Day surgery and general anaesthesia : what makes patients anxious?

For many patients the prospective of undergoing surgery and general anaesthesia is highly anxiety provoking. With the global rise in day surgery and limited nurse/ patient contact, anxiety has become a prominent issue. The aim of the study was to establish the degree of anxiety arising from elective day surgery and general anaesthesia and uncover specific anxiety provoking aspects. Day surgery patients (n=460) completed a questionnaire during recovery at home and return it by post. The majority of patients (85%) were anxious on the day of surgery and 50% desired a detailed level of information. Anaesthetic information provision, catastrophising and imminence of surgery were deemed to be reliable predictors of anxiety. The planned provision of anaesthetic information in advance of the day of surgery, emphasising ‘controlled unconsciousness’, provision of information to help limit catastrophising thoughts and assistance to reduce the impact of ‘waiting’ are recommended for the effective management of anxiety

Nursing knowledge and the expansion of day surgery in the United Kingdom

Background: The amount of surgery undertaken within United Kingdom Day Surgery Units has risen considerably over the past 15–20 years. Throughout this pioneering era, nursing roles and responsibilities within the modern surgical environment have developed although have largely shadowed medical advances. Evidence based nursing knowledge appears to have contributed very little to the recent success of day surgery. This may be due, in part, to the lack of attention given to modern surgical practices within current pre-registration nurse education programmes of study. Aim: The aim of this educational audit was to evaluate the consideration given to modern surgical practices in the programmes of study of recently qualified staff nurses employed within Day Surgery Units in the United Kingdom in order to gauge the extent of the challenge. Method: A postal audit was designed and sent to n = 247 Day Surgery Units. The audit was intended to elicit information from the staff nurses regarding their experiences of modern, elective day surgery during their nurse education programmes of study. Results: Two hundred and seventy seven staff nurses responded revealing that the level of attention to day surgery practices within pre-registration programmes was extremely low. The professions’ actual and potential theoretical contribution to modern surgical practices was virtually nil. Their experience of pre-operative nursing intervention appeared mainly to involve the teaching of traditional surgical in-patients nursing skills. The inclusion of modern surgical practices into the theoretical assignments within the programmes of study was very limited. Once qualified, the vast majority of staff nurses experienced no additional formal education for their new role. Conclusions: The results are discussed in relation to the re-focusing of pre-registration nurse education, changing clinical roles and the future of nursing within the modern surgical arena

Patient anxiety and modern elective surgery: a literature review

Medical advances have led to a considerable rise in the level of elective surgery undertaken as day-case surgery and with minimal hospital stay. However, amid such advances, preoperative psychological care has remained relatively static. A considerable number of patients are very anxious prior to elective surgery and little formal care is undertaken to address this major issue. A review of the literature from 1990 to 2002 was therefore undertaken in order to assess the present level of knowledge and interventions concerning patient anxiety when undergoing modern, intermediate surgical intervention. Thirty-four studies embracing data from 3754 patients undergoing both inpatient and day-case procedures were reviewed. Three main themes emerged -causes of anxiety, clinical concerns and measurement, and anxiety management. Each theme is discussed alongside details extracted from the relevant studies. Finally, the main issues arising are summarized and future research challenges identified

Patient anxiety and conscious surgery

The amount of surgery undertaken on the conscious patient is increasing. However, many patients are anxious and resistant to such surgery. Patients (n=214) were surveyed to determine their related apprehensions. Being awake, feeling or seeing the body cut open and experiencing pain all increased anxiety. The potential for insufficient information provision was also a source of concern. Formal management of intra-operative apprehension may help limit anxiety and expel apparent misapprehensions

Day surgery nurses' selection of patient pre-operative information

Aims and Objectives: To determine selection and delivery of pre-operative verbal information deemed important by nurses to relay to patients immediately prior to day surgery. Background: Elective day-case surgery is expanding, patient turnover is high and nurse/ patient contact limited. In the brief time-frame available, nurses must select and precisely deliver information to patients, provide answers to questions and gain compliance to ensure a sustained, co-ordinated patient throughput. Concise information selection is therefore necessary especially given continued day surgery expansion. Study Design: Electronic questionnaire. Methods: A survey investigating nurses’ choice of patient information prior to surgery was distributed throughout the United Kingdom via email addresses listed on the British Association of Day Surgery member’s website (Jan 2015 - Apr 2015). Results: Participants were requested to undertake the survey within 2 to 3 weeks with n=137 completed giving a 44% response rate. Verbal information deemed most important by nurses pre-operatively was checking fasting time, information about procedure/ operation, checking medication, ensuring presence of medical records/ test results and medical investigations checks concluded. To a lesser extent was theatre environment information, procedure/ operation start time and possible time to discharge. Significant differences were established between perceived importance of information and information delivery concerning the procedure/ operation and anaesthesia details. Conclusion: Nurses working with competing demands and frequent interruptions, prioritised patient safety information. Although providing technical details during time-limited encounters, efforts were made to individualise provision. A more formal plan of verbal information provision could help ease nurses’ cognitive workload and enhance patient satisfaction. Relevance to clinical practice: This study provides evidence that verbal information provided immediately prior to day surgery may vary with experience. Nurse educators and managers may need to provide greater guidance for such complex care settings as delivery of increasingly technical details during brief encounters is gaining increasing priority

Cranial integration in the ring-necked parakeet, Psittacula krameri (Psittaciformes: Psittaculidae)

The study of integration and modularity aims to describe the organization of components that make up organisms, and the evolutionary, developmental and functional relationships among them. Both have been studied at the interspecific (evolutionary) and intraspecific (phenotypic and ontogenetic) levels to different degrees across various clades. Although evolutionary modularity and integration are well-characterized across birds, knowledge of intraspecific patterns is lacking. Here, we use a high-density, three-dimensional geometric morphometric approach to investigate patterns of integration and modularity in Psittacula krameri, a highly successful invasive parrot species that exhibits the derived vertical palate and cranio-facial hinge of the Psittaciformes. Showing a pattern of nine distinct cranial modules, our results support findings from recent research that uses similar methods to investigate interspecific integration in birds. Allometry is not a significant influence on cranial shape variation within this species; however, within-module integration is significantly negatively correlated with disparity, with high variation concentrated in the weakly integrated rostrum, palate and vault modules. As previous studies have demonstrated differences in beak shape between invasive and native populations, variation in the weakly integrated palate and rostrum may have facilitated evolutionary change in these parts of the skull, contributing to the ring-necked parakeet’s success as an invasive species

The structure of tagetitoxin

Based on detailed analysis of newly acquired NMR data, we show that the previously revised structure of tagetitoxin is incorrect. A new structure of tagetitoxin is proposed which is consistent with the NMR and MS data

Prospectively Collected Characteristics of Adult Patients, Their Consultations and Outcomes as They Report Breathlessness When Presenting to General Practice in Australia

Introduction:Breathlessness is a subjective sensation, so understanding its impacts requires patients' reports, including prospective patient-defined breathlessness as a reason for presenting to general practitioners (GP).The aim of this study was to define the prevalence of breathlessness as a reason for GP consultations while defining the clinico-demographic factors of these patients and the characteristics and outcomes of those consultations.Methods:Using nine years of the Family Medicine Research Centre database of 100 consecutive encounters from 1,000 practices annually, the patient-defined reason for encounter 'breathlessness' was explored using prospectively collected data in people ≥18 years with clinical data coded using the International Classification for Primary Care V2. Dichotomous variables were analysed using chi square and 95% confidence intervals calculated using Kish's formula for a single stage clustered design.Results:Of all the 755,729 consultations collected over a nine year period from 1 April, 2000, 7255 included breathlessness as a reason for encounter (0.96%; 95% CI 0.93 to 0.99) most frequently attributed to chronic obstructive pulmonary disease. Only 48.3% of GPs saw someone reporting breathlessness. The proportion of consultations with breathlessness increased with age. Breathlessness trebled the likelihood that the consultation occurred in the community rather than the consulting room (p<0.0001) and increased 2.5 fold the likelihood of urgent referral to hospital (p<0.0001). Of those with breathlessness, 12% had undiagnosed breathlessness at the end of the consultation (873/7255) with higher likelihood of being younger females.Discussion:Breathlessness is a prevalent symptom in general practitioner. Such prevalence enables future research focused on understanding the temporal pattern of breathlessness and the longitudinal care offered to, and outcomes for these patients, including those who leave the consultation without a diagnosis. © 2013 Currow et al

Redox linked flavin sites in extracellular decaheme proteins involved in microbe-mineral electron transfer

Extracellular microbe-mineral electron transfer is a major driving force for the oxidation of organic carbon in many subsurface environments. Extracellular multi-heme cytochromes of the Shewenella genus play a major role in this process but the mechanism of electron exchange at the interface between cytochrome and acceptor is widely debated. The 1.8 Å x-ray crystal structure of the decaheme MtrC revealed a highly conserved CX8C disulfide that, when substituted for AX8A, severely compromised the ability of S. oneidensis to grow under aerobic conditions. Reductive cleavage of the disulfide in the presence of flavin mononucleotide (FMN) resulted in the reversible formation of a stable flavocytochrome. Similar results were also observed with other decaheme cytochromes, OmcA, MtrF and UndA. The data suggest that these decaheme cytochromes can transition between highly reactive flavocytochromes or less reactive cytochromes, and that this transition is controlled by a redox active disulfide that responds to the presence of oxygen

Daily emollient during infancy for prevention of eczema: the BEEP randomised controlled trial.

BACKGROUND: Skin barrier dysfunction precedes eczema development. We tested whether daily use of emollient in the first year could prevent eczema in high-risk children. METHODS: We did a multicentre, pragmatic, parallel-group, randomised controlled trial in 12 hospitals and four primary care sites across the UK. Families were approached via antenatal or postnatal services for recruitment of term infants (at least 37 weeks' gestation) at high risk of developing eczema (ie, at least one first-degree relative with parent-reported eczema, allergic rhinitis, or asthma, diagnosed by a doctor). Term newborns with a family history of atopic disease were randomly assigned (1:1) to application of emollient daily (either Diprobase cream or DoubleBase gel) for the first year plus standard skin-care advice (emollient group) or standard skin-care advice only (control group). The randomisation schedule was created using computer-generated code (stratified by recruiting centre and number of first-degree relatives with atopic disease) and participants were assigned to groups using an internet-based randomisation system. The primary outcome was eczema at age 2 years (defined by UK working party criteria) with analysis as randomised regardless of adherence to allocation for participants with outcome data collected, and adjusting for stratification variables. This trial is registered with ISRCTN, ISRCTN21528841. Data collection for long-term follow-up is ongoing, but the trial is closed to recruitment. FINDINGS: 1394 newborns were randomly assigned to study groups between Nov 19, 2014, and Nov 18, 2016; 693 were assigned to the emollient group and 701 to the control group. Adherence in the emollient group was 88% (466 of 532) at 3 months, 82% (427 of 519) at 6 months, and 74% (375 of 506) at 12 months in those with complete questionnaire data. At age 2 years, eczema was present in 139 (23%) of 598 infants with outcome data collected in the emollient group and 150 (25%) of 612 infants in the control group (adjusted relative risk 0·95 [95% CI 0·78 to 1·16], p=0·61; adjusted risk difference -1·2% [-5·9 to 3·6]). Other eczema definitions supported the results of the primary analysis. Mean number of skin infections per child in year 1 was 0·23 (SD 0·68) in the emollient group versus 0·15 (0·46) in the control group; adjusted incidence rate ratio 1·55 (95% CI 1·15 to 2·09). INTERPRETATION: We found no evidence that daily emollient during the first year of life prevents eczema in high-risk children and some evidence to suggest an increased risk of skin infections. Our study shows that families with eczema, asthma, or allergic rhinitis should not use daily emollients to try and prevent eczema in their newborn. FUNDING: National Institute for Health Research Health Technology Assessment