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This document is a compilation of abstracts from the journal Anaesthesia, featuring research papers and case presentations on various topics related to anaesthesia. The abstracts cover a wide range of subjects, such as non-invasive haemoglobin measurement, anaesthetic registrar handover, and the use of noise-cancelling headphones in regional anaesthesia. These abstracts offer a glimpse into the diverse research being conducted in the field of anaesthesia. Library patrons conducting research in this area can find valuable information and insights from this resource. [Extracted from the article]

Several free paper abstracts are presented including "A Complication of a Rectus Sheath Catheter" by A. White, C. Nutt and K. Spence, "Pythia - Probability Based Operating List Scheduling - Made in Scotland from Data" by D. Duncan and T. Aziz and "Investigating Analgesic and Psychological Factors Associated With Risk of Postpartum Depression Development" by TPT Pham, HY Chen and T. Suhitharan.

We analysed how long it has taken for papers authored by Scott Reuben, Joachim Boldt and Yoshitaka Fujii to be retracted: investigations into these three anaesthetists have shown much of their research to be unethical or fraudulent. To date, 94% of their combined papers requiring retraction have been retracted; however, only 85% of the retraction notices were compliant with guidelines produced by the Committee on Publication Ethics. We contacted the Editors-in-Chief and/or publishers of all the journals containing articles that had been identified as requiring retraction but had not yet been retracted. In response to our enquiries, 16 articles have since been retracted; we have documented the journals' responses regarding the remaining papers and await further retractions in the future. There is room for improvement in the way that unethical or fraudulent papers are handled by journals and publishers, beyond the identification of the authors' misconduct. [ABSTRACT FROM AUTHOR]

Summary: The dedication of the international anaesthetic community to reducing the environmental impact of healthcare is important and to be celebrated. When this is underpinned by robust science, it has the potential to make a real difference. However, volatile anaesthetic agents have been widely promoted in the medical literature as damaging to the climate, leading to a drive to remove them from clinical practice. This is based on notional 'CO2‐equivalent' values created using the simple emission metric known as the global warming potential. Here, we assert that when proper consideration is given to the science of climate change, volatile anaesthetic gas emissions cannot be simply equated to real carbon dioxide emissions, and that their climate impact is vanishingly small. This paper gives anaesthetists a framework to make informed choices founded on climate science and calls for attention to be refocused on the urgent need to reduce the real carbon dioxide emissions associated with healthcare. [ABSTRACT FROM AUTHOR]

The article discusses the lack of skills in doctors needed for evaluating and interpreting scientific papers. The purpose of a scientific publication, of which there are numerous types, is to communicate information. Editorials are summary or personal views, perhaps commenting on a specific paper. Reviews are longer, in-depth analyses of the literature. There are generally two aspects to excellence in an experimental study -- first, the study's conduct and second, its presentation. Particular attention should be given to the avoidance of surrogate measures, appropriate measurement tools, appropriate use of control groups, and appropriate application and interpretation of statistics.

We determined how the quality of trial design and its reporting in scientific papers published in Anaesthesia has changed in the last 25 years. All articles between the years 1983–87 and 2003–07 were reviewed and classified according to methodology. Reporting and trial design of all prospective, comparative clinical interventional trials were compared between the two time periods using 12 criteria. Fewer articles now originate from the United Kingdom and Ireland than 25 years ago. Although fewer human interventional trials are now published in Anaesthesia, the quality of these trials has improved in terms of study design, bias control and proper disclosure. Significant improvements were observed in all criteria of trial design except for the declaration of non-primary adverse outcomes and the minimisation of the risk of type I errors. Further improvements could still be made with respect to sample size calculation, description of the method of randomisation, and blinding. [ABSTRACT FROM AUTHOR]

Forty anaesthetists calculated maximum permissible doses of eight local anaesthetic formulations for simulated patients three times with three methods: an electronic calculator; nomogram; and pen and paper. Correct dose calculations with the nomogram (85/120) were more frequent than with the calculator (71/120) or pen and paper (57/120), Bayes Factor 4 and 287, p = 0.01 and p = 0.0003, respectively. The rates of calculations at least 120% the recommended dose with each method were different, Bayes Factor 7.9, p = 0.0007: 14/120 with the calculator; 5/120 with the nomogram; 13/120 with pen and paper. The median (IQR [range]) speed of calculation with pen and paper, 38.0 (25.0-56.3 [5-142]) s, was slower than with the calculator, 24.5 (17.8-37.5 [6-204]) s, p = 0.0001, or nomogram, 23.0 (18.0-29.0 [4-100]) s, p = 1 × 10-7 . Local anaesthetic dose calculations with the nomogram were more accurate than with an electronic calculator or pen and paper and were faster than with pen and paper. [ABSTRACT FROM AUTHOR]

Guidance for writing a narrative review paper for I Anaesthesia i is shown in Table 3. 3 Table Guidance for writing a narrative review for Anaesthesia. Keywords: evidence; narrative review; peri-operative; systematic review EN evidence narrative review peri-operative systematic review 1162 1166 5 08/07/23 20230901 NES 230901 Over recent years, there has been a marked increase in the number and types of reviews seen in the medical literature. Flaws of narrative reviews Critics will argue that narrative reviews are the lowest form of clinical evidence because they are entirely dependent on the knowledge, experience and communicative ability of the authors. [Extracted from the article]

The article discusses the common statistical errors seen in published scientific studies or review papers. It highlights the two of the myriad problems identified in science reporting such as the misuse of statistics and the overinterpretation of data. The most often used statistical tests seen in the medical literature are also explored including the t-test and Chi-square test.

The primary aim of this review was to identify, analyse and codify the prominence and nature of human factors and ergonomics within difficult airway management algorithms. A directed search across OVID Medline and PubMed databases was performed. All articles were screened for relevance to the research aims and according to predetermined exclusion criteria. We identified 26 published airway management algorithms. A coding framework was iteratively developed identifying human factors and ergonomic specific words and phrases based on the Systems Engineering Initiative for Patient Safety model. This framework was applied to the papers to delineate qualitative and quantitative results. Our results show that human factors are well represented within recent airway management guidelines. Human factors associated with work systems and processes featured more prominently than user and patient outcome measurement and adaption. Human factors are an evolving area in airway management and our results highlight that further considerations are necessary in further guideline development. [ABSTRACT FROM AUTHOR]

The article titled "Judgements of quality of care in NAP7: a clarification from the authors" is a response to an editorial accompanying the 7th National Audit Project (NAP7) paper on obstetric peri-operative cardiac arrest. The authors aim to correct a possible misinterpretation in the editorial regarding the causes of cardiac arrest and inferences about the quality of care. They clarify that while anaesthetic management factors were considered a key cause of maternal cardiac arrests in NAP7, this does not necessarily indicate poor care. The authors provide examples and data to support their argument and emphasize that overall care in obstetric patients was rated good in 53% of cases. [Extracted from the article]

Summary: Over a decade ago, bibliometric analysis predicted the disappearance of UK publishing in anaesthesia by 2020. We repeated this analysis to assess if this had turned out to be the case, searching PubMed for papers associated with UK consultant anaesthetists for 2017–2019 across 15 journals. Although the rate of decline has flattened using the same search filter, including a wider range of publication types shows that outputs still remain at half 1990s levels (381 papers for all 3 years combined), authored by 769 anaesthetists, 274 of whom are associated with an academic centre. There are now 11 identifiable academic units, and a further 15 places where anaesthetists have affiliations with academic centres as individuals. The majority of papers (71%) are in secondary analysis (observational, database and association studies, surveys and meta‐analyses), rather than in primary research (clinical trials or laboratory studies). These data reflect the current academic capacity in terms of publications, academic units and staffing. We discuss how this information can be used to inform a new strategy for UK academic anaesthesia. [ABSTRACT FROM AUTHOR]

The article discusses a study on whether there are any cost benefit in using Litholyme compared to soda lime. The cost of soda lime and Litholyme was compared over 2 sequential 4-week periods in 44 anaesthetic workstations and soda lime canisters were recharged according to Anaesthesia Patient Safety Foundation recommendations once a week routinely. Results show that the hospital might save an estimated 6,747 British pounds per annum by switching from soda lime to Litholyme. [ABSTRACT FROM AUTHOR]

Day-case paediatric tonsillectomy: why is there still a debate? Traditionally, patients undergoing tonsillectomy surgery complicated by OSA were excluded from day-case pathways. Keywords: day surgery; paediatrics; tonsillectomy EN day surgery paediatrics tonsillectomy 248 251 4 02/07/22 20220301 NES 220301 Paediatric day surgery dates back to 1909 when James Nichols, the "father of day surgery", wrote his seminal paper. In addition, the COVID-19 pandemic has highlighted to patients that hospital environments are often not the best place to be unless it is absolutely necessary, and this heightened awareness coupled with the increasing waiting times associated with inpatient surgery should serve to drive the day surgery agenda to the forefront of surgical services planning. [Extracted from the article]

Summary: The Earth's mean surface temperature is already approximately 1.1°C higher than pre‐industrial levels. Exceeding a mean 1.5°C rise by 2050 will make global adaptation to the consequences of climate change less possible. To protect public health, anaesthesia providers need to reduce the contribution their practice makes to global warming. We convened a Working Group of 45 anaesthesia providers with a recognised interest in sustainability, and used a three‐stage modified Delphi consensus process to agree on principles of environmentally sustainable anaesthesia that are achievable worldwide. The Working Group agreed on the following three important underlying statements: patient safety should not be compromised by sustainable anaesthetic practices; high‐, middle‐ and low‐income countries should support each other appropriately in delivering sustainable healthcare (including anaesthesia); and healthcare systems should be mandated to reduce their contribution to global warming. We set out seven fundamental principles to guide anaesthesia providers in the move to environmentally sustainable practice, including: choice of medications and equipment; minimising waste and overuse of resources; and addressing environmental sustainability in anaesthetists' education, research, quality improvement and local healthcare leadership activities. These changes are achievable with minimal material resource and financial investment, and should undergo re‐evaluation and updates as better evidence is published. This paper discusses each principle individually, and directs readers towards further important references. [ABSTRACT FROM AUTHOR]

Traumatic brain injury is the alteration in brain function due to an external force. It is common and affects millions of people worldwide annually. The World Health Organization estimates that 90% of global deaths caused by injuries occur in low- and middle-income countries, with traumatic brain injury contributing up to half of these trauma-related deaths. Patients with traumatic brain injury in low- and middle-income countries have twice the odds of dying compared with their counterparts in high-income countries. Sedation is a key element of care in the management of traumatic brain injury, used for its neuroprotective effects and to prevent secondary brain injury. While sedatives have the potential to improve outcomes, they can be challenging to administer and have potentially dangerous complications. Sedation in low-resource settings should aim to be effective, safe, affordable and feasible. In this paper, we summarise the indications for sedation in traumatic brain injury, the choice of sedative drugs and the pragmatic management and monitoring of sedated traumatic brain injury patients in low-resource settings. [ABSTRACT FROM AUTHOR]

Cervical spine injury occurs in 3%-4% of trauma patients, with around 25% of these patients having a cervical spinal cord injury [2]. Keywords: trauma; intubation, tracheal; cervical spine injury; manual in-line stabilisation; cervical immobilisation EN trauma intubation, tracheal cervical spine injury manual in-line stabilisation cervical immobilisation 850 853 4 05/05/21 20210601 NES 210601 This month's ' I Contemporary Classic i ' focuses on a landmark paper from the 1990s. Like MILS, there is a lack of evidence supporting its efficacy in preventing secondary spinal cord injury and yet this practice is entrenched in trauma practice despite being associated with adverse effects and iatrogenic injury [21, 22]. The authors then simulated the tracheal intubation of the patient with traumatic cervical spine injury by placing the patient's head in a neutral position and applying MILS and cricoid force (Fig. [Extracted from the article]

In 2016 the World Health Organization recommended intra-operative ventilation with 80% inspired oxygen to reduce surgical site infection rates, based upon a meta-analysis of 15 randomised controlled trials, of which two were by Mario Schietroma's research group. Five trials by this group have been retracted for duplication, plagiarism, statistical error and lack of ethical approval. We analysed 40 papers by this group: 24 randomised controlled trials (5064 participants) and 16 observational studies (1847 patients). There was evidence that data integrity was compromised in 38 out of the 40 analysed papers. The distribution of baseline characteristics in randomised controlled trials was unlikely, p = 1.5 × 10-8 : continuous variables within trials were heterogeneous, p = 1.9 × 10-9 , and categorical variables were homogeneous, p = 8.5 × 10-20 . Effects of interventions varied less than expected between studies: for categorical variables, for instance postoperative wound infection, p < 1 × 10-7 , and for continuous variables, for instance HLA-DR concentration, p = 0.00001. Of 184 calculable p values, for baseline variables or results, 179 (98%) were incorrect, ranging from three orders of magnitude too small to 10 orders of magnitude too large. Twenty-one graphs occurred 81 times in 23 out of 40 papers. Liberal peri-operative oxygen did not reduce surgical site infection in a meta-analysis of 20 trials that excluded seven trials by Mario Schietroma and colleagues (odds ratio (95%CI) 0.89 (0.73-1.08); p = 0.23). An update by the World Health Organization has now excluded trials of liberal oxygen by Schietroma's group, four of which have not been retracted. We conclude that Mario Schietroma's work should not inform practice until investigated. [ABSTRACT FROM AUTHOR]

Historical pain was chosen as it was likely to be a more stable pain experience than acute experimental pain. This opinion that measurement of pain is useful holds true today as, although we strive to achieve good peri-operative pain management, almost one fifth of our patients continue to experience severe pain in the first 24 h after surgery [13]. Keywords: pain; pain measurement; visual analogue pain scale EN pain pain measurement visual analogue pain scale 559 562 4 03/04/21 20210401 NES 210401 Michael Rosen's 1976 paper on the reliability of the linear analogue for evaluating pain - now more commonly called a visual analogue scale (VAS) - starts with the words: " I pain is difficult to measure i " [1]. From these recommendations, the modern inpatient pain service evolved, with pain assessment in hospitals today continuing to focus on pain intensity evaluated with the numerical rating, visual analogue or verbal rating scales. [Extracted from the article]

Summary: Concerned that studies contain false data, I analysed the baseline summary data of randomised controlled trials when they were submitted to Anaesthesia from February 2017 to March 2020. I categorised trials with false data as 'zombie' if I thought that the trial was fatally flawed. I analysed 526 submitted trials: 73 (14%) had false data and 43 (8%) I categorised zombie. Individual patient data increased detection of false data and categorisation of trials as zombie compared with trials without individual patient data: 67/153 (44%) false vs. 6/373 (2%) false; and 40/153 (26%) zombie vs. 3/373 (1%) zombie, respectively. The analysis of individual patient data was independently associated with false data (odds ratio (95% credible interval) 47 (17–144); p = 1.3 × 10−12) and zombie trials (odds ratio (95% credible interval) 79 (19–384); p = 5.6 × 10−9). Authors from five countries submitted the majority of trials: China 96 (18%); South Korea 87 (17%); India 44 (8%); Japan 35 (7%); and Egypt 32 (6%). I identified trials with false data and in turn categorised trials zombie for: 27/56 (48%) and 20/56 (36%) Chinese trials; 7/22 (32%) and 1/22 (5%) South Korean trials; 8/13 (62%) and 6/13 (46%) Indian trials; 2/11 (18%) and 2/11 (18%) Japanese trials; and 9/10 (90%) and 7/10 (70%) Egyptian trials, respectively. The review of individual patient data of submitted randomised controlled trials revealed false data in 44%. I think journals should assume that all submitted papers are potentially flawed and editors should review individual patient data before publishing randomised controlled trials. [ABSTRACT FROM AUTHOR]

Summary: Postoperative critical care is a finite resource that is recommended for high‐risk patients. Despite national recommendations specifying that such patients should receive postoperative critical care, there is evidence that these recommendations are not universally followed. We performed a national survey aiming to better understand how patients are risk‐stratified in practice; elucidate clinicians' opinions about how patients should be selected for critical care; and determine factors which affect the actual provision of postoperative critical care. As part of the second Sprint National Anaesthesia Project, epidemiology of critical care after surgery study, we distributed a paper survey to anaesthetists, surgeons and intensivists providing peri‐operative care during a single week in March 2017. We collected data on respondent characteristics, and their opinions of postoperative critical care provision, potential benefits and real‐world challenges. We undertook both quantitative and qualitative analyses to interpret the responses. We received 10,383 survey responses from 237 hospitals across the UK. Consultants used a lower threshold for critical care admission than other career grades, indicating potentially more risk‐averse behaviour. The majority of respondents reported that critical care provision was inadequate, and cited the value of critical care as being predominantly due to higher nurse: patient ratios. Use of objective risk assessment tools was poor, and patients were commonly selected for critical care based on procedure‐specific pathways rather than individualised risk assessment. Challenges were highlighted in the delivery of peri‐operative critical care services, such as an overall lack of capacity, competition for beds with non‐surgical cases and poor flow through the hospital leading to bed 'blockages'. Critical care is perceived to provide benefit to high‐risk surgical patients, but there is variation in practice about the definition and determination of risk, how patients are referred and how to deal with the lack of critical care resources. Future work should focus on evaluating 'enhanced care' units for postoperative patients, how to better implement individualised risk assessment in practice, and how to improve patient flow through hospitals. [ABSTRACT FROM AUTHOR]

Pilot and feasibility studies are preliminary investigations undertaken before a larger study. We hypothesised that only a small proportion of pilot or feasibility studies published in anaesthesia journals were correctly labelled as such. We searched for papers published between 2007 and 2017 in six anaesthesia journals using the text words 'pilot' OR 'feasibility' and included 266 original articles with 26,682 human participants. Only 34 (12.8%) were correctly labelled as a pilot or feasibility study. They were more likely to: have more median (IQR [range]) participants, 73 (40-130 [4-2716]) vs. 27 (15-60 [2-3305], p < 0.001; report feasibility outcomes, 82.4% vs. 4.3%, p < 0.001; and report an intention to convert, 100% vs. 39.7%, p < 0.001. They were less likely to test the efficacy of the primary outcome, 50% vs. 72.8%, p = 0.009; and report firm clinical conclusions 41.2% vs. 67.7%, p = 0.004. Of the studies published more than 5 years ago, correctly labelled pilot or feasibility studies were more likely to precede a published conversion study, 53.8% vs. 16%, p = 0.004. There was no difference between the number of citations 18 (9-44 [2-216]) vs. 20 (7-47 [0-251]), p = 0.865. These results have important consequences for patients, trialists, researchers and funders. We argue that correctly labelled pilot studies enhance the quality of scientific research by encouraging methodological rigour, ensuring scientific validity and reducing research waste. Authors, reviewers, editors and publishers should ensure they adhere to the contents of the 2016 CONSORT extension for pilot and feasibility studies. [ABSTRACT FROM AUTHOR]

The NEWS is a track and trigger risk score designed to identify deteriorating patients with a high risk of death/unintended intensive care admission within 24 h of those vital signs being taken [[4]]. He is indeed correct that the National Early Warning Score (NEWS) was much better at predicting 24-h mortality in the Kovacs et al. [[3]] study on emergency surgical admissions (c-statistic 0.89), than 30-day mortality following emergency bowel surgery in our paper (c-statistic 0.71). [Extracted from the article]

Following the welcome publication of the new consensus guidelines on preventing unrecognised oesophageal intubation by the Project for Universal Management of Airways (PUMA), there have been ongoing discussions on the merits of focusing exclusively on waveform capnography to exclude oesophageal intubation [[1]]. Recalling some landmark cases in airway management, we can estimate the approximate timeframe between induction of anaesthesia and the final outcome. Even rapid sequence induction does not actually describe what rapid means; Safar's landmark 1970 paper refers to I "quick intubation" i , yet this is not quantified [[3]]. [Extracted from the article]

In this paper I explain why I think that most of the models that predict postoperative mortality should not be used when we're talking to patients about postoperative survival. Available models are isolated in time (from survival in the present) and space (from survival outside hospital). We know a lot about survival outside hospitals, with sufficient detail that we can discriminate between a man born in 1975 vs. 1976, or a woman aged 64 years vs. 65 years. We can use survival outside hospitals to inform what we do in hospital. I use my own survival to contrast with the survival of people older or younger than me. I will use my survival to illustrate how I might expect my mortality hazard to temporarily change when I have a scheduled operation (total hip replacement) and when I'm unwell and have an operation (for a fractured femoral neck). People live longer and longer and we operate on people older and older. We are also intervening earlier in progressive diseases, knowing that people are living long enough to experience harm from their progression. There is an evolving conflict between operating on older people and operating on younger people. Who has most to gain from the operation and who has most to gain from peri-operative critical care? Do we prioritise on reducing death now, in patients with relatively short life expectancies, or do we invest in the long-term survival of patients with relatively low rates of dying now? This conundrum is not informed by current risk models, with their focus on one to three postoperative months: we need to know survival outside hospital to gauge the value of what we do in hospital. [ABSTRACT FROM AUTHOR]

We examined the prevalence of novel acronyms in the titles of anaesthetic and related studies and the response of anaesthetists to them. We separately analysed trainee-led research projects in the UK supported by the Research and Audit Federation of Trainees (RAFT), and a 10-year cohort of papers identified using the PubMed literature search tool. We also conducted a survey of 20 anaesthetists within our institution regarding the utility and impact of titles containing acronyms, and their recall of the associated topics. Finally, we developed a scoring system for acronym accuracy and complexity, the ORigin of AcroNym letterinG Used Term AppropriateNess (ORANGUTAN) score, and measured the progression of acronym usage over the 10-year period studied. Our results show that while acronyms themselves are sometimes considered memorable, they do not aid recall of topics and are, in general, not considered helpful. There has been an increase in the prevalence of acronymic titles over 10 years, and in the complexity of acronyms used, suggesting that there is currently a selective pressure favouring the use of acronyms even if they are of limited benefit. [ABSTRACT FROM AUTHOR]

Keywords: cardiac surgery; haemorrhage; resternotomy EN cardiac surgery haemorrhage resternotomy 3 5 3 12/11/20 20210101 NES 210101 Outcomes following cardiac surgery are recorded rigorously and analysed in most countries, with low rates of death in-hospital or within 30 days of surgery. It is not possible to conclude from the paper by Agarwal et al. why the mortality is so high in patients requiring resternotomy, or whether the reason for resternotomy was in any way contributory to a fatal outcome. Agarwal et al. have drawn attention to a sub-group of patients, representing 3.5% of patients having cardiac surgery, who undergo resternotomy and have a subsequent mortality of 16.4%, representing 0.6% of all patients having surgery or nearly 20% of all patients who die following surgery. [Extracted from the article]

To evaluate the performance of four kinds of carbon dioxide (CO2) absorbents (Medisorb® GE Healthcare, Amsorb® Plus Armstrong Medical, YabashiLime® Yabashi Industries, and Sodasorb® LF Grace Performance Chemicals), we measured their dust production, acceptability of colour indicator, and CO2 absorption capacity in in vitro experimental settings and the concentration of compound A in an inspired anaesthetic circuit during in vivo clinical practice. In vitro, the order of the dust amount was Sodasorb LF > Medisorb > Amsorb Plus = YabashiLime both before and after shaking. The order of the color acceptability was similar: Sodasorb LF > Amsorb Plus = Medisorb > YabashiLime both initially and 16 h after CO2 exhaustion. During exposure to 200 ml.min−1 CO2 in vitro, the period until 1 kg of fresh soda lime allowed inspired CO2 to increase to 0.7 kPa (as a mark of utilisation of the absorbent) was longer with Medisorb (1978 min) than with the other absorbents (1270–1375 min). In vivo, compound A (1.0% inspired sevoflurane) was detected only when using Medisorb. While Medisorb has the best ability to absorb CO2, it alone produces compound A. [ABSTRACT FROM AUTHOR]

In a previous paper, one of the authors (JBC) used a chi-squared method to analyse the means (SD) of baseline variables, such as height or weight, from randomised controlled trials by Fujii et al., concluding that the probabilities that the reported distributions arose by chance were infinitesimally small. Subsequent testing of that chi-squared method, using simulation, suggested that the method was incorrect. This paper corrects the chi-squared method and tests its performance and the performance of Monte Carlo simulations and ANOVA to analyse the probability of random sampling. The corrected chi-squared method and ANOVA method became inaccurate when applied to means that were reported imprecisely. Monte Carlo simulations confirmed that baseline data from 158 randomised controlled trials by Fujii et al. were different to those from 329 trials published by other authors and that the distribution of Fujii et al.'s data were different to the expected distribution, both p < 10(-16) . The number of Fujii randomised controlled trials with unlikely distributions was less with Monte Carlo simulation than with the 2012 chi-squared method: 102 vs 117 trials with p < 0.05; 60 vs 86 for p < 0.01; 30 vs 56 for p < 0.001; and 12 vs 24 for p < 0.00001, respectively. The Monte Carlo analysis nevertheless confirmed the original conclusion that the distribution of the data presented by Fujii et al. was extremely unlikely to have arisen from observed data. The Monte Carlo analysis may be an appropriate screening tool to check for non-random (i.e. unreliable) data in randomised controlled trials submitted to journals. [ABSTRACT FROM AUTHOR]

There are multiple methods of assessing the height of block before caesarean section under regional anaesthesia, and surveys of practice suggest considerable variation in practice. So far, little emphasis has been placed on the guidance to be gained from published research literature or textbooks. We therefore set out to investigate the methods of block assessment documented in published articles and textbooks over the past 30 years. We performed two searches of PubMed for randomised clinical trials with caesarean section and either spinal anaesthesia or epidural anaesthesia as major Medical Subject Headings. A total of 284 papers, from 1984 to 2013, were analysed for methods of assessment of sensory and motor block, and the height of block deemed adequate for surgery. We also examined 45 editions of seven anaesthetic textbooks spanning 1950-2014 for recommended methods of assessment and height of block required for caesarean section. Analysis of published papers demonstrated a wide variation in techniques, though there has been a trend towards the increased use of touch, and an increased use of a block height of T5 over the study period. Only 115/284 (40.5%) papers described the method of assessing motor block, with most of those that did (102/115; 88.7%) describing it as the 'Bromage scale', although only five of these (4.9%) matched the original description by Bromage. The required height of block recommended by textbooks has risen over the last 30 years to T4, although only four textbooks made any recommendation about the preferred sensory modality. The variation in methods suggested by surveys of practice is reflected in variation in published trials, and there is little consensus or guidance in anaesthetic textbooks. [ABSTRACT FROM AUTHOR]

In a recent editorial, Myles [1] discusses various tools (and some of their weaknesses) used for judging the quality of anaesthesia research. The first is that it gives limited recognition to researchers who have produced truly ground-breaking, high-impact research but with a relatively small overall number of papers, as their h-index can never be greater than the total number of papers they have published. Self-citations and the quality of anaesthesia research. [Extracted from the article]

A narrative review was carried out to identify articles on monitoring of teamwork, with particular relevance to anaesthetists. The papers reviewed showed that team monitoring takes place both implicitly and explicitly in the anaesthetic environment. No single optimal model of teamwork monitoring for all situations was identified. Most of the studies identified were of a pre-intervention, post-intervention design, without randomisation or control group. Information shared during a formal briefing is more likely to be recalled, and provides a basis for a shared team mental model. A number of studies appeared to show that targeted teamwork training has a positive impact on both teamwork and patient safety. [ABSTRACT FROM AUTHOR]

The article discusses evidence of misunderstanding statistics in scientific papers. It notes that using statistics outside the proper context can mislead the public, markets, and individuals as they deal with uncertainty. It cites that 69 percent of American primary care doctors failed to recommend the correct test when shown statistics for two screening tests. It notes that subjective interpretation makes it difficult to understand statistics and compare risks from different time frames.

This paper shows how recent tax changes to pensions (i.e. new lifetime and annual allowance contribution limits) mean that NHS consultants will need to adopt one of four rational strategies to work and financial planning. Two of those strategies (termed 'Earn Fast, Drop Out' and 'Never Enter') involve a break between work and pensions. The logical consequence of this break is that consultants may exercise options to maximise their total income, which in turn will result in less work within the NHS and more work in alternative higher paying (e.g. private) sectors. A third strategy ('Go Slow, Stay Low') also involves less-than-full-time NHS work. Only one option ('Do Nothing' as a result of the tax changes) has no effect. In short, the tax changes will predictably lead to future senior consultants devoting proportionately much less of their time to NHS work than before. The article discusses the important implications of this conclusion for NHS workforce planning. [ABSTRACT FROM AUTHOR]

There is little known about recyclable intensive care unit waste. We tested the hypotheses that the intensive care unit produces a small proportion (< 10%) of hospital waste, that much waste (> 30%) is recyclable and that there is little (< 10%) cross-contamination of non-infectious with infectious waste. For seven consecutive days in an Australian 10-bedded intensive care unit, we prospectively sorted all waste. The total intensive care unit waste for the week was 540 kg, representing 5% of hospital waste. Of the 401 kg of intensive care unit general waste, recyclables were 230 kg (57%; 95% CI 53–61%), mainly plastics, cardboard and paper. There were 0.4 kg of infectious cross-contamination in the 401 kg of general waste. Intensive care unit waste was a small proportion of all hospital waste. However, there was minimal infectious waste cross-contamination and almost 60% of intensive care unit general waste could be recycled with appropriate safeguards, education and training. [ABSTRACT FROM AUTHOR]

The clinical indications for anaesthetic drugs are developed through peer-reviewed publication of clinical trials. We performed a bibliometric analysis of all human research papers reported in nine general anaesthesia journals over 6 years ( n = 6489), to determine any effects of the 2004 European Clinical Trials Directive on reported drug research in anaesthesia originating from Europe and the United Kingdom. We found 89% studies involved patients and 11% volunteers. Of 3234 (50%) drug studies, 96% were phase IV (post-marketing) trials. Worldwide, the number of research papers fell by 3.6% (p < 0.004) in the 3 years following introduction of the European Clinical Trials Directive (5% Europe, 18% United Kingdom), and drug research papers fell by 12% (p < 0.001; 15% Europe, 29% United Kingdom). The introduction of the Clinical Trials Directive has therefore coincided with a decline in European drug research, particularly that originating from the United Kingdom. We suggest a number of measures researchers could take in response, and we propose a simplification of the application process for phase IV clinical trials, emphasising patient risk assessment. [ABSTRACT FROM AUTHOR]

Both papers mention the rising prevalence of diabetic and prediabetic (approximately 40%) patients needing surgery. Screening for diabetes peri-operatively: should we be measuring glucose, HbA1c ... and insulin? Analysing observational data from 26,653 patients who underwent surgery within one year of recruitment to the UK Biobank, Lam et al. found a significantly raised composite 30-day complication and 90-day mortality rate in 1305 non-diabetics with raised HbA SB 1c sb (>=42 mmol.l SP -1 sp ) compared with 23,255 non-diabetics with "normal" HbA SB 1c sb (<42 mmol.l SP -1 sp ) (4.4% vs. 2.9%, OR [95%CI] 1.43 [1.02-2.02]; p = 0.04), an association which the authors concede was likely confounded by end-organ comorbidity [1]. [Extracted from the article]

We thank O'Sullivan et al. [1] for their interest in our paper [2] and appreciate the opportunity to address some of the concerns they raise about reducing nocebo effects in the context of informed consent. However, the 15 generic patient information sheets pertaining to anaesthesia risk present information in a way that appears to ignore their potential for nocebo effects. During this time, anaesthesia professional bodies and clinicians have attempted to adapt clinical care and communication with patients through the legal lens of informed consent [3]. [Extracted from the article]

The Obstetric Anaesthetists' Association and Difficult Airway Society have developed the first national obstetric guidelines for the safe management of difficult and failed tracheal intubation during general anaesthesia. They comprise four algorithms and two tables. A master algorithm provides an overview. Algorithm 1 gives a framework on how to optimise a safe general anaesthetic technique in the obstetric patient, and emphasises: planning and multidisciplinary communication; how to prevent the rapid oxygen desaturation seen in pregnant women by advocating nasal oxygenation and mask ventilation immediately after induction; limiting intubation attempts to two; and consideration of early release of cricoid pressure if difficulties are encountered. Algorithm 2 summarises the management after declaring failed tracheal intubation with clear decision points, and encourages early insertion of a (preferably second-generation) supraglottic airway device if appropriate. Algorithm 3 covers the management of the 'can't intubate, can't oxygenate' situation and emergency front-of-neck airway access, including the necessity for timely perimortem caesarean section if maternal oxygenation cannot be achieved. Table 1 gives a structure for assessing the individual factors relevant in the decision to awaken or proceed should intubation fail, which include: urgency related to maternal or fetal factors; seniority of the anaesthetist; obesity of the patient; surgical complexity; aspiration risk; potential difficulty with provision of alternative anaesthesia; and post-induction airway device and airway patency. This decision should be considered by the team in advance of performing a general anaesthetic to make a provisional plan should failed intubation occur. The table is also intended to be used as a teaching tool to facilitate discussion and learning regarding the complex nature of decision-making when faced with a failed intubation. Table 2 gives practical considerations of how to awaken or proceed with surgery. The background paper covers recommendations on drugs, new equipment, teaching and training. [ABSTRACT FROM AUTHOR]

This retraction follows an investigation by Jacob-Liebig-University into the research conduct of J. Boldt while teaching at the university and working at the Hospital of the City of Ludwigshafen. They found that data included in his student's MD theses were significantly different from the data in the published research papers where J. Boldt was the responsible author. Therefore the Jacob-Liebig-University recommends that journal editors retract all papers where J. Boldt is the responsible author. [Extracted from the article]

This retraction follows an investigation by Jacob-Liebig-University into the research conduct of J. Boldt while teaching at the university and working at the Hospital of the City of Ludwigshafen. Therefore the Jacob-Liebig-University recommends that journal editors retract all papers where J. Boldt is the responsible author. They found that data included in his student's MD theses were significantly different from the data in the published research papers where J. Boldt was the responsible author. [Extracted from the article]

They found that data included in his student's MD theses were significantly different from the data in the published research papers where J. Boldt was the responsible author. Therefore the Jacob-Liebig-University recommends that journal editors retract all papers where J. Boldt is the responsible author. Retraction: Schmidt CC, Suttner SW, Piper SN, Nagel D, Boldt J. Comparison of the effects of desflurane and isoflurane anaesthesia on hepatocellular function assessed by alpha glutathione S-transferase. [Extracted from the article]

Accidental awareness during general anaesthesia with recall is a potentially distressing complication of general anaesthesia that can lead to psychological harm. The 5th National Audit Project was designed to investigate the reported incidence, predisposing factors, causality and impact of accidental awareness. A nationwide network of local co-ordinators across all UK and Irish public hospitals reported all new patient reports of accidental awareness to a central database, using a system of monthly anonymised reporting over a calendar year. The database collected the details of the reported event, anaesthetic and surgical technique, and any sequelae. These reports were categorised into main types by a multidisciplinary panel, using a formalised process of analysis. The main categories of accidental awareness were: certain or probable; possible; during sedation; on or from the intensive care unit; could not be determined; unlikely; drug errors; and statement only. The degree of evidence to support the categorisation was also defined for each report. Patient experience and sequelae were categorised using current tools or modifications of such. The 5th National Audit Project methodology may be used to assess new reports of accidental awareness during general anaesthesia in a standardised manner, especially for the development of an ongoing database of case reporting. This paper is a shortened version describing the protocols, methods and data analysis from 5th National Audit Project - the full report can be found at . [ABSTRACT FROM AUTHOR]

We present the main findings of the 5th National Audit Project on accidental awareness during general anaesthesia. Incidences were estimated using reports of accidental awareness as the numerator, and a parallel national anaesthetic activity survey to provide denominator data. The incidence of certain/probable and possible accidental awareness cases was ~1:19 600 anaesthetics (95% CI 1:16 700-23 450). However, there was considerable variation across subtypes of techniques or subspecialties. The incidence with neuromuscular blockade was ~1:8200 (1:7030-9700), and without it was ~1:135 900 (1:78 600-299 000). The cases of accidental awareness during general anaesthesia reported to 5th National Audit Project were overwhelmingly cases of unintended awareness during neuromuscular blockade. The incidence of accidental awareness during caesarean section was ~1:670 (1:380-1300). Two thirds (82, 66%) of cases of accidental awareness experiences arose in the dynamic phases of anaesthesia, namely induction of and emergence from anaesthesia. During induction of anaesthesia, contributory factors included: use of thiopental; rapid sequence induction; obesity; difficult airway management; neuromuscular blockade; and interruptions of anaesthetic delivery during movement from anaesthetic room to theatre. During emergence from anaesthesia, residual paralysis was perceived by patients as accidental awareness, and commonly related to a failure to ensure full return of motor capacity. One third (43, 33%) of accidental awareness events arose during the maintenance phase of anaesthesia, most due to problems at induction or towards the end of anaesthesia. Factors increasing the risk of accidental awareness included: female sex; age (younger adults, but not children); obesity; anaesthetist seniority (junior trainees); previous awareness; out-of-hours operating; emergencies; type of surgery (obstetric, cardiac, thoracic); and use of neuromuscular blockade. The following factors were not risk factors for accidental awareness: ASA physical status; race; and use or omission of nitrous oxide. We recommend that an anaesthetic checklist, to be an integral part of the World Health Organization Safer Surgery checklist, is introduced as an aid to preventing accidental awareness. This paper is a shortened version describing the main findings from 5th National Audit Project - the full report can be found at . [ABSTRACT FROM AUTHOR]

We thank Cook et al. [1] for their interest in our paper [2]. References 1 Cook TM, Kelly F, Pearse R, Nolan J. Anaesthesia research capacity: time for a rethink in light of the COVID-19 pandemic. [Extracted from the article]

Two recent papers in I Anaesthesia i studied aerosol generation with anaesthesia (tracheal intubation and extubation) and appear to present opposing conclusions. The data (especially that of Brown et al. [2]) need to be reconciled with the best data we have of rates of infection amongst anaesthetists engaged in aerosol-generating procedures, which is that from the intubateCOVID study [3, 4]. [Extracted from the article]

The endothelial glycocalyx is an important part of the vascular barrier. The glycocalyx is intimately linked to the homoeostatic functions of the endothelium. Damage to the glycocalyx precedes vascular pathology. In the first part of this paper, we have reviewed the structure, physiology and pathology of the endothelial glycocalyx, based on a literature search of the past five years. In the second part, we have systematically reviewed interventions to protect or repair the glycocalyx. Glycocalyx damage can be caused by hypervolaemia and hyperglycaemia and can be prevented by maintaining a physiological concentration of plasma protein, particularly albumin. Other interventions have been investigated in animal models: these require clinical research before their introduction into medical practice. [ABSTRACT FROM AUTHOR]

Although epidural analgesia is routinely used in many institutions for patients undergoing hepatic resection, there are unresolved issues regarding its safety and efficacy in this setting. We performed a review of papers published in the area of anaesthesia and analgesia for liver resection surgery and selected four areas of current controversy for the focus of this review: the safety of epidural catheters with respect to postoperative coagulopathy, a common feature of this type of surgery; analgesic efficacy; associated peri-operative fluid administration; and the role of epidural analgesia in enhanced recovery protocols. In all four areas, issues are raised that question whether epidural anaesthesia is always the best choice for these patients. Unfortunately, the evidence available is insufficient to provide definitive answers, and it is clear that there are a number of areas of controversy that would benefit from high-quality clinical trials. [ABSTRACT FROM AUTHOR]

The number of anaesthetists who are involved in magnetic resonance (MR) units is increasing. Magnetic resonance systems are becoming more powerful and interventional procedures are now possible. This paper updates information relating to safety terminology, occupational exposure, reactions to gadolinium-based contrast agents and the risk of nephrogenic systemic fibrosis. Magnetic resonance examinations of patients with pacemakers are still generally contra-indicated but have been carried out in specialist centres under strictly controlled conditions. As availability of MR increases, so the education of anaesthetists, who are occasionally required to provide a service, must be considered. Anaesthesia in MR units was first described in the 1980s. Guidelines on the provision of anaesthetic services in MR units were published by the Association of Anaesthetists of Great Britain and Ireland (AAGBI) in 2002 [1]. Since then, the number of hospitals with MR units, and hence the number of patients requiring anaesthesia for MR, has increased. While the issues relating to setting up anaesthetic services in MR have not changed, there have been a number of developments that warrant this update: 1 Safety terminology and guidelines have changed. 2 MR systems utilise higher magnetic-field strengths and more open designs are available. 3 Interventional and intra-operative MR are now routine in some centres. 4 Mobile MR scanners are increasingly used to reduce waiting lists. 5 Although still generally contra-indicated, some patients with pacemakers have been scanned under strictly controlled conditions in specialist centres. 6 'MR safe' medical implants are now being produced. 7 New equipment is now available for use in MR. 8 Out-of-hours availability of MR investigations has increased. 9 Reports of allergic reactions to MR contrast media have increased. 10 Gadolinium based contrast agents (Gd-CAs) are associated with a varying degree of risk of nephrogenic systemic fibrosis in patients with impaired renal function. [ABSTRACT FROM AUTHOR]