Tarek Shams

Induced hypotension for functional endoscopic sinus surgery: A comparative study of dexmedetomidine versus esmolol.

Objective: A comparative study to evaluate the efficacy of dexmedetomidine as a hypotensive agent in comparison to esmolol in Functional Endoscopic Sinus Surgery (FESS). Methods: Forty patients ASA I or II scheduled for FESS were equally randomly assigned to receive either dexmedetomidine 1 μg/Kg over 10 min before induction of anesthesia followed by 0.4-0.8 μg/Kg/h infusion during maintenance (DEX group), or esmolol, loading dose 1mg/kg was infused over one min followed by 0.4-0.8 mg/kg/h infusion during maintenance (E group) to maintain mean arterial blood pressure (MAP) between (55-65 mmHg). General anesthesia was maintained with sevoflurane 2%-4%. The surgical field was assessed using Average Category Scale and average blood loss was calculated. Hemodynamic variables (MAP and HR); arterial blood gas analysis; plasma cortisol level; intraoperative fentanyl consumption; Emergence time and total recovery from anesthesia (Aldrete score ≥9) were recorded. Sedation score was determined at 15, 30, 60 min after tracheal extubation and time to first analgesic request was recorded. Result: Both DEX group and E group reached the desired MAP (55-65 mmHg) with no intergroup differences in MAP or HR. The for the quality of the surgical filed in the range of MAP (55-65 mmHg) were <=2 with no significant differences between group scores during hypotensive period. Mean intraoperative fentanyl consumption was significantly lower in DEX group than E group. Cortisol level showed no significant changes between or within groups. No significant changes were observed in arterial blood gases. Emergence time and time to achieve Aldrete score ≥9 were significantly lower in E group compared with DEX group. The sedation score were significantly lower in E group compared with DEX group at 15 and 30 minutes postoperatively. Time to first analgesic request was significantly longer in DEX group. Conclusion: Both dexmedetomidine or esmolol with sevoflurane are safe agents for controlled hypotension and are effective in providing ideal surgical field during FESS. Compared with esmolol, dexmedetomidine offers the advantage of inherent analgesic, sedative and anesthetic sparing effect.

Ketofol-Dexmedetomidine combination in ECT: A punch for depression and agitation.

Background and Aims : The choice of anaesthetic agent for electroconvulsive therapy (ECT) depends on seizure duration, haemodynamic, and recovery parameters. The aim of the study was to assess the effects of ketamine-propofol induction with dexmedetomidine preadministration (ketofol-dex group) and without its preadministration (ketofol group) on haemodynamics, depression, seizure duration, recovery characteristics, and agitation following ECT in patients with depression. Methods : 40 patients aged 18-60 years were scheduled for ECT for treatment of depression. Dexmedetomidine (0.5 μg/kg) diluted to a volume of 10 ml with 0.9% saline or 10 ml 0.9% saline were infused intravenously over 10 minutes before induction of anaesthesia with ketamine and propofol (ketofol). Statistical analysis was carried out using the Statistical Software for the Social Sciences (SPSS) package. Results : Motor seizure duration in ketofol group was significantly less compared to ketofol-dex group (35.8 ± 6.6s versus 38.9 ± 4.9s). Total ketofol used was significantly less in ketofol-dex group compared to ketofol group (78.5 ± 10.8mg versus 90 ± 13.2mg). The number of patients with agitation score >2 was significantly lower in ketofol-dex group (1.4%) compared to ketofol group (8.6%). There was significant decrease (P = 0.000) in mean arterial pressure (MAP) and heart rate (HR) in ketofol-dex group compared to ketofol group at 20, 30, and 40 minutes for MAP and at 10, 20, 30, and 40 minutes for HR. Conclusions : Ketofol-dex mixture in ECT is associated with longer mean seizure duration, effective anti-depression, less incidence of agitation, more patient satisfaction, and acceptable decreases in blood pressure and HR when compared to ketofol alone.

2655 – Adherence in egyptian patients with schizophrenia: the role of insight, medication beliefs and spirituality

Objective Reports about medication adherence in Arab patients with schizophrenia and the possible confounding factors are lacking. The aim of this study was to determine whether insight, spirituality and patient beliefs about the necessity and concerns about medication were associated with adherence among those presenting with schizophrenia in an outpatient facility. Methods At the end of a routine follow up with their psychiatrist, patients completed questionnaires including the Schedule for the Assessment of Insight (SAI- E), Morisky Medication Adherence Scale (MMAS), Arabic Daily Spiritual Experience Scale (DSES) and Beliefs about Medicines Questionnaire (BMQ) in addition to demographic and clinical information from patients and their medical files. Results A convenience sample of 92 patients with schizophrenia was studied .On the basis of the MMAS results, 33 (14.7%) patients were categorized as medication adherent and 59 (49.3%) as medication nonadherent. Regression analysis showed that the BMQ concern subscale and DSES scores were negative predictors of adherence whereas the SAI score was a positive predictor of adherence. The most important predictor of adherence was DSES and SAI, followed by BMQ concern subscale Conclusions This study extended prior research on the role of insight, spirituality and patient beliefs in medication adherence in a sample of Arab patients with schizophrenia which is consistent with previous research conducted in western cultures.

Efficacy and tolerability of quetiapine versus haloperidol in first-episode schizophrenia: a randomized clinical trial.

Background Schizophrenia is a chronic disease of global importance. The second-generation antipsychotic quetiapine has a favorable side-effect profile, however, its clinical effectiveness has been called into question when compared with first-generation antipsychotics such as haloperidol. This study evaluates the efficacy and tolerability of quetiapine versus haloperidol for first-episode schizophrenia in the outpatient setting. Methods 156 adult patients with first-episode schizophrenia participated in an outpatient clinical trial and were randomized to quetiapine (200 mg/d; n = 78) or haloperidol (5 mg/d; n = 78). The study medications were titrated to a mean daily dose of 705 mg for quetiapeine and 14 mg for haloperidol. The patients were assessed at baseline, six weeks, and twelve weeks. The primary outcome measures were positive and negative scores of the Positive and Negative Syndrome Scale (PANSS). Secondary measures were Global Assessment of Functioning (GAF) scale for overall psychosocial functioning, and Simpson-Angus Scale (SAS) for extra-pyramidal symptoms. Results At twelve weeks, the quetiapine group had a greater decrease in PANSS positive (18.9 vs. 15.3, p = 0.013) and negative scores (15.5 vs. 11.6, p = 0.012), however, haloperidol showed a greater decrease in general psychopathology score (23.8 vs. 27.7, p = 0.012). No significant difference between groups were found for total PANSS (58.3 vs. 54.8, p = 0.24) and GAF (45.7 vs. 46.2, p = 0.79). ANOVA identified significant group interactions on PANSS positive (F = 18.72, df = 1.6,52.4, p < 0.0001), negative (F = 5.20, df = 1.1,35.7, p < 0.0001), depression/anxiety (F = 106.49, df = 1.14,37.8, p < 0.0001), and total scores (F = 7.51, df = 1.4,45.6, p = 0.001). SAS (8.62 vs. 0.26, p < 0.0001) and adverse events of akathisia (78% vs. 0%, p = 0.000), parkinsonism (66.6% vs. 0%, p < 0.0001), and fatigue (84.6% vs. 66.6%, p = 0.009) were greater in haloperidol compared to quetiapine, whereas headache was more common in quetiapine treated patients (11.5% vs. 35.9%, p < 0.0001). Conclusions Quetiapine has greater efficacy for positive and negative symptoms with less extra-pyramidal symptoms than haloperidol when used for first-episode schizophrenia in the outpatient setting.

Perceived Stress and Burnout among Medical Students during the Clinical Period of Their Education

Background: the transition from preclinical to clinical training has been identified as a crucial stage of medical school, regarding student stress and when entering the clinical environs students may become more prone to burnout. Aims: this study aims to determine the prevalence, sources and predictors of high stress level and burnout among medical students at King Faisal University, Saudi Arabia during the clinical phase of medical education. Method: this is a cross-sectional survey study of Saudi medical students belong to 4 th , 5 th and 6 th years at Al-Ahssa Medical College during the academic year 2011-12. All 324 regular course attendants were invited in the study with 233 responses (response rate of 71.9%). A self-reported questionnaire was used which covered three categories including 18 items of sources of stress. Short Perceived stress scale and Emotional Exhaustion Subscale of Maslach Burnout Inventory were used to measure stress and burnout. Result : 6 th year students were more likely to cite relationship, hospital and professional issues as stressors. In this study the top stressors cited by final year students were worry about the future, defective clinical skills practice, fear of hurting patient and high parental expectation while they were transportation problems to hospital, fear of infection and time limitation for training in the starting year of clinical period. The prevalence of emotional exhaustion and high level of perceived stress was 76.8 and 71.7% respectively. Year of study was the only single independent risk factor of burnout and high level of stress amongst students of clinical years. Conclusions: clinical phase of medical education is a necessary area of intervention in order to provide a better and less anxious transition between preclinical and clinical phases as well as adoption of new curriculum with integration of preclinical and clinical training of students from an early stage of the education is warranted. Key word: Saudi Arabia – Medical students – Clinical period – Perceived stress – Emotional exhaustion.

Effect of prophylactic vitamin D on anesthetic outcome in children with sickle cell disease

Background: Few previous studies proved that complications related to sickle cell disease (SCD) were common with regional anesthesia compared with general anesthesia while others reported no differences. This study was carried out to evaluate the role of prophylactic vitamin D on anesthetic outcome among male children with SCD undergoing circumcision. Materials and Methods: A comparative study was carried out on 58 children undergoing circumcision with the regional block under light general anesthesia. The study sample was classified into two groups: one group received daily 400 IU vitamin D for 6 months before surgery while the other group without vitamin D. All patients were followed regarding the post-operative analgesia and the incidence of post-operative SCD related complications (acute chest syndrome, painful crisis and cerebrovascular accident). Data were analyzed with Statistical Package for Social Sciences version 13, produced by IBM SPSS, Inc. in Chicago, Illinois, USA. Results: There was a highly significant difference between the two groups (P < 0.001) regarding first analgesic request and total analgesic consumption per day: there was delayed analgesic request and less total analgesic consumption per day in vitamin D group. Comparison of post-operative sedation scores showed highly significant difference (P < 0.001) between the two groups, Sedation scores was increased significantly in vitamin D group. This study also reported that the administration of vitamin D was associated with less noticeable post-operative SCD complications. Conclusion: The use of prophylactic vitamin D in SCD will result in delayed post-operative analgesic request and less total analgesic requirement. Administration of vitamin D was also associated with less post-operative complications.

Cons and pros of female anesthesiologists: Academic versus nonacademic.

Background and Aims: We hypothesized that “Feminization” of medicine has an impact on the choice of anesthesiology as a specialty. However anesthesiology is still not a more popular choice among women in medicine. We aimed to evaluate the implications of anesthesiology as a profession on personal and family life of women anesthesiologists; the differences between academic and nonacademic women anesthesiologists with respect to these effects and the effect of women anesthesiologists on the profession. Materials and Methods: This study surveyed a total of 46 woman anesthesiologists; both academic and nonacademic institutions in our country between January and May 2013. A convenient sampling method was used. A constructed self-reported questionnaire was developed to explore the 29 items of woman-anesthesiology-related implications (family, personal, and job), in the form of close-ended questions. Results: Negative implications of anesthesiology on personal and family life of woman were common. With the exception of financial limitation, academic group was significantly more affected. Increased surgeons conflict (98%), poor surgeon acceptance (87%), poor patient acceptance and recurrent change of work schedule (80% each) were the most common perceived negative impacts of women in the field of anesthesiology. Some positive implications were perceived as independent, positive social interaction, empowerment, soothing work environment, emotional reaction to patient complaint, and increased perfectionism (nearly 94%, 98%, 87%, 91%, 89%, and 76%, respectively). Conclusion: Serious implications exist for the personality and family life of women who chose anesthesiology as a specialty and career, and most of these implications were significantly more prevalent among women with an academic career. Furthermore, anesthesiology as a profession was significantly affected by women joining the department.

Assessment of current undergraduate anesthesia course in a Saudi University

Background: The assessment of the anesthesia course in our university comprises Objective Structured Clinical Examinations (OSCEs), in conjunction with portfolio and multiple-choice questions (MCQ). The objective of this study was to evaluate the outcome of different forms of anesthesia course assessment among 5th year medical students in our university, as well as study the influence of gender on student performance in anesthesia. Methods: We examined the performance of 154, 5th year medical students through OSCE, portfolios, and MCQ. Results: The score ranges in the portfolio, OSCE, and MCQs were 16-24, 4.2-28.9, and 15.5-44.5, respectively. There was highly significant difference in scores in relation to gender in all assessments other than the written one (P=0.000 for Portfolio, OSCE, and Total exam, whereas P=0.164 for written exam). In the generated linear regression model, OSCE alone could predict 86.4% of the total mark if used alone. In addition, if the score of the written examination is added, OSCE will drop to 57.2% and the written exam will be 56.8% of the total mark. Conclusions: This study demonstrates that different clinical methods used to assess medical students during their anesthesia course were consistent and integrated. The performance of female was superior to male in OSCE and portfolio. This information is the basis for improving educational and assessment standards in anesthesiology and for introducing a platform for developing modern learning media in countries with dearth of anesthesia personnel.

Does haloperidol prophylaxis reduce ketamine-induced emergence delirium in children?

OBJECTIVES Ketamine is a non-barbiturate agent with rapid action onset that induces profound sedation; however, some emergency physicians tend not to use ketamine because of the risk of emergence delirium (ED). This study aimed to evaluate the effectiveness of haloperidol prophylaxis in postoperative ketamine delirium in children. METHODS Prospective data relating to any emergence dreams, delirium, hallucinations, agitation, crying, altered perceptions, and necessary interventions were recorded in consecutive cases of ketamine delirium in patients attending Mansoura University Hospital, Egypt, from June 2010 to May 2011. RESULTS A total of 537 records were available for analysis. Of those, 267 received prophylactic haloperidol (49.7%). There were significant differences between the two groups regarding post-anaesthetic care unit behaviour. The ketamine-haloperidol groups included more patients who were sleepy, calm (P ≤0.01) and less irritable (P ≤0.01), with a lower incidence of crying (P ≤0.01) and disorientation (P ≤0.01). CONCLUSION We found that preoperative administration of haloperidol decreases the incidence of postoperative delirium in a sample of Egyptian children undergoing minor surgery. This is congruent with earlier work conducted in adults. This work carries great hope to decrease and even prevent ED in hospitalised, non-surgical patients.