1
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Hayashi K, Lesnak JB, Plumb AN, Janowski AJ, Smith AF, Hill JK, Sluka KA. Brain-derived neurotrophic factor contributes to activity-induced muscle pain in male but not female mice. bioRxiv 2023:2023.10.31.565022. [PMID: 37961342 PMCID: PMC10635076 DOI: 10.1101/2023.10.31.565022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
Activity-induced muscle pain increases release of interleukin-1β (IL-1β) in muscle macrophages and the development of pain is prevented by blockade of IL-1β. Brain derived neurotrophic factor (BDNF) is released from sensory neurons in response to IL-1β and mediates both inflammatory and neuropathic pain. Thus, we hypothesized that metabolites released during fatiguing muscle contractions activate macrophages to release IL-1β, which subsequently activate sensory neurons to secrete BDNF. To test this hypothesis, we used an animal model of activity-induced pain induced by repeated intramuscular acidic saline injections combined with fatiguing muscle contractions. Intrathecal or intramuscular injection of inhibitors of BDNF-Tropomyosin receptor kinase B (TrkB) signaling, ANA-12 or TrkB-Fc, reduced the decrease in muscle withdrawal thresholds in male, but not in female, mice when given before or 24hr after, but not 1 week after induction of the model. BDNF messenger ribonucleic acid (mRNA) was significantly increased in L4-L6 dorsal root ganglion (DRG), but not the spinal dorsal horn or gastrocnemius muscle, 24hr after induction of the model in either male or female mice. No changes in TrkB mRNA or p75 neurotrophin receptor mRNA were observed. BDNF protein expression via immunohistochemistry was significantly increased in L4-L6 spinal dorsal horn and retrogradely labelled muscle afferent DRG neurons, at 24hr after induction of the model in both sexes. In cultured DRG, fatigue metabolites combined with IL-1β significantly increased BDNF expression in both sexes. In summary, fatigue metabolites release, combined with IL-1β, BDNF from primary DRG neurons and contribute to activity-induced muscle pain only in males, while there were no sex differences in the changes in expression observed in BDNF.
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Affiliation(s)
- Kazuhiro Hayashi
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, USA
| | - Joseph B. Lesnak
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, USA
| | - Ashley N. Plumb
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, USA
| | - Adam J. Janowski
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, USA
| | - Angela F. Smith
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, USA
| | - Joslyn K. Hill
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, USA
| | - Kathleen A. Sluka
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, USA
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2
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Thompson AL, Grenald SA, Ciccone HA, Mohty D, Smith AF, Coleman DL, Bahramnejad E, De Leon E, Kasper-Conella L, Uhrlab JL, Margolis DS, Salvemini D, Largent-Milnes TM, Vanderah TW. Morphine-induced osteolysis and hypersensitivity is mediated through toll-like receptor-4 in a murine model of metastatic breast cancer. Pain 2023; 164:2463-2476. [PMID: 37326644 PMCID: PMC10578422 DOI: 10.1097/j.pain.0000000000002953] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 03/28/2023] [Accepted: 04/18/2023] [Indexed: 06/17/2023]
Abstract
ABSTRACT The propensity for breast cancer to metastasize to bone is coupled to the most common complaint among breast cancer patients: bone pain. Classically, this type of pain is treated using escalating doses of opioids, which lack long-term efficacy due to analgesic tolerance, opioid-induced hypersensitivity, and have recently been linked to enhanced bone loss. To date, the molecular mechanisms underlying these adverse effects have not been fully explored. Using an immunocompetent murine model of metastatic breast cancer, we demonstrated that sustained morphine infusion induced a significant increase in osteolysis and hypersensitivity within the ipsilateral femur through the activation of toll-like receptor-4 (TLR4). Pharmacological blockade with TAK242 (resatorvid) as well as the use of a TLR4 genetic knockout ameliorated the chronic morphine-induced osteolysis and hypersensitivity. Genetic MOR knockout did not mitigate chronic morphine hypersensitivity or bone loss. In vitro studies using RAW264.7 murine macrophages precursor cells demonstrated morphine-enhanced osteoclastogenesis that was inhibited by the TLR4 antagonist. Together, these data indicate that morphine induces osteolysis and hypersensitivity that are mediated, in part, through a TLR4 receptor mechanism.
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Affiliation(s)
- Austen L. Thompson
- Department of Medical Pharmacology, University of Arizona College of Medicine, Tucson, AZ, United States
| | - Shaness A. Grenald
- Department of Medical Pharmacology, University of Arizona College of Medicine, Tucson, AZ, United States
| | - Haley A. Ciccone
- Department of Medical Pharmacology, University of Arizona College of Medicine, Tucson, AZ, United States
| | - Dieter Mohty
- Department of Medical Pharmacology, University of Arizona College of Medicine, Tucson, AZ, United States
| | - Angela F. Smith
- Department of Medical Pharmacology, University of Arizona College of Medicine, Tucson, AZ, United States
| | - Deziree L. Coleman
- Department of Medical Pharmacology, University of Arizona College of Medicine, Tucson, AZ, United States
| | - Erfan Bahramnejad
- Department of Medical Pharmacology, University of Arizona College of Medicine, Tucson, AZ, United States
| | - Erick De Leon
- Department of Biomedical Engineering, University of Arizona, Tucson, AZ, United States
| | - Logan Kasper-Conella
- Department of Biomedical Engineering, University of Arizona, Tucson, AZ, United States
| | | | - David S. Margolis
- Department of Biomedical Engineering, University of Arizona, Tucson, AZ, United States
- Orthopaedic Surgery, University of Arizona College of Medicine, Tucson, AZ, United States
| | - Daniela Salvemini
- Department of Pharmacology and Physiology and Henry and Amelia Nasrallah Center for Neuroscience, Saint Louis University School of Medicine, St. Louis, MO, United States
| | - Tally M. Largent-Milnes
- Department of Medical Pharmacology, University of Arizona College of Medicine, Tucson, AZ, United States
- Comprehensive Pain and Addiction Center, University of Arizona, Tucson, AZ, United States
| | - Todd W. Vanderah
- Department of Medical Pharmacology, University of Arizona College of Medicine, Tucson, AZ, United States
- Comprehensive Pain and Addiction Center, University of Arizona, Tucson, AZ, United States
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3
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Chin KW, Smith AF. Choice of airway device and the incidence and severity of postoperative pulmonary complications in older patients. Anaesthesia 2023; 78:1191-1194. [PMID: 37345266 DOI: 10.1111/anae.16077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2023] [Indexed: 06/23/2023]
Affiliation(s)
- K W Chin
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
| | - A F Smith
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
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4
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Affiliation(s)
- L C Savic
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - A F Smith
- Department of Anaesthesia, University Hospitals of Morecambe Bay NHS Foundation Trust, Kendal, UK.,Faculty of Health and Medicine, University of Lancaster, Lancaster, UK
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5
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Ruslan N, Smith AF. The thirst for improvement: ensuring shorter and safer pre-operative fasting times in children. Anaesthesia 2022; 77:743-747. [PMID: 35545991 DOI: 10.1111/anae.15751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2022] [Indexed: 11/27/2022]
Affiliation(s)
- N Ruslan
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
| | - A F Smith
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
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6
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Allen C, Smith AF, Nathanson MH. What can anaesthetists do to help combat the global climate emergency? Anaesthesia 2022; 77:367-371. [PMID: 35229285 DOI: 10.1111/anae.15663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 12/21/2021] [Accepted: 12/29/2021] [Indexed: 11/25/2022]
Affiliation(s)
- C Allen
- Department of Anaesthesia, James Cook Hospital, Middlesbrough, UK
| | - A F Smith
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
| | - M H Nathanson
- Department of Anaesthesia, Nottingham University Hospitals NHS Trust, Nottingham, UK
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7
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Foo I, Eipe N, Smith AF. The use of intravenous lidocaine for postoperative pain and recovery: a reply. Anaesthesia 2021; 76:1141-1142. [PMID: 33970497 DOI: 10.1111/anae.15506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2021] [Indexed: 10/21/2022]
Affiliation(s)
- I Foo
- Western General Hospital, Edinburgh, UK
| | - N Eipe
- The Ottawa Hospital, Ottawa, Canada
| | - A F Smith
- Royal Lancaster Infirmary, Lancaster, UK
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8
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Zhang H, Lipinski AA, Liktor-Busa E, Smith AF, Moutal A, Khanna R, Langlais PR, Largent-Milnes TM, Vanderah TW. The Effects of Repeated Morphine Treatment on the Endogenous Cannabinoid System in the Ventral Tegmental Area. Front Pharmacol 2021; 12:632757. [PMID: 33953672 PMCID: PMC8090348 DOI: 10.3389/fphar.2021.632757] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 02/26/2021] [Indexed: 12/18/2022] Open
Abstract
The therapeutic utility of opioids is diminished by their ability to induce rewarding behaviors that may lead to opioid use disorder. Recently, the endogenous cannabinoid system has emerged as a hot topic in the study of opioid reward but relatively little is known about how repeated opioid exposure may affect the endogenous cannabinoid system in the mesolimbic reward circuitry. In the present study, we investigated how sustained morphine may modulate the endogenous cannabinoid system in the ventral tegmental area (VTA) of Sprague Dawley rats, a critical region in the mesolimbic reward circuitry. Studies here using proteomic analysis and quantitative real-time PCR (qRT-PCR) found that the VTA expresses 32 different proteins or genes related to the endogenous cannabinoid system; three of these proteins or genes (PLCγ2, ABHD6, and CB2R) were significantly affected after repeated morphine exposure (CB2R was only detected by qRT-PCR but not proteomics). We also identified that repeated morphine treatment does not alter either anandamide (AEA) or 2-arachidonoylglycerol (2-AG) levels in the VTA compared to saline treatment; however, there may be diminished levels of anandamide (AEA) production in the VTA 4 h after a single morphine injection in both chronic saline and morphine pretreated cohorts. Treating the animals with an inhibitor of 2-AG degradation significantly decreased repeated opioid rewarding behavior. Taken together, our studies reveal a potential influence of sustained opioids on the endocannabinoid system in the VTA, suggesting that the endogenous cannabinoid system may participate in the opioid-induced reward.
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Affiliation(s)
- Hong Zhang
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, AZ, United States
| | - Austin A. Lipinski
- Department of Medicine, Division of Endocrinology, College of Medicine, University of Arizona, Tucson, AZ, United States
| | - Erika Liktor-Busa
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, AZ, United States
| | - Angela F. Smith
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, AZ, United States
| | - Aubin Moutal
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, AZ, United States
| | - Rajesh Khanna
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, AZ, United States
| | - Paul R. Langlais
- Department of Medicine, Division of Endocrinology, College of Medicine, University of Arizona, Tucson, AZ, United States
| | - Tally M. Largent-Milnes
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, AZ, United States
| | - Todd W. Vanderah
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, AZ, United States
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9
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Affiliation(s)
- M Devlin
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
| | - A F Smith
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
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10
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Smith AF, Foo I. The use of intravenous lidocaine for postoperative pain and recovery: a reply. Anaesthesia 2021; 76:722. [PMID: 33687735 DOI: 10.1111/anae.15455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2021] [Indexed: 12/01/2022]
Affiliation(s)
- A F Smith
- Royal Lancaster Infirmary, Lancaster, UK
| | - I Foo
- Western General Hospital, Edinburgh, UK
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11
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Sellers R, Harold GT, Smith AF, Neiderhiser JM, Reiss D, Shaw D, Natsuaki MN, Thapar A, Leve LD. Disentangling nature from nurture in examining the interplay between parent-child relationships, ADHD, and early academic attainment. Psychol Med 2021; 51:645-652. [PMID: 31839017 PMCID: PMC7295681 DOI: 10.1017/s0033291719003593] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Attention deficit hyperactivity disorder (ADHD) is highly heritable and is associated with lower educational attainment. ADHD is linked to family adversity, including hostile parenting. Questions remain regarding the role of genetic and environmental factors underlying processes through which ADHD symptoms develop and influence academic attainment. METHOD This study employed a parent-offspring adoption design (N = 345) to examine the interplay between genetic susceptibility to child attention problems (birth mother ADHD symptoms) and adoptive parent (mother and father) hostility on child lower academic outcomes, via child ADHD symptoms. Questionnaires assessed birth mother ADHD symptoms, adoptive parent (mother and father) hostility to child, early child impulsivity/activation, and child ADHD symptoms. The Woodcock-Johnson test was used to examine child reading and math aptitude. RESULTS Building on a previous study (Harold et al., 2013, Journal of Child Psychology and Psychiatry, 54(10), 1038-1046), heritable influences were found: birth mother ADHD symptoms predicted child impulsivity/activation. In turn, child impulsivity/activation (4.5 years) evoked maternal and paternal hostility, which was associated with children's ADHD continuity (6 years). Both maternal and paternal hostility (4.5 years) contributed to impairments in math but not reading (7 years), via impacts on ADHD symptoms (6 years). CONCLUSION Findings highlight the importance of early child behavior dysregulation evoking parent hostility in both mothers and fathers, with maternal and paternal hostility contributing to the continuation of ADHD symptoms and lower levels of later math ability. Early interventions may be important for the promotion of child math skills in those with ADHD symptoms, especially where children have high levels of early behavior dysregulation.
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Affiliation(s)
- R Sellers
- School of Psychology, Andrew and Virginia Rudd Centre for Adoption Research and Practice, University of Sussex, Brighton, UK
- Institute of Psychological Medicine and Clinical Neurosciences, School of Medicine, MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Cardiff, UK
| | - G T Harold
- School of Psychology, Andrew and Virginia Rudd Centre for Adoption Research and Practice, University of Sussex, Brighton, UK
- Institute of Psychological Medicine and Clinical Neurosciences, School of Medicine, MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Cardiff, UK
- School of Psychology, Trinity College Dublin, The University of Dublin, Ireland
| | - A F Smith
- School of Psychology, Andrew and Virginia Rudd Centre for Adoption Research and Practice, University of Sussex, Brighton, UK
| | - J M Neiderhiser
- Department of Psychology, The Pennsylvania State University, University Park, PA, USA
| | - D Reiss
- Yale Child Study Center, New Haven, CT, USA
| | - D Shaw
- University of Pittsburgh, Pittsburgh, PA, USA
| | | | - A Thapar
- Institute of Psychological Medicine and Clinical Neurosciences, School of Medicine, MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Cardiff, UK
| | - L D Leve
- Prevention Science Institute, University of Oregon, Eugene, ORUSA
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12
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Collier H, Darwen C, Smith AF. Anti-emetic drugs for preventing postoperative nausea and vomiting: new evidence from a Cochrane network meta-analysis. Anaesthesia 2021; 76:883-887. [PMID: 33537997 DOI: 10.1111/anae.15398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2020] [Indexed: 12/25/2022]
Affiliation(s)
- H Collier
- Health Education North West, Manchester, UK
| | - C Darwen
- Health Education North West, Manchester, UK
| | - A F Smith
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
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13
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Ahmad I, Smith AF. Principles for guidelines and guidelines for principles of universal airway management. Anaesthesia 2020; 75:1570-1573. [PMID: 33165957 DOI: 10.1111/anae.15298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2020] [Indexed: 12/14/2022]
Affiliation(s)
- I Ahmad
- Department of Anaesthesia and Peri-operative Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's College London, UK
| | - A F Smith
- Department of Anaesthesia, Lancaster Royal Infirmary, Lancaster, UK.,Lancaster University, Lancaster, UK
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14
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Foo I, Macfarlane AJR, Srivastava D, Bhaskar A, Barker H, Knaggs R, Eipe N, Smith AF. The use of intravenous lidocaine for postoperative pain and recovery: international consensus statement on efficacy and safety. Anaesthesia 2020; 76:238-250. [PMID: 33141959 DOI: 10.1111/anae.15270] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2020] [Indexed: 12/15/2022]
Abstract
Intravenous lidocaine is used widely for its effect on postoperative pain and recovery but it can be, and has been, fatal when used inappropriately and incorrectly. The risk-benefit ratio of i.v. lidocaine varies with type of surgery and with patient factors such as comorbidity (including pre-existing chronic pain). This consensus statement aims to address three questions. First, does i.v. lidocaine effectively reduce postoperative pain and facilitate recovery? Second, is i.v. lidocaine safe? Third, does the fact that i.v. lidocaine is not licensed for this indication affect its use? We suggest that i.v. lidocaine should be regarded as a 'high-risk' medicine. Individual anaesthetists may feel that, in selected patients, i.v. lidocaine may be beneficial as part of a multimodal peri-operative pain management strategy. This approach should be approved by hospital medication governance systems, and the individual clinical decision should be made with properly informed consent from the patient concerned. If i.v. lidocaine is used, we recommend an initial dose of no more than 1.5 mg.kg-1 , calculated using the patient's ideal body weight and given as an infusion over 10 min. Thereafter, an infusion of no more than 1.5 mg.kg-1 .h-1 for no longer than 24 h is recommended, subject to review and re-assessment. Intravenous lidocaine should not be used at the same time as, or within the period of action of, other local anaesthetic interventions. This includes not starting i.v. lidocaine within 4 h after any nerve block, and not performing any nerve block until 4 h after discontinuing an i.v. lidocaine infusion.
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Affiliation(s)
- I Foo
- Western General Infirmary, Edinburgh, UK
| | | | | | - A Bhaskar
- Imperial College Healthcare NHS Trust, London, UK
| | - H Barker
- Ashford and St Peter's Hospitals NHS Foundation Trust, Chertsey, UK
| | - R Knaggs
- University of Nottingham, Nottingham, UK
| | - N Eipe
- Ottowa Hospital, Ottowa, Canada
| | - A F Smith
- Royal Lancaster Infirmary, Lancaster, UK
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15
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Shelton CL, Smith AF. Workplace distractions in the digital era - are smartphones a threat to safety or an essential tool? Anaesthesia 2020; 76:305-308. [PMID: 32815165 DOI: 10.1111/anae.15234] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2020] [Indexed: 12/15/2022]
Affiliation(s)
- C L Shelton
- Department of Anaesthesia, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.,Lancaster Medical School, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - A F Smith
- Department of Anaesthesia, University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, UK.,Lancaster Medical School, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
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16
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Amare M, McEvoy M, Quay TAW, Smith AF. The Cochrane Anaesthesia Review Group at 20: achievements and challenges in systematic reviews of evidence in peri-operative care. Anaesthesia 2020; 75:1142-1145. [PMID: 32592493 DOI: 10.1111/anae.15177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2020] [Indexed: 12/11/2022]
Affiliation(s)
- M Amare
- Anaesthesia and Intensive Care Medicine, Wythenshawe Hospital, Manchester, UK
| | - M McEvoy
- Anaesthesia and Intensive Care Medicine, Wythenshawe Hospital, Manchester, UK
| | - T A W Quay
- Cochrane Anaesthesia and Cochrane Emergency and Critical Care, Herlev Hospital, Copenhagen, Denmark
| | - A F Smith
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
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17
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McCracken GC, Smith AF. Breaking the fast for procedural sedation: changing risk or risking change? Anaesthesia 2020; 75:1010-1013. [PMID: 32147808 DOI: 10.1111/anae.15018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2020] [Indexed: 11/28/2022]
Affiliation(s)
- G C McCracken
- Department of Anaesthesia, Royal Victoria Hospital, Belfast, UK
| | - A F Smith
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
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18
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Sellers R, Smith AF, Leve LD, Nixon E, Cane T, Cassell JA, Harold GT. Utilising Genetically-Informed Research Designs to Better Understand Family Processes and Child Development: Implications for Adoption and Foster Care Focused Interventions. Adopt Foster 2019; 43:351-371. [PMID: 31576061 PMCID: PMC6771282 DOI: 10.1177/0308575919866526] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Understanding the interplay between genetic factors and family environmental processes (e.g., inter-parental relationship quality, positive versus negative parenting practices) and children's mental health (e.g., anxiety, depression, conduct problems, ADHD) in the contexts of adoption and foster-care research and practice is critical for effective prevention and intervention programme development. Whilst evidence highlights the importance of family environmental processes for the mental health and well-being of children in adoption and foster care, there is relatively limited evidence of effective interventions specifically for these families. Additionally, family-based interventions not specific to the context of adoption and foster-care typically show small to medium effects, and even where interventions are efficacious, not all children benefit. One explanation for why interventions may not work well for some is that responses to intervention may be influenced by an individual's genetic make-up. This paper summarises how genetically-informed research designs can help disentangle genetic from environmental processes underlying psychopathology outcomes for children, and how this evidence can provide improved insights into the development of more effective preventative intervention targets for adoption and foster-care families. We discuss current difficulties in translating behavioural genetics research to prevention science, and provide recommendations to bridge the gap between behavioural genetics research and prevention science, with lessons for adoption and foster-care research and practice.
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Affiliation(s)
- R Sellers
- School of Psychology, Andrew and Virginia Rudd Centre for Adoption Research and Practice, University of Sussex, Brighton, UK
- Institute of Psychological Medicine and Clinical Neurosciences, School of Medicine, MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Cardiff, UK
| | - A F Smith
- School of Psychology, Andrew and Virginia Rudd Centre for Adoption Research and Practice, University of Sussex, Brighton, UK
| | - L D Leve
- Prevention Science Institute, University of Oregon, Eugene, USA
| | - E Nixon
- School of Psychology, Trinity College Dublin, The University of Dublin, Ireland
| | - T Cane
- School of Social Work and Social Care, University of Sussex, UK
| | - J A Cassell
- Brighton and Sussex Medical School, Falmer, Brighton BN1 9PH
| | - G T Harold
- School of Psychology, Andrew and Virginia Rudd Centre for Adoption Research and Practice, University of Sussex, Brighton, UK
- Institute of Psychological Medicine and Clinical Neurosciences, School of Medicine, MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Cardiff, UK
- School of Psychology, Trinity College Dublin, The University of Dublin, Ireland
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19
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Hounsome J, Lee A, Greenhalgh J, Lewis SR, Schofield-Robinson OJ, Coldwell CH, Smith AF. A systematic review of information format and timing before scheduled adult surgery for peri-operative anxiety. Anaesthesia 2019; 72:1265-1272. [PMID: 28891062 DOI: 10.1111/anae.14018] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2017] [Indexed: 12/28/2022]
Abstract
We included 34 trials with 3742 participants, identified through 6 database and supplementary searches (to May 2017): 29 were randomised; 4 were quasi-randomised and 1 was cluster-randomised. Disparate measurements and outcomes precluded meta-analyses. Blinding was attempted in only 6 out of 34 (18%) trials. A multimedia format, alone or in combination with text or verbal formats, was studied in 20/34 (59%) trials: pre-operative anxiety was unaffected in 10 out of 14 trials and reduced by the multimedia format in three; postoperative anxiety was unaffected in four out of five trials in which formats were compared. Multimedia formats increased knowledge more than text, which in turn increased knowledge more than verbal formats. Other outcomes were unaffected by information format. The timing of information did not affect pre-operative anxiety, postoperative pain or length of stay. In conclusion, the effects of pre-operative information on peri-operative anxiety and other outcomes were affected little by format or timing.
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Affiliation(s)
- J Hounsome
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - A Lee
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong.,Hong Kong Branch of The Chinese Cochrane Centre, The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - J Greenhalgh
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - S R Lewis
- Patient Safety Research Unit, Royal Lancaster Infirmary, Lancaster, UK
| | | | - C H Coldwell
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
| | - A F Smith
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
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Lewis SR, Butler AR, Parker J, Cook TM, Schofield-Robinson OJ, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation: a Cochrane Systematic Review. Br J Anaesth 2019; 119:369-383. [PMID: 28969318 DOI: 10.1093/bja/aex228] [Citation(s) in RCA: 206] [Impact Index Per Article: 41.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2017] [Indexed: 02/06/2023] Open
Abstract
Difficulties with tracheal intubation commonly arise and impact patient safety. This systematic review evaluates whether videolaryngoscopes reduce intubation failure and complications compared with direct laryngoscopy in adults. We searched CENTRAL, MEDLINE, Embase and clinicaltrials.gov up to February 2015, and conducted forward and backward citation tracking. We included randomized controlled trials that compared adult patients undergoing laryngoscopy with videolaryngoscopy or Macintosh laryngoscopy. We did not primarily intend to compare individual videolaryngoscopes. Sixty-four studies (7044 participants) were included. Moderate quality evidence showed that videolaryngoscopy reduced failed intubations (Odds Ratio (OR) 0.35, 95% Confidence Interval (CI) 0.19-0.65) including in participants with anticipated difficult airways (OR 0.28, 95% CI 0.15-0.55). There was no evidence of reduction in hypoxia or mortality, but few studies reported these outcomes. Videolaryngoscopes reduced laryngeal/airway trauma (OR 0.68, 95% CI 0.48-0.96) and hoarseness (OR 0.57, 95% CI 0.36-0.88). Videolaryngoscopy increased easy laryngeal views (OR 6.77, 95% CI 4.17-10.98) and reduced difficult views (OR 0.18, 95% CI 0.13-0.27) and intubation difficulty, typically using an 'intubation difficulty score' (OR 7.13, 95% CI 3.12-16.31). Failed intubations were reduced with experienced operators (OR 0.32, 95% CI 0.13-0.75) but not with inexperienced users. We identified no difference in number of first attempts and incidence of sore throat. Heterogeneity around time for intubation data prevented meta-analysis. We found evidence of differential performance between different videolaryngoscope designs. Lack of data prevented analysis of impact of obesity or clinical location on failed intubation rates. Videolaryngoscopes may reduce the number of failed intubations, particularly among patients presenting with a difficult airway. They improve the glottic view and may reduce laryngeal/airway trauma. Currently, no evidence indicates that use of a videolaryngoscope reduces the number of intubation attempts or the incidence of hypoxia or respiratory complications, and no evidence indicates that use of a videolaryngoscope affects time required for intubation.
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Affiliation(s)
- S R Lewis
- Patient Safety Research Department, Royal Lancaster Infirmary, Lancaster, UK
| | - A R Butler
- Patient Safety Research Department, Royal Lancaster Infirmary, Lancaster, UK
| | - J Parker
- Department of Gastroenterology, Royal Bolton Hospital, Bolton, UK
| | - T M Cook
- Department of Anaesthesia, Royal United Hospitals Bath, NHS Foundation Trust, Bath, UK.,Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
| | | | - A F Smith
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
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Abstract
This article outlines recent developments in safety science. It describes the progression of three ‘ages’ of safety, namely the ‘age of technology’, the ‘age of human factors’ and the ‘age of safety management’. Safety science outside healthcare is moving from an approach focused on the analysis and management of error (‘Safety‐1’) to one which also aims to understand the inherent properties of safety systems that usually prevent accidents from occurring (‘Safety‐2’). A key factor in the understanding of safety within organisations relates to the distinction between ‘work as imagined’ and ‘work as done’. ‘Work as imagined’ assumes that if the correct standard procedures are followed, safety will follow as a matter of course. However, staff at the ‘sharp end’ of organisations know that to create safety in their work, variability is not only desirable but essential. This positive adaptability within systems that allows good outcomes in the presence of both favourable and adverse conditions is termed resilience. We argue that clinical and organisational work can be made safer, not only by addressing negative outcomes, but also by fostering excellence and promoting resilience. We outline conceptual and investigative approaches for achieving this that include ‘appreciative inquiry’, ‘positive deviance’ and excellence reporting.
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Affiliation(s)
- A F Smith
- Royal Lancaster Infirmary, Lancaster, UK
| | - E Plunkett
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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22
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Abstract
This review attempts to draw on the published literature to address three practical clinical questions. First, what means of testing the degree of regional blockade pre-operatively are available, and can eventual success or failure be determined soon after injection? Second, is it possible to predict if a block inserted after the induction of general anaesthesia will be effective when the patient wakes? Third, what features, and what duration, should cause concern when a block does not resolve as expected after surgery? Although the relevant literature is limited, we recommend testing of multiple sensory modalities before surgery commences; temperature and thermographic changes may offer additional early warning of success or failure. There are a number of existing methods of assessing nociception under general anaesthesia, but none has yet been applied to gauge the onset of a regional block. Finally, criteria for further investigation and neurological referral when block symptoms persist postoperatively are presented.
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Affiliation(s)
- K Ode
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
| | - S Selvaraj
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
| | - A F Smith
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
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Forrest AP, Black RB, Humeniuk V, Cant EL, Hawkins RA, Prescott RJ, Roberts MM, Shivas AA, Stewart HJ, Smith AF, Sumerling M, Sumerling M. Preoperative Assessment and Staging of Breast Cancer: Preliminary Communication. J R Soc Med 2018; 73:561-6. [PMID: 7230232 PMCID: PMC1437852 DOI: 10.1177/014107688007300805] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
A prospective study has been carried out in 172 women to determine the sensitivity of methods to detect occult metastatic disease in the skeleton and liver. With the exception of bone scintiscans, the results of these tests bore little relationship to recurrence rates. On the other hand, knowledge of the histopathology of the lower axillary (pectoral) lymph nodes is of value in this respect. A follow-up study is also reported which confirms the importance of accurate measurements of the primary tumour clinical node status and oestrogen receptor contact of the tumour in defining prognostic groups. Elastosis (estimated in 165 tumours) did not prove to be a useful prognostic index.
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Hounsome J, Greenhalgh J, Schofield-Robinson OJ, Lewis SR, Cook TM, Smith AF. Nitrous oxide-based vs. nitrous oxide-free general anaesthesia and accidental awareness in surgical patients: an abridged Cochrane systematic review. Anaesthesia 2017; 73:365-374. [PMID: 29034449 DOI: 10.1111/anae.14065] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2017] [Indexed: 12/29/2022]
Abstract
Accidental awareness during general anaesthesia can arise from a failure to deliver sufficient anaesthetic agent, or from a patient's resistance to an expected sufficient dose of such an agent. Awareness is 'explicit' if the patient is subsequently able to recall the event. We conducted a systematic review into the effect of nitrous oxide used as part of a general anaesthetic on the risk of accidental awareness in people over the age of five years undergoing general anaesthesia for surgery. We included 15 randomised controlled trials, 14 of which, representing a total of 3439 participants, were included in our primary analysis of the frequency of accidental awareness events. The awareness incidence rate was rare within these studies, and all were considered underpowered with respect to this outcome. The risk of bias across all studies was judged to be high, and 76% of studies failed adequately to conceal participant allocation. We considered the available evidence to be of very poor quality. There were a total of three accidental awareness events reported in two studies, one of which reported that the awareness was the result of a kink in a propofol intravenous line. There were insufficient data to conduct a meta- or sub-group analysis and there was insufficient evidence to draw outcome-related conclusions. We can, however, recommend that future studies focus on potentially high-risk groups such as obstetric or cardiac surgery patients, or those receiving neuromuscular blocking drugs or total intravenous anaesthesia.
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Affiliation(s)
- J Hounsome
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - J Greenhalgh
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - O J Schofield-Robinson
- Patient Safety Research Unit, Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
| | - S R Lewis
- Patient Safety Research Unit, Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
| | - T M Cook
- Royal United Hospital Bath NHS Foundation Trust, Bath, UK
- School of Clinical Sciences, University of Bristol, Bristol, UK
| | - A F Smith
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
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Smith AF, Hall PS, Hulme CT, Dunn JA, McConkey CC, Rahman JK, McCabe C, Mehanna H. Cost-effectiveness analysis of PET-CT-guided management for locally advanced head and neck cancer. Eur J Cancer 2017; 85:6-14. [PMID: 28881249 DOI: 10.1016/j.ejca.2017.07.054] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 07/31/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND A recent large United Kingdom (UK) clinical trial demonstrated that positron-emission tomography-computed tomography (PET-CT)-guided administration of neck dissection (ND) in patients with advanced head and neck cancer after primary chemo-radiotherapy treatment produces similar survival outcomes to planned ND (standard care) and is cost-effective over a short-term horizon. Further assessment of long-term outcomes is required to inform a robust adoption decision. Here we present results of a lifetime cost-effectiveness analysis of PET-CT-guided management from a UK secondary care perspective. METHODS Initial 6-month cost and health outcomes were derived from trial data; subsequent incidence of recurrence and mortality was simulated using a de novo Markov model. Health benefit was measured in quality-adjusted life years (QALYs) and costs reported in 2015 British pounds. Model parameters were derived from trial data and published literature. Sensitivity analyses were conducted to assess the impact of uncertainty and broader National Health Service (NHS) and personal social services (PSS) costs on the results. RESULTS PET-CT management produced an average per-person lifetime cost saving of £1485 and an additional 0.13 QALYs. At a £20,000 willingness-to-pay per additional QALY threshold, there was a 75% probability that PET-CT was cost-effective, and the results remained cost-effective over the majority of sensitivity analyses. When adopting a broader NHS and PSS perspective, PET-CT management produced an average saving of £700 and had an 81% probability of being cost-effective. CONCLUSIONS This analysis indicates that PET-CT-guided management is cost-effective in the long-term and supports the case for wide-scale adoption.
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Affiliation(s)
- A F Smith
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, UK; National Institute of Health Research (NIHR) Diagnostic Evidence Cooperative (DEC) Leeds, UK.
| | - P S Hall
- National Institute of Health Research (NIHR) Diagnostic Evidence Cooperative (DEC) Leeds, UK; Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, UK
| | - C T Hulme
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, UK
| | - J A Dunn
- Warwick Clinical Trials Unit, University of Warwick, Coventry, West Midlands, UK
| | - C C McConkey
- Warwick Clinical Trials Unit, University of Warwick, Coventry, West Midlands, UK
| | - J K Rahman
- Institute of Head & Neck Studies and Education, University of Birmingham, UK
| | - C McCabe
- Department of Emergency Medicine, University of Alberta, Edmonton, Canada
| | - H Mehanna
- Institute of Head & Neck Studies and Education, University of Birmingham, UK
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26
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Howard DR, Munir T, McParland L, Rawstron AC, Milligan D, Schuh A, Hockaday A, Allsup DJ, Marshall S, Duncombe AS, O'Dwyer JL, Smith AF, Longo R, Varghese A, Hillmen P. Results of the randomized phase IIB ARCTIC trial of low-dose rituximab in previously untreated CLL. Leukemia 2017; 31:2416-2425. [PMID: 28336937 DOI: 10.1038/leu.2017.96] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 01/27/2017] [Accepted: 03/08/2017] [Indexed: 01/20/2023]
Abstract
ARCTIC was a multicenter, randomized-controlled, open, phase IIB non-inferiority trial in previously untreated chronic lymphocytic leukemia (CLL). Conventional frontline therapy in fit patients is fludarabine, cyclophosphamide and rituximab (FCR). The trial hypothesized that including mitoxantrone with low-dose rituximab (FCM-miniR) would be non-inferior to FCR. A total of 200 patients were recruited to assess the primary end point of complete remission (CR) rates according to IWCLL criteria. Secondary end points were progression-free survival (PFS), overall survival (OS), overall response rate, minimal residual disease (MRD) negativity, safety and cost-effectiveness. The trial closed following a pre-planned interim analysis. At final analysis, CR rates were 76 FCR vs 55% FCM-miniR (adjusted odds ratio: 0.37; 95% confidence interval: 0.19-0.73). MRD-negativity rates were 54 FCR vs 44% FCM-miniR. More participants experienced serious adverse reactions with FCM-miniR (49%) compared to FCR (41%). There are no significant differences between the treatment groups for PFS and OS. FCM-miniR is not expected to be cost-effective over a lifetime horizon. In summary, FCM-miniR is less well tolerated than FCR with an inferior response and MRD-negativity rate and increased toxicity, and will not be taken forward into a confirmatory trial. The trial demonstrated that oral FCR yields high response rates compared to historical series with intravenous chemotherapy.
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Affiliation(s)
- D R Howard
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - T Munir
- Department of Haematology, St James's University Hospital, Leeds, UK
| | - L McParland
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - A C Rawstron
- Haematological Malignancy Diagnostic Service, St James's University Hospital, Leeds, UK
| | - D Milligan
- Centre for Haematology and Stem Cell Transplantation, Heartlands Hospital, Birmingham, UK
| | - A Schuh
- Department of Oncology, University of Oxford and Department of Haematology, Oxford University Hospital Trust, Oxford, UK
| | - A Hockaday
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - D J Allsup
- Department of Haematology, Hull and East Yorkshire NHS Trust, Hull, United Kingdom and Hull York Medical School, University of Hull, Hull, UK
| | - S Marshall
- Department of Haematology, City Hospitals Sunderland, Sunderland, UK
| | - A S Duncombe
- Department of Haematology, University Hospital Southampton, Southampton, UK
| | - J L O'Dwyer
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - A F Smith
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - R Longo
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - A Varghese
- Department of Haematology, St James's University Hospital, Leeds, UK
| | - P Hillmen
- Section of Experimental Haematology, Leeds Institute of Cancer and Pathology (LICAP), University of Leeds, Leeds, UK
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28
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Kenwright DA, Bernjak A, Draegni T, Dzeroski S, Entwistle M, Horvat M, Kvandal P, Landsverk SA, McClintock PVE, Musizza B, Petrovčič J, Raeder J, Sheppard LW, Smith AF, Stankovski T, Stefanovska A. The discriminatory value of cardiorespiratory interactions in distinguishing awake from anaesthetised states: a randomised observational study. Anaesthesia 2015; 70:1356-68. [PMID: 26350998 PMCID: PMC4989441 DOI: 10.1111/anae.13208] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2015] [Indexed: 12/20/2022]
Abstract
Depth of anaesthesia monitors usually analyse cerebral function with or without other physiological signals; non‐invasive monitoring of the measured cardiorespiratory signals alone would offer a simple, practical alternative. We aimed to investigate whether such signals, analysed with novel, non‐linear dynamic methods, would distinguish between the awake and anaesthetised states. We recorded ECG, respiration, skin temperature, pulse and skin conductivity before and during general anaesthesia in 27 subjects in good cardiovascular health, randomly allocated to receive propofol or sevoflurane. Mean values, variability and dynamic interactions were determined. Respiratory rate (p = 0.0002), skin conductivity (p = 0.03) and skin temperature (p = 0.00006) changed with sevoflurane, and skin temperature (p = 0.0005) with propofol. Pulse transit time increased by 17% with sevoflurane (p = 0.02) and 11% with propofol (p = 0.007). Sevoflurane reduced the wavelet energy of heart (p = 0.0004) and respiratory (p = 0.02) rate variability at all frequencies, whereas propofol decreased only the heart rate variability below 0.021 Hz (p < 0.05). The phase coherence was reduced by both agents at frequencies below 0.145 Hz (p < 0.05), whereas the cardiorespiratory synchronisation time was increased (p < 0.05). A classification analysis based on an optimal set of discriminatory parameters distinguished with 95% success between the awake and anaesthetised states. We suggest that these results can contribute to the design of new monitors of anaesthetic depth based on cardiovascular signals alone.
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Affiliation(s)
| | | | - T Draegni
- Oslo University Hospital, Ullevaal, Norway
| | - S Dzeroski
- Jožef Stefan Institute, Ljubljana, Slovenia
| | | | - M Horvat
- Faculty of Mathematics and Physics, University of Ljubljana, Ljubljana, Slovenia
| | - P Kvandal
- Oslo University Hospital, Ullevaal, Norway
| | | | | | - B Musizza
- Jožef Stefan Institute, Ljubljana, Slovenia
| | | | - J Raeder
- Oslo University Hospital, Ullevaal, Norway
| | | | - A F Smith
- Royal Lancaster Infirmary, Lancaster, UK
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29
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Affiliation(s)
- A F Smith
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK. .,Lancaster University, Lancaster, UK.
| | - J Carlisle
- Torbay Hospital, South Devon NHS Foundation Trust, Torquay, UK
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30
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Hall PS, Hamilton P, Hulme CT, Meads DM, Jones H, Newsham A, Marti J, Smith AF, Mason H, Velikova G, Ashley L, Wright P. Costs of cancer care for use in economic evaluation: a UK analysis of patient-level routine health system data. Br J Cancer 2015; 112:948-56. [PMID: 25602964 PMCID: PMC4453947 DOI: 10.1038/bjc.2014.644] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Revised: 11/17/2014] [Accepted: 12/01/2014] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The rising financial burden of cancer on health-care systems worldwide has led to the increased demand for evidence-based research on which to base reimbursement decisions. Economic evaluations are an integral component of this necessary research. Ascertainment of reliable health-care cost and quality-of-life estimates to inform such studies has historically been challenging, but recent advances in informatics in the United Kingdom provide new opportunities. METHODS The costs of hospital care for breast, colorectal and prostate cancer disease-free survivors were calculated over 15 months from initial diagnosis of cancer using routinely collected data within a UK National Health Service (NHS) Hospital Trust. Costs were linked at patient level to patient-reported outcomes and registry-derived sociodemographic factors. Predictors of cost and the relationship between costs and patient-reported utility were examined. RESULTS The study population included 223 breast cancer patients, 145 colorectal and 104 prostate cancer patients. The mean 15-month cumulative health-care costs were £12 595 (95% CI £11 517-£13 722), £12 643 (£11 282-£14 102) and £3722 (£3263-£4208), per-patient respectively. The majority of costs occurred within the first 6 months from diagnosis. Clinical stage was the most important predictor of costs for all cancer types. EQ-5D score was predictive of costs in colorectal cancer but not in breast or prostate cancer. CONCLUSION It is now possible to evaluate health-care cost using routine NHS data sets. Such methods can be utilised in future retrospective and prospective studies to efficiently collect economic data.
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Affiliation(s)
- P S Hall
- Academic Unit of Health Economics, University of Leeds, Charles Thackrah Building, 101 Clarendon Road, Woodhouse, Leeds LS2 9LJ, UK
- St James Institute of Oncology, Leeds, Bexley Wing, St James University Hospital, Beckett Street, Leeds, West Yorkshire LS9 7TF, UK
| | - P Hamilton
- Manchester Royal Infirmary, Manchester Institute of Nephrology and Transplantation, Oxford Road, Manchester M139WL, UK
| | - C T Hulme
- Academic Unit of Health Economics, University of Leeds, Charles Thackrah Building, 101 Clarendon Road, Woodhouse, Leeds LS2 9LJ, UK
| | - D M Meads
- Academic Unit of Health Economics, University of Leeds, Charles Thackrah Building, 101 Clarendon Road, Woodhouse, Leeds LS2 9LJ, UK
| | - H Jones
- Leeds Institute of Cancer and Pathology, University of Leeds, Bexley Wing, St James University Hospital, Beckett Street, Leeds, West Yorkshire LS9 7TF, UK
| | - A Newsham
- Leeds Institute of Cancer and Pathology, University of Leeds, Bexley Wing, St James University Hospital, Beckett Street, Leeds, West Yorkshire LS9 7TF, UK
| | - J Marti
- Academic Unit of Health Economics, University of Leeds, Charles Thackrah Building, 101 Clarendon Road, Woodhouse, Leeds LS2 9LJ, UK
| | - A F Smith
- Academic Unit of Health Economics, University of Leeds, Charles Thackrah Building, 101 Clarendon Road, Woodhouse, Leeds LS2 9LJ, UK
| | - H Mason
- Sheffield Teaching Hospitals NHS Foundation Trust, Herries Road, Sheffield, South Yorkshire S5 7AU, UK
| | - G Velikova
- Leeds Institute of Cancer and Pathology, University of Leeds, Bexley Wing, St James University Hospital, Beckett Street, Leeds, West Yorkshire LS9 7TF, UK
| | - L Ashley
- School of Social, Psychological and Communication Sciences, Faculty of Health and Social Sciences, Leeds Beckett University, Calverley Building, City Campus, Leeds LS1 3HE, UK
| | - P Wright
- Leeds Institute of Cancer and Pathology, University of Leeds, Bexley Wing, St James University Hospital, Beckett Street, Leeds, West Yorkshire LS9 7TF, UK
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Nicholson A, Lowe MC, Parker J, Lewis SR, Alderson P, Smith AF. Systematic review and meta-analysis of enhanced recovery programmes in surgical patients. Br J Surg 2014; 101:172-88. [PMID: 24469618 DOI: 10.1002/bjs.9394] [Citation(s) in RCA: 307] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2013] [Indexed: 01/30/2023]
Abstract
BACKGROUND Enhanced recovery programmes (ERPs) have been developed over the past 10 years to improve patient outcomes and to accelerate recovery after surgery. The existing literature focuses on specific specialties, mainly colorectal surgery. The aim of this review was to investigate whether the effect of ERPs on patient outcomes varies across surgical specialties or with the design of individual programmes. METHODS MEDLINE, Embase, CINAHL and the Cochrane Central Register of Controlled Trials were searched from inception to January 2013 for randomized or quasi-randomized trials comparing ERPs with standard care in adult elective surgical patients. RESULTS Thirty-eight trials were included in the review, with a total of 5099 participants. Study design and quality was poor. Meta-analyses showed that ERPs reduced the primary length of stay (standardized mean difference -1·14 (95 per cent confidence interval -1·45 to -0·85)) and reduced the risk of all complications within 30 days (risk ratio (RR) 0·71, 95 per cent c.i. 0·60 to 0·86). There was no evidence of a reduction in mortality (RR 0·69, 95 per cent c.i. 0·34 to 1·39), major complications (RR 0·95, 0·69 to 1·31) or readmission rates (RR 0·96, 0·59 to 1·58). The impact of ERPs was similar across specialties and there was no consistent evidence that elements included within ERPs affected patient outcomes. CONCLUSION ERPs are effective in reducing length of hospital stay and overall complication rates across surgical specialties. It was not possible to identify individual components that improved outcome. Qualitative synthesis may be more appropriate to investigate the determinants of success.
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Affiliation(s)
- A Nicholson
- Faculty of Health and Medicine, Lancaster University, Lancaster, UK
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32
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Reed S, Arnal D, Frank O, Gomez-Arnau JI, Hansen J, Lester O, Mikkelsen KL, Rhaiem T, Rosenberg PH, St Pierre M, Schleppers A, Staender S, Smith AF. National critical incident reporting systems relevant to anaesthesia: a European survey. Br J Anaesth 2013; 112:546-55. [PMID: 24318857 DOI: 10.1093/bja/aet406] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Critical incident reporting is a key tool in the promotion of patient safety in anaesthesia. METHODS We surveyed representatives of national incident reporting systems in six European countries, inviting information on scope and organization, and intelligence on factors determining success and failure. RESULTS Some systems are government-run and nationally conceived; others started out as small, specialty-focused initiatives, which have since acquired a national reach. However, both national co-ordination and specialty enthusiasts seem to be necessary for an optimally functioning system. The role of reporting culture, definitional issues, and dissemination is discussed. CONCLUSIONS We make recommendations for others intending to start new systems and speculate on the prospects for sharing patient safety lessons relevant to anaesthesia at European level.
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Affiliation(s)
- S Reed
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
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33
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Campbell G, Rollin AM, Smith AF. Cases relating to anaesthetists handled by the UK General Medical Council in 2009: methodological approach and patterns of referral. Anaesthesia 2013; 68:453-60. [PMID: 23573842 DOI: 10.1111/anae.12117] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2012] [Indexed: 11/30/2022]
Abstract
The General Medical Council is the regulatory body charged with maintaining standards in the medical profession in the UK. We analysed cases relating to anaesthetists handled in 2009 using fitness-to-practise data, comparing them with the profession as a whole and examining patterns of referral. Complaints were made about 105 doctors practising in anaesthesia. The 81 anaesthetists who were investigated further were subject to a total of 225 separate allegations, median (IQR [range]) of 2 (1-3 ) allegations per anaesthetist. Anaesthetists had a lower rate of referral compared with doctors in general (0.095% vs 0.20%, respectively, p = 0.0001). They were less likely than doctors in general to be referred by an individual member of the public (27% vs 64%, respectively, p = 0.0001). As with other specialties, allegations were most commonly made about clinical care, probity and relationships with patients. On the basis of 2009 data, we calculated that a mean (95% CI) of 1 in 120 (1 in 100-145) doctors practising in anaesthesia in the UK will be referred to the General Medical Council every year. We have provided examples of allegations and made recommendations for maintaining good practice in anaesthesia.
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Affiliation(s)
- G Campbell
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancs, UK
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Smith AF. Assessment of severity of critical illness: many factors can influence physicians' decisions. Minerva Anestesiol 2013; 79:576. [PMID: 23306401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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Abstract
Communication is a key skill for anaesthetic practice. The 'non-informational' aspects of communication, such as non-verbal elements and the degree to which the style of communication reflects the implied relationship between the sender and the recipient, are relevant to interactions both between anaesthetists and patients and to interactions with other members of staff in the team. Communication and interaction between members of the anaesthesia team in isolation has received less attention than communication in the operating theatre during surgery. Most aspects of such communication are informally learned and developed with experience. Studies of communication at induction of anaesthesia have used qualitative methods to identify a range of styles of talk. This is nominally directed at the patient but also serves to unite and co-ordinate the team to ensure the patient's smooth, safe progress into anaesthesia. In particular, the use of positive words and phrases seems to benefit patient comfort and safety. On emergence, a more limited range of communication styles is found. Handover of the recently anaesthetized patient to recovery room staff is often brief and distracted by concurrent patient-related activities. Both information about the patient, and responsibility for the patient's continuing care, have to be transferred. The handover event also serves as an opportunity to review the care the patient has received and plan for further progress. Anaesthetists and nurses use unspoken and implicit negotiation strategies to achieve the aims of handover without compromising future collaborative work. This is in contrast to the more formalized handover approaches in other safety-critical settings.
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Affiliation(s)
- A F Smith
- Department of Anaesthesia, Royal Lancaster Infirmary, Ashton Road, Lancaster LA1 4RP, UK.
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Baxter SD, Guinn CH, Royer JA, Hardin JW, Mackelprang AJ, Smith AF. Accuracy of children's school-breakfast reports and school-lunch reports (in 24-h dietary recalls) differs by retention interval. Eur J Clin Nutr 2009; 63:1394-403. [PMID: 19756033 PMCID: PMC2788046 DOI: 10.1038/ejcn.2009.107] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND/OBJECTIVES Validation-study data were analyzed to investigate the effect of retention interval (time between the to-be-reported meal and interview) on accuracy of children's school-breakfast reports and school-lunch reports in 24-h recalls, and to compare accuracy of children's school-breakfast reports for two breakfast locations (classroom; cafeteria). SUBJECTS/METHODS Each of 374 fourth-grade children was interviewed to obtain a 24-h recall using one of six conditions from crossing two target periods (prior 24 h; previous day) with three interview times (morning; afternoon; evening). Each condition had 62 or 64 children (half boys). A recall's target period included one school breakfast and one school lunch, for which the child had been observed. Food-item variables (observed number; reported number; omission rate; intrusion rate) and energy variables (observed; reported; report rate; correspondence rate; inflation ratio) were calculated for each child for school breakfast and school lunch separately. RESULTS Accuracy for school-breakfast reports and school-lunch reports was inversely related to retention interval. Specifically, as indicated by smaller omission rates, smaller intrusion rates, larger correspondence rates and smaller inflation ratios, accuracy for school-breakfast reports was best for prior-24-h recalls in the morning, and accuracy for school-lunch reports was best for prior-24-h recalls in the afternoon. For neither school meal was a significant sex effect found for any variable. For school-breakfast reports, there was no significant school-breakfast location effect for any variable. CONCLUSIONS By shortening the retention interval, accuracy can be improved for school-breakfast reports and school-lunch reports in children's 24-h recalls.
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Affiliation(s)
- S D Baxter
- Institute for Families in Society, University of South Carolina, Columbia, SC 29208, USA.
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Smith AF, Pope C, Goodwin D, Mort M. Interprofessional handover and patient safety in anaesthesia: observational study of handovers in the recovery room. Br J Anaesth 2008; 101:332-7. [PMID: 18556692 DOI: 10.1093/bja/aen168] [Citation(s) in RCA: 118] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND We aimed to describe how anaesthetists hand over information and professional responsibility to nurses in the operating theatre recovery room. METHODS We carried out non-participant practice observation and in-depth interviews with practitioners working in the recovery room of an English hospital and used qualitative methods to analyse the resulting transcripts. RESULTS We observed 45 handovers taking place between 17 anaesthetists and 15 nurses in the recovery room of the operating theatre suite. These took place in an environment that is event-driven, time-pressured, and prone to concurrent distractions. Anaesthetists and nurses often had differing expectations of the content and timing of information transfer. The point at which transfer of responsibility for the patient occurred during the handover process was variable and depended not only on the condition of the patient but also on the professional relationship between the nurse and doctor concerned. Handover also provided an 'audit point' in care where the patient's intraoperative progress was reviewed and plans were made for further management. Here, as in the transfer of responsibility, we found evidence that nurses play a greater role in defining the limits of anaesthetists' practice than might be expected. CONCLUSIONS Patient handovers in the recovery room are largely informal, but nevertheless show many inherent tensions, both professional and organizational. Although formalized handover procedures are often advocated for the promotion of safety, we suggest that they are likely to work best when the informal elements, and the cultural factors underlying them, are acknowledged.
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Affiliation(s)
- A F Smith
- Department of Anaesthesia, Royal Lancaster Infirmary, Ashton Road, Lancaster LA1 4RP, UK.
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Abstract
Incident reporting is a central strategy for improving safety in the NHS (UK National Health Service). In this paper we discuss incident reporting in anaesthesia. We discuss four schemes for reporting: longstanding, departmental based schemes; newer, hospital wide schemes; a national scheme; and an inter-departmental scheme (developed by the authors). We also discuss an example report. We argue that this example report gives an expert 'story' of an incident, describing the incident in a way that is useful for the practical activities of maintaining and improving safety. We argue that stories are told and retold in reporting schemes. The reporting schemes are not just there to collect data but to afford the stories of what went wrong. In turn these schemes must be afforded stories by the anaesthetists, safety managers and the organisation at large. We consider how schemes can be designed to afford a 'good' story, one that is useful for the maintaining and improvement of safety.
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Affiliation(s)
- J Rooksby
- Computing Department, Lancaster University, UK.
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Abstract
Audit and other means of scrutiny are an essential part of professional clinical practice. However, if we and our patients are to benefit fully from audit, its processes must be supported by the necessary organizational changes to allow improvements to be made to our systems of care.
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Affiliation(s)
- A F Smith
- Department of Anaesthesia, Royal Lancaster Infirmary, Ashton Road, Lancaster, LA1 4RP, UK
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Abstract
BACKGROUND Published work on knowledge in regional anaesthesia has focused on competence, for instance by identifying numbers of procedures required to achieve competence, or by defining criteria for successful performance of blocks. We aimed to define expertise in regional anaesthesia and examine how it is acquired. METHODS We observed anaesthetists performing 15 regional anaesthetic blocks and analysed the resulting transcripts qualitatively and in detail. RESULTS Expertise in regional anaesthesia encompasses technical fluency but also includes non-cognitive skills such as handling of the patient (communicating, anticipating and minimizing discomfort) and recognizing the limits of safe practice (particularly deciding when to stop trying to insert a block). Such elements may be underplayed by the experts who possess them. Focusing on a small number of regional anaesthetic procedures in detail (as is standard with such qualitative analytical approaches) has also allowed us to develop a model for the acquisition of expertise. In this model, trainees learn how to balance theoretical and practical knowledge by reflection on their clinical experiences, an iterative process which leads to the embedding of knowledge in the expert's personal repertoire of individual techniques. CONCLUSIONS Expertise in regional anaesthesia extends beyond competence at technical performance; non-cognitive elements are also vital. Further work is needed to test our learning model, and the hypothesis that learning can be enhanced by deliberate promotion of the tacit elements of 'expertise' we have described.
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Affiliation(s)
- A F Smith
- Department of Anaesthesia, Royal Lancaster Infirmary Ashton Road, Lancaster, UK.
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Abstract
BACKGROUND This study aimed to explore how critical and acceptable practice are defined in anaesthesia and how this influences the discussion and reporting of adverse incidents. Method. We conducted workplace observations of, and interviews with, anaesthetists and anaesthetic staff. Transcripts were analysed qualitatively for recurrent themes and quantitatively for adverse events in anaesthetic process witnessed. We also observed departmental audit meetings and analysed meeting minutes and report forms. RESULTS The educational value of discussing events was well-recognized; 28 events were discussed at departmental meetings, of which 5 (18%) were presented as 'critical incidents'. However, only one incident was reported formally. Our observations of anaesthetic practice revealed 103 minor events during the course of over 50 anaesthetic procedures, but none were acknowledged as offering the potential to improve safety, although some were direct violations of 'acceptable' practice. Formal reporting appears to be constrained by changing boundaries of what might be considered 'critical', by concerns of loss of control over formally reported incidents and by the perception that reporting schemes outside anaesthesia have purposes other than education. CONCLUSIONS Despite clear official definitions of criticality in anaesthesia, there is ambiguity in how these are applied in practice. Many educationally useful events fall outside critical incident reporting schemes. Professional expertise in anaesthesia brings its own implicit safety culture but the reluctance to adopt a more explicit 'systems approach' to adverse events may impede further gains in patient safety in anaesthesia.
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Affiliation(s)
- A F Smith
- Department of Anaesthesia, Lancaster University, Lancaster LA1 4YT, UK.
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Abstract
In this qualitative study using observation and interviews, 10 anaesthetists from five Departments of Anaesthesia in the North-West region of England were enlisted to participate in the design of an online system to allow the sharing of critical incidents. Respondents perceived that existing schemes had differing and sometimes conflicting aims. Reporting was used for reasons other than simply logging incidents in the interests of promoting patient safety. No existing scheme allowed the lessons learned from incidents to be shared between members of the professional group from which they arose. Using participants' suggestions, we designed a simple, secure, anonymous system favouring free-text description, intended to enable the on-line sharing and discussion of selected incidents. Seven incidents were posted during the 6-month pilot period. The practitioners in our study valued the opportunity to share and discuss educational incidents 'horizontally' within their community of practice. We suggest that large-scale reporting systems either incorporate such a function or allow other systems that permit such sharing to co-exist.
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Affiliation(s)
- S Sharma
- Department of Anaesthesia, Blackburn Royal Infirmary, Infirmary Road, Blackburn, BB2 3LR, UK.
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Smith AF, Oakey RJ. Incidence and significance of errors in a patient 'track and trigger' system during an epidemic of Legionnaires' disease: retrospective casenote analysis. Anaesthesia 2006; 61:222-8. [PMID: 16480345 DOI: 10.1111/j.1365-2044.2005.04513.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Early warning scoring is designed to be an objective tool to aid identification of hospital patients at risk of deterioration. 'Track and trigger' systems using such scores are widely used but many aspects of scoring have not been clarified. We aimed to document how observations and scores are used in practice as part of a typical track and trigger system. We extracted patient observations and early warning scores from the casenotes of 189 patients admitted to Furness General Hospital during a large outbreak of Legionnaires' disease in 2002. We used these 3739 sets of primary observations to recalculate scores, and compared them with those recorded in the casenotes. Recording of patient observations was variable. Early warning scores were derived from 2607 sets of observations (69.7%), of which 571 (21.9%) had been incorrectly calculated. Incorrect scoring meant that 66 of 270 patients (24.4%) whose observations should have reached the trigger value did not. Patients with more abnormal observations were more likely to be misscored. Scoring errors were more likely to lead to underscoring as the degree of physiological abnormality increased. Patients with confirmed Legionnaires' disease were more likely to be incorrectly scored. We conclude that the assignment of early warning scores is prone to error and this may delay referral of at-risk patients for critical care management.
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Affiliation(s)
- A F Smith
- Department of Anaesthesia, University Hospitals of Morecambe Bay NHS Trust, Royal Lancaster Infirmary, Lancaster LA1 4RR, UK
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Abstract
This review examines the basic concepts of workload and methods of measuring them. The components of anaesthetists' operating room activities, and the factors contributing to workload, are analysed using an ergonomic-based model for technological environments. The available evidence on the relationship between workload and training and supervision is presented and the effect of workload on the quality and safety of anaesthetic care is reviewed. There is, as yet, only a small body of work examining workload and its effects in anaesthesia. While studies have identified the general pattern of workload in relation to the different stages of the perioperative period, measurement, particularly of overlapping tasks, is still evolving. It is clear, however, that induction and emergence are the most intense periods of both practical and 'non-technical' aspects of work. Allocation of attention to a range of tasks simultaneously is a key characteristic of anaesthetic practice. Experienced staff appear to show 'spare capacity' in performance during routine cases, which, we suggest, allows them an attentional 'safety margin' should adverse events occur. The effects of production pressure and mental 'overload' remain speculative and so practical recommendations for anaesthetic staffing, both in terms of numbers and matching skills to surgical demand, cannot be made. The potential for delegation of tasks, for instance to non-physician anaesthetists, can also not be made on evidence-based grounds. Strategies for active management of workload may be useful in practice.
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Affiliation(s)
- J M Leedal
- Department of Anaesthesia, Royal Lancaster Infirmary, Ashton Road, Lancaster LA1 4RP, UK
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