Definitions of anaesthetic technique and the implications for clinical research

Anaesthesia provision challenges in public hospitals of Pakistan's Punjab province: a qualitative study of expert perspectives

OBJECTIVES

Anaesthesia delivery in Pakistan remains limited to conventional intraoperative procedures, with research showing ongoing challenges in quality and resourcing. We aimed to identify systemic challenges in the delivery of the WHO-World Federation of Societies of Anaesthesiologists' (WHO-WFSA) 'highly recommended' standards of quality anaesthesia services for surgical support in Pakistan's Punjab province.

STUDY DESIGN AND SETTING

This single-method qualitative study included 22 semistructured interviews with purposively selected anaesthesia system experts in Punjab province, including heads of teaching hospital anaesthesia departments, healthcare commission (HCC) representatives and health department officials. We analysed data thematically, using deductive and inductive coding.

PARTICIPANTS

10 participants worked as anaesthesia department heads of teaching hospitals across Punjab, 5 worked for the HCC and 7 worked for the health department. All were selected purposively and had at least 5 years of experience working as head of department or serving in legislative departments.

RESULTS

We identified three themes experienced as major challenges within the specialty, namely anaesthetist recruitment and retention, quality of care and in-service training, and discrepancies between specialities. Findings indicated that workforce shortages and maldistribution, insufficient in-service training and standards, inadequate equipment maintenance and lack of anaesthesia representation in decision-making compromised anaesthesia provision quality and safety.

CONCLUSIONS

Improving anaesthesia provision in Punjab would require increasing physician and non-physician anaesthetist numbers and rotation to peripheral postings, strengthening training quality and ensuring availability of WFSA-specified essential equipment and supplies. To achieve essential anaesthesia provision standards, policy interventions are needed to, for example, balance anaesthesiologist and surgeon/obstetrician-gynaecologist numbers, require that anaesthesiology postgraduates work a few years in-country (eg, scholarship bonds), ensure in-service training attendance for skills updates and implement quality assurance standards for equipment and supplies.

Development of a definition for real-world evidence using the Jandhyala method for observing consensus opinion among medical affairs pharmaceutical physicians

OBJECTIVE

Low rates of inclusion of real-world evidence (RWE) during regulation may arise from lack of clarity and consensus on its definition. A conceptually mature definition of RWE may have pragmatic utility, increasing its inclusion during regulation. The aim was to develop a definition of RWE to promote inclusion in regulatory submissions and assess its conceptual maturity.

METHODS

Thirteen medical affairs pharmaceutical physicians completed two qualitative online surveys to generate items needed in a definition of RWE. Items that reached a consensus index of > 50% (CI > = 0.51) were retained in the final definition. The maturity of the definition was assessed using concept analysis.

RESULTS

After attrition, 11 participants completed the study and generated 18 items to be included in a definition of RWE. All items reached the consensus threshold and were included. The definition was conceptually mature on three of the four dimensions: the potential for a consensual definition across stakeholders, a description of its characteristics and clear preconditions and outcomes. Further research is needed to delineate the boundaries of RWE.

CONCLUSIONS

A definition of RWE was generated that may increase its inclusion during medicines regulation, especially with further refinement from regulators and other stakeholders.

Development of a Definition for Medical Affairs Using the Jandhyala Method for Observing Consensus Opinion Among Medical Affairs Pharmaceutical Physicians

Background: There is currently no standard definition of medical affairs, despite its increasing importance to the pharmaceutical industry. The evolution of medical affairs necessitated the development of a standardised definition to guide policy and practice to ensure that patients' interests remain central amid shifts that have, in the past, created fertile ground for ethical violations. Objectives: The aim of this study was to use an empirical method to observe a consensus of expert opinion on the definition of medical affairs to guide policy and practice within this function. Methods: In total, 11 medical affairs pharmaceutical physicians (MAPPs) completed a qualitative online survey to identify a list of key items to define medical affairs using the Jandhyala method for generating a consensus of expert opinion. Responses were coded and scored, and aggregated responses were presented to participants in a consensus round. Participants rated their agreement with each item on a 5-point Likert scale from strongly agree to strongly disagree. Indicators that reached a consensus index of >50% (CI > = 0.51) were retained. Items were categorised per previously defined medical affairs functions to determine the scope of the definition. A comparative content analysis using a previous definition identified in the literature was conducted to determine the utility of the definition generated here. Results: In total, 11 MAPPs generated 15 unique items to define medical affairs. Item awareness indices ranged from 0.24 ('communication/education') to 1.00 ('design/strategy'). All items had a CI of more than 0.5 and were included in the final definition. All items could be categorised per previously defined medical affairs functions. Comparative content analysis showed that our definition varied in four ways: the designation of medical affairs as a medical specialty (and its primary aim, therefore, is to protect patients), the leadership of medical affairs in medicine adoption, the generation of real-world evidence and the specification of distinct stakeholders who benefit from medical affairs. Conclusion: A standard definition of medical affairs that incorporates the key principles of medical affairs as a medical specialty that leads medicine adoption and generates real-world evidence for specific stakeholders may protect and further the interests of patients by governing practice and policy.

A systematic review of reporting quality for anaesthetic interventions in randomised controlled trials

Interventions from randomised controlled trials can only be replicated if they are reported in sufficient detail. The results of trials can only be confidently interpreted if the delivery of the intervention was systematic and the protocol adhered to. We systematically reviewed trials of anaesthetic interventions published in 12 journals from January 2016 to September 2019. We assessed the detail with which interventions were reported, using the Consolidated Standards of Reporting Trials statement for non-pharmacological treatments. We analysed 162 interventions reported by 78 trials in 18,675 participants. Detail sufficiently precise to replicate the intervention was reported for 111 (69%) interventions. Intervention standardisation was reported for 135 (83%) out of the 162 interventions, and protocol adherence was reported for 20 (12%) interventions. Sixty (77%) out of the 78 trials reported the administrative context in which interventions were delivered and 36 (46%) trials detailed the expertise of the practitioners. We conclude that bespoke reporting tools should be developed for anaesthetic interventions and interventions in other areas such as critical care.

MiR-191 downregulation protects against isoflurane-induced neurotoxicity through targeting BDNF

BACKGROUND

Isoflurane inhalation can cause nerve damage, and miR-191 is abnormally expressed in nerve crush injuries. This study aimed to explore the effect of miR-191 on isoflurane-induced cognition impairment and neurotoxicity in vivo and in vitro, as well as its potential mechanism.

METHODS

Sprague-Dawley male rats and primary hippocampal neurons were applied and exposed to 2% isoflurane. The level of miR-191 was regulated both in vitro and in vivo to investigate the role of miR-191 in isoflurane-induced neurotoxicity. Morris water maze assay was used to evaluate the neurological function of rats. The level of miR-191 was measured by qRT-PCR. CCK-8 assay and Flow cytometry were applied to detect the cell viability and apoptosis. Dual luciferase reporter gene detection was used for the target gene analysis.

RESULTS

miR-191 was up-regulated in the hippocampal tissues of rats exposed to isoflurane. Downregulation of miR-191 ameliorated isoflurane-induced cognition impairment, including the increase of the neurological score and the escape latency, and the decrease of the time spent in the original quadrant for the rats exposed to isoflurane. Isoflurane exposure inhibited hippocampal neuron viability and promoted cell apoptosis, which was reversed by down-regulation of miR-191. BDNF is a target gene of miR-191.

CONCLUSIONS

Isoflurane causes some neurotoxic effect which is mediated through miR-191 abnormal expression targeting BDNF. Downregulation of miR-191 has a protective role against isoflurane-induced neurotoxicity, regulates the vitality and slows down neuronal cell apoptosis.

Scoping review of mode of anaesthesia in emergency surgery

BACKGROUND

Emergency surgery encompasses more than 50 per cent of the surgical workload; however, research efforts are disproportionally low. The mode of anaesthesia used during emergency surgery may affect outcomes, but the extent of research and the impact of the different modes of anaesthesia used are unclear.

METHODS

MEDLINE and Embase were searched using scoping review methodology with a rapid systematic search strategy, identifying any study comparing locoregional (local, nerve block, subarachnoid, epidural) anaesthesia with general anaesthesia. All studies describing outcomes of emergency surgery with differing modes of anaesthesia were identified. Excluded were: studies published before 2003, studies enrolling patients aged less than 18 years and studies using sedation only.

RESULTS

Forty-two studies were identified, describing 11 surgical procedures. Most publications were retrospective cohort studies (32). A very broad range of clinical and patient-reported outcomes were described, with wide variation in the outcomes reported in different studies.

CONCLUSION

Reporting of mode of anaesthesia is inconsistent across different procedures and is often absent. There is a need for directed research efforts to improve the reporting standards of anaesthesia interventions, to understand the role of different modes of anaesthesia in specific emergency surgical procedures, and to standardize outcome reporting using core outcome sets.

Protocol for a systematic review of reporting standards of anaesthetic interventions in randomised controlled trials

INTRODUCTION

There is significant variation in how anaesthesia is defined and reported in clinical research. This lack of standardisation complicates the interpretation of published evidence and planning of future clinical trials. This systematic review will assess the reporting of anaesthesia as an intervention in randomised controlled trials (RCT) against the Consolidated Standards of Reporting Trials for Non-Pharmacological Treatments (CONSORT-NPT) framework.

METHODS AND ANALYSIS

Online archives of the top six journals ranked by impact factor for anaesthesia and the top three general medicine and general surgery journals will be systematically hand searched over a 42-month time period to identify RCTs describing the use of anaesthetic interventions for any invasive procedure. All modes of anaesthesia and anaesthesia techniques will be included. All study data, including the type of anaesthetic intervention described, will be extracted in keeping with the CONSORT-NPT checklist. Descriptive statistics will be used to summarise general study details including types/modes of anaesthetic interventions, and reporting standards of the trials.

ETHICS AND DISSEMINATION

No ethical approval is required. The results will be used to inform a funding application to formally standardise general, local, regional anaesthesia and sedation for use in clinical research. The systematic review will be disseminated via peer-reviewed manuscript and conferences.

PROSPERO REGISTRATION NUMBER

CRD42019141670.

Qualitative study of clinician and patient perspectives on the mode of anaesthesia for emergency surgery

Background

Although delivering a chosen mode of anaesthesia for certain emergency surgery procedures is potentially beneficial to patients, it is a complex intervention to evaluate. This qualitative study explored clinician and patient perspectives about mode of anaesthesia for emergency surgery.

Methods

Snowball sampling was used to recruit participants from eight National Health Service Trusts that cover the following three emergency surgery settings: ruptured abdominal aortic aneurysms, hip fractures and inguinal hernias. A qualitative researcher conducted interviews with clinicians and patients. Thematic analysis was applied to the interview transcripts.

Results

Interviews were conducted with 21 anaesthetists, 21 surgeons, 14 operating theatre staff and 23 patients. There were two main themes. The first, impact of mode of anaesthesia in emergency surgery, had four subthemes assessing clinician and patient ideas about: context and the ‘best’ mode of anaesthesia; balance in choosing it over others; change and developments in anaesthesia; and the importance of mode of anaesthesia in emergency surgery. The second, tensions in decision‐making about mode of anaesthesia, comprised four subthemes: clinical autonomy and guidelines in anaesthesia; conforming to norms in mode of anaesthesia; the relationship between expertise, preference and patient involvement; and team dynamics in emergency surgery. The results highlight several interlinking factors affecting decision‐making, including expertise, preference, habit, practicalities, norms and policies.

Conclusion

There is variation in practice in choosing the mode of anaesthesia for surgery, alongside debate as to whether anaesthetic autonomy is necessary or results in a lack of willingness to change.

Local anaesthesia for endovascular repair of ruptured abdominal aortic aneurysm

BACKGROUND

Case series and a post hoc subgroup analysis of a large randomized trial have suggested a potential benefit in treating ruptured abdominal aortic aneurysms (rAAAs) using endovascular aneurysm repair (EVAR) with local anaesthesia (LA) rather than general anaesthesia (GA). The uptake and outcomes of LA in clinical practice remain unknown.

METHODS

The UK National Vascular Registry was interrogated for patients presenting with rAAA managed with EVAR under different modes of anaesthesia between 1 January 2014 and 31 December 2016. The primary outcome was in-hospital mortality. Secondary outcomes included: the number of centres performing EVAR under LA; the proportion of patients receiving this technique; duration of hospital stay; and postoperative complications.

RESULTS

Some 3101 patients with rAAA were treated in 72 hospitals during the study: 2306 underwent on open procedure and 795 had EVAR (LA, 319; GA, 435; regional anaesthesia, 41). Overall, 56 of 72 hospitals (78 per cent) offered LA for EVAR of rAAA. Baseline characteristics and morphology were similar across the three EVAR subgroups. Patients who had surgery under LA had a lower in-hospital mortality rate than patients who received GA (59 of 319 (18·5 per cent) versus 122 of 435 (28·0 per cent)), and this was unchanged after adjustment for factors known to influence survival (adjusted hazard ratio 0·62, 95 per cent c.i. 0·45 to 0·85; P = 0·003). Median hospital stay and postoperative morbidity from other complications were similar.

CONCLUSION

The use of LA for EVAR of rAAA has been adopted widely in the UK. Mortality rates appear lower than in patients undergoing EVAR with GA.