Peri-operative care of the elderly 2014: Association of Anaesthetists of Great Britain and Ireland.

Increasing numbers of elderly patients are undergoing an increasing variety of surgical procedures. There is an age-related decline in physiological reserve, which may be compounded by illness, cognitive decline, frailty and polypharmacy. Compared with younger surgical patients, the elderly are at relatively higher risk of mortality and morbidity after elective and (especially) emergency surgery. Multidisciplinary care improves outcomes for elderly surgical patients. Protocol-driven integrated pathways guide care effectively, but must be individualised to suit each patient. The AAGBI strongly supports an expanded role for senior geriatricians in coordinating peri-operative care for the elderly, with input from senior anaesthetists (consultants/associate specialists) and surgeons. The aims of peri-operative care are to treat elderly patients in a timely, dignified manner, and to optimise rehabilitation by avoiding postoperative complications. Effective peri-operative care improves the likelihood of very elderly surgical patients returning to their same pre-morbid place of residence, and maintains the continuity of their community care when in hospital. Postoperative delirium is common, but underdiagnosed, in elderly surgical patients, and delays rehabilitation. Multimodal intervention strategies are recommended for preventing postoperative delirium. Peri-operative pain is common, but underappreciated, in elderly surgical patients, particularly if they are cognitively impaired. Anaesthetists should administer opioid-sparing analgesia where possible, and follow published guidance on the management of pain in older people. Elderly patients should be assumed to have the mental capacity to make decisions about their treatment. Good communication is essential to this process. If they clearly lack that capacity, proxy information should be sought to determine what treatment, if any, is in the patient's best interests. Anaesthetists must not ration surgical or critical care on the basis of age, but must be involved in discussions about the utility of surgery and/or resuscitation. The evidence base informing peri-operative care for the elderly remains poor. Anaesthetists are strongly encouraged to become involved in national audit projects and outcomes research specifically involving elderly surgical patients.

Elbow extension test to rule out elbow fracture: multicentre, prospective validation and observational study of diagnostic accuracy in adults and children.

OBJECTIVE: To determine whether full elbow extension as assessed by the elbow extension test can be used in routine clinical practice to rule out bony injury in patients presenting with elbow injury. DESIGN: Adults: multicentre prospective interventional validation study in secondary care. Children: multicentre prospective observational study in secondary care. SETTING: Five emergency departments in southwest England. PARTICIPANTS: 2127 adults and children presenting to the emergency department with acute elbow injury. INTERVENTION: Elbow extension test during routine care by clinical staff to determine the need for radiography in adults and to guide follow-up in children. MAIN OUTCOME MEASURES: Presence of elbow fracture on radiograph, or recovery with no indication for further review at 7-10 days. RESULTS: Of 1740 eligible participants, 602 patients were able to fully extend their elbow; 17 of these patients had a fracture. Two adult patients with olecranon fractures needed a change in treatment. In the 1138 patients without full elbow extension, 521 fractures were identified. Overall, the test had sensitivity and specificity (95% confidence interval) for detecting elbow fracture of 96.8% (95.0 to 98.2) and 48.5% (45.6 to 51.4). Full elbow extension had a negative predictive value for fracture of 98.4% (96.3 to 99.5) in adults and 95.8% (92.6 to 97.8) in children. Negative likelihood ratios were 0.03 (0.01 to 0.08) in adults and 0.11 (0.06 to 0.19) in children. CONCLUSION: The elbow extension test can be used in routine practice to inform clinical decision making. Patients who cannot fully extend their elbow after injury should be referred for radiography, as they have a nearly 50% chance of fracture. For those able to fully extend their elbow, radiography can be deferred if the practitioner is confident that an olecranon fracture is not present. Patients who do not undergo radiography should return if symptoms have not resolved within 7-10 days.

Phase Equilibria and Crystal Chemistry in Portions of the System SrO-CaO-Bi2O3-CuO, Part II-The System SrO-Bi2O3-CuO.

New data are presented on the phase equilibria and crystal chemistry of the binary systems Sr0-Bi203 and SrO-CuO and the ternary system SrO-Bi2O3-CuO. Symmetry data and unit cell dimensions based on single crystal and powder x-ray diffraction measurements are reported for all the binary SrO-Bi2O3 phases, including a new phase identified as Sr6Bi2O9. The ternary system contains at least four ternary phases which can be formed in air at ~900 °C. These are identified as Sr2Bi2CuO6, Sr8Bi4Cu5O19+x , Sr3Bi2Cu2O8 and a solid solution (the Raveau phase) which, for equilibrium conditions at ~900 °C, corresponds approximately to the formula Sr1.8-x Bi2.2+x Cu1±x/2O z .(0.0⩽x⩽~0.15). Superconductivity in this phase apparently occurs only in compositions that correspond to negative values of x. Compositions that lie outside the equilibrium Raveau-phase field often form nearly homogeneous Raveau-phase products. Typically this occurs after relatively brief heat treatments, or in crystallization of a quenched melt.