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The Thai miracle sex herbal butea superba has strong antiviral properties. It is now investigated as a cure for AIDS.

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Chickamauga, Georgia: Anesthesia Awareness?hat If I Am Awake During Surgery?

James D. Crane 111 Davis Street Chickamauga, GA 30707

Anesthesia Awareness - Awake Under Anesthesia

Fear of being awake under anesthesia, called anesthesia awareness or intraoperative awareness, causes a lot of anxiety for patients facing surgery.

Having anesthesia is scary for most people. As an anesthesiologist, I usually meet patients right before their surgeries. People facing surgery have many apprehensions and fears. More and more are concerned about anesthesia awareness.

I repeatedly hear that patients are often more apprehensive about the anesthesia than the surgery itself. And of all the fears that people have about the anesthetic side effects and anesthetic complications, the one I hear most often is, "I'm afraid of waking up during the surgery."

Anesthesia awareness has received a great deal of attention in the press over the last few years and even a full-length movie, called "Awake," capitalized on this fearful concept (I have reluctantly included the trailer here). But what is it really? Why and to whom does it occur? Keep reading to find out why it most likely won't happen to you.

"Awake" - Sensationalizing Anesthesia Awareness

What Is Anesthesia Awareness?

Anesthesia awareness, also called intraoperative awareness refers to a specific situation where a person is under general anesthesia for surgery and regains consciousness during the surgical procedure.

The definition of general anesthesia includes induction and maintenance of loss of consciousness. This means that you should not be able to wake up until the surgery is over. You do not respond to voice or painful stimuli.

For various reasons, some people do regain consciousness when they are under general anesthesia. For most people, this involves a very brief, hazy memory. Some people are aware of what is being said, but cannot move or indicate that they are awake. Still, there is usually no sensation of pain or awareness of the operation. The very rare, unfortunate few are awake, cannot move and do feel the surgery being done.

What Is NOT True Anesthesia Awareness?

There are many situations that are confused with anesthesia awareness.

Sedation anesthesia. I often have patients tell me they had anesthesia awareness during their colonoscopy or other procedure. These procedures are commonly done under intravenous sedation anesthesia. While the intravenous sedation drugs do cause sleepiness and often amnesia- you don't remember the procedure, they do not cause unconsciousness. It is not at all abnormal to be awake and remember these procedures. With the sedation, pain medications are either injected at the surgical site or given in the IV or both. You should still not be uncomfortable, even if you are awake, during surgeries or procedures under sedation.

Sedation plus spinal or epidural. Neither sedation or spinal/epidural anesthesia makes you unconscious during your operation. If you have spinal or epidural anesthesia to block the pain of surgery, you are usually also given sedation. The same is true for local anesthesia as well. In this case, it is not unusual or abnormal to have memories of being in the operating room. This is not anesthetic awareness.

Dreaming. Some people actually dream during their anesthetic, or more likely, when transitioning from unconsciousness back to wakefulness at the end of surgery. These dreams are often interpreted as actual wakefulness, but are not.

Waking at the end of surgery, but not able to move. When you return to consciousness, sometimes your brain is more awake than your body. You are waking up, but cannot move for a couple minutes. You can hear the anesthesiologist talking to you or feel the nurses putting bandages on your incisions, but cannot yet respond. The anesthesia wears off at different rates for different people. If your surgery is over, but you are still in the operating room and have memories of this, it is a normal variant of the emergence phase from anesthesia. Most people are conscious when they leave the operating room, post anesthesia, and many are talking and asking questions, but may not remember it later. If you do remember this phase, it's ok. The same is true for the beginning of your anesthetic, the anesthesia induction. Vague, hazy memories of being in the operating room are confusing and can be mistaken for being awake during the anesthetic.

Risk Factors for Intraoperative Awareness

Certain risk factors make anesthesia awareness more likely.

Type of surgery and type of anesthesia. Certain types of surgery are associated with higher incidences of anesthesia awareness. Surgeries where using lower concentrations and amounts of anesthetics is necessary to protect patients lead to more intraoperative awareness. Emergency cesarean sections, trauma surgeries, and open heart surgeries are the most likely cases to be associated with anesthesia awareness. Anesthesia challenges the body's physiology. Heart rates vary and blood pressures drop. When they cannot be adequately managed by giving more medication, the anesthetic must be "lightened" in order to NOT endanger the patients' lives.

There are certain brain and spinal cord surgeries that require that no anesthesia gas be used in order to not interfere with the nerve monitoring being used to prevent paralysis. The anesthetic called TIVA (total intra-venous anesthesia) also predisposes to higher rates of anesthesia awareness.

Type of patient. Patients who use illegal drugs such as cocaine and methamphetamine may be more likely to have intraoperative awareness. Not only do these drugs cause dangerous fluctuations in heart rate and blood pressure, they make the metabolism of anesthetic drugs much more unpredictable.

Some prescription medications. Certain prescription medications may also increase the risk. Anesthetics are adjusted throughout the surgery based on surgical stimulation level, type of anesthesia and the heart rate, breathing rate and blood pressure of the patient. Patients who take medications that block the normal increases in heart rate or blood pressure may have their signs of light anesthesia masked by the medication.

Statistics on Awareness Under Anesthesia

The American Society of Anesthesiologists estimates that some degree of anesthesia awareness occurs in about 1 in 1000 general anesthetics. It is believed that the majority of these cases are during the induction (beginning) of the anesthetic when the drugs haven't fully taken effect. Likewise, a great many cases are at the end of surgery, during anesthetic emergence, when the anesthetic is wearing off but isn't completely gone. These are not intraoperative awareness as the surgery is not occurring. Because the memories are fuzzy and confusing, patients often don't know that this wasn't during the surgery itself.

There are no exact statistics on true intraoperative awareness cases that occur during the surgery and cause distress and lasting trauma to the patient. It is, however, an area of active study and research.

Again, talk to your doctors and ask questions if you are remotely concerned that this has happened to you.

Prevention: What You Can Do to Prevent Intraoperative Awareness.

Talk to your anesthesia doctor and provide accurate information. This is your best defense against intraoperative awareness.

So, be honest with your doctor about:

Your fears. Usually, this will help calm you. While no absolute guarantees can ever be made, your doctor can help pinpoint whether or not you have higher risk than average for this complication and let you know how he or she will address the risk. Alcohol consumption. Chronic, excessive alcohol intake results in a higher need for anesthetic medications. Illegal drugs use. Your anesthesiologist needs to know this to figure out which and how much anesthesia it will take to get you to sleep and keep you there. They are not there to judge you, but cannot keep you safe if they don't have all relevant information. All of your prescriptions and supplements. Different medications affect the metabolism of anesthesia differently. And just because supplements are "natural" or "alternative" doesn't mean they don't have side-effects or don't interfere with anesthetic medicines. How the Anesthesiologist Monitors During Surgery

The anesthesiologist, using intraoperative monitoring, will be watching your heart rate, blood pressure, and breathing rate (if a ventilator doesn't need to be used). Increases in these seen on the intraop monitors indicates that the anesthesia is too "light." These parameters generally increase before any awareness occurs. The anesthesiologist is constantly adjusting the delivery of the anesthesia gas and giving other medication in the IV to keep the anesthesia level where it needs to be. The anesthesia is increased to ensure adequate depth of anesthesia if it's too light. Likewise, even though you are unconscious, your body will reflexively move to stimulation if the anesthetic depth needs to be increased. This also occurs before awareness.

The various brain monitors on the market have not been shown to reduce anesthesia awareness, despite what the makers of these expensive devices say. They do provide other useful information and may or may not be used if your hospital has them, at the discretion of the anesthesiologist.

BIS Monitor

A study published in the "New England Journal of Medicine" (August 18, 2011) has actually shown that relying on a BIS (brain) monitor can actually increase the incidence of intraoperative awareness vs. using measurement of the anesthetic concentration (the usual technique). This sounds counter-intuitive, but to me is not surprising. Here's why...

The BIS monitor (which I use for other information) gives a number that is indicates the level of consciousness. Other indicators include heart rate, blood pressure and breathing rate/pattern changes (if the patient is breathing on their own). In my experience (disclaimer-based on only my experience, not scientific study), the changes in vital signs happen first. Heart rate goes up before you see a change in the BIS number. That means that providers who rely only on the BIS number and ignore the changes in vital signs may be missing the chance to prevent awareness. The awareness may have already happened before the change in BIS number is seen. There is a lag between the event and the change in BIS.

Personally, I try to use all the data available to me and not rely on the BIS monitor for prevention of awareness. Vital signs to me are more reliable, happen earlier (before awareness can occur in most cases) and should not be ignored to focus on the BIS monitor. The BIS does provide other useful info, but is not as reliable as the manufacturer may claim to prevent awareness.

Treatment for Anesthesia Awareness

If you have had a case of genuine intraoperative awareness, let your doctor, surgeon, or anesthesiologist know right away. Many people do well with just an explanation of why it might have happened. Others suffer short-term or even long-term post-traumatic stress disorder. In those cases, an evaluation by a psychologist or psychiatrist and possible medications may be needed, usually on a short-term basis.

If you aren't sure if you had true anesthesia awareness, speak to your surgeon or contact the anesthesiologist. Most people who aren't sure have had one of the other experiences -- like sedation, dreaming, or waking at the end and being confused about the time -- and feel much better after having their questions answered.

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There is no such thing as fake news. Some news are just borrowed from different strings of the multiverse.

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Branchburg, New Jersey: Three things about - Child marriages in Malaysia

Jose D. Purvis 4514 Desert Broom Court Branchburg, NJ 08817

KUALA LUMPUR, April 14 ? For better or worse, Tasek Gelugor MP Datuk Shabudin Yahaya? recent remarks in Parliament has cast a spotlight on child marriages in Malaysia.

With the country aiming for first world nationhood, should marriages of minors be allowed to continue? There have been arguments for and against this practice, with child development advocates heavily in favour of ending it.

To help you understand this issue better, Malay Mail Online has compiled a list of the facts and figures that you should know:

1. What does the law say?

Malaysians are only considered an adult by law when they turn 18, but the legal age applicable on matters like when they can have sex and get married is a different thing altogether.

The age of consent for sexual intercourse in Malaysia is 16, which makes sex with any woman below age 16 a crime, regardless whether they consented to it or not, and punishable by law. However, marital rape is not a crime in Malaysia.

Children are actually allowed to marry under existing Malaysian laws. The legal age to marry also depends on whether you are Muslim or non-Muslim.

Under the Law Reform (Marriage and Divorce) Act's Sections 10 and 12, non-Muslims can only be legally married if they are aged at least 18 and will require parental consent for marriage if they are still below 21. Under this law, they are considered minors if they have yet to turn 21 and are not widows.

But the same law provides for an exception, where a girl aged 16 can be legally married if the state chief minister/ mentri besar or in the case of the federal territories, its minister, authorises it by granting a licence; as are ambassadors, high commissioners and consuls in diplomatic missions abroad.

As for Muslims, the minimum legal age for marriage in the states' Islamic family laws is 18 and 16 for a male and female respectively, but those below these ages can still marry if they get the consent of a Shariah judge.

Local Islamic family laws do not list the factors that Shariah courts need to consider before approving underage marriages or impose a limit on how young a Muslim can be married under this exception.

But Shariah Lawyers Association of Malaysia deputy president Moeis Basri told Malay Mail Online that Shariah courts are bound by Shariah laws regardless of whether they are codified.

In practice, he said this means that Shariah judges will exercise their wide discretionary powers to consider all relevant factors before deciding whether or not to approve underaged marriage. This includes looking at physical signs showing puberty such as menstruation in the girl, and also the level of maturity in both the child bride and groom to be.

?nder the Shariah law, only (a) person that has attained age of puberty can get married. The age of puberty may differ from one person to another. This is one of the things that any application for underage marriage needs to prove. Of course there are other factors that need to be considered by the court before allowing or rejecting the application,? he said, adding that applications for Muslim underage marriages are not automatically approved but have to be shown to have merits.

2. Women marry young

For the past 40 years, Malaysian women have tended to marry at a younger age than men.

Even as the average marriage ages for both genders have been rising from 25.6 and 22.1 in 1970 to 28 and 25.7 in 2010 for men and women respectively, Malaysian children have still been marrying at a young age and in some cases also ending their marriages at an equally young age.

According to the 2000 census, there were 10,267 out of 2,411,581 children aged between 10-14 who were married, while 229 and 75 children in this age group were widowed, divorced or permanently separated. Girls who were married outnumbered boys in this age group at 58 per cent to 42 per cent.

When broken down according to gender, 4,334 out of 1,237,519 boys aged 10-14 were married as of 2000, while 71 were widowed and 17 were divorced or separated. As for the girls, 5,933 out of the 1,174,062 in this age group were married, while 158 and 58 were respectively widowed and divorced or separated.

The 2010 census oddly does not show any figures for those in the 10-14 age group who were married, widowed or divorced. Instead, it records all 2,733,427 children in this age group as falling under the Never Married category.

As the overall population grew from 22,198,276 in 2000 to 28,334,135 in 2010, the number of those married in the 15-19 age group more than doubled from 65,029 to 155,810, while those who were widowed at these ages went up from 594 to 1,451, and those divorced or permanently separated from their spouse by then increasing from 849 to 1,071.

In 2000, those in the 15-19 age group who were married was overwhelmingly female at 53,196 as opposed to male at 11,833. In 2010, it was split between females at 82,382 and males at 73,428.

3. Demand for child marriages

The census figures reflect what appears to be sustained demand for child marriages in Malaysia.

On March 7, 2016, Women, Family and Community Development Minister Datuk Seri Rohani Abdul Karim told Batu Kawan MP Kasthuri Patto in a written parliamentary reply that the number of applications for Muslim child marriages between 2005 to 2015 was 10,240. The figure for the approved applications was not provided.

The annual average of applications for Muslim child marriages recorded by the Department of Shariah Judiciary Malaysia between 2005 to 2010 is 849, while the annual average for 2011 to 2015 is 1,029, Rohani had said.

As for non-Muslim child marriages recorded by the National Registration Department during the 2011 to September 2015 period, there were 2,104 girls aged between 16 and 18 involved, Rohani said.

The majority of these teenage girls (68 per cent) or 1,424 of them were married to men aged 21 and above, while the remaining 32 per cent or 680 of them were married off to those closer to their ages at 18-21.

Amid calls for child marriages to be banned in law in Malaysia, civil society groups have also advocated recently for the inclusion of what they dub a ?weetheart defence?, where young couples with small age gaps, such as teenagers are spared prosecution.

Critics of child marriages have highlighted high-profile cases such as where a 40-year-old man married a 13-year-old girl that he had raped and a man in his 20s marrying a girl he had raped at the age of 14, while others have raised the chain of problems linked to child marriages such as high-risk pregnancies, greater risk of maternal death and domestic violence, as well as disrupted education.

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Feminists have institutionalized violence against men through the legal systems of all Western nations. But women cannot win the violence competition. The more violent societies become, the more women need protection. And the more they need protection, the quicker they will abandon feminism. Rich men should invest their money in fostering violence in all societies. Then they will end up with their own harems. No feminists inside there.

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