Diagnosis and treatment of cardiovascular manifestations of COVID-19: a narrative review

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) was the main pathogen in the COVID-19 pandemic. This viral infection has been associated with several respiratory and non-respiratory complications contributing to a higher mortality rate, especially in patients with underlying heart diseases worldwide. Once considered a respiratory tract disease, it is now well-known that COVID-19 patients may experience a wide range of cardiac manifestations. Because of its remarkable direct and indirect effects on the cardiovascular system, herein, we examined the published literature that studied the hypothetical mechanisms of injury, manifestations, and diagnostic modalities, including changes in molecular biomarkers with a predictive value in the prognostication of the disease, as well as emerging evidence regarding the long-term cardiac complications of the disease.

Do Intrathecal Opioids Improve Surgical Outcomes After Coronary Artery Bypass Grafting? A Systematic Review and Analysis

BACKGROUND

Intrathecal opioids have long been used as analgesia for intractable cancer pain or as part of spinal anesthesia during obstetric operations. More recently, they have been used preoperatively as a pain management adjuvant for open cardiac and thoracic procedures.

OBJECTIVE

This study aims to analyze the impact of administering intrathecal opioids before cardiac and thoracic surgeries on postoperative pain and mechanical ventilation.

STUDY DESIGN

Systematic review and meta-analysis.

SETTING

University, School of Medicine, and several university-affiliated hospitals.

METHODS

Five outcomes were studied, including the primary outcome of time to extubation, secondary outcomes of analgesia requirements at 24 and 48 hours, resting pain scores at 1 and 24 hours post-extubation, ICU length of stay in hours, and hospital length of stay in days. A search of multiple databases provided 28 studies reporting 4,000 total patients. Outcomes were measured using continuous mean difference with a 95% confidence interval, and the studies were examined for heterogeneity and sensitivity analysis.

RESULTS

The primary outcome analysis suggested that time to extubation was 42 minutes shorter in the intrathecal opioid group (ranging from 82 to 1 minute, P = 0.04). There was also a decrease in postoperative analgesia requirements at both 24 hours (mean difference (MD) = -8.95 mg morphine equivalent doses (MED) [-9.4, -8.5], P < 0.001) and 48 hours (MD = -17.7 mg MED [-23.1, -12.4], P < 0.001) with I2 of 94% and 85% respectively, an improvement of pain scores at both 1 hour (MD = -2.24 [-3.16, -1.32], P < 0.001) and 24-hours (MD = -1.64 [-2.48, -0.80], P =< 0.001) I2 of 94% and 85%, no change in both ICU length of stay (MD = -0.27 hours [-0.55, 0.01], P = 0.06) I2 = 77% and hospital length of stay (MD = -0.30 days [-0.66, 0.06], P = 0.11) I2 = 32%.

LIMITATIONS

The major limitation of this meta-analysis was the inconsistent dosages of intrathecal opioids utilized. Some used the same dose for each patient, while other studies used weight-based doses. The differences in the outcomes observed may then be a result of the different amounts of opioids administered rather than the technique itself. Another limitation was the inconsistent timing of reports for pain scores and postoperative analgesic requirements. Further studies were analyzed at the 2 time periods for both secondary outcomes, making it difficult to attribute the 2 effects solely to the intervention.

CONCLUSIONS

We conclude that preoperative injection of intrathecal opioids is significantly associated with decreased time to extubation, decreased postoperative analgesia requirement, and improved pain scores. In controlled conditions with adequate staff education, this method of analgesia may make it possible to extubate the patients after the surgery in the operating room and fast-track their discharge from the hospital.

Evaluation of Cholera Toxin Adjuvanticity Effect on the Production of Specific Antibodies Induced by Avian Infectious Bronchitis Vaccine in Chickens

Cholera toxin (CT) is one of the most well-known immunostimulants. Mammalian studies have shown that CT can generate immune responses against antigen. However, it has not exhibited a definite effect on poultry yet. In this study, focusing on a cost-effective method, the effect of different concentrations of CT obtained from Vibrio cholerae biotype El Tor and serotype Inaba was investigated on the immunogenicity of infectious bronchitis vaccine. After culturing and concentrating CT, different concentrations of CT (0.1, 1, 2, and 5 micrograms) were combined with avian infectious bronchitis vaccine strain H120 produced by Razi Vaccine and Serum Research Institute (RVSRI) and, at 7 days of age, inoculated via the eye drop administration in 42 specific-pathogen-free chickens (seven groups of six chicks that included four experimental groups, two negative control groups (PBS and toxin), and one positive control group). Blood samples were taken weekly from the wing veins of the chickens, and the immunoglobulin G (IgG) titer was checked by enzyme-linked immunosorbent assay. The results showed that 2 µg of CT in comparison with other concentrations caused a significant increase in the antibody titer against avian infectious bronchitis in the blood serums of the chickens. One-way ANOVA test showed that all the results of this study were significant at P<0.05 level. Our data show that CT has the potential to further stimulate the immune system of chickens and may increase the immunogenicity of the infectious bronchitis vaccine. However, more research is needed to examine all aspects of the use of this toxin in animal vaccines.

A Comparison Between Low-Level Laser Therapy and Intra-articular Ozone Injection in Knee Osteoarthritis Treatment: A Randomized Clinical Trial

Introduction: Knee osteoarthritis (KOA) is a common degenerative joint disease, causing deformity, pain and a limited joint range of motion. Modification of the lifestyle and an exercise training program are the cornerstone of treatment. Alternative therapies such as laser or ozone are commonly used, but there is not any comparative study of low-level laser therapy (LLLT) versus ozone therapy. The aim of the study was to compare the efficacy and safety of the LLLT versus ozone in patients with KOA. Methods: In this single-blinded randomized clinical trial, 60 patients with KOA were assigned to LLLT or ozone groups (n=30). The First basic pain severity, the Western Ontario and McMaster Universities Arthritis Index (WOMAC) score and physical function were determined. Then in the LLLT group, the patients were provided with 12 sessions of LLLT. In the ozone group, 6 sessions of intra-articular injection of ozone were organized (in each session a mixture of 10 mL of bupivacaine 0.25% with 15 mL of ozone 30 μg/mL). In the middle and at the end of the intervention period, we reassessed the joint pain and physical function and the degree of improvement compared between the two groups. Results: In the middle and at the end of the treatment period in both groups, the joint pain decreased significantly. The same as pain, the self-administrated WOMAC score and the range of joint motion improved significantly in both groups. All of these variables exposed more improvement in the ozone group patients. Conclusion: The study showed that both LLLT and ozone are acceptable non-invasive methods in the non-surgical treatment of KOA. Compared to LLLT, the ozone was more effective. These methods must be considered in any patient who is not suitable for surgical interventions or does not experience enough improvement in symptoms following long periods of common exercise training programs.

Cytotoxic Effect of Biebersteinia multifida Alcoholic Extracts on MCF-7, HeLa, and A2780 Cell Lines

Conventional cancer treatments are costly and have different serious side effects for patients. Natural herbal treatments are widely accepted among people because of their minimal side effects, although there is little scientific knowledge about them. One of these remedies utilizes the root of Biebersteinia multifidi that has been used for years in Iran to treat different chronic genital diseases. The current study examined the effects of methanolic and ethanolic extracts of B. multifida (induction of necrosis and apoptosis) on breast cancer (MCF-7), ovarian cancer (A2780), and human cervix cancer (HeLa) cell lines in comparison with normal breast cells. These effects were determined to be morphological alterations in cell light microscopy, by flow cytometry (staining with annexin V and propidium iodide), and by measuring live cells and inhibition concentrations by MTT assay. IC50 of B. multifida on the MCF-7 cell line (methanolic extract) was 400 µg/ml and for A2780 was 250 µg/ml. The IC50 amount of B. multifida on the MCF-7 cell line (ethanolic extract) was 750 µg/ml and 1500 for A2780. Results demonstrated that apoptosis and necrosis occurred in MCF-7 and A2780 following the addition of ethanolic and methanolic extracts of B. multifida to the medium. These findings confirmed the anti-cancer effects of mehthanolic extracts of Biebersteinia multifida root and its safety for normal cells; thus, it can be applied in cancer therapy as a novel medication.

The Evaluation of Factors Affecting Hemodynamic Variability in Mechanically-Ventilated Patients After Cardiac Surgery

Background

Optimizing cardiac preload is usually the first step in patients with unstable hemodynamic. However, it should be remembered that an unnecessary volume expansion may exacerbate the hemodynamic. In mechanically ventilated patients, the ventilatory induced hemodynamic variations (VIHV) can be used to predict the fluid requirement. These variations (called dynamic indices of cardiac filling pressure), are superior to static indices (central venous and pulmonary artery occlusion pressure) in diagnosing any volume requirement. We theorized that some conditions other than hypovolemia might affect these hemodynamic variations.

Objectives

The current study aimed to discover these conditions in adult patients admitted to post-cardiac surgery ICU.

Methods

This antegrade cross-sectional study was conducted on 304 adult patients who were admitted to ICU after elective cardiac surgery in a teaching hospital (Tabriz-Iran). During the first 3 hours of the admission, the systolic (ΔSBP), diastolic (ΔDBP), mean (ΔMAP), and arterial blood pulse pressures (ΔPP) were invasively monitored and calculated in percent value. Because of the return of spontaneous breathing in most of the patients, the calculations were done only during the first 3-hour. All patients with spontaneous breathing, irregular cardiac rhythm, or re-admission to OR in this period were excluded from the study. We recorded demographic and surgical characteristics, perioperative hemodynamic and echocardiographic, and complications data and surveyed the correlation between VIHV and perioperative data.

Results

Two hundred and ninety two patients met the inclusion criteria. Coronary artery bypass grafting (CABG) was the most common surgery (64.4 %). Cardiopulmonary bypass (CPB) was used in 95.55% of the surgeries. In the first 24-hour, 51 patients required re-operation because of sternum closure, bleeding control, cardiac tamponade, and coronary artery revascularization. Mortality and morbidity occurred in 2 (0.68%) and 50 (17.12%) patients, respectively. Among VIHVs, the ΔPP had the most significant value. Thus, mean ΔPP was calculated and the correlation between its severity (≤ 20% vs. > 20%) and other values surveyed. It was high in patients with cardiac dysfunction and tamponade (P value < 0.001). No significant correlation was found between mean ΔPP severity and hemorrhage rate, fluid balance, need to vasoactive agents, blood products, or bleeding control, redo CABG or sternum closure surgery, time to tracheal extubation, ICU stay, and postoperative complications. Patients with closed sternum were the same as those with the unclosed sternum.

Conclusions

The ΔPP was the most sensitive VIHV parameter. Cardiac dysfunction and tamponade increased ΔPP. Unclosed sternum did not affect its value. ΔPP value did not affect postoperative complications rate, time to tracheal extubation, or ICU stay.

Effect of Pressure on the Yinmen Point in Relief of Pain After Middle Ear Surgery: A Randomized Clinical Trial

Background

Postoperative pain is a common problem after middle ear surgery. Several analgesic agents are available for pain relief, but they cause numerous side effects. Therefore, complementary analgesic methods are developed to reduce patient’s postoperative pain and discomfort.

Objectives

The current study aimed to investigate the effect of the acupressure on post middle ear surgery pain, applying pressure on the Yinmen acupoint of the sciatic nerve.

Methods

In this randomized clinical trial, 100 adult patients who were candidate for elective middle ear surgery were selected and divided into two groups of Yinmen and placebo, each with 50 subjects. After admission to the ward, patients’ postoperative pain score was measured using the visual analog score (VAS) tool. Then, patients were placed in the prone position. In the Yinmen group, using a fist, we applied a continuous pressure (11 - 20 kg) to the posterior aspect of the thighs at the Yinmen acupoint for 2 minutes. In the placebo group, only soft contact was kept between the fist and Yinmen point for the same period. The maneuver repeated every two hours for four times. The pain intensity surveyed 10 minutes after the first maneuver, then every hour for 8 hours. For those with a VAS score ≥ 4, intravenous paracetamol and/or meperidine was administered. Any nausea and vomiting was managed using ondansetron 2 mg, IV. The pain score, paracetamol, and meperidine consumption were recorded and compared between the two groups. The chi-square and student t-tests were used to compare the two groups.

Results

No significant difference was found between patients’ characteristics and the first pain score. For all measurements, pain intensity was lower in the Yinmen group (P value < 0.01). The pain after the first maneuver was relieved exactly when the acupressure was true. The intervention could reduce patients’ need to take paracetamol (6.68 ± 2.58 vs. 10.42 ± 3.87 mg/kg) and meperidine (0.21 ± 0.17 vs. 0.39 ± 0.23 mg/kg) in the Yinmen group. The two groups were not significantly different concerning the need to take ondansetron to manage postoperative nausea and vomiting.

Conclusions

Applying 2 minutes pressure (11 - 20 kg) on the Yinmen acupoint of the sciatic nerves can reduce post middle ear surgery pain and analgesic consumption.

The Efficacy of Low-Level Laser Therapy in the Treatment of Bell's Palsy in Diabetic Patients

Introduction: The most common causes of the abrupt onset of unilateral facial weakness are stroke and Bell's palsy. The drug regimen together with electrical stimulation was more effective in treating Bell's palsy than conventional drug treatment alone. We aimed to evaluate more effective and safe therapies for the treatment of Bell's palsy. Methods: This clinical interventional study was conducted on 30 diabetic patients with Bell's palsy who referred to a pain clinic for 1 year and were treated by low-level laser (LLL). The system of House-Brackmann was used for assessing the severity of nerve damage and patients were evaluated by electromyography and nerve conduction study (NCS) before and after treatment with low-level laser. These patients had not consumed any other medication for facial nerve palsy. Results: In the present study, 30 cases with poorly controlled diabetes mellitus (18 females and 12 males) were studied. After 12 sessions of low-level laser therapy (LLLT), we could observe complete recovery in 18 patients and partial recovery in 6 patients after 3 months. Conclusion: The recovery rate showed that LLLT is a safe, reliable and proper alternative approach for the treatment of facial nerve palsy, especially in the presence of underlying conditions such as diabetes mellitus.

The Determination of an Appropriate Time for Placement of the Classic Laryngeal Mask Airway in Patients Undergoing General Anesthesia

Background

The management of the airways is an essential component of anesthesia planning. Laryngeal mask airway (LMA) plays an important role in modern anesthesia, however, intubation by LMA has some complications. It may cause inadequate anesthesia depth, which can lead to adverse events. The aim of this study was to evaluate the optimal time for intubation by LMA under general anesthesia.

Methods

This study was conducted on 96 patients, who underwent operation and were appropriate candidates for intubation with appropriate LMA. The participants were divided to four groups, each with 24 cases, based on the time interval between anesthetic agent administration and intubation with LMA; 15 seconds for the first group, 16 to 30 seconds for the second group, 31 to 45 seconds for the third group, and 45 to 60 seconds for the fourth group. The patients involved in these groups were selected based on the following prerequisites, patients’ age, gender, easy intubation, need for additional drug administration, basic blood pressure before drug administration, within the time intervals one, three, and five minutes after placement of LMA, duration of LMA, SaO₂ before and after placement of LMA, coughing, patient’s movement, laryngospasm, gag reflex after intubation, allowing appropriate ventilation, presence of sore throat after surgery, number of attempts, extent of mouth opening and leak in peri-LMA space.

Results

Overall, 72 males and 24 females participated in this study with a mean age of 40.64. Intubation by LMA was performed easily during the first attempt in 58% of the participants, with minimal resistance in 28.6% and with some problems during the second attempt in 10.5% of the cases. Throat pain after the operation was significantly lower. Systolic and diastolic pressure and heart rate had no statistically significant difference.

Conclusions

The results showed that in the first 15 seconds after the drug (e.g. propofol) administration, there were lower complications, rapid placement, and optimized time for the placement of LMA. The rate of success and its quality were reduced during the first attempt of insertion and termination of the effect of propofol.

The effect of passive leg-raising maneuver on hemodynamic stability during anesthesia induction for adult cardiac surgery

Introduction

Some cardiac patients do not tolerate the intravenous fluid load commonly administered before anesthesia induction. This study investigated preinduction passive leg-raising maneuver (PLRM) as an alternative method to fluid loading before cardiac anesthesia.

Methods and materials

During a 6-month period, 120 adult elective heart surgery patients were enrolled in this study and allocated into 2 groups: PLRM group vs control group (n=60). Anesthesia was induced using midazolam, fentanyl, and cisatracurium. Initially, 250 mL of fluid was administrated intravenously in all of patients before anesthesia induction. Then in the PLRM group, PLRM was performed starting 2 minutes before anesthesia induction and continued for 20 minutes after tracheal intubation. In the control group, anesthesia was induced in a simple supine position. Heart rate, invasive mean arterial blood pressure (MAP), and central venous pressure (CVP) were recorded before PLRM, before anesthetic induction, before laryngoscopy, and at 5, 10, and 20 minutes after tracheal intubation. The hypotension episode rate (MAP <70 mmHg) and CVP changes were compared between the 2 groups. The predictive value of the ≥3 mmHg increase in CVP value in response to PLRM for hypotension prevention was defined.

Results

Hypotension rates were lower in the PLRM group (63.3% vs 81.6%; P-value 0.04), and MAP was higher among PLRM patients immediately before anesthetic injection, before laryngoscopy, and 20 minutes after intubation, compared to the control group. PLRM increased CVP by 3.57±4.9 mmHg (from 7.50±2.94 to 11.05±3.55 mmHg), which required several minutes to reach peak value, returning to baseline after 15 minutes. This change did not correlate to subsequent MAP changes; an increase in the CVP value ≥3 mmHg decreased the postinduction hypotension rate by 62.50%.

Conclusion

Preinduction PLRM can provide a more stable hemodynamic status in adult cardiac surgery patients and decreases anesthesia-induced hypotension rates by 62.50%. Rate of the changes in the CVP value caused by PLRM is not predictive of subsequent MAP changes.

A Comparison of Continuous Thoracic Epidural Analgesia with Bupivacaine Versus Bupivacaine and Dexmedetomidine for Pain Control in Patients with Multiple Rib Fractures

Background

The control of pain in traumatic patients with chest injury leading to rib fracture is one of the primary goals in traumatic patients. The efficacy of the thoracic epidural approach in comparison with other approaches for relieving post-thoracotomy pain is unknown. The goal of the present study was to compare thoracic epidural analgesia with bupivacaine alone and in combination with dexmedetomidine in patients with multiple rib fractures.

Methods

64 traumatic patients with multiple rib fractures were selected and randomly assigned to two similar groups. For pain relief, a thoracic epidural catheter was inserted to infuse bupivacaine alone or the combination of bupivacaine and dexmedetomidine. Then, we recorded and analyzed pain scores and ABG changes.

Results

Based on the results, the two approaches could result in proper analgesia, but analgesia with the combination of bupivacaine and dexmedetomidine was significantly improved compared to bupivacaine alone (P < 0.05). In addition, ABG of patients significantly changed when the combination of bupivacaine and dexmedetomidine was used within 2 to 4 days (P < 0.05).

Conclusions

The results of the present study showed that epidural infusion of a combination of bupivacaine and dexmedetomidine could provide better control of rib fracture pain in traumatic patients, and is a proper alternative for bupivacaine alone.

Adult patient with Becker dystrophy undergoing orthopedic surgery: an anesthesia challenge

Muscular dystrophies are considered to be a series of neuromuscular diseases with genetic causes and are characterized by progressive muscle weakness and degeneration of the skeletal muscle. The case of an adult man with Becker dystrophy referred for repair of the patella tendon tearing and patella fracture is described. He underwent successful surgery using total intravenous anesthesia without any complications.

The correlation between preoperative erythrocyte sedimentation rate and postoperative outcome in adult cardiac surgery

Introduction

Over the past decades, it has been recommended that preoperative assessment mainly relies on history and physical examination rather than unnecessary laboratory tests. In Iranian hospitals, erythrocyte sedimentation rate (ESR) has been routinely measured in most of the patients awaiting major surgery, which has in turn exacted heavy costs on the health system. Therefore, the aim of the present study was to assess the preoperative routine measurement of ESR in such patients.

Materials and methods

This is a retrospective study, in which we evaluated the medical files of 620 patients. Patients older than 18 years, who had undergone elective heart surgery in our hospital in 2014, were included in the study. The data associated with demography, heart disease diagnosis, type of surgery, significant preoperative tests, delay or postponing of surgery and the reason for it, type and characteristics of the subspecialty consultation, and finally, postoperative complication and mortality rate were collected and analyzed. The patients were categorized into four groups according to ESR value: normal (<15 mm/h in females or <20 mm/h in males), moderately increased (<40 mm/h), severely increased (≥40 mm/h), and not measured.

Results

Of the 620 patients’ files, 402 were of males and 218 were of females. Demographic values and preoperative characteristics were similar in the four groups. A total of 105 consultations were given to 79 patients preoperatively, where only in five cases, the elevation in ESR was the main reason for consultation. In no other cases did the consultations result in new diagnoses. Overall, postoperative complication and mortality rate were the same in all four groups; in severely increased ESR group, on the other hand, the need for long periods of intensive care unit (ICU) and hospital stays was higher than that of other groups.

Conclusion

It is concluded that elevated preoperative ESR does not cancel or defer the surgery, nor does it help diagnose a new, previously undiagnosed disease. Furthermore, it does not generally affect postoperative morbidity or mortality rate unless increased to ≥40 mm/h, where it can increase postoperative ICU and hospital stay. Ultimately, routine preoperative ESR measurement in patients is not conducive to elective heart surgery.

Pregnancy after allogeneic hematopoietic stem cell transplantation in a Fanconi anemia patient

Pregnancy in patients with Fanconi anemia (FA) is rare. However, there are reports of successful pregnancy in Fanconi patients after bone marrow transplantation (BMT, hematopoietic stem cell transplantation). We describe the case of a term pregnant woman with FA who was treated with BMT 2 years earlier. She underwent successful delivery with cesarean section using spinal anesthesia without any complications.

Role of diclofenac in reducing post-endoscopic retrograde cholangiopancreatography pancreatitis

BACKGROUND AND AIMS

Acute pancreatitis following endoscopic retrograde cholangiography presents a unique opportunity for prophylaxis and early modification of the disease process because the initial triggering event is temporally well defined and takes place in the hospital. We report a prospective, single-center, randomized, double-blind controlled trial to determine if rectal diclofenac reduces the incidence of pancreatitis following cholangiopancreatography.

METHODS

Entry to the trial was restricted to patients who underwent endoscopic retrograde pancreatography. Immediately after endoscopy, patients were given a suppository containing either 100 mg diclofenac or placebo. Estimation of serum amylase level and clinical evaluation were performed in all patients.

RESULTS

One hundred patients entered the trial, and 50 received rectal diclofenac. Fifteen patients developed pancreatitis (15%), of whom two received rectal diclofenac and 13 received placebo (P < 0.01).

CONCLUSIONS

This trial shows that rectal diclofenac given immediately after endoscopic retrograde cholangiopancreatography can reduce the incidence of acute pancreatitis.

Role of diclofenac in reducing post-endoscopic retrograde cholangiopancreatography pancreatitis

BACKGROUND AND AIMS

Acute pancreatitis following endoscopic retrograde cholangiography presents a unique opportunity for prophylaxis and early modification of the disease process because the initial triggering event is temporally well defined and takes place in the hospital. We report a prospective, single-center, randomized, double-blind controlled trial to determine if rectal diclofenac reduces the incidence of pancreatitis following cholangiopancreatography.

METHODS

Entry to the trial was restricted to patients who underwent endoscopic retrograde pancreatography. Immediately after endoscopy, patients were given a suppository containing either 100 mg diclofenac or placebo. Estimation of serum amylase level and clinical evaluation were performed in all patients.

RESULTS

One hundred patients entered the trial, and 50 received rectal diclofenac. Fifteen patients developed pancreatitis (15%), of whom two received rectal diclofenac and 13 received placebo (P < 0.01).

CONCLUSIONS

This trial shows that rectal diclofenac given immediately after endoscopic retrograde cholangiopancreatography can reduce the incidence of acute pancreatitis.