Context:Little is known about the relationship between sedative drugs used preoperatively and postoperative delirium. Melatonin is a drug used to sedate patients preoperatively and is hypothesized by recent works to have a curative effect on postoperative delirium.Aims:The incidence of postoperative delirium will be tested if affected by three different sedative drugs including melatonin.Settings and Design:Controlled randomized doubleblind study.Patients and Methods:Three-hundred patients aged>65 years scheduled for hip arthroplasty under spinal anesthesia were randomly distributed to one of the four groups. Group 1 (control) received nothing for sedation. Group 2 (melatonin) received 5 mg melatonin. Group 3 (midazolam) received 7.5 mg midazolam. Group 4 (clonidine) received 100 μg clonidine. These medications were given orally at sleep time at night of operation and another dose 90 min before operative time. Patients who developed postoperative delirium received 5 mg of melatonin 9 pm for three successive days in a trial to treat delirium.Statistical Analysis Used:Statistical analysis was done using the SPSS Software (version 13).Results:Total of 222 patients completed the study. Percentage of postoperative delirium in the control group was 32.65% (16/49 patients). The melatonin group showed a statistically significant decrease in the percentage of postoperative delirium to 9.43% (5/53 patients). Melatonin was successful in treating 58.06% of patients suffered postoperative delirium (36/62 patients) with no difference between different groups.Conclusions:Postoperative delirium is affected with the drug used for preoperative sedation. Melatonin was successful in decreasing postoperative delirium when used preoperatively and in treating more than half of patients developed postoperative delirium when used for three postoperative nights.

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Context:Cytokine release is a well-known response to surgery especially when it is linked to cancer. Paravertebral block (PVB) is the suitable regional anesthesia for breast surgery.Aim:We tested the effect of replacing general anesthesia (GA) with PVB on cytokine response during and after surgeries for cancer breast.Settings and Design:Controlled randomized study.Methods:Forty cancer breast patients were divided in two groups; Group I received PVB and Group II received GA during performance of unilateral breast surgery without axillary clearance. Plasma concentrations of interleukin (IL)-6, IL-10, IL-12 and interferon-γ (IFN-γ) were measured and IL-10/IFN-γ were estimated in the following points; before starting PVB in Group I or induction of GA in Group II (Sample A), before skin incision (Sample B), at the end of procedure before shifting out of operating room (Sample C), 4-h post-operatively (Sample D) and 24-h post-operatively (Sample E).Statistical Analysis:unpaired Student t-test.Results:IL-6 increased progressively in both groups with statistically significant lower levels in samples C and D in Group I. IL-10 levels showed progressive increasing in both groups without differences between groups. IL-12 showed progressive decrease in both groups with statistically significant higher levels in samples C and D in Group I. IFN-levels showed significantly higher levels in samples C and D in Group I. IL-10/IFN-γ ratio was significantly lower in Group II in samples C and D.Conclusion:Replacing GA with PVB can attenuate cytokines response to cancer breast surgeries.

Myeloperoxidase (MPO) is a hemoprotein that is released during inflammation and may lead to irreversible protein and lipid modification, increasing levels of oxidized low density lipoprotein, and promoting athrogenesis. Recently, it has been considered as a risk factor for cardiovascular diseases. Similarly, the measurement of carotid intima-media thickness gives an indication about the degree of atherosclerosis and prediction of clinical cardiovascular events. Elevated white blood cells counts may indicate a state of acute inflammation and follow its progression. Dialysis patients are at a high risk of developing cardiovascular disease compared with healthy subjects. The role of N-terminal pro-brain natriuretic peptide and increased cardiac troponin in identification and prognostication of cardiovascular diseases in end-stage renal disease patients has been investigated. The current study aimed to evaluate plasma MPO and its possible relationship with carotid intima-media thickness, troponin I, N-terminal pro-brain natriuretic peptide (NT-proBNP), and insulin resistance as measured by homeostatic model assessment (HOMA index) in a cohort of Saudi patients who are undergoing hemodialysis (HD) vs. continuous ambulatory peritoneal dialysis for end-stage renal disease. Plasma MPO was significantly higher in patients on continuous ambulatory peritoneal dialysis (CAPD) than in those on HD and in normal subjects (P<0.001). Conversely, NT-proBNP plasma levels were significantly higher in patients on HD (both predialysis and postdialysis) than in those on CAPD (P<0.01) and than normal subjects. Similarly, plasma troponin-I levels were significantly higher in patients on HD compared with those of CAPD and than normal subjects (P<0.001). Plasma troponin-I and NT-proBNP levels were positively correlated in the 3 groups namely those on CAPD, Pre-HD, and post-HD (r: 0.464 and P=0.047; r: 0.330 and P=0.013; and r: 0.452 and P=0.024), respectively. There was no correlation between the MPO level and carotid intima-media thickness (P>0.05). However, plasma MPO level correlated positively with the white blood cell count in patients on CAPD and in those on HD (P<0.05). Our findings suggest an increased oxidative stress in CAPD patients compared with HD patients, while the reported difference in plasma NT-proBNP and troponin-I may be related to the rapid decline of residual renal function in HD and type of membrane used in the HD dialysis procedure itself.

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Context:Many techniques are used for sedation of colonoscopies. Patient-controlled sedation (PCS) is utilizing many drugs or drug combinations.Aims:The aim of this study is to compare the safety and feasibility of propofol/remifentanil versus propofol/alfentanil given to sedate patients undergoing outpatient colonoscopies through a patient-controlled technique.Settings and Design:Controlled randomized and double-blind study.Materials and Methods:A total of 80 patients were randomly divided into two groups; PA group received a combination of propofol/alfentanil and PR group received propofol/remifentanil combination. Patients were monitored for heart rate (HR), blood pressure (BP), oxygen saturation, and Ramsay sedation scale (RSS). Times of the following events were recorded; initiation of sedation, insertion and removal of the colonoscope, recovery and discharge. Five intervals were calculated; time to sedation, procedure time, postprocedure time, procedure room time, and postanesthesia care unit (PACU) time. Endoscopist and patient satisfaction scores were obtained.Statistical Analysis Used:Unpaired Student's t-test was used to compare between the two groups. Paired Student's t-test was used to compare baseline readings with readings after 30 min of sedation in the same group when needed.Results:Both groups showed slowing of the HR and decrease in mean arterial BP. HR and mean arterial BP were significantly lower 5 and 10 min after initiation of sedation in PR group when compared with PA group. Both HR and mean arterial BP returned to presedation readings 30 min after initiation of sedation in PR group but not in PA group. No differences between the two groups concerning oxygen saturation, RSS, endoscopist and patient satisfaction scores. Postprocedure and PACU times were significantly prolonged in PA group.Conclusion:PCS with either remifentanil/propofol or alfentanil/propofol for patients undergoing outpatient colonoscopy is safe and feasible. Remifentanil/proofol has more beneficial advantages in this setting secondary to its more rapid clearance.

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Objectives: Knowledge of peripheral vascular disease (PVD) risk factors and their modification may impact disease progression and outcome. Our purpose was to determine if there was a difference in patient awareness based on insurance status and what subpopulations benefit most from screening.Methods: 916 asymptomatic patients were screened for carotid stenosis, abdominal aortic aneurysm, and/or PVD. Knowledge about risk factors for vascular diseases were assessed via questionnaires. Insurance status, medications, symptoms of PVD, and past medical history were queried. Data were analyzed with Chi squared and logistic regression, and statistical significance set at p Ͻ 0.05.Results: Patients were mostly female (71.1%), Caucasian (86.1%), Hispanic (85.8%), and uninsured (47.8%). Insurance status was associated with improved knowledge of PVD risk factors including diabetes mellitus (p Ͻ 0.001), hypertension (p ϭ 0.003), and family history (p Ͻ 0.001). Non-Hispanics exhibited better education (diabetes mellitus p Ͻ 0.001, family history p Ͻ 0.001). Feet pallor, coolness, numbness and tingling, and lower extremity claudication correlated with abnormal ABI (p ϭ 0.001, 0.021, 0.028, and 0.001, respectively). Feet pallor and claudication were independent predictors of PVD (OR ϭ 2.70, CI 1.01 -7.23, and OR 3.09, CI 1.21 -7.90, respectively). Additionally, diabetes, hypertension, smoking, history of myocardial infarction, and hyperlipidemia correlated with PVD (p Ͻ 0.001, Ͻ 0.001, ϭ 0.015, 0.013, and Ͻ 0.001, respectively).Conclusions: These data suggest a difference in knowledge of PVD risk factors depending on insurance status. In addition, patients with risk factors such as smoking, diabetes, hypertension and hyperlipidemia are in need of early screening.Objectives: CMI due to MALS is an erratic entity yet it is an imperative trigger of abdominal pain, often arduous to diagnose and challenging to treat. Theories invoking neuro-vascular origin have been proposed.Methods: We appraised our encounter in treating such proviso over 8-year period. Follow-up was done by duplex ultrasound surveillance and clinical assessment at 6-monthly intervals, as well as completion of Quality of Life questionnaires. Mean age was 51 (19-70) years, M:F ratio was 1:9, 4 of 10 patients were smokers but all were none diabetics, mean BMI was 19.4Kg/m2 and mean duration of symptoms prior to surgery was 2.6years. 10 patients were treated for CMI with MAL decompression and CGS. Three had mesenteric reconstruction, Coeliac to SMA, aorta to SMA and SMA to celiac bypass.Results: Mean hospital stay was 48hours. There was no morbidity or mortality. Symptomatic response with resolution of symptoms was seen in all patients, although a sustained weight gain was noted in six patients, all of whom had MAL decompression with CGS but no reconstruction. At a mean of 26 months follow-up, duplex ultrasound showed high velocity in the celiac axis in 50% of patients. However this did not correlate with return of symptoms, with 71% of patients remaining symptom free a...