Journal of

 Introduction: The aim of this study is to compare the efficacy of epidural versus entonox methods for labor analgesia in nulliparous women. 

Methods: This randomized controlled trial was performed on 84 nulliparous women with - pregnancy admitted to Imam Reza Hospital in 10 May 2010- 10 May 2011. 

They were randomly divided into two groups 42 women inhaled entonox in active phase at the beginning of each contraction, and for 42 cases, epidural catheter was inserted and analgesic substance was injected and it was increased adjusted with contraction progressing by bupivacaine combined with fentanyl. The rate of pain was measured with pain scores (minimum pain 0 and maximum pain 10).

 Results: In epidural analgesia, pain score was lower in all stages of labor than entonox analgesia 42% of cases had no pain, while as in entonox group, pain has been decreased 4 scores in 7% of cases and there was no complete analgesia. Duration of different stages of labor was not statistically different between two groups (P=0.89). Cesarean rate was similar in two groups. First and five minute Apgar were not statistically different between two groups (P=0.87, P=0.75, respectively). 

Conclusions: Epidural analgesia with more relief in labor pain is the desired method. This method doesn’t cause more cesarean rate or prolonged labor duration. Although Entonox decreases labor pain in first stage, but doesn’t affect on second stage and fetus Apgar.  

Introduction: Deep sternal wound infection is a rare but serious complication after cardiac surgery that can increase mortality and morbidity. The aim of this study was to investigate the incidence and causative germs of deep sternal wound infection following cardiac surgery.

Methods: Data were collected retrospectively from patients who underwent different cardiac surgeries including coronary artery bypass grafting and valvular heart surgeries between July 2010 and October 2012 at a teaching hospital in the north east of Iran. Patients with a deep sternal wound infection (DSWI) were defined based on clinical findings and culture results of the wound. The patients were tracked for the development of DSWI and causative germs and sensitivity were identified according to the microbiological studies.

Results: 4621 patients underwent different cardiac surgeries during the study period. There were 82 cases (1.77%) of DSWI with mean age of 53.93 years and male to female ratio of 47:35 with mortality rate of 10.9%. The most common germs in order of decreasing frequency included Klebsiella, Pseudomonas, Staphylococus Coagulase Negative, Acinetobacter, Staphylocciaureus, Escherichia coli, methicillin resistant Staphylocciaureus, Providenciarettgeri, and Obligatory anaerobe Streptococus.

Conclusions: We conclude that DSWI remains a rare but devastating complication and is associated with significant comorbidity, increased hospital mortality, and reduced long-term survival with gram negative rods as the most common pathogens. 

 Introduction: Several mehods have been proposed to alleviate pain after hysterectomy. Pre-emptive analgesia has been used to relieve pain following abdominal hysterectomy with conflicting results. This study was performed to evaluate the efficacy of pre-incision skin infiltration of Lidocaine in relieving postoperative pain in patients undergoing abdominal hysterectomy. 

Methods: 60 patients with ASA class of I or II scheduled for abdominal hysterectomy were recruited for the study. The patients were randomly assigned to receive pre-incision skin infiltration of either lidocaine or normal saline. The patients were evaluated with respect to postoperative pain scores and analgesic requirements in the first two postoperative days. They were also asked for satisfaction regarding the pain relief intervention.

Results: The patients were similar with respect to demographic characteristics. Patients in the saline group complained of more pain than the lidocaine group in the recovery room(p<0.001). However, the patients were similar with respect to postoperative pain scores and analgesic requirements. They were also similar regarding satisfaction rates during the first 24 hours postoperatively.

 Conclusions: We conclude that pre-incision skin infiltration of lidocaine is not effective in reducing postoperative pain following abdominal hysterectomy and does not affect the patients’ satisfaction. 

Introduction: To present our experience about the safety of conservative management in asymptomatic and non-complicated hepatic hydatid cyst in pregnancy.

Methods: Seven pregnant patients with hepatic hydatid cysts as an incidental finding in routine obstetrical ultrasonography were referred to our center during 2001 to 2008. Three patients were visited in the second and the rest in the third trimester of their pregnancy. It was found that all of them had asymptomatic and non-complicated cysts. They were suggested to participate in our close conservative plan as their treating method. Monthly ultrasonography and clinical examination was performed to find out any changes in size or clinical course of the cysts.

Results: Cesarean section and simultaneous surgical treatment of the cyst were performed in three patients while for the rest went through a natural vaginal delivery and surgical treatment of the cysts were postponed until six weeks after delivery. No complication was seen in these two groups.

Conclusions: Conservative management of asymptomatic and non-complicated hepatic hydatid cysts until delivery may be a safe method in management of hepatic hydatid cysts in pregnancy which prevents preterm labor and other cyst related procedures complications.

Introduction: Hemodialysis through creation of arteriovenous fistula (AVF) is an established surgical procedure for patients with End Stage Renal Disease (ESRD). Anesthetic methods management for this surgery should deal with different risk factors such as hypertension, ischemic heart disease and diabetes. Intravenous Regional Anesthesia (IVRA) or Bier block anesthesia as an option for AVF creation has reportedly been attributed to some advantages over other techniques in AVF creation. The present study aims to evaluate the efficacy of Bier block in AVF creation and compare its efficacy with local anesthesia. 

Methods: The subjects of the study were the patients (n=60, aged 20-65 years), who had been admitted for an AVF creation. The patients were divided into two randomly assigned matched groups: Local Anesthesia (LA) group and Intravenous Regional Anesthesia (IVRA) group. 

Results: The patients’ satisfaction levels, simplicity and feasibility of the procedure in the IVRA group were higher, compared to the LA group (94.1%, 66.7%, and 4.85% vs. 82.8%, 51.7% and 3.5%, respectively). However, these differences were not statistically significant.

Conclusions: The two main advantages of Bier block technique are the simplicity of operation and provision of a bloodless field for surgeon. It provides maximum dilatation in veins through the injection of the anesthetic drug and placing a tourniquet on it.

Objective(s): Appendicitis remains the most common condition in the pediatric population requiring emergency abdominal operation. Management of acute simple appendicitis is well described but controversy remains as to the optimal treatment of complicated appendicitis. Common complications of acute appendicitis include: localized peritonitis and abscess formation, flegmon and general peritonitis.

Methods: In this prospective study we have evaluated the results of aggressive therapy in management of complicated appendicitis in children in Sarvar pediatric hospital of Mashhad, Iran.

Results: Among 60 children with acute complicated appendicitis male to female ratio was 4:1 and mean age was 7.18±2.17 years. 60% were operated via low mid line incision and 40% by Rocky Davis incision. The most common final diagnosis was appendicular abscess that was observed in 34 patients. Primary wound closure was performed in 96.7% and placement of drain in peritoneal cavity in right lower quadrant was done only in 13.3%. Safe appendectomy was performed in all 60 cases and post operative complications included two cases with wound infection and 4 cases with Chronic abdominal pain that were managed conservatively. Only one patient was re admitted and underwent re-laparotomy because of bowel obstruction.

Conclusions: according to our findings the current non operative approach to complicated appendicitis in children needs a revision.

Introduction: Although patients do not experience sever pain after laparoscopic surgery, most of them experience acute or chronic pain afterward. While conventional pain killers including NSAID and narcotics in laparoscopic surgery have specific side effects, their application is inevitable. This study compares the efficacy of local anesthetic drugs and conventional pain killers in post-operative pain control.

Methods: This prospective clinical trial was conducted in two groups of patients (n=93). Group 1, as control group, was given conventional pain killers such as narcotics and NSAIDs. In another group as treatment group, at the end of laparoscopic surgeries, prior to port withdrawal, a local anesthetic mixture, a short acting (Lidocaine 2%) plus a long acting (Bupivacaine 0.5%) is instilled through the port lumen between the abdominal wall layers. The efficacy of both types of medications was compared with regards to their effectiveness and side effects.

Results: 85% of the control group, received 5 to 20ml Morphine for pain control while the others were controlled with trans-rectal NSAIDs. In the treatment group, the pain of 65% of the patients was controlled only by local anesthetic drugs, 30% required NSAIDs and the other 5% required narcotics administration for pain control.

Conclusions: The administration of local anesthetic drugs after laparoscopic surgery is an effective method for pain control with a low complication rate and side effects of narcotics.

Introduction: Transhiatal esophagectomy is a widely accepted approach for palliative resection of subcarinal esophageal cancers. This study was designed to evaluate the necessity of routine thoracostomy tube insertion in this technique. 

Methods: This descriptive study was conducted on 123 consecutive patients with esophageal cancers undergoing transhiatal esophagectomy from March 2001 to February 2005. Chest tube insertion was performed according to our defined criteria. Thoracostomy tube would be inserted intraoperatively, if the estimated amount of bleeding was more than 200 ml. In patients with unilateral or bilateral diffuse haziness in chest-x-ray representative of considerable fluid collection, and symptomatic patients with each amount of pleural fluid, it would be inserted postoperatively.  

Results: Thoracostomy tube was intraoperatively inserted in 41 cases (33.3%). Among other 82 patients only 19 cases (15.4%) required chest tube during admission period. There was significant relation between intraoperatively and postoperatively inserted thoracostomy tubes (p<0.001). There was no statistically relation between chest tube insertion and hospital mortality (p=0.71). The mortality rate didn’t show a significant relation with the amount of chest tube drainage (p=0.056).

Conclusions: Routine intraoperative chest tube insertion is not necessary for all patients following THE, and it should be limited to the patients with significant intrathoracic bleeding. 

 Introduction: shorter hospital stay and less pain in comparison to open surgery considered to be major benefits for laparoscopic cholecystectomy. We compared the effect of intraperitoneal hydrocortisone plus bupivacaine with bupivacaine alone on pain relief following laparoscopic cholecystectomy. 

Methods: Sixty two patients participated in this double-blind, randomized clinical trial. Patients randomly received intraperitoneal instillation of either 100 mg bupivacaine in 250 ml normal saline (n=32) or 100 mg hydrocortisone plus 100 mg bupivacaine in 250 ml normal saline (n=30) before insufflation of CO₂ into the peritoneum. Abdominal and shoulder pain were evaluated using VAS postoperatively. The patients were also followed for postoperative analgesic requirements, nausea and vomiting, and return of bowel function. 

We used independent Student t-test and Chi-square test and Mann-Whitney U tests with SPSS software to compare quantitative and qualitative variables, respectively. P value less than 0.05 was considered significant. 

 Results: Sixty patients completed the study. Patients in the hydrocortisone plus bupivacaine group had significantly lower abdominal and shoulder pain scores (11.72 vs 8.92 in the bupivacaine and bupivacaine plus hydrocortisone group, respectively P<0.01). The patients were similar regarding analgesic requirements .The patients were similar with respect to return of bowel function, nausea and vomiting. No adverse reaction was observed in either group. 

Conclusions: Intraperitoneal administrations of hydrocortisone plus bupivacaine can alleviate pain after laparoscopic cholecystectomy better than intraperitoneal bupivacaine alone.  

ntroduction: Electrocautery device is one of the most widely used electronic devices in operating rooms despite its advantages in operations, production risks such as the halo of smoke above the operating position. The smoke with hazardous substances,cause to transmitting HIV, HPV and hepatitis and complications such as respiratory distress, nausea and vomiting, eye irritation, headache, and so on The purpose of the present study was to determine Surgical Team' Knowledge of electrocautery smoke complications in the Educational hospitals in Birjand, 2011. Methods: In this descriptive and cross-sectional study Surgical Team in Birjand Educational hospitals who were available were selected. After ensuring that they were content with and cooperate in the study, a researcher designed questionnaire was filled. The questionnaire included demographic questions (4 items) and knowledge questions (21 items) of electrocautery smoke complications. The obtained data was analyzed by SPSS software (V: 16), using Kruskal-Wallis and Mann-Whitney at the significant level P<0.05. Results: Mean score Surgical Team ' knowledge of electrocautery smoke complications were 9.0±4.88 (of the total 21 points) that is, 57% of them had low knowledge of electrocautery smoke complications. Conclusions: Given the low level of knowledge about electrocautery smoke complications in Surgical Team, planning to enhance their knowledge through workshops and continuing education programs and training is essential.

Introduction: A growing number of children around the world are being born by surgical delivery, or cesarean section. Concerns about the steep increase in cesarean deliveries have been raised because of the possibility that surgical delivery is associated with greater maternal and infant mortality and morbidity than vaginal delivery. The purpose of the present study was to determine Prevalence of cesarean section and related causes of in women referring to Vali-e-Asr and tamin -e-ejtemaee hospitals in Birjand, 2010.
Methods: In this descriptive study, which cross-sectionally was carried out, 293 pregnant women referring to Vali-e-Asr and tamin -e-ejtemaee hospitals were studied. A questionnaire in 2 portions was filled out at mothers’ bed, in delivery room, operation room, and women's ward. The obtained data was analyzed by SPSS software, using chi square test at the significant level P<0/05.
Results: From 293 pregnant women in this study 147 (50.2%) had a normal delivery and 146 (49.8%) by Cesarean. The most common causes for caesarean were cephalopelvic disproportion (22.4%), malpresentation (21.7%) and Failure to progress (16.8%).
Conclusions: In this study, the prevalence of caesarean section is more than the WHO standard. In order decrease the number of unnecessary cesarean, teaching the young pregnant mothers about the disadvantages of cesarean is necessary.

Introduction: Postoperative shivering is one of the common problems following general anesthesia and may lead to multiple complications. This study aimed to compare the impact of Ketamine and Pethidine on postoperative shivering. 

Methods: In a randomized clinical trial, one hundred and thirty-five patients undergoing elective abdominal surgery were recruited for the study. The patients were randomly divided to groups received Normal Saline, Ketamine or Pethidine at the end of surgery. The frequency of shivering was determined immediately after surgery, and at 10. 20. And 30 minutes, postoperatively.

Results: In zero time the rate of shivering was more severe than other times in the three groups. Also the rate of postoperative shivering was significance less different in the pethedine and Ketamine groups than the Normal Saline group. However, no significant difference was seen between the pethedine and Ketamine groups.

Conclusions: The result of this study showed that exactly after operation, the rate of postoperative shivering was more severe than other times in 3 groups. Ketamine and Pethidine might reduce postoperative shivering with no significant difference.  

Introduction: Breast cancer is the most common cancer and the second cause of death in women. It is essential to have the highest level of confidence in axillary staging assessment. Many surgeons and pathologists believe that fewer lymph nodes are present in axillary dissection specimens of women treated by neoadjuvant chemotherapy. Consequently, the purpose of this study was to compare the lymph node counts of axillary dissection specimens from patients having received neoadjuvant chemotherapy with those of patients treated with primary operation.
Methods: This descriptive study was conducted on 100 women with invasive breast cancer who underwent level I and II axillary lymph node dissections from 2012 through 2013 in Quaem hospital surgery department . these patients dichotomized into two categories: Women from the neoadjuvant chemotherapy group (n=50) were compared with those from the primary surgery group (n=50). The total number of lymph nodes harvested was compared ,the obtained data was analyzed by SPSS software (V: 16), using Kruskal-Wallis and Mann-Whitney at the significant level P<0/05.
Results: range of age in Neoadjuvant and Surgery group respectively was 23–68 and 26–89 years. The median number of lymph nodes retrieved in the neoadjuvant chemotherapy group was 14.0 (range 5 to 25) compared with 16 (range 5 to 32) in Surgery-first group, although there was not statistically significant difference between the two groups (P=0.122). Tumor stage and nodal stage were significantly higher in the neoadjuvant group (p≤0.001). Conclusions: This study suggests that administration of neoadjuvant chemotherapy to breast cancer patient's results in a reduced number of lymph nodes retrieved in the axillary dissection specimens.

 Introduction: Despite advances in cardiac surgery, many patients might still encounter some post-surgical complications and difficulties. To overcome such difficulties, they should receive the required education. In view of the fact that determining the educational needs is the first step in educational planning, the present study aims to determine the educational needs of patients undergoing heart valve replacement. 

Methods: This descriptive-analytic study was conducted cross-sectionally during the summer of 2012. The questionnaire was designed by the researchers and covered demographics and knowledge assessment sections (in four categories including the nature of diseases, different types of artificial heart valves, drugs and nutritional diets, and the activity level). The validity of the questionnaire was checked based on content validity and its reliability was calculated 0.89 by Chronbach's alpha. Participants were between 15-80 years of age. Their surgery was performed in the last 3 years. The data was analyzed in SPSS (version 16.0) using descriptive statistical tests (mean and standard deviation), t-test, and ANOVA. The significance level was set at P<0.05.

 Results: The finding showed that the highest mean score belonged to the knowledge of the nature of the disease whereas the lowest one, to the knowledge of drugs. As regards to the nature of the disease, there was a significant relationship between educational needs of the patients and their gender (P=0.01), age (P=0.02), education (P=0.005), and marital status (P=0.01). As for the knowledge of drugs, there was a significant relationship between gender and education. On the contrary, there was no significant relationship between the patients’ educational needs and previously-received trainings.  

Conclusions: Based on the results of the current study and the changing needs of the patients, nurses should perform needs analysis before starting any educational program. Moreover, by designing a well-organized program and investigating the patients before they leave the hospital, nurses should ensure that such a basic need is met. The findings of this study can help nurses to identify the educational priorities of patients undergoing heart valve replacement. 

Introduction: Detection of malignant cells in the peritoneal cavity indicates the extension of cancer cells. The aim of this study is to evaluate the incidence rate of positive cytology in colorectal cancer and its relationship with the local progress of the tumor. 

Methods: In a 2-year prospective study in Mashhad and Iran Universities of Medical Sciences, peritoneal lavage was performed on 40 patients with colorectal cancer from May 2012 to May 2013. Before any manipulation of the abdominal cavity, about 100 cc of normal saline was entered into the peritoneal cavity. Then, the samples were submitted for cytology. A sample was considered as positive if at least one cancer cell was detected.  

Results: From among 40 patients, 19 were male and 21 were female. The mean age of the patients was 51 years. They consisted of 17 cases of colon cancer and 23 cases of rectal cancer. Totally, positive cytology was identified in three patients. Among them, one case had abdominal carcinomatosis and the other two cases were involved at the levels of T3 and/or T4.

conclusions: It appears that peritoneal cytology is an appropriate method to evaluate tumor staging. Results of this method can be correlated between positive cytology and peritoneal seeding and survival, although the result of negative cytology cannot exclude advanced colorectal cancer and patients with carcinomatosis may have a negative peritoneal lavage.   

Introduction: Nowadays, spinal anesthesia is associated with few complications in many surgical practices especially the elective caesarean which is taken as a suitable replacement for general anesthesia. Different drugs are used for spinal anesthesia. This study aims to compare lidocaine 5% in combination with meperidine 5% plus lidocaine 5% for spinal anesthesia in non-emergency cesarean patients.

 Methods: This is a double-blind clinical trial that Was performed on fifty full term pregnant women, physical status I or II, presenting for non-emergency cesarean section under spinal anesthesia were randomly divided into two groups with 25 in each. All patient received IV 15 ml/kg Ringers solution 15 minutes prior to block. For spinal anesthesia, patients were given either 5% Meperidine 1.25 mg/kg or 5% heavy Lidocaine 60-75 mg intrathecally. The sensory blockade in all except two patients in Lidocaine group and one patient in Meperidine group, who required sedation and analgesia during surgery, was adequate for cesarean section. Data were analyzed by spss software.

 Results: Post-operation analgesia duration was 342.5±18.5 minutes in the lidocaine plus meperidine group and was 131.6±15 minutes in the lidocaine group. The mean difference of blood pressure before and 15 min after blockage was not significant in the lidocaine group and lidocaine plus meperidine group.

 Conclusions: It seems that lidocaine-meperidine combination has stronger medical effects than lidocaine used alone. Besides, the combination can be a proper drug for spinal anesthesia given the longer analgesia duration and lack of significant complications for the patient or adverse effects on the baby. 

 Introduction: Bacterial translocation is defined as the passage of bacteria from intestinal tract to the extraintestinal organs such as the peritoneum and blood circulation. The aim of this study is to examine bacterial translocation (regarding type of bacteria and effect of time of obstruction on bacterial translocation) from intestinal lumen to the peritoneum and viscera in acute, simple mechanical, small bowel obstruction in rats. 

 Methods: In this cohort study, thirty female Wistar rats were divided into three groups with two subgroups, each sub-group containing 5 rats. The 1st group consisted of two sham-operated and non-operated control subgroups. The 2nd group was the IO-24 group, and the 3rd group was the IO-48 group in which the interval between producing intestinal obstruction and the second laparotomy was 24 h and 48 h respectively. Each subgroup was divided into two subgroups of partial and complete obstruction. The data was analyzed using Fisher’s exact test and K2 test in SPSS. 

 Results: The most common types of bacteria were E. coli in aerobic culturing and bacteroid in anaerobic culturing. However, as the time of obstruction increased, the pattern of bacterial translocation changed to anaerobic bacteria.

 Conclusions: Our study showed that with increased time of obstruction, pattern of bacterial translocation changed from aerobic to anaerobic. Enterococci were the most common type of bacteria in an aerobic group. 

 Introduction: Prevalence of stroke following coronary artery bypass graft surgery (CABG) is % 2.1-5.2 and associated with high mortality. The purpose of this study was to investigate the prevalence of carotid artery disease in patients undergoing CABG surgery. 

Methods: This cross-sectional study was performed in the years 2010-2011 on 192 patients who underwent open heart surgery (CABG) in Imam Reza Hospital in Mashhad. Questionnaires with items about demographic data, risk factors, and outcome of coronary angiography were completed by participants. Carotid Doppler ultrasonography was performed by a radiologist for all the patients, and the data were analyzed in SPSS (V: 15) using chi-square and t-test at p<0.05. 

Results: In this study, 192 patients (116 male and 76 female) with the mean age of 60.3 ± 10.82 were examined. The prevalence of 50% carotid stenos was 26.6%. Carotid stenosis was found to be directly and significantly related with age and severity of coronary artery disease.

Conclusions: Given the high prevalence of carotid artery stenosis in patients with coronary artery disease, evaluation of carotid arteries in patients undergoing CABG is very important, especially in case of old age and severe coronary lesions.  

  Introduction: As a key member of the healthcare workforce, nurses play an important role in patient care. N ursing care performance, especially sterilization, is of significant importance in provision of health and prevention of complications such as hospital infections. This study aimed to investigate nurses’ performance concerning sterilization while performing nursing techniques in ICU wards of educational hospitals affiliated to Birjand University of Medical Sciences.

  Methods: In this descriptive-analytic study, 36 nurses working in the ICU ward were selected by census method. A researcher-made observational checklist with three choices for each item was designed to check the sterilization techniques used by nurses in terms of obtaining intravenous (IV) access (10 items), suctioning of the endotracheal tube (7 items), and dressing (8 items).For each technique, a total score of≥75% was considered as good, between 50-75% as moderate, and <50% as poor performance. Content validity was used to confirm the validity of the checklist, and Cronbach’s alpha was calculated 0.67 to confirm its reliability. Data were analyzed in SPSS (version 16) using independent t-test at the significant level of P<0.05.

  Results: Mean score in the suction technique (out of 21) was 15.3±0.88 for which 8.3% of participants had good and 91.7% had moderate performance. As for the dressing technique, the mean score (out of 24) was 18.1±0.68 for which 46.4% of participants had good and 53.6% had moderate performance. Mean score in the obtaining IV access (out of 30) was 18.64±1.03 for which 100% of participants had moderate performance. No poor technical performance was observed, nor was there a Significant differences between the participants’ demographics and their performance.

  Conclusions: Nurses’ performance concerning sterilization techniques used in the ICU wards was moderate. Considering the results, periodic re-education programs are suggested to improve nurses’ performance.