Evaluation of emergence delirium in Asian children using the Pediatric Anesthesia Emergence Delirium Scale

Background: Emergence delirium (ED) is a common problem in children recovering from general anesthesia. ED causes disruption in the postanesthetic care unit, making nursing and monitoring more difficult, and is potentially dangerous to the child. The greatest hindrance to understanding ED was the lack of a standardized tool to assess it. The Pediatric Anesthesia Emergence Delirium (PAED) Scale was recently described to measure the degree of ED in children. In this prospective observational study, we sought to evaluate the incidence of ED by grading emergence behavior using the PAED Score in healthy Asian children undergoing outpatient surgery. Methods: Three hundred sixteen children aged 2–12 years undergoing general anesthesia for elective outpatient surgery were included. No premedication was administered. Induction behavior was graded using the induction compliance checklist, and the presence of any excitation on induction documented. Emergence behavior was recorded using the PAED Scale, and the children were separately assessed for clinical agitation. Results: One hundred and thirty‐six children (43%) had PAED Scores >0 and 33 (10.4%) had PAED Scores of ≥10. Only 28 children (8.9%) had clinical agitation consistent with ED, the rest were agitated for other reasons. A score of ≥10 on the PAED Scale was the best discriminator between presence and absence of clinical agitation. The area under the receiver operating characteristic curve for PAED Score of ≥10 was 0.98, with a true‐positive rate (sensitivity) of 0.85 and a false‐positive rate (1‐specificity) of 0.041. Four factors were found to be predictive of ED. These include young age, poor compliance at induction, lack of intraoperative fentanyl use and rapid time to awakening. Conclusions: The incidence of ED is approximately 10% in our population of healthy, unpremedicated Asian children undergoing day surgery. Young age, poor compliance at induction, lack of intraoperative fentanyl use and rapid time to awakening were predictive risk factors for ED in our population. A PAED Score of ≥10 was correlated with clinically significant ED and appeared to be the ideal cutoff score for ED.     

Leg ulcers caused by yaws and endemic syphilis

Treponematoses as a cause of leg ulcer is today an infrequent phenomenon and is reported sporadically. ¹ Availability and widespread use of a large variety of potent antibiotics, improvements in living conditions, increased social awareness and hygiene, and worldwide improvements in medical care have all contributed to its containment. However, in the underdeveloped, third world countries, pockets of endemic treponematoses continue to persist. Of late, a resurgence of the disease appears to have occurred in Western and Central Africa, and in the Asia Pacific region,^{2 7} following the easing of surveillance and control measures. The current concept as far as the classification of human-associated treponematoses is concerned is given in Table 1.^8,9     

Management Strategies for Pain in Breast Carcinoma Patients: Current Opinions and Future Perspectives

Breast cancer is the most frequently encountered carcinoma in women worldwide. Pain is the most distressing symptom in patients with breast carcinoma and can occur at all stages of the disease due to the cancer per se as well as due to various diagnostic and treatment modalities. A proper pain assessment helps in identification of pain syndromes and guides in formulating analgesic strategies. Primary therapies of breast carcinoma like surgery, chemotherapy, and radiotherapy for bony metastases can cause substantial pain relief. However, multimodal analgesic approaches incorporating pharmacological, interventional as well as non-conventional techniques should be employed prior to, in conjunction with, and after primary therapies of breast cancer. The prevalence of chronic neuropathic pain following breast cancer surgery may exceed 50% by current estimates, and with the increase in life expectancy of these patients, providing adequate pain relief is of paramount importance to improve their quality of life. In this review, we discuss prevailing methods of evaluation and management of pain in patients of breast carcinoma and the new techniques that may become the mainstay of pain management protocols in future.     

Ultrasound of Adnexal Masses

Current advancements in imaging technology, especially three-dimensional/four-dimensional ultrasound and contrast-enhanced imaging, have increased the diagnostic yield of adnexal masses. The benefit of ultrasound is the characterization of an adnexal mass, suggesting the probable etiology of the mass. Masses may be divided as solid, cystic, or complex. It is predominantly the solid and complex masses that need a thorough evaluation. The role of color-flow imaging is now gaining importance and criteria for distinguishing between benign and malignant masses are often possible. Availability of a scoring system enables the differentiation of small adnexal masses. Several benign lesions may present as complex masses but can be distinguished and diagnosed on sonography. The availability of 3D ultrasound has been of great use to understand spatial relations and vascular morphology. Sonography allows a more detailed assessment of morphologic features of an adnexal mass. With a benign-appearing adnexal mass on sonography, the need for any further diagnostic tests is often obviated.     

Perspectives on Intravenous Oxycodone for Control of Postoperative Pain

Intravenous (IV) analgesia has particular advantages in the immediate postoperative period. For example, IV administration results in a faster onset of pain relief and results in more predictable pharmacokinetics than does administration by other routes. It also allows for convenient dosing before or during surgery, permitting the initiation of effective analgesia in the early phase of the postoperative period. In addition, when patients are able to tolerate oral intake, they can be switched from IV to oral dosing based on maintaining the predictable analgesia established by the IV route. IV morphine is widely used for the control of postoperative pain, but there is a trend toward the use of oxycodone. Oxycodone (which may be mediated partly through kappa‐ as well as mu‐opioid receptors) offers several potential advantages. Published studies comparing IV oxycodone to other IV opioids for postsurgical pain report that oxycodone is a safe and effective analgesic. Some studies show that IV oxycodone may be associated with greater pain control, fewer or less severe adverse events, and faster onset of action, although the results are not consistent across all studies. Oxycodone has been reported to be safe in the geriatric and other special populations when adequate clinical adjustments are made. Thus, the clinical reports and oxycodone's pharmacologic profile make intravenous oxycodone a potentially important “new” old drug for postoperative pain control.     

Impact of Diabetes Mellitus (DM) on the Health-Care Utilization and Clinical Outcomes of Patients with Stroke in Singapore

Objective:  This study aims to assess the impact of diabetes mellitus (DM) on the health-care utilization and clinical outcomes of patients with acute stroke.
Methods:  This is a retrospective cohort study. All patients who were admitted for the first time to one of the three public hospitals in the National Healthcare Group in Singapore from January 2005 to June 2007 with a primary diagnosis of acute stroke were included and were followed up for 1 year after the index hospitalization. The study population was divided into two groups: with DM and without DM. Both univariate and multivariate analyses were applied to compare the hospital length of stay (LOS), hospitalization costs, mortality, as well as the 1-year hospital readmissions between the DM and non-DM groups.
Results:  There were 9766 study patients, and 38.5% of them had DM. DM patients with ischemic stroke (IS) and transient ischemic attack (TIA) stayed 1-day and 0.6-day longer, and incurred 10% and 26% higher hospital cost during index admission, respectively, compared with their counterparts in the non-DM group. They also had more hospital readmission within 1 year. The mortality rate in IS patients with diabetes was 24% higher. After risk adjustment, subarachnoid hemorrhage patients with diabetes had more hospitalizations. Intracerebral hemorrhage (ICH) and IS patients in the DM group had all worse outcomes but the 1-year stroke recurrence; TIA patients with DM incurred longer LOS and hospital costs.
Conclusion:  DM predicts worse clinical outcomes and higher health-care expenditures in the 1-year poststroke especially for the IS, ICH, and TIA stroke subtypes.     

A study of intestinal function and morphology in nonspecific ulcerative colitis in acute phase and remission in India

Smallintestinal functions and villous morphology were studied in 32 cases of nonspecific ulcerative colitis—22 in acute phase and 10 in remission. In the acute phase, mild steatorrhea was detected in 7 of 22 cases and abnormald-xylose excretion in 8 of 18 cases. Significant morphologic changes in intestinal mucosa were present in 6 of 17 cases in the acute phase. Radiologically, a mild deficiency pattern was detected in 6 of the 12 cases. Malabsorptive derangement observed in the acute phase disappeared during remission. No malabsorptive or structural derangement was detected in cases with long remission. No motility disturbances were detected in any case. Intestinal dysfunction and morphologic changes correlated well with the severity of the disease. Anemia did not seem to play any role in the genesis of malabsorption, and hypoproteinemia showed some correlation with fecal fat excretion only.