/pdf/dexmedetomidine-in-neurosurgical-anesthesia-4e1qr43l5x.pdf

Dexmedetomidine in neurosurgical anesthesia

At the heart of the unparalleled crisis of COVID-19, healthcare workers (HCWs) face several challenges treating patients with COVID-19: reducing the spread of infection; developing suitable short-term strategies; and formulating long-term plans. The psychological burden and overall wellness of HCWs has received heightened awareness in news and research publications. The purpose of this study was to provide a review on current publications measuring the effects of COVID-19 on wellness of healthcare providers to inform interventional strategies. Between April 6-May 17, 2020, we conducted systematic searches using combinations of these keywords and synonyms in conjunction with the controlled vocabulary of the database: "physician," "wellness, "wellbeing," "stress," "burnout," "COVID-19," and "SARS-CoV-2." We excluded articles without original data, research studies regarding the wellness of non-healthcare occupations or the general public exclusively, other outbreaks, or wellness as an epidemic. A total of 37 studies were included in this review. The review of literature revealed consistent reports of stress, anxiety, and depressive symptoms in HCWs as a result of COVID-19. We describe published data on HCW distress and burnout but urge future research on strategies to enhance HCW well-being.

/pdf/the-impact-of-covid-19-on-healthcare-worker-wellness-a-4jztoh34zt.pdf

The Impact of COVID-19 on Healthcare Worker Wellness: A Scoping Review

Malignant tumors of the breast

Economic impact of COVID-19 pandemic on healthcare facilities and systems: International perspectives

Background
A wide variety of grafts have been introduced with the aim of improving the outcomes of traditional native tissue repair (colporrhaphy) for vaginal prolapse.

Objectives
To determine the safety and effectiveness of transvaginal mesh or biological grafts compared to native tissue repair for vaginal prolapse.

Search methods
We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, ongoing trials registers, and handsearching of journals and conference proceedings (6 July 2015). We also contacted researchers in the field.

Selection criteria
Randomised controlled trials (RCTs) comparing different types of vaginal repair (mesh, biological graft, or native tissue).

Data collection and analysis
Two review authors independently selected trials, assessed risk of bias, and extracted data. The primary outcomes were awareness of prolapse, repeat surgery, and recurrent prolapse on examination.

Main results
We included 37 RCTs (4023 women). The quality of the evidence ranged from very low to moderate. The main limitations were poor reporting of study methods, inconsistency, and imprecision.

Permanent mesh versus native tissue repair

Awareness of prolapse at one to three years was less likely after mesh repair (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.54 to 0.81, 12 RCTs, n = 1614, I2 = 3%, moderate-quality evidence). This suggests that if 19% of women are aware of prolapse after native tissue repair, between 10% and 15% will be aware of prolapse after permanent mesh repair.

Rates of repeat surgery for prolapse were lower in the mesh group (RR 0.53, 95% CI 0.31 to 0.88, 12 RCTs, n = 1675, I2 = 0%, moderate-quality evidence). There was no evidence of a difference between the groups in rates of repeat surgery for continence (RR 1.07, 95% CI 0.62 to 1.83, 9 RCTs, n = 1284, I2 = 21%, low-quality evidence). More women in the mesh group required repeat surgery for the combined outcome of prolapse, stress incontinence, or mesh exposure (RR 2.40, 95% CI 1.51 to 3.81, 7 RCTs, n = 867, I2 = 0%, moderate-quality evidence). This suggests that if 5% of women require repeat surgery after native tissue repair, between 7% and 18% in the permanent mesh group will do so. Eight per cent of women in the mesh group required repeat surgery for mesh exposure.

Recurrent prolapse on examination was less likely after mesh repair (RR 0.40, 95% CI 0.30 to 0.53, 21 RCTs, n = 2494, I2 = 73%, low-quality evidence). This suggests that if 38% of women have recurrent prolapse after native tissue repair, between 11% and 20% will do so after mesh repair.

Permanent mesh was associated with higher rates of de novo stress incontinence (RR 1.39, 95% CI 1.06 to 1.82, 12 RCTs, 1512 women, I2 = 0%, low-quality evidence) and bladder injury (RR 3.92, 95% CI 1.62 to 9.50, 11 RCTs, n = 1514, I2 = 0%, moderate-quality evidence). There was no evidence of a difference between the groups in rates of de novo dyspareunia (RR 0.92, 95% CI 0.58 to 1.47, 11 RCTs, n = 764, I2 = 21%, low-quality evidence). Effects on quality of life were uncertain due to the very low-quality evidence.

Absorbable mesh versus native tissue repair

There was very low-quality evidence for the effectiveness of either form of repair at two years on the rate of awareness of prolapse (RR 1.05, 95% CI 0.77 to 1.44, 1 RCT, n = 54).

There was very low-quality evidence for the effectiveness of either form of repair on the rate of repeat surgery for prolapse (RR 0.47, 95% CI 0.09 to 2.40, 1 RCT, n = 66).

Recurrent prolapse on examination was less likely in the mesh group (RR 0.71, 95% CI 0.52 to 0.96, 3 RCTs, n = 292, I2 = 21%, low-quality evidence)

The effect of either form of repair was uncertain for urinary outcomes, dyspareunia, and quality of life.

Biological graft versus native tissue repair

There was no evidence of a difference between the groups at one to three years for the outcome awareness of prolapse (RR 0.97, 95% CI 0.65 to 1.43, 7 RCTs, n = 777, low-quality evidence).

There was no evidence of a difference between the groups for the outcome repeat surgery for prolapse (RR 1.22, 95% CI 0.61 to 2.44, 5 RCTs, n = 306, I2 = 8%, low-quality evidence).

The effect of either approach was very uncertain for recurrent prolapse (RR 0.94, 95% CI 0.60 to 1.47, 7 RCTs, n = 587, I2 = 59%, very low-quality evidence).

There was no evidence of a difference between the groups for dyspareunia or quality of life outcomes (very low-quality evidence).

Authors' conclusions
While transvaginal permanent mesh is associated with lower rates of awareness of prolapse, repeat surgery for prolapse, and prolapse on examination than native tissue repair, it is also associated with higher rates of repeat surgery for prolapse or stress urinary incontinence or mesh exposure (as a composite outcome), and with higher rates of bladder injury at surgery and de novo stress urinary incontinence. The risk-benefit profile means that transvaginal mesh has limited utility in primary surgery. While it is possible that in women with higher risk of recurrence the benefits may outweigh the risks, there is currently no evidence to support this position.

Limited evidence suggests that absorbable mesh may reduce rates of recurrent prolapse on examination compared to native tissue repair, but there was insufficient evidence on absorbable mesh for us to draw any conclusions for other outcomes. There was also insufficient evidence for us to draw any conclusions regarding biological grafts compared to native tissue repair.

In 2011, many transvaginal permanent meshes were voluntarily withdrawn from the market, and the newer, lightweight transvaginal permanent meshes still available have not been evaluated within a RCT. In the meantime, these newer transvaginal meshes should be utilised under the discretion of the ethics committee.

/pdf/transvaginal-mesh-or-grafts-compared-with-native-tissue-4ulupk31xa.pdf

Transvaginal mesh or grafts compared with native tissue repair for vaginal prolapse.

OBJECTIVES 
To determine the effect of adding dexmedetomidine to bupivacaine for neuraxial anesthesia.
 METHODS 
Sixty-six patients were studied between April and May 2008 in the University of Jordan, Amman Jordan. They were randomly assigned into 3 groups, each receiving spinal bupivacaine 12.5mg combined with normal saline (group N) Dexmedetomidine 5 microg (group D5), or dexmedetomidine 10 microg (group D10). The onset times to reach T10 sensory and Bromage 3 motor block, and the regression times to reach S1 sensory level and Bromage 0 motor scale, were recorded.
 RESULTS 
The mean time of sensory block to reach the T10 dermatome was 4.7 +/- 2.0 minutes in D10 group, 6.3 +/- 2.7 minutes in D5, and 9.5 +/- 3.0 minutes in group N. The mean time to reach Bromage 3 scale was 10.4 +/- 3.4 minutes in group D10, 13.0+/-3.4 minutes in D5, and 18.0 +/- 3.3 minutes in group N. The regression time to reach S1 dermatome was 338.9 +/- 44.8 minutes in group D10, 277.1 +/- 23.2 minutes in D5, and 165.5 +/- 32.9 minutes in group N. The regression to Bromage 0 was 302.9 +/- 36.7 minutes in D10, 246.4 +/- 25.7 minutes in D5, and 140.1 +/- 32.3 minutes in group N. Onset and regression of sensory and motor block were highly significant (N vesus D5, N versus D10, and D5 versus D10, p<0.001).
 CONCLUSIONS 
Dexmedetomidine has a dose dependant effect on the onset and regression of sensory and motor block when used as an adjuvant to bupivacaine in spinal anesthesia.

Effect of dexmedetomidine added to spinal bupivacaine for urological procedures.

Problem statement: The purpose of this study was to evaluate the onset and duration of sensory and motor block as well as operative analgesia and adverse effects of Dex Metedo Midine (DXM) or fentanyl given intrathecally with plain 0.5% bupivacaine for spinal anesthesia. Approach: seventy six patients classified as American Society of Anesthesiologists (ASA) status I, II and III scheduled for vaginal hysterectomy, vaginal wall repair and tension free vaginal tape were prospectively studied. Patients were randomly allocated to receive intrathecally either 10 mg isobaric bupivacaine plus 5 µg dexmetedomidine (group D n = 38) or 10 mg isobaric bupivacaine plus 25 mg fentanyl (group F n = 38), the onset time to reach peak sensory and motor level, the regression time for sensory and motor block, hemodynamic changes, and side effects were recorded. Results: Patients in group D had significant longer sensory and motor block times than patients in group F. the mean time of sensory regression to S1 was 274±73 min in group D and 179±47 min in group F (P < 0.001). The regression time of motor block to reach modified Bromage 0 was 240±60 min in group D and 155±46 min in group F (P< 0.001). The onset times to reach T10 dermatome and to reach peak sensory level as well as onset time to reach modified Bromage 3 motor block were not significantly different between the two groups. Conclusion: In women undergoing vaginal reconstructive surgery under spinal analgesia, 10 mg plain bupivacaine supplemented with 5 µg dexmetedomidine produces prolonged motor and sensory block compared with 25 µg fentanyl.

/pdf/effect-of-adding-dexmedetomidine-versus-fentanyl-to-1tsthojz1d.pdf

Effect of Adding Dexmedetomidine versus Fentanyl to Intrathecal Bupivacaine on Spinal Block Characteristics in Gynecological Procedures: A Double Blind Controlled Study

The number of COVID-19 (Coronavirus Disease of 2019) cases in Jordan is rising rapidly. A serious threat to the healthcare system appears on the horizon. Our study aims to evaluate preparedness of Jordanian frontline doctors to the worsening scenario. It has a questionnaire-based cross-sectional structure. The questionnaire was designed to evaluate preparedness according to knowledge about virus transmission and protective measures, adherence to protection guidelines, and psychological impacts affecting doctors. Institutional factors affecting doctors' readiness like adopting approach protocols and making protection equipment available were investigated; 308 doctors from different healthcare facilities participated (response rate: 53.9%). Approximately 25% of doctors (n = 77) previously took care of COVID-19 patients, and 173 (56.2%) have institutional COVID-19 approach protocols. Only 57 doctors (18.5%) reported all PPE (Personal Protective Equipment) available. The self-reported score of preparedness to deal with COVID-19 patients was 4.9 ± 2.4. Doctors having institutional protocols for dealing with COVID-19 cases and those with sustained availability of PPE reported higher scores of preparedness (5.5 ± 2.3 and 6.2 ± 2.1 with p < 0.001, respectively). Correlations with knowledge score, adherence to PPE score, and psychological impacts were investigated. The study revealed multiple challenges and insufficiencies that can affect frontline doctors' preparedness. Policy makers are urged to take these findings into consideration and to act promptly.

https://www.mdpi.com/1660-4601/17/9/3181/pdf

Preparedness of Frontline Doctors in Jordan Healthcare Facilities to COVID-19 Outbreak.

BACKGROUND The prolongation of spinal anesthesia by using clonidine through the oral, intravenous and spinal route has been known. The new alpha 2 agonist, dexmedetomidine has been proved to prolong the spinal anesthesia through the intrathecal route. We hypothesized that dexmedetomidine when administered intravenously following spinal block, also prolongs spinal analgesia. METHODS 48 patients were randomly allocated into two equal groups following receiving spinal isobaric bupivacaine 12.5 mg. Patients in group D received intravenously a loading dose of 1 microg/kg dexmedetomidine over 10 min and a maintenance dose of 0.5 microg/kg/hr. Patients in group C (the control group) received normal saline. The regression times to reach S1 sensory level and Bromage 0 motor scale, hemodynamic changes and the level of sedation were recorded. RESULTS The duration of sensory block was longer in intravenous dexmedetomidine group compared with control group (261.5 +/- 34.8 min versus 165.2 +/- 31.5 min, P < 0.05). The duration of motor block was longer in dexmedetomidine group than control group (199 +/- 42.8 min versus 138.4 +/- 31.3 min, P < 0.05). CONCLUSION Intravenous dexmedetomidine administration prolonged the sensory and motor blocks of bupivacaine spinal analgesia with good sedation effect and hemodynamic stability.

Intravenous dexmedetomidine prolongs bupivacaine spinal analgesia.

OBJECTIVES 
To evaluate the effect of adding dexmedetomidine to a balanced anesthetic technique on postoperative nausea and vomiting after laparoscopic gynecological surgeries.
 METHODS 
A prospective double-blind randomized study was designed at Jordan University Hospital, Amman, Jordan between December 2008 and February 2009. Eighty-one female patients in their child-bearing age (17-48 years); American Society of Anesthesiologists (ASA) clinical status I, who were scheduled for elective diagnostic laparoscopic surgeries under general anesthesia were divided into 2 groups. Group D (n=42) received dexmedetomidine infusion, while group P (n=39) received 0.9% sodium chloride infusion along with the balanced anesthesia. The incidence of early (up to 24 hours) postoperative nausea, vomiting, nausea and vomiting, and the need for postoperative rescue anti-emetic medications were recorded.
 RESULTS 
The total incidence of postoperative nausea and vomiting decreased significantly in group D; 13 out of 42 patients (31%), compared to group P; 23 out of 39 patients (59%), vomiting alone did not significantly change, the incidence of postoperative nausea, and the use of rescue anti-emetic medications were significantly different. A significant drop in overall consumption of fentanyl and sevoflurane was also noted in group D.
 CONCLUSIONS 
Combining dexmedetomidine to other anesthetic agents, results in more balanced anesthesia and a significant drop in the incidence of postoperative nausea and vomiting after laparoscopic gynecological surgeries.

Mahmoud M. Al-Mustafa

Papers

Effect of dexmedetomidine added to spinal bupivacaine for urological procedures.

Effect of Adding Dexmedetomidine versus Fentanyl to Intrathecal Bupivacaine on Spinal Block Characteristics in Gynecological Procedures: A Double Blind Controlled Study

Preparedness of Frontline Doctors in Jordan Healthcare Facilities to COVID-19 Outbreak.

Intravenous dexmedetomidine prolongs bupivacaine spinal analgesia.

A balanced anesthesia with dexmedetomidine decreases postoperative nausea and vomiting after laparoscopic surgery.