectively, in reporting opium use. The results also showed excellent reliability, with intra-class correlation coefficients of 0.96 for ever opium use and 0.88 (95% CI: 0.80, 0.92) for regular opium use. In the main phase, we recruited 3299 cancer cases (99% response rate) and 3477 hospital visitor controls (89% response rate). The proportion of ever-use of opium was 40% among cases and 18% among controls.

CONCLUSION

The IROPICAN study will serve as a major resource in studies addressing the effect of opium on risk of cancers of the head and neck, bladder, lung, and colon and rectum.

Predictive Factors of Preoperative Anxiety in the Anesthesia Clinic: A Survey of 231 Surgical Candidates

Background: Despite the growing advancements of surgical and anesthetic techniques resulting in decreased morbidity and mortality, the period before surgery remains stressful for most patients. Considering the adverse effect of preoperative anxiety on anesthesia and surgery outcomes, we conducted this study to evaluate the level of anxiety in the anesthesia clinic among Iranian patients undergoing surgery and also to determine its associated factors. Methods: This was a cross-sectional study performed on 231 patients admitted to the anesthesia clinic of Imam Khomeini hospital, Tehran, Iran. Data were collected by using a three-part questionnaire consisting of demographic data, clinical findings and the translated version of Spielberger state-trait anxiety inventory (STAI). Chi-square test and binary logistic regression model were performed for univariate and multivariate analysis, respectively. A p-value< 0.05 was considered statistically significant. Results: The mean (SD) score for state and trait anxiety were 39.8 (13.4) and 36.5 (12.2), respectively. A significant association was seen between state anxiety and age, gender, occupation, level of education, marital status, patients’ awareness of type of anesthesia and patients’ awareness of anesthesia adverse events (p< 0.05). The most predictive factors for state anxiety were age, patients’ awareness of anesthesia adverse events and female gender, and for trait anxiety these factors were age, place of residence and female gender. Conclusion: Screening for anxiety and identifying individuals vulnerable to preoperative anxiety (e.g. younger patients, females…) can help reduce undesirable surgery outcomes and their economic burden on the healthcare system.

Clinical course teaching in transport of critically ill patients: Small group methods

Critically ill patient transfer is potentially risky and may be lead to morbidity and mortality. Physicians' skill is very important for safe transport. We want to evaluate the effect of clinical course teaching on the promotion of physicians' abilities in the transport of critically ill patients. In an interventional study, 320 interns, male and female, were taught about patient transfer in two groups include in one day clinical course as the small group system (n=160) and other group the lecture base learning (n=160). In the clinical course, each participant under observation of an anesthesiologist in the operation room and ICU was acquainted with mask ventilation, intubation and learned to work with a defibrillator, infusion pump, portable ventilator and pulse oximeter. In lecture group, the anesthesiologist explained the topics by video and dummy. At the end of education course, the interns' abilities were evaluated based on checklist method and scored by the project colleague in all educational items. Three hundred twenty interns, 122 males, and 198 females; were enrolled, two groups. The clinical course training caused improvements in the interns' knowledge and abilities in intubation and use of the defibrillator and portable ventilator vs.lecture group significantly (P<0.005). The males were better than females in laryngoscopy, but the progress of the females was significantly better than males (P=0.003). The rate of adverse events was reduced significantly after clinical course teaching (P=0.041) Clinical course teaching could promote interns' clinical competencies in the transport of critically ill patients.

An ultra-low dose of naloxone added to lidocaine or lidocaine-fentanyl mixture prolongs axillary brachial plexus blockade

INTRODUCTION

In this prospective, randomized, double-blind study, we evaluated the effect of an ultra-low dose of naloxone added to lidocaine and fentanyl mixture on the onset and duration of axillary brachial plexus block.

METHODS

One hundred twelve patients scheduled for elective forearm surgery under axillary brachial plexus block were randomly allocated to receive 34 mL lidocaine 1.5% with 3 mL of isotonic saline chloride (control group, n = 28), 34 mL lidocaine 1.5% with 2 mL (100 microg) of fentanyl and 1 mL of isotonic saline chloride (fentanyl group, n = 28), 34 mL lidocaine 1.5% with 2 mL saline chloride and 100 ng (1 mL) naloxone (naloxone group, n = 28), or 34 mL lidocaine 1.5% with 2 mL (100 microg) of fentanyl and 100 ng (1 mL) naloxone (naloxone + fentanyl group, n = 28). A multiple stimulation technique was used in all patients. After performing the block, sensory and motor blockades of radial, median, musculocutaneous, and ulnar nerves were recorded at 5, 15, and 30 min. The onset time of the sensory and motor blockades was defined as the time between the last injection and the total abolition of the pinprick response and complete paralysis, respectively. The duration of sensory and motor blocks was considered as the time interval between the complete block and the first postoperative pain and complete recovery of motor functions.

RESULTS

Sensory and motor onset times were longer in the naloxone (sensory onset time: 15 +/- 3, and motor onset time: 21 +/- 4) and naloxone + fentanyl group than control or fentanyl groups (sensory onset time: 10 +/- 3 min in control group, 10 +/- 4 min in fentanyl group, and 17 +/- 3 min in naloxone + fentanyl group, motor onset time: 15 +/- 5 min in control group, 14 +/- 7 min in fentanyl group, and 17.3 +/- 3.4 min in naloxone + fentanyl group) (P < 0.001). The duration of time to first postoperative pain and motor blockade was significantly longer in the naloxone (92 +/- 10 and 115 +/- 10 min) and naloxone + fentanyl groups (98 +/- 12 and 122 +/- 16 min) than control (68 +/- 7 and 89 +/- 11 min) and fentanyl groups (68 +/- 11 and 90 +/- 12 min) (P < 0.001). The time to first postoperative pain was significantly longer in the naloxone and naloxone + fentanyl groups than in the control or fentanyl groups (P < 0.001).

CONCLUSIONS

The addition of an ultra-low dose of naloxone to lidocaine 1.5% solution with or without fentanyl solution in axillary brachial plexus block prolongs the time to first postoperative pain and motor blockade but also lengthens the onset time.