The association of chronic pain and postoperative delirium: a prospective observational cohort study.

BACKGROUND: Postoperative delirium (POD) is an acute and common complication after surgery that can increase morbidity and mortality. Few previous studies with inconsistent findings have examined the association of preoperative pain and POD. Our purpose is to investigate the association of preoperative chronic pain and POD. METHODS: This prospective observational cohort study included 200 patients ≥ 18 years scheduled for elective surgery under general anaesthesia in a tertiary care hospital. POD was defined as meeting diagnostic criteria during the study visits (according to delirium screening tests and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition), or by diagnosis of the responsible physicians. Chronic pain was defined as pain lasting six months or longer. Features of chronic pain were assessed with the German Pain Questionnaire, including the Depression Anxiety and Stress Scale-21 (DASS-21). Associations with POD were assessed using logistic regression analysis adjusting for confounding factors. RESULTS: Thirty-nine (22%) out of 176 patients developed POD. Chronic pain was not associated with POD after adjustment for ASA physical status, duration of anesthesia and DASS-21 Anxiety score (Odds ratio [OR], 95%-Confidence Interval [CI], 2.216 [0.968;5.070], P=0.060). A subgroup analysis of chronic pain patients revealed that current pain intensity was higher in patients with POD. CONCLUSIONS: Preoperative chronic pain was no independent predictor for POD. Current pain intensity was higher in chronic pain patients with POD. This indicates that certain features of pain might be influential. Further research is needed to examine different forms of preoperative pain and their possible influence on POD.

Electrical neurostimulation in glaucoma with progressive vision loss.

BACKGROUND: The retrospective study provides real-world evidence for long-term clinical efficacy of electrical optic nerve stimulation (ONS) in glaucoma with progressive vision loss. METHODS: Seventy glaucoma patients (45 to 86 y) with progressive vision loss despite therapeutic reduction of intraocular pressure (IOP) underwent electrical ONS. Closed eyes were separately stimulated by bipolar rectangular pulses with stimulus intensities up to 1.2 mA sufficient to provoke phosphenes. Ten daily stimulation sessions within 2 weeks lasted about 80 min each. Right before ONS at baseline (PRE), vision loss was documented by static threshold perimetry and compared to the same assessment approximately 1 year afterwards (POST). Mean defect (MD) was defined as primary outcome parameter. Perimetries with a reliability factor (RF) of max. 20% were considered. RESULTS: Perimetry follow-up of 101 eyes in 70 patients fulfilled the criterion of a max. 20% RF. Follow-up was performed on average 362.2 days after ONS. MD significantly decreased from PRE 14.0 dB (median) to POST 13.4 dB (p < 0.01). 64 eyes in 49 patients showed constant or reduced MD as compared to baseline (PRE 13.4 dB vs. POST 11.2 dB). In 37 eyes of 30 patients, MD increased from PRE 14.9 dB to POST 15.6 dB. CONCLUSIONS: Innovative treatments that preserve visual function through mechanisms other than lowering IOP are required for glaucoma with progressive vision loss. The present long-term data document progression halt in more than 63% of affected eyes after ONS and, thus, extend existing evidence from clinical trials.

Validation of 3-minute diagnostic interview for CAM-defined Delirium to detect postoperative delirium in the recovery room: A prospective diagnostic study.

BACKGROUND: Recent guidelines on postoperative delirium (POD) recommend POD screening in all patients, using a validated tool, starting in the recovery room. An operationalisation of the Confusion Assessment Method (CAM) criteria, the 3-Minute Diagnostic Interview for CAM-defined Delirium (3D-CAM), has been developed for use in general medical units. OBJECTIVES: The aim of this study was to evaluate 3D-CAM performance in an adult patient population to detect POD in the recovery room. DESIGN: A prospective diagnostic study. SETTING: Recovery room of a tertiary care university hospital in Berlin, Germany, in 2017. PATIENTS: Patients at least 18 years of age undergoing elective surgery. MAIN OUTCOME MEASURES: Patients were subjected to evaluation by blinded investigators using the 3D-CAM and the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5, reference standard). Sensitivity, specificity and positive predictive value (PPV) and negative predictive value (NPV) were analysed for 3D-CAM, in addition to test-retest and inter-rater reliability analyses. RESULTS: Sixteen out of 176 patients (9.1%) developed POD. The 3D-CAM demonstrated strong test performance (specificity 0.88, sensitivity 1.0, area under the curve 0.94, PPV 0.44 and NPV 1.0), with a test-retest reliability of 90% (n = 10) and inter-rater reliability of 80% (n = 10). CONCLUSION: In this diagnostic study, 3D-CAM showed strong performance for detection of POD in the recovery room. Due to the low training requirements, fast application and high sensitivity, it might be particularly appropriate for clinical staff with limited experience in the assessment of POD. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02992717.

[3D-CAM Guideline-Conform Translation for German-Speaking Countries]. / 3D-CAM: Delir-Testinstrument für deutschsprachigen Raum übersetzt.

Postoperative delirium (POD) is an acute change in the mental state with consciousness and attention deficits. It is a common complication after surgical procedures and can have serious consequences. Thus, the evidence- and consensus-based guidelines for POD appeals with the highest recommendation level that patients be regularly screened for delirium in the postoperative phase, from the recovery room to the fifth postoperative day and at least once per shift, using a validated test instrument for the detection of POD. In 2014, Marcantonio et al. published the 3D-CAM (3-Minute Diagnostic Interview for CAM-defined Delirium). In the 3D-CAM, the algorithm of the Confusion Assessment Method (CAM) is maintained by using individual elements that operationalize the evaluation of the criteria. Therefore, it requires less training, be faster to use, and, due to a standardized approach, has less interrater variability than the CAM, whereas the high sensitivity and specificity are maintained. Our goal was to translate the 3D-CAM from English to German, so as to make this instrument available to German-speaking countries. The translation of the 3D-CAM was based on the 2005 published guideline on Translation and Cultural Adaptation of Patient Reported Outcome Measures of the International Society for Pharmacoeconomics and Outcome Research. Three independent forward translations were harmonized to a preliminary translation, which then was translated back into the original language. Original authors reviewed the back translation. According to a cognitive debriefing, the translation was revised and in addition was adapted for use in the recovery room. Due to close contact with the original authors during the translation process, it was possible to ensure that the contents of the test instrument were remained intact during the translation process.

Urbanization and health in developing countries: a systematic review.

BACKGROUND: Future population growth will take place predominantly in cities of the developing world. The impact of urbanization on health is discussed controversially. We review recent research on urban-rural and intra-urban health differences in developing countries and investigate whether a health advantage was found for urban areas. METHODS: We systematically searched the databases JSTOR, PubMed, ScienceDirect and SSRN for studies that compare health status in urban and rural areas. The studies had to examine selected World Health Organization health indicators. RESULTS: Eleven studies of the association between urbanization and the selected health indicators in developing countries met our selection criteria. Urbanization was associated with a lower risk of undernutrition but a higher risk of overweight in children. A lower total fertility rate and lower odds of giving birth were found for urban areas. The association between urbanization and life expectancy was positive but insignificant. Common risk factors for chronic diseases were more prevalent in urban areas. Urban-rural differences in mortality from communicable diseases depended on the disease studied. CONCLUSION: Several health outcomes were correlated with urbanization in developing countries. Urbanization may improve some health problems developing countries face and worsen others. Therefore, urbanization itself should not be embraced as a solution to health problems but should be accompanied by an informed and reactive health policy.