Pre-discharge prognostic factors of physical function among older adults with hip fracture surgery: a systematic review.

INTRODUCTION: To identify, organize, and assess the evidence level of pre-discharge prognostic factors of physical function beyond discharge after hip fracture surgery. METHODS: We performed a systematic search of four databases (PubMed, Embase, CINAHL, PsycINFO) for longitudinal studies of prognostic factors of physical function at ≥ 1 month among older adults ≥ 50 years old with surgically treated hip fracture, complemented with hand-searching. Two reviewers independently screened papers for inclusion and assessed the quality of all the included papers using the Quality in Prognosis Studies (QUIPS) tool. We assigned the evidence level for each prognostic factor based on consistency in findings and study quality. RESULTS: From 98 papers that met our inclusion criteria, we identified 107 pre-discharge prognostic factors and organized them into the following seven categories: demographic, physical, cognitive, psychosocial, socioeconomic, injury-related, and process of care. Potentially modifiable factors with strong or moderate evidence of an association included total length of stay, physical function at discharge, and grip strength. Factors with strong or moderate evidence of no association included gender, fracture type, and time to surgery. Factors with limited, conflicting, or inconclusive evidence included body-mass index, psychological resilience, depression, and anxiety. CONCLUSIONS: Our findings highlight potentially modifiable prognostic factors that could be targeted and non-modifiable prognostic factors that could be used to identify patients who may benefit from more intensive intervention or to advise patients on their expectations on recovery. Examining the efficacies of existing interventions targeting these prognostic factors would inform future studies and whether any of such interventions could be incorporated into clinical practice.

Nematode control failure due to anthelmintic resistance in a sheep farm in Malaysia: First identification of the F200Y mutation in the isotype 1 ß-tubulin gene.

This paper reports total nematode anthelmintic resistance towards albendazole, fenbendazole, levamisole and ivermectin in a commercial sheep farm located in Terengganu, Malaysia. Faecal Egg Count Reduction Test (FECRT) was conducted on 25 sheep, where five sheep in each group were treated with the respective four anthelmintics based on live bodyweight. The balance of five sheep placed in the control group were not treated with any anthelmintics. At day 13 post-treatment, faecal egg count was conducted and nematode worm egg count reduction percentage was calculated to determine the resistance status towards the respective anthelmintics tested. Results showed that nematodes were resistant to all the anthelmintics tested, namely albendazole, fenbendazole, levamisole and ivermectin with reduction percentage of 87%, 46%, 94% and 68%, respectively. Subsequently, the third stage larvae of Haemonchus contortus and Trichostrongylus colubriformis recovered from post-treatment faecal cultures were subjected to allele-specific polymerase chain reaction (AS-PCR) assay to determine the presence of the benzimidazole resistance gene. This study reports the occurrence of the classical F200Y mutation in the isotype 1 ßtubulin gene, for the first time in Malaysia.

Nucleotide variability in the 5-enolpyruvylshikimate-3-phosphate synthase gene from Eleusine indica (L.) Gaertn.

This study reports the results of the partial DNA sequence analysis of the 5-enolpyruvyl-shikimate-3-phosphate synthase (EPSPS) gene in glyphosate-resistant (R) and glyphosate-susceptible (S) biotypes of Eleusine indica (L.) Gaertn from Peninsular Malaysia. Sequencing results revealed point mutation at nucleotide position 875 in the R biotypes of Bidor, Chaah and Temerloh. In the Chaah R population, substitution of cytosine (C) to adenine (A) resulted in the change of threonine (Thr106) to proline (Pro106) and from C to thymidine (T) in the Bidor R population, leading to serine (Ser106) from Pro106. As for the Temerloh R, C was substituted by T resulting in the change of Pro106 to Ser106. A new mutation previously undetected in the Temerloh R was revealed with C being substituted with A, resulting in the change of Pro106 to Thr106 indicating multiple founding events rather than to the spread of a single resistant allele. There was no point mutation recorded at nucleotide position 875 previously demonstrated to play a pivotal role in conferring glyphosate resistance to E. indica for the Lenggeng, Kuala Selangor, Melaka R populations. Thus, there may be another resistance mechanism yet undiscovered in the resistant Lenggeng, Kuala Selangor and Melaka populations.

Comprehension skill and global coherence: a paradoxical picture of poor comprehenders' abilities.

The authors investigated good and poor comprehenders' maintenance of global coherence during reading. Participants read stories in which a character's action was consistent or inconsistent with a description of the character presented earlier in the story. In Experiment 1, the description and action were adjacent in the text (local coherence) or were separated by intervening text (global coherence). Both groups of comprehenders read inconsistent actions more slowly than consistent actions in the local coherence condition, but only good comprehenders showed the reading time difference in the global coherence condition. In Experiment 2, the authors disconfirmed the hypothesis that poor comprehenders fail to maintain global coherence because they fail to activate prior text information. Thus, the results present a paradoxical picture in which poor readers activate relevant knowledge during reading but fail to integrate it into their developing representation.

Single dose diclofenac suppository reduces post-Cesarean PCEA requirements.

PURPOSE: To assess the analgesic efficacy of administering, immediately after surgery, a single dose of diclofenac (100 mg suppository) to women who had undergone lower segment Cesarean section (LSCS) under combined spinal-epidural anesthesia, and received post-operative patient-controlled epidural analgesia (PCEA) with ropivacaine 0.2% and fentanyl 2 microg x ml(-1). METHODS: Forty-eight ASA physical status I or II term parturients scheduled for elective LSCS under regional anesthesia were enrolled into this randomised double-blind study. The patient-controlled epidural analgesia device was programmed to deliver a bolus of 4 ml of local anesthetic mixture with a lockout period of ten minutes and an hourly limit of 12 ml. There was no baseline infusion. The study commenced upon the patient's first demand for analgesia post-operatively and the patients were assessed at one, six, 12 and 24 hr post-operatively for pain scores on movement, dermatomal level of sensory blockade, degree of motor blockade and volume of local anesthetic used. At conclusion of the study, patients' satisfaction scores were recorded. RESULTS: The two groups of patients were similar demographically. Patients who received a diclofenac suppository used 52.8 +/- 17.8 ml of local anesthetic mixture while those who did not, used 74 +/- 25 ml (P <0.005). Pain scores and satisfaction scores did not differ significantly between the groups. CONCLUSION: A single administration of 100 mg diclofenac suppository is effective in reducing post-Cesarean epidural local anesthetic/opioid requirements by 33% for the first 24 hr post-operatively.

A case report on the treatment of intractable anal pain from metastatic carcinoma of the cervix.

INTRODUCTION: Cancer pain in the terminally ill often poses great therapeutic dilemma. Opioids, whilst being useful in most cases, often leaves a patient heavily sedated and constipated at high doses and sometimes, in persistent agony from cancer pain. CLINICAL PICTURE: An Indian lady who suffered from metastatic carcinoma of the cervix experienced tremendous pain and disability despite high doses of narcotics and membrane stabilizers. TREATMENT: A ganglion of impar block and superior hypogastric plexus block were performed with a neurolytic agent. OUTCOME: The patient's pain and opioids usage were markedly reduced. CONCLUSION: Neurolytic nerve block can offer a great therapeutic option in selected cancer patients.

The effect of adding fentanyl to ropivacaine 0.125% on patient-controlled epidural analgesia during labour.

The use of patient-controlled epidural analgesia (PCEA) for labour analgesia is rapidly gaining acceptance. However, the ideal PCEA solution and PCEA program remains uncertain. We studied the effect of adding fentanyl 2 micrograms/ml on demand-only PCEA using ropivacaine 0.125% for labour analgesia. With the approval of the Hospital Ethics Committee, this prospective randomized controlled trial was conducted on 36 nulliparous ASA 1/2 parturients in early, but established, labour. Upon written consent, epidural analgesia was started with 10 ml ropivacaine 0.2%. The parturients subsequently were randomized to receive either ropivacaine 0.125% (n = 18) or ropivacaine 0.125% with fentanyl 2 micrograms/ml (n = 18). The PCEA was programmed to a demand-only mode with bolus of 5 ml, lockout time of 10 minutes and maximum volume per hour of 20 ml. The degree of pain relief was similar in both groups. However, the total amount of ropivacaine used per hour was lower in the group that received fentanyl (median 7.1 vs 10.1 mg, P < 0.05). This was not associated with a decrease in motor blockade or a decrease in instrumental deliveries. The ratio of successful PCEA demand to total number of demands, the satisfaction score and the maternal-fetal outcome were similar in both groups. In conclusion, the addition of fentanyl had a dose-sparing effect on the requirement of ropivacaine. This PCEA regimen produced a low incidence of motor block, good labour pain relief and excellent patient satisfaction.

The effect of the addition of ropivacaine or bupivacaine upon pruritus induced by intrathecal fentanyl in labour.

Sixty patients in early labour were randomly allocated to one of three groups. The control group received intrathecal fentanyl 25 microg, the ropivacaine group received intrathecal fentanyl 25 microg and ropivacaine 2.5 mg while the bupivacaine group received intrathecal fentanyl 25 microg and bupivacaine 2.5 mg. The incidence of pruritus was 100% in controls, compared with 85% in the ropivacaine group (not significant) and 75% in the bupivacaine group (p = 0.003). The severity of pruritus was significantly less in the ropivacaine (p = 0.006) and bupivacaine (p = 0.001) groups. Most patients developed pruritus by 30 min. Pruritus above the abdomen was not reduced in patients receiving local anaesthetics. There were no significant differences in the mean pain visual analogue score, systolic blood pressure, maternal heart rate and upper level of reduced pin-prick sensation in the first 30 min. Intrathecal ropivacaine and, more so, intrathecal bupivacaine reduce the incidence and severity of pruritus from intrathecal fentanyl for labour analgesia.

A comparison of patient-controlled epidural analgesia following gynaecological surgery with and without a background infusion.

We conducted a randomised, controlled study to investigate the effect of adding a background infusion to patient-controlled epidural analgesia for postoperative pain relief. Forty-two patients scheduled for elective lower abdominal gynaecological surgery received patient-controlled epidural analgesia postoperatively using a mixture of 0.2% ropivacaine and 2.0 microg x ml-1 fentanyl. Patients in group B (n = 20) were given a background infusion of 5 ml x h-1, whereas those in group N (n = 21) were not. There was no difference in pain scores or patient satisfaction scores between the two groups. Patients in group B had a higher total drug consumption (156.8 +/- 34.8 ml vs. 89.5 +/- 41.0 ml; p < 0.0001) and incidence of side-effects (71.4% vs. 30.0%; p = 0.007). Motor blockade during the 24-h study period was also greater in group B (median [range] area under the curve 7.5 [0.0-39.0] h vs. 3.0 [0.0-36.0] h; p = 0.035). We conclude that the addition of a background infusion to patient-controlled epidural anaesthesia is not recommended as it confers no additional benefits.

Motor blockade is reduced with ropivacaine 0.125% for parturient-controlled epidural analgesia during labour.

PURPOSE: To compare the effect on the incidence of motor block by reducing the concentration of ropivacaine from 0.2% to 0.125% in parturient-controlled epidural analgesia (PCEA) for labour. METHODS: Randomized, controlled and double-blind trial involving parturients in early labour who received demand-only PCEA regimen (bolus 5 ml, lockout 10 min, maximum volume per hour of 20 ml) with either 0.2% (R0.2 group, n = 25) or 0.125% (R0.125 group, n = 25) ropivacaine. Pain scores, the degree of motor block, the rate of drug consumption, the proportion of good to total PCEA demands and the overall satisfaction scores were documented. RESULTS: Fewer parturients in the R0.125 group had lower limb motor block (4 vs. 11, P<0.05) although the degree of block was mild in all the affected parturients. The ratio of good to total PCEA demands was more favourable in the R0.2% group (median 0.72 vs. 0.52, P<0.01) although the hourly rate of ropivacaine consumption, the degree of pain relief, the maternal-fetal outcome and the overall satisfaction scores were similar. CONCLUSION: Both ropivacaine 0.2% and 0.125% provided comparably effective analgesia but motor block occurred more commonly in the 0.2% group.

Epidural 0.2% ropivacaine for labour analgesia: parturient-controlled or continuous infusion?

In this randomized, open study, we compared the incidence of lower limb motor block associated with epidural labour analgesia provided by parturient-controlled method (PCEA) with continuous infusion (CIEA) using 0.2% ropivacaine. The PCEA group (n = 20) received a demand-only regimen (bolus 5 ml, lockout 15 minutes). The rate of infusion of the CIEA group (n = 20) was 8 ml/h. We found that pain relief was not significantly different between the two groups, although the PCEA group had a higher satisfaction score (P < 0.05). Fewer parturients in the PCEA group had lower limb motor block (6 vs 14, P < 0.05). The total volume of ropivacaine used per hour was also lower in the PCEA group (median 8.75 vs 10.5 ml, P < 0.05). No difference in the maternal or fetal outcome was detected. We conclude that PCEA with ropivacaine is an effective mode of analgesia which is dose-sparing and produces less motor block in comparison with CIEA.

Combination of intrathecal sufentanil 10 mug plus bupivacaine 2.5 mg for labor analgesia: is half the dose enough?

UNLABELLED: This controlled, double-blinded, prospective trial of 42 parturients in early labor was conducted to determine whether halving the total amount of intrathecal (i.t.) sufentanil and bupivacaine reduced the incidence of systemic hypotension while providing adequate analgesia with minimal lower limb motor block. Combined spinal-epidural analgesia (CSE) was instituted; Group A (n = 21) received a total of 10 microg of sulfentanil plus 2.5 mg of bupivacaine, whereas Group B (n = 21) received half that dose. Compared with Group B, Group A had a higher incidence of hypotension (nine parturients in Group A, two in Group B; P < 0.05), a greater degree of motor block (P < 0.05), and a higher incidence of sedation (nine parturients in Group A were sedated, one in Group B; P < 0.01). Group B had higher pain scores for the first 5 min (P < 0.05) and a lower level of sensory blockade (median of T7 in Group B compared with T4 in Group A; P < 0.01). We conclude that halving the total amount of i.t. 10 microg of sufentanil plus 2.5 mg of bupivacaine is a suitable option for CSE in labor because it reduces the incidence of some side effects, such as hypotension and maternal sedation, without compromising overall high maternal satisfaction. IMPLICATIONS: We showed that adequate labor pain relief could be provided by halving the recommended dose of 10 microg of intrathecal sufentanil plus 2.5 mg of bupivacaine. The larger dose, however, produced faster pain relief, which lasted longer than the reduced dose. The mother and baby were not adversely affected with either dose.

Combined spinal epidural for labour analgesia--duration, efficacy and side effects of adding sufentanil or fentanyl to bupivacaine intrathecally vs plain bupivacaine.

AIM OF STUDY: The aim of the study was to evaluate the efficacy and side effects of adding sufentanil 10 micrograms, fentanyl 10 micrograms or a control of 1 mL saline to 2.5 mg bupivacaine given intrathecally via combined spinal epidural (CSE) for labour pain relief in the first stage. METHOD: Sixty ASA I or II patients who requested for epidural analgesia were randomised to three groups. CSE was performed with a 16G Touhy needle and 27G Whitacre needle. RESULTS: Patients in the sufentanil/bupivacaine group had a significantly longer duration of analgesia (162.9 min +/- 63.4) compared with fentanyl/bupivacaine (110.0 min +/- 44.6) compared with plain bupivacaine (70.0 min +/- 32.1). Pruritus was significant in patients with sufentanil (80%) and fentanyl (47.4%) but did not occur with plain bupivacaine. There was no significant difference in the incidence of nausea or vomiting, hypotension and motor blockade although blood pressures in the sufentanil group were consistently lower than the other two groups. Pain scores were lowest in the sufentanil group. Fetal heart rate changes and Apgar scores were not significantly different between the groups. CONCLUSION: In combined spinal epidural for labour analgesia, adding sufentanil 10 micrograms to intrathecal bupivacaine 2.5 mg provided fast onset and good analgesia for a longer duration compared with adding fentanyl 10 micrograms and with plain bupivacaine. The main side effect was pruritus. Neonatal outcome was similar.

Intrathecal sufentanil as the sole agent in combined spinal-epidural analgesia for the ambulatory parturient.

PURPOSE: To compare the effect of a combination of intrathecal (i.t.) sufentanil plus bupivacaine with i.t. sufentanil alone, on the incidence of hypotension and the success of ambulation in parturients. METHODS: This was a controlled, double-blind prospective trial involving 50 parturients in early labour who had received combined spinal-epidural analgesia (CSE). They were divided equally into two groups; group A received 10 micrograms i.t. sufentanil while group B received i.t. 10 micrograms sufentanil plus 2.5 mg plain bupivacaine. The blood pressure, pain scores, the highest sensory block and the degree of motor blockade were documented over the first 30 min by an unbiased anaesthetist. The ability and the desire to ambulate was studied 30 min after CSE. The side effects were documented throughout labour. RESULTS: Group B had a higher incidence of hypotension; (12 vs 3: P < 0.01). Fewer parturients in group B could ambulate (19 vs 25: P < 0.05). Group B also had a higher sensory blockade than group A (median T4 VS T7-8: P < 0.01). Of all the 44 parturients who could ambulate, 13 desired not to do so, usually due to sedation. CONCLUSION: The quality of analgesia in all subjects in the study was excellent. Side effects were more common in the i.t. sufentanil-bupivacaine combination group.

Dose response study of lidocaine 1% for spinal anaesthesia for lower limb and perineal surgery.

PURPOSE: To compare the sensory and motor block produced by three different volumes of intrathecal lidocaine 1% and thereby determine the appropriate volume to administer for surgery of the lower limbs and perineum. METHODS: Forty-eight patients scheduled for perineal or lower limb surgery were randomly assigned to receive 4, 6 or 8 ml lidocaine 1% intrathecally. The onset, spread, duration and regression of analgesia and motor block and side effects were evaluated (by a blinded observer whenever possible). RESULTS: The maximum cephalad spread in the 6 ml (T8 +/- 3) and 8 ml (T4 +/- 1.7) groups were higher than the 4 ml group (T12 +/- 2.2, P < 0.01). In the 4 ml group, six patients (33%) did not achieve analgesia to T12 and four (22%) did not have complete motor blockade. Patients given 8 ml had longer duration of block (duration at T12: 104 +/- 23 vs 60 +/- 24, 67 +/- 14 min. P < 0.01: 8 ml vs 4, 6 ml) and slower recovery times (sensory recovery: 188 +/- 27 vs 142 +/- 27, 157 +/- 28 min. P < 0.01; 8 ml vs 4, 6 ml). Two patients (18%) from the 8 ml group and one (5%) from the 6 ml group had transient hypotension. CONCLUSION: Four millilitres intrathecal lidocaine 1% is adequate for perineal surgery but for lower limb procedures, 6 ml is more appropriate as it consistently provides sensory analgesia above L1 dermatome and complete motor block. Eight ml gives an unnecessarily high block with higher incidence of hypotension.

The addition of intrathecal sufentanil and fentanyl to bupivacaine for caesarean section.

AIM OF STUDY: Intrathecal sufentanil has recently been used in labour as part of a combined spinal epidural technique. This study was conducted to compare its use in combination with bupivacaine for caesarean section with fentanyl added to bupivacaine and bupivacaine alone. METHODS: Sixty ASA I and II patients for non-emergency caesarean section under spinal anaesthesia were divided into three groups to receive 15 micrograms fentanyl added to 7.5 mg bupivacaine, 10 micrograms sufentanil added to 7.5 mg bupivacaine and 7.5 mg bupivacaine. Onset time of sensory blockade, side effects, surgical conditions, neonatal outcome and quality of the anaesthetic was assessed. On the first postoperative day, duration of effective analgesia, side effects and patient satisfaction were noted. RESULTS: The duration of effective analgesia of bupivacaine alone was prolonged with the addition of sufentanil and fentanyl by 358% and 256% respectively. No patient in the sufentanil and fentanyl groups required additional intra-operative analgesics compared with 17.6% of patients in the bupivacaine alone group. There was an increase in incidence of desaturation in the sufentanil group (45%) and fentanyl group (5.6%) compared with the bupivacaine only group (0%). The incidence of pruritus was 35% with sufentanil, 27.8% with fentanyl against 0% with bupivacaine alone. CONCLUSION: The addition of 10 micrograms of sufentanil and 15 micrograms of fentanyl to 7.5 mg of bupivacaine prolonged the duration of effective analgesia and improved intra-operative analgesia. However, the incidence of pruritus and episodes of desaturation were increased more with 10 micrograms sufentanil than with 15 micrograms fentanyl.

Severe mitral stenosis in a parturient with congestive cardiac failure and hypoglycaemia.

We report a case of maternal mortality in a 34-year-old multipara who presented at the 35th week of gestation with severe hypoglycaemia. She had no history of diabetes mellitus. This episode was a prelude to catastrophic and refractory congestive cardiac failure due to previously undiagnosed severe mitral stenosis. The rapid cardiovascular deterioration initially appeared to be consistent with amniotic fluid embolism. She also developed deranged liver function with disseminated intravascular coagulation, which mimicked acute fatty liver of pregnancy. The problems of diagnosis and management are discussed. Unfortunately the patient died before mitral valvular commissurotomy could be effected.