Background Caudal epidural analgesia is a widely used and effective regional anesthetic technique for pediatric infraumbilical surgeries. Although bupivacaine provides reliable analgesia, its relatively short duration has prompted the use of adjuvants to prolong postoperative pain relief. Dexmedetomidine, a selective α2-adrenergic agonist, and tramadol, a centrally acting analgesic, are commonly employed caudal adjuvants; however, their comparative effects when combined with bupivacaine remain incompletely defined. Methods This prospective, randomized, double-blind study included 60 pediatric patients aged two to eight years undergoing elective infraumbilical surgeries under general anesthesia. All patients received a caudal block with 0.25% bupivacaine (1 mL/kg) and were randomized into two groups: Group D received dexmedetomidine 0.5 µg/kg (n = 30), and Group T received tramadol 1 mg/kg (n = 30). Hemodynamic parameters, including heart rate (HR) and mean arterial pressure (MAP), were recorded intraoperatively and at extubation. The primary outcome was time to first rescue analgesia, defined as the time from skin closure to a Face, Legs, Activity, Cry, Consolability (FLACC) score >4. Data were analyzed using appropriate parametric tests, with p < 0.05 considered statistically significant. Results Demographic characteristics and duration of surgery were comparable between the groups. Mean age was 4.19 ± 1.91 years in Group D and 4.55 ± 2.10 years in Group T (p = 0.49), while mean body weight was 14.15 ± 4.00 kg and 15.16 ± 4.24 kg, respectively (p = 0.35). The duration of postoperative analgesia was significantly longer in the dexmedetomidine group compared with the tramadol group (812.70 ± 46.15 minutes vs. 605.53 ± 45.12 minutes; p < 0.0001). HR and MAP decreased gradually in both groups following induction, with lower values observed in the dexmedetomidine group; however, differences in HR at all measured time points were not statistically significant. MAP after extubation was significantly lower in Group D compared with Group T (66.73 ± 5.96 mmHg vs. 70.17 ± 6.86 mmHg; p = 0.04). No episodes of bradycardia or hypotension requiring intervention occurred in either group. Conclusion Dexmedetomidine (0.5 µg/kg) as an adjuvant to caudal bupivacaine provided significantly prolonged postoperative analgesia compared with tramadol (1 mg/kg) in pediatric infraumbilical surgeries. Both agents maintained stable perioperative hemodynamics without clinically significant adverse effects; however, dexmedetomidine demonstrated better attenuation of hemodynamic responses, particularly after extubation. Low-dose dexmedetomidine appears to be an effective and safe caudal adjuvant in pediatric patients undergoing infraumbilical surgical procedures.

This report describes a rare case of severe cerebral injury secondary to an air embolism following endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction. Through meticulous analysis of this complication, we aim to elucidate the potential mechanisms responsible for inadvertent gas entry during therapeutic procedures, evaluate strategies for early detection, and discuss precautionary measures to enhance procedural safety in biliary interventions. This study provides valuable insights into understanding and potentially reducing such adverse iatrogenic outcomes in interventional endoscopy practice.

Sodium 2-mercaptobenzothiazole (MBTNa) is a water-soluble benzothiazole compound widely used in industrial applications, yet its potential vascular developmental toxicity remains insufficiently understood. In this study, zebrafish embryos were used to evaluate the cardiovascular and vascular developmental effects of MBTNa and to explore the possible molecular mechanisms involved. Embryos were exposed to 0.001-1 μM MBTNa from 4 to 72 hpf, and cardiovascular morphology, vascular development, apoptosis-related signals, network toxicology prediction, molecular docking, Western blot analysis, and PTK787-based rescue experiments were performed. MBTNa exposure induced selective cardiovascular and vascular defects, including pericardial edema, bradycardia, impaired intersegmental vessel development, common cardinal vein dilation, and ectopic subintestinal vessel sprouting. Network toxicology and molecular docking identified Kdr/PI3K/Akt-associated signaling as a potential pathway involved in MBTNa-induced vascular abnormalities. RT-qPCR analysis showed altered expression of PI3K/Akt/GSK3β-related and apoptosis-related genes, and Western blot analysis further showed increased relative levels of p-AKT and p-GSK3β after MBTNa exposure. In addition, PTK787 co-treatment partially attenuated MBTNa-induced vascular abnormalities and reversed selected transcriptional alterations. These findings suggest that Kdr/PI3K/Akt-associated signaling is involved in MBTNa-induced vascular developmental toxicity and highlight the need to include vascular endpoints in the risk assessment of benzothiazole-related contaminants.

Few studies have described physiological and cardiac rhythm responses to maximal voluntary breath-holding in elite freedivers. This case study presents minute ventilation, PETO2, PETCO2, involuntary breathing movements (IBMs; surface electromyography), SpO2, muscle and cerebral oxygenation (near-infrared spectroscopy), and cardiac rhythm changes (electrocardiogram) before, during, and after a maximal dry static voluntary breath-hold in a world champion freediver. Glossopharyngeal insufflation prior to the breath-hold increased forced vital capacity from 6.92L (138% predicted) to 9.04L (180% predicted). Compared to resting end-tidal gas pressures, the breathe-up in preparation of the breath-hold increased PETO2 (108mmHg to 135mmHg) and decreased PETCO2 (36mmHg to 21mmHg). The breath-hold was 06'07" in duration, of which 02'20" was spent in the easy-going phase and 03'47" in the struggle phase - the latter encompassing a total of 48 IBMs. Throughout the breath-hold, PETO2 decreased to 38mmHg and PETCO2 increased to 65mmHg. SpO2 decreased from 97% to 73%. Muscle oxygenation decreased from 50% to 22%, whereas cerebral oxygenation remained relatively stable until the final ∼20s of the breath-hold (∼68% to ∼62%). Heart rate variability-based markers of autonomic cardiac activity decreased during the easy-going phase, increased during the struggle phase, and normalized after. Asymptomatic bradycardia with competition between sinus bradycardia and junctional rhythm and (supra)ventricular extrasystoles manifested throughout the struggle phase and resolved after breath-hold cessation. This report of a world champion freediver shows that a long voluntary breath-hold induced transient asymptomatic cardiac arrhythmias, likely linked to the physiological stress of extreme voluntary breath-holding.

Bohring-Opitz syndrome (BOS) is characterized by distinctive facial features and posture, growth failure, variable but usually severe intellectual disability, and variable anomalies. The facial features may include microcephaly or trigonocephaly / prominent (but not fused) metopic ridge, hypotonic facies with full cheeks, synophrys, glabellar and eyelid nevus flammeus (simplex), prominent globes, widely set eyes, palate anomalies, and micrognathia. The BOS posture, which is most striking in early childhood and often becomes less apparent with age, is characterized by flexion at the elbows with ulnar deviation and flexion of the wrists and metacarpophalangeal joints. Feeding difficulties in early childhood, including cyclic vomiting, have a significant impact on overall health; feeding tends to improve with age. Seizures are common and typically responsive to standard epileptic medications. Minor cardiac anomalies and transient bradycardia and apnea may be present. Affected individuals may experience recurrent infections, which also tend to improve with age. Isolated case reports suggest that individuals with BOS are at greater risk for Wilms tumor than the general population, but large-scale epidemiologic studies have not been conducted.

Background: Head and neck paragangliomas (HNPGLs) are rare neuroendocrine neoplasms that may be sporadic or hereditary and may occur as isolated, multifocal, or syndromic disease within the pheochromocytoma-paraganglioma spectrum. Synchronous bilateral carotid body tumors (CBTs) and bilateral vagal paragangliomas (VPGLs) are exceptional, particularly when biochemical activity and metastatic nodal involvement coexist. Case Presentation: We report a 33-year-old man with a 2-year history of enlarging bilateral neck masses, positive family history, and markedly elevated noradrenaline (6430 pg/mL; reference range <750 pg/mL). Initial CT angiography suggested bilateral CBTs, and Metaiodobenzylguanidine (MIBG) scintigraphy did not demonstrate abnormal adrenal or distant uptake. After alpha- and beta-blockade, staged surgery was performed. Right CBT excision demonstrated metastatic PGL, with two of four lymph nodes positive. Subsequent MRI and operative reassessment revealed synchronous bilateral CBTs and bilateral VPGLs. Left-sided surgery required partial debulking of a vagal-adherent mass to preserve nerve continuity; pathology confirmed PGL with Ki-67 index approximately 2% and left neck nodes were negative. Postoperatively, profound bradycardia required temporary then permanent pacing, together with bilateral vocal cord paralysis. During follow-up, swallowing and voice improved, the pacemaker was removed, and late imaging showed stable residual cervical disease without visceral metastasis on chest/abdominal CT. Conclusions: This case highlights the diagnostic and therapeutic complexity of multicentric, biochemically active HNPGLs and supports individualized multidisciplinary management, genetic counseling, biochemical surveillance, and long-term follow-up.

Mad honey contains the neurotoxin grayanotoxin, which is produced by the flowers and nectar of the Rhododendron family. Bees incorporate this toxin into honey. Mad honey is consumed as a medicinal remedy in certain parts of the world, leading to persistent vagal activation and potentially serious complications, including hemodynamic instability. We report the case of a 75-year-old male patient with a medical history of hyperlipidemia and hypertension (managed with atorvastatin 20 mg and amlodipine 5 mg, respectively) who presented to the emergency department complaining of near-syncope, dizziness, lethargy, nausea, and one episode of diarrhea one hour after ingesting 20-30 mL of wild honey brought as a gift from abroad. On presentation, he was conscious and alert. Triage observations revealed a blood pressure of 65/41 mmHg, a heart rate of 45 beats/minute, a respiratory rate of 20 breaths/minute, an oxygen saturation of 98% on room air, and a temperature of 36.8°C. Physical examination was unremarkable. Electrocardiogram demonstrated sinus bradycardia. The patient was resuscitated with intravenous fluids and 0.6 mg of intravenous atropine, which normalized his heart rate and blood pressure within seconds. He was admitted for observation for 36 hours and was discharged without sequelae. Mad honey poisoning is rare in the United Kingdom and requires a high index of suspicion. Symptoms of hypotension and bradycardia following honey consumption should alert clinicians to this poisoning. Treatment with atropine is successful in alleviating symptoms, which typically resolve within 24 hours.

The trigeminocardiac reflex (TCR) is clinically defined as the sudden onset of increased parasympathetic activity resulting from stimulation of the trigeminal nerve. This reflex increases parasympathetic tone and can lead to significant bradycardia and hypotension. We report the case of severe bradycardia and hypotension that occurred under general anesthesia during insertion of a cotton swab into the nasal cavity. A 57-year-old woman was scheduled for nasotracheal intubation for oral surgery, and following loss of consciousness, intubation was initiated using cotton swabs soaked in a solution of 2% lidocaine and 1:100,000 epinephrine that were inserted through the left nostril. The patient immediately developed severe bradycardia and hypotension which were managed with intravenous ephedrine after removing the cotton swabs rather than atropine due to concerns related to closed-angle glaucoma. The patient responded promptly to the ephedrine bolus, and no further complications occurred. It was assumed that the ophthalmic (V1) and maxillary (V2) branches of the trigeminal nerve were stimulated by the cotton swabs being inserted into the nasal cavity, triggering the TCR. Anesthesiologists need to be aware of the risks associated with administering mydriatic drugs such as ephedrine and epinephrine, which are relatively contraindicated, as well as atropine to patients with closed-angle glaucoma.