Comparison of Glucose Control by Added Liraglutide to Only Insulin Infusion in Diabetic Patient Undergoing Cardiac Surgery: A Preliminary Randomized?Controlled Trial

Background: Liraglutide, glucagon-like peptide-1 (GLP-1) receptor agonist, has been investigated for safety and effectiveness for blood glucose (BG) control in a surgical setting. However, there are only a few studies specific to cardiac surgery patients. Aims: To primarily compare perioperative 1) BG and 2) glycemic variability (GV) between added liraglutide and only insulin infusion in diabetes mellitus (DM) patients undergoing cardiac surgery. Setting and Design: A randomized control trial was conducted in DM patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). Inclusion criteria were age 20� years and DM Type 2. Material and Methods: The recruited patients were randomly assigned to Group 1 (added liraglutide with insulin infusion) and Group 2 (insulin infusion). Insulin infusion was based on institutional protocol. Point of care testing (POCT) glucose was used for the adjustment of insulin and BG analysis. Continuous glucose monitor (CGM) was for GV analysis (using Standard deviation: SD). Statistics: t?test, Chi?square or Fisher?exact test, or Mann朩hitney U test. Results: Finally, 60 patients were in our study (Group 1 = 32 vs Group 2 = 28). Perioperative mean BG levels of Group 1 were significantly lower than Group 2 with a mean difference of 15.9 mg/dL. Nine patients (18.7% vs 10.7%, P = 0.384) had BG of 60� with mean BGs (109.1 vs 147.9, P = 0.001) in the morning. Thirteen patients (9.4% vs 35.7%, P = 0.025) had BG >180 mg/dL at the 1st operative hour. SDs were increasing, but lower SD of Group 1 were observed at the postoperative period. Mean of SDs at postoperative day 2 were 23.65 vs 32.79 mg/dL, P = 0.018. Conclusions: Liraglutide added with insulin infusion can attenuate perioperative BG and is beneficial in the aspect of lowering GV together with BG at the postoperative period in DM patients. Liraglutide can be applied in cardiac surgery but a rearrangement of time and dosage should be further investigated.

Enhancing physicians’ communication skills is not enough: an approach by Habermas social theories.

Introduction: A high gap of communication between physicians and patients has been widely documented. Based on Habermas, communication problems originally came from systematization and technology, in which these conditions lead physicians to form inappropriate communications called ‘strategic action’ (SA). To avoid communication conflicts, Habermas promotes the ‘communicative action’ (CA) The objective of this study was to prove theoretical conditions of occurrences of SA and CA in physicians’ thoughts. Methods: Samples were collected from in-training physicians at King Chulalongkorn Memorial Hospital. A self-administered, Thai-version, questionnaire was the study tool. The questionnaire was composed of eight scales that were constructed and qualified. A theoretical model of multiple relationships causing SA and CA was tested by path analysis. Results: The total respondents were 173. Analyzed data indicated the theoretical model was valid (RMSEA = 0.000). Conditions that significantly influenced SA were ‘medical ideology (MI)’ (total effect = 0.10), ‘system ideology (SI)’ (total effect = 0.09) and ‘cognitive-instrumental rationality’ (total effect = 0.30). Conditions that significantly influenced CA could not be identified. Based on the theory, ‘morality ideology should influence moral-practical rationality’, but ‘system ideology’ was found to significantly influence instead (path coefficient= 0.25). Discussion: The ‘technocratic ideology’ (MI and SI) together with the cognitive-instrumental rationality was proved to lead physicians’ SA. These findings confirmed 1) the significance of thoughts that base personal actions and 2) an extension of systematization that influenced on moral rationality. Probably, this influence might obstruct the natural moral developments so that CA could not be developed. In other words, systematization facilitates SA. Conclusion: Physicians communications were fundamentally SA because of continuing embedded ‘technocratic ideology’. Therefore, solving physicians’ inappropriate communication should realize the significance of ideology and rationality levels, such as, cessation of embedding ‘technocratic ideology’.

Parecoxib versus tramadol for post-appendectomy pain.

Open uncomplicated appendectomy is known for low to medium degree of postoperative pain and a short hospital stay. Based on multimodal pain therapy, non-opioid analgesics have widely been a part in pain control. Parecoxib and tramadol have advantages over traditional opioids that are causing less nausea or vomiting, respiratory depression and sedation. As a result, the authors aimed to compare parecoxib and tramadol regarding quality of pain control after open appendectomy. Fifty patients, underwent open appendectomy with spinal anesthesia, were randomized to receive either parecoxib or tramadol (n = 25 each). Parecoxib 40 mg and tramadol 50 mg IV were administered twice, when closing the peritoneum and at 12 h later Doses of rescued meperidine for 24 h were recorded. Pain score, sedation, nausea or vomiting and satisfaction scores were assessed at 6, 12 and 24 h after operation. The mean rescued doses of meperidine were 4.6 +/- 10.9 and 18.6 +/- 21.0 mg in parecoxib and tramadol groups respectively (p = 0.005). There was a significantly higher pain score at 24 h (p = 0.01) and sedation score at 6 h (p = 0.003) in the tramadol group. Parecoxib provided a lower pain and sedation scores and lesser meperidine consumption than tramadol for post-appendectomy pain. IMPLICATION: Parecoxib, as a primary analgesic, is better in analgesia and has less sedation than tramadolfor post-appendectomy pain.

Maternal satisfaction to epidural and spinal anesthesia for cesarean section.

BACKGROUND AND OBJECTIVE: The differences between epidural (EA) and spinal (SA) anesthesia that can affect maternal satisfaction are the procedures, quality of anesthesia and postoperative events. Dominantly, postoperative events such as postdural puncture headache, pruritus and nausea or vomiting after spinal anesthesia are claimed to be its disadvantages. However, maternal satisfactory perception to theses two techniques has not been revealed. The authors' purpose was to compare maternal satisfaction regarding the techniques and their outcomes between EA and SA by the developed valid and reliable tool. MATERIAL AND METHOD: Patients were randomly classified into two groups: epidural (Group E, n=56) and spinal (Group S, n = 58). Epidural and spinal anesthesia were administered with bupivacaine, 20 mL 0.5% with 1:200,000 epinephrine combined with two doses of 5 mg morphine and hyperbaric bupivacaine 2.2-2.4 mL 0.5% combined with 0.2 mg morphine respectively. Guidelines for treatment of intraoperative and postoperative events, which might be the confounding factors, were set up. Maternal satisfaction was evaluated by the 11-item, qualified, self-administered questionnaire comprised of 4 common factors. The score of 0-10 Visual analog scale was used to access the degree of satisfaction. Trained personnel performed data collections in the post-anesthesia care unit and ward. The means of the factor and total satisfaction scores were compared between the two groups by Mann Whitney U test. A p-value < 0.05 considered significant. RESULTS: There was no statistical difference in the factor scores between the two groups. The total satisfactory score was 89.48 +/- 9.31 and 90.03 +/- 11.26 in Group E and S respectively. No statistical difference of the total satisfaction score was detected. CONCLUSION: There was no difference in maternal satisfaction regarding to the techniques and the outcomes between EA and SA.

A questionnaire for measuring patient satisfaction to general anesthesia.

BACKGROUND AND OBJECTIVES: Measurement of patient satisfaction to general anesthesia needs a valid and reliable tool to cover all dimensions of satisfaction. However, there is no standard tool in a Thai version for measurement of this satisfaction. The objective of this study was to develop a valid and reliable tool for measurement of patient satisfaction to general anesthesia. METHOD: Review of the medical literature and patients' interviews were performed to generate the ideas and dimensions of satisfaction. Items were generated according to customer satisfaction. The pilot questionnaire was set and verified for content validity by item correlation. One item of low item correlation was deleted. The pilot study was performed by application of the pilot questionnaire to patients to detect problems on processes to derive responses and problems of the questionnaire. Another two items were excluded due to high missing responses. The results of reliability analysis were satisfactory. Revision of the pilot questionnaire was taken eventually into the final questionnaire. Then, the final questionnaire was processed to obtain Cronbach's alpha coefficient at King Chulalongkorn Memorial Hospital. Finally, retest for reliability was taken at Police General Hospital in order to prove its generalization. RESULTS: The constructed final questionnaire composed of ten items. All item correlations were higher than 0.5. Cronbach's alpha coefficients obtained in King Chulalongkorn Memorial Hospital and Police General Hospital were 0.8775 and 0.7571, respectively. CONCLUSION: The developed questionnaire was qualified for both validity and reliability. Also verified for the wide application in another hospital.