Evaluating the Likelihood of Use of Bispectral Index Guided Anesthesia as a Strategy to Reduce Postoperative Delirium in Surgical Patients 65 Years of Age or Older

Postoperative delirium (POD) is the most common postoperative complication in the elderly, accounting for approximately $164 billion in costs per year in the United States (Inouye, Westendorp, & Saczynski, 2014, p. 911). This complication occurs in as many as 50% of elderly patients, but can be prevented as much as 40% of the time (Inouye et al., 2014). The use of processed encephalographic monitoring, such as Bispectral Index (BIS) monitoring, to guide anesthetic dosage is the single intraoperative intervention with enough evidence to support it as a recommendation for use to reduce POD (American Geriatrics Society, 2015). There were two parts to this project. The goal of part 1 was to evaluate recent trends in BIS monitor use for patients 65 years of age or older through retrospective chart review. The goal of part 2 was to conduct a voluntary survey to assess anesthesia provider’s knowledge of current recommendations, opinions, barriers to use, and if there are plans for practice change related to BIS monitor use. Data collected during part 1 demonstrated the odds ratio of BIS use in this sample overall 0.078, indicating that the likelihood of BIS being used in this sample was 12.8 times lower than BIS not being used (n=281, p

Peri-operative cardiac morbidity: prediction, prevention and the novel role of B-type natriuretic peptide

Cardiovascular disease is the leading cause of death in surgical patients and because of this a number of strategies have been utilised to attempt to predict the cardiac risk of surgery. Theoretically, accurate pre-operative risk stratification would allow patients at low risk to have their surgery expedited efficiently, whilst those at higher risk could have a change made to their treatment plan such as peri-operative cardiac optimisation or in some cases, modification of the operative procedure. Despite this rationale, no guidelines currently exist in the United Kingdom for the management of the surgical patient at high cardiac risk. This may partly reflect the limited methods of risk stratification currently available. Clinical scoring systems are simple and inexpensive but limited by their predictive value. Trans-thoracic echocardiography provides prognostic information but is inconsistent, adding little to clinical information alone. The most accurate methods of pre-operative cardiac risk prediction at the present time are dobutamine stress echocardiography and dipyridamole thallium scanning. However they are expensive, time consuming and have shown poor positive predictive ability, even in high risk cohorts. Few studies have studied the usefulness of biochemical markers in the prediction of post-operative cardiac events. In particular, no information was available in the literature regarding the role of B-type natriuretic peptide (BNP) in the prediction of cardiac events in non-cardiac surgical patients; despite the fact that its measurement has been shown to be an important prognostic tool in both non-surgical and cardiac surgical cohorts. In this thesis the aim was to determine whether pre-operative BNP concentration related to cardiac outcome following non-cardiac surgery; and also to determine whether measurement of other markers such as C- reactive protein (CRP) and cardiac troponin I (CTnI) would be of benefit in pre-operative cardiac risk stratification. To assess the effectiveness of plasma BNP measurement in the prediction of peri-operative cardiac morbidity a pilot study of 41 patients undergoing vascular surgery was conducted. To ensure that any post-operative rise in CTnI was due to operative stress, this was measured pre-operatively along with CRP. Median pre-operative BNP concentration was significantly higher in patients who suffered a post-operative cardiac event (cardiac death, non-fatal myocardial infarction (MI)) than in those who did not (210 (165-380) pg/ml vs. 34.5 (14-70) pg/ml, p<0.001). On the basis of these results a single-centre, prospective, observational cohort study was performed of all patients undergoing non-cardiac surgery. Of the 149 patients recruited to this study, 15 had a cardiac event. The median BNP in those patients having a cardiac event was more than ten-times higher than in those who did not (351 (127-1034) vs. 30.5 pg/ml (11-79.5), p<0.001). A BNP concentration of 108.5pg/ml was the best performing cut-off value having a sensitivity and a specificity of 87%. Although CTnI had originally been measured to ensure that any post-operative rise was due to operative stress, 3 patients had a pre-operative elevation all of whom underwent lower extremity amputation. The amputation group, and in particular those patients who had a raised pre-operative cTnI were therefore analysed further. Amputation patients in general had a high cardiac event rate (23%); however the outcome in those patients who had a raised pre-operative cTnI was particularly poor with 2 suffering a cardiac death post-operatively and one suffering a non-fatal MI. A pre-operative rise in CTnI was the only significant single predictor of peri-operative cardiac events in patients undergoing amputation (p= 0.009). Pre-operative CRP concentration was measured routinely in vascular patients. The concentration in those who had a cardiac event was significantly higher than those who did not (69 (0-260) vs. 12 (0-285), (p=0.003). The cardiac event rate rose with each logarithmic increment in CRP concentration (0-10mg/l (5.7%); 11-100mg/l (22.4%), >100mg/l (55.6%) (p=0.002). Measurement of CRP was of most potential benefit in patients undergoing aortic aneurysm surgery. In conclusion, this thesis has shown that pre-operative measurement of biochemical markers (BNP, CTnI, and CRP) can allow accurate peri-operative risk stratification. BNP concentration in particular was a sensitive and specific predictor of cardiac outcome. Careful case selection using a combination of clinical assessment and the results of these markers may lead to a reduction in the cardiac event rate

EVERY PARENT MATTERS: REFLECTIONS FROM ENGLAND UPON NEW LABOUR’S PARENT POLICY

In England, until May 2010, the New Labour party had been in power for thirteen years. This paper is a reflection back upon its period in office and its strident policies on parents and families. It questions its stance on parental voice and choice, looks at issues of trust and contract, and considers the idea of parent empowerment in the context of a preference for the middle class that underpinned much of its policy

PEA‐15 (Phosphoprotein Enriched in Astrocytes 15) Is a Protective Mediator in the Vasculature and Is Regulated During Neointimal Hyperplasia

This work was supported by a grant from the Medical Research Council, UK (MR/K012789/1). Additional information can be downloaded from the publisher's websitePeer reviewedPublisher PD

Blocked dihydropteridines as nitric oxide synthase activators

It has been shown that 6-acetyl-7,7-dimethyl-5,6,7,8-tetrahydropteridin-4(3H)-one can act as a competent cofactor for the production of nitric oxide by neuronal nitric oxide synthase (nNOS). More information was sought on the structural features that could contribute to strong binding within the enzyme whilst maintaining a fast electron transfer rate. This study was concerned with expansion at the C2-position of the pteridine scaffold. The evidence suggests that expansion at the C2-position had a deleterious effect with respect to Km and as a consequence electron transfer rate. Unexpectedly, several lines of evidence suggested that a methyl substituent on nitrogen at C2 reduced the electron density in the pyrimidine and dihydropterin rings

Losing your head: Are principals attached to their school?

This article explores the effects on former principals who have undergone involuntary job dissolution. It draws upon a study of 10 former principals who have experienced involuntary job dissolution in England and Australia; however, none of the participants were dismissed. Hour-long, one-to-one interviews were conducted with each participant and key emergent themes analysed. There was a high level of congruence between data from the two countries and key findings were effects on former principals’ physical and emotional health, self-belief, professional identity and finances, plus a sense of loss of power. The effects of these job losses were significant and long-lasting. The analysis positions these results within the established literature on job loss, particularly with regard to Bowlby’s attachment theory. The manner of departure appears to carry substantial meaning and there are implications here for the management of school principals. Attachment theory suggests people undergo physical and emotional loss when separated from loved ones. The participants displayed a sense of grief akin to loss of a significant other. The authors put forward the concept that principalship involves attachment to the school institution as in a love relationship

Identifying patient concerns during consultations in tertiary burns services: development of the Adult Burns Patient Concerns Inventory

ObjectivesIdentifying the issues and concerns that matter most to burns survivors can be challenging. For a number of reasons, but mainly relating to patient empowerment, some of the most pressing concerns patients may have during a clinical encounter may not naturally be the focal point of that encounter. The Patient Concerns Inventory (PCI) is a tried and tested concept initially developed in the field of head and neck cancer that empowers patients during a clinical encounter through provision of a list of prompts that allows patients to self-report concerns prior to consultation. The aim of this study was to develop a PCI for adult burns patients.DesignContent for the PCI was generated from three sources: burns health-related quality of life tools, thematic analysis of one-to-one interviews with 12 adult burns patients and 17 multidisciplinary team (MDT) members. Content was refined using a Delphi consensus technique, with patients and staff members, using SurveyMonkey.SettingWithin outpatient secondary care.ParticipantsTwelve adult burns patients and MDT members from two regional burns centres.ResultsA total of 111 individual items were generated from the three sources. The Delphi process refined the total number of items to 58. The main emergent domains were physical and functional well-being (18 items), psychological, emotional and spiritual well-being (22 items), social care and social well-being (7 items) and treatment-related concerns (11 items).ConclusionsThe Adult Burns Patient Concerns Inventory is a 58-item, holistic prompt list, designed to be used in the outpatient clinic. It offers a new tool in burn care to improve communication between healthcare professionals and patients, empowering them to identify their most pressing concerns and hence deliver a more focused and targeted patient-centred clinical encounter

A comparison of cortical and trabecular bone from C57 Black 6 mice using Raman spectroscopy

Peer reviewedPostprin

Self-consistent massive disks in triaxial dark matter halos

Galactic disks in triaxial dark matter halos become deformed by the elliptical potential in the plane of the disk in such a way as to counteract the halo ellipticity. We develop a technique to calculate the equilibrium configuration of such a disk in the combined disk-halo potential, which is based on the method of Jog (2000) but accounts for the radial variation in both the halo potential and the disk ellipticity. This crucial ingredient results in qualitatively different behavior of the disk: the disk circularizes the potential at small radii, even for a reasonably low disk mass. This effect has important implications for proposals to reconcile cuspy halo density profiles with low surface brightness galaxy rotation curves using halo triaxiality. The disk ellipticities in our models are consistent with observational estimates based on two-dimensional velocity fields and isophotal axis ratios.Comment: ApJ, in pres