Analgesic Effect of Intraperitoneal Bupivacaine Hydrochloride After Laparoscopic Sleeve Gastrectomy: a Randomized Clinical Trial

Background

The indications for sleeve gastrectomy as a primary procedure for the surgical treatment of morbid obesity have increased worldwide. Pain is the most common complaint for patients on the first day after laparoscopic sleeve gastrectomy. There are various methods for decreasing pain after laparoscopic sleeve gastrectomy such as the use of intraperitoneal bupivacaine hydrochloride. This clinical trial was an attempt to discover the effects of intraperitoneal bupivacaine hydrochloride on alleviating postoperative pain after laparoscopic sleeve gastrectomy.

Methods

In general, 120 patients meeting the inclusion criteria were enrolled. Patients were randomly allocated into two interventions and control groups using a balanced block randomization technique. One group received intraperitoneal bupivacaine hydrochloride (30 cm³), and the other group served as the control one and did not receive bupivacaine hydrochloride. Diclofenac suppository and paracetamol injection were administered to both groups for postoperative pain management.

Results

The mean subjective postoperative pain score was significantly decreased in patients who received intraperitoneal bupivacaine hydrochloride within the first 24 h after the surgery; thus, the instillation of bupivacaine hydrochloride was beneficial in managing postoperative pain.

Conclusions

The intraoperative peritoneal irrigation of bupivacaine hydrochloride (30 cm³, 0.25%) in sleeve gastrectomy patients was safe and effective in reducing postoperative pain, nausea, and vomiting (IRCT2016120329181N4).

     

Obesity and dyslipidemia

Dyslipidemia associated with obesity and the metabolic syndrome is one of the central features contributing to the increased CV risk in these patients. In view of the pandemic of the metabolic syndrome, it is imperative to fully understand the mechanisms leading to the metabolic lipid phenotype before embarking upon optimal treatment strategies. The traditional concept that insulin resistance causes increased FFA flux via increased TG hydrolysis in adipose tissue is still of a central theme in the general hypothesis. The combination of increased hepatic VLDL secretion with impaired LPL-mediated TG clearance explains the hypertriglyceridemia phenotype of the metabolic syndrome. Hence, central IR may be an important factor contributing to peripheral hypertriglyceridemia. Recently recognized regulatory systems include the profound impact of the hypothalamus on TG secretion and glucose control. In addition, dysfunctional (or inflamed) intra abdominal adipose tissue has emerged as a potent regulator of dyslipidemia and IR. It will be a challenge to design novel treatment modalities that target “dysfunctional” fat or central IR to attempt to prevent the epidemic of CV disease secondary to the metabolic syndrome.     

The Therapeutic Relationship in the Shadow: Nurses’ Experiences of Barriers to the Nurse–Patient Relationship in the Psychiatric Ward

The therapeutic relationship is widely accepted as the basic core and essence of the psychiatric nurse's role and is thus essential for providing quality mental health care. A detailed and clear perception of the issues that facilitate or obstruct this relationship is therefore important. The purpose of this study was to gain insights into the experiences of nurses working in psychiatry wards, of the barriers to the nurse–patient relationship. A qualitative content-analysis study was undertaken using a purpose-based sampling approach with the participation of 15 nurses employed in psychiatric wards in hospitals located in South Iran. Semi-structured interviews provided the source of data, and an inductive content-analysis approach was used for data analysis. The main concept extracted from the study was identified as ‘the therapeutic relationship in the shadow’, which captured the sense that this critical relationship is mostly unseen in the daily practice of the nurses interviewed. Factors that functioned as barriers to this relationship were classified into three main categories: nurse-related, patient-related and organization-related. The results of this study revealed that, despite the widely claimed importance of the nurse–patient relationship in psychiatric settings, this relationship is powerfully influenced by individual and organizational factors that have not been considered adequately in previous research. It is strongly recommended that greater consideration of these factors be given to care planning in psychiatric wards.     

Changes in pro-oxidant-antioxidant balance after bare metal and drug eluting stent implantation in patients with stable coronary disease

ObjectivesIn this study we aimed to assess the changes in pro-oxidant–antioxidant balance (PAB) after the placement of either a drug-eluting-stent (DES) or bare-metal-stent (BMS) in patients with stable coronary artery disease.Design and methodsPercutaneous coronary interventions (PCI) with either BMS or DES were undertaken for 152 patients (82 in the BMS and 70 in the DES groups respectively). PAB values were measured 24 h before and after PCI.ResultsBaseline PAB values were 80.68 (64.98–99.37) and 98.86 (64.70–140.62) for BMS and DES group, respectively, which were not significantly different between the 2 groups (P > 0.05). Following PCI, median PAB values decreased to 72.10 (61.40–96.13) and 81.40 (54.15–121.90) in BMS and DES groups, respectively. The reduction was significant in both BMS and DES groups (P < 0.05). The changes in PAB values were ?2.81 (?12.76 to 2.31) for BMS and ?2.82 (?29.88 to 8.93) for DES group, which were not significantly different between the 2 groups (P > 0.05).ConclusionWe found that the reported difference in clinical outcomes following DES or BMS implantation cannot be attributed to differences in early changes in oxidative stress induction as assessed by changes in PAB values.     

The Efficacy of an Herbal Medicine, Carmint, on the Relief of Abdominal Pain and Bloating in Patients with Irritable Bowel Syndrome: A Pilot Study

Carmint contains total extracts of Melissa officinalis, Mentha spicata, and Coriandrum sativum, which have antispasmodic, carminative, and sedative effects. As abdominal pain/discomfort and bloating are commonly observed in patients with irritable bowel syndrome, we decided to evaluate the effectiveness of Carmint in relieving these symptoms in irritable bowel syndrome patients. We randomly assigned 32 irritable bowel syndrome patients to receive either Carmint or placebo, plus Loperamide or psyllium (based on their predominant bowel function), for 8 weeks. T-test analysis of the results showed that the severity and frequency of abdominal pain/discomfort were significantly lower in the Carmint group than the placebo group at the end of the treatment (P=0.016 and P=0.001, respectively), as were the severity and frequency of bloating (P=0.02 and P=0.002, respectively). This pilot study suggests that Carmint plus loperamide or Carmint plus psyllium (depending on the irritable bowel syndrome subtype) might be effective in these patients.     

Cytotoxic T-lymphocyte antigen 4 gene polymorphisms and susceptibility to chronic hepatitis B

AIM:To assess the three polymorphism regions withincytotoxic T-lymphocyte antigen 4(CTLA-4)gene,a C/Tbase exchange in the promoter region-318(CTLA-4-318C/T),an A/G substitution in the exon 1 position49(CTLA-4 49A/G),a T/C substitution in 1172(CTLA-4-1172T/C)in patients with chronic hepatitis B.METHODS:Fifty-one patients with chronic hepatitis Bvirus infection and 150 healthy subjects were recruitedsequentially as they presented to the hepatic clinic.Clas-sification of chronic hepatitis B virus(HBV)-infected pa-tients was as asymptomatic carrier state(26 patients)and chronic hepatitis B(25 patients).Genomic DNA wasisolated from anti-coagulated peripheral blood Buffy coatusing Miller's salting-out method.The presence of theCTLA-4 gene polymorphisms was determined using poly-merase chain reaction amplification refractory mutationsystem(ARMS).RESULTS:We observed a significant association be-tween-318 genotypes frequency(T C-,T C ,T-C )and susceptibility to chronic hepatitis B(P=0.012,OR=0.49,95%CI:0.206-1.162).However,we did notobserve a significant association for 49 genotype fre-quency(T C ,T C- T-C )and -1172 genotype fre-quency(C T ,T C- C T-)and state of disease.CONCLUSION:Our results suggest that CTLA-4 genepolymorphisms may partially be involved in the suscepti-bility to chronic hepatitis B.     

Insulin resistance in chronic hepatitis B and C.

AIM: To determine whether insulin resistance occurs in patients with chronic hepatitis B (CHB) and chronic hepatitis C (CHC) and its relationship with the presence of liver fibrosis and steatosis. METHODS: Untreated patients with CHC (n=60) or CHB (n=40), similar in age, gender, body mass index and waist-hip ratio, were studied. Relationship between anthropometric, biochemical (fasting serum insulin, C-peptide, ferritin, iron, TNF-alpha, cholesterol, triglyceride, bilirubin, hemoglobin and platelet concentrations) and liver biopsy (43 CHC and 20 CHB patients) findings was investigated by insulin resistance determined via the homeostasis model assessment (HOMA-IR). RESULTS: The mean fasting serum insulin was 14.9 (11.9) mU/mL in CHC and 21.4 (17.4) in the CHB group (normal range 0.7-9; p=0.049) and mean HOMA-IR was 3.1 (2.6) in CHC versus 4.7 (4.1) in the CHB group (normal range 0.12-4.61; p=0.036). HOMA-IR was significantly associated with fibrosis stage in the CHC group (p=0.015), but not in the CHB group. CONCLUSION: Hyperinsulinemia occurs in chronic viral hepatitis B and hepatitis C; insulin resistance is associated with stage of fibrosis in hepatitis C.