Guidelines on suicide amongst anaesthetists 2019.

Anaesthetists are thought to be at increased risk of suicide amongst the medical profession. The aims of the following guidelines are: increase awareness of suicide and associated vulnerabilities, risk factors and precipitants; to emphasise safe ways to respond to individuals in distress, both for them and for colleagues working alongside them; and to support individuals, departments and organisations in coping with a suicide.

A mixed-methods evaluation of the Association of Anaesthetists of Great Britain and Ireland Uganda Fellowship Scheme.

The Association of Anaesthetists of Great Britain and Ireland and the then Uganda Society of Anaesthesia established the Uganda Fellowship Scheme in 2006, to provide scholarships to encourage doctors to train in anaesthesia in Uganda. We conducted an evaluation of this programme using online questionnaires and face-to-face semi-structured interviews with trainees who received scholarships, as well as with senior surgeons and anaesthetists. Focus group discussions were held to assess changes in attitudes towards anaesthesia over the last 10 years. Interviews were recorded, transcribed and analysed using the constant comparative method. A total of 54 Ugandan doctors have received anaesthesia scholarships since 2006 (median funding per trainee (IQR [range]) £5520 (£5520-£6750 [£765-£9000]). There has been a four-fold increase in the number of physician anaesthetists in Uganda during this time. All those who received funding remain in the region. The speciality of anaesthesia is undergoing a dramatic transformation led by this group of motivated young anaesthetists. There is increased access to intensive care, and this has allowed surgical specialities to develop. There is greater understanding and visibility of anaesthesia, and the quality of education in anaesthesia throughout the country has improved. The Uganda Fellowship Scheme provided a relatively small financial incentive to encourage doctors to train as anaesthetists. Evaluation of the project shows a wide-ranging impact that extends beyond the initial goal of simply improving human resource capacity. Financial incentives combined with strong 'north-south' links between professional organisations can play an important role in tackling the shortage of anaesthesia providers in a low-income country and in improving access to safe surgery and anaesthesia.

Secondary analysis of outcomes after 11,085 hip fracture operations from the prospective UK Anaesthesia Sprint Audit of Practice (ASAP-2).

We re-analysed prospective data collected by anaesthetists in the Anaesthesia Sprint Audit of Practice (ASAP-1) to describe associations with linked outcome data. Mortality was 165/11,085 (1.5%) 5 days and 563/11,085 (5.1%) 30 days after surgery and was not associated with anaesthetic technique (general vs. spinal, with or without peripheral nerve blockade). The risk of death increased as blood pressure fell: the odds ratio (95% CI) for mortality within five days after surgery was 0.983 (0.973-0.994) for each 5 mmHg intra-operative increment in systolic blood pressure, p = 0.0016, and 0.980 (0.967-0.993) for each mmHg increment in mean pressure, p = 0.0039. The equivalent odds ratios (95% CI) for 30-day mortality were 0.968 (0.951-0.985), p = 0.0003 and 0.976 (0.964-0.988), p = 0.0001, respectively. The lowest systolic blood pressure after intrathecal local anaesthetic relative to before induction was weakly correlated with a higher volume of subarachnoid bupivacaine: r(2) -0.10 and -0.16 for hyperbaric and isobaric bupivacaine, respectively. A mean 20% relative fall in systolic blood pressure correlated with an administered volume of 1.44 ml hyperbaric bupivacaine. Future research should focus on refining standardised anaesthesia towards administering lower doses of spinal (and general) anaesthesia and maintaining normotension.

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.

Emergency contraception provision in the UK.

PIP: In the UK, 1/3 of births are unplanned despite the wide availability of free contraception. Therefore, the Family Planning (FP) Association has been reviewing the provision of emergency contraception (EC). The IUD and hormonal formulations have long been available for EC use, and about 400,000 women in the UK use EC each year, with most of them choosing the hormonal pill regimen. This entails 2 doses of 100 mcg estrogen and 500 mcg progestogen, with the 1st dose taken within 72 hours of unprotected intercourse and the 2nd dose taken exactly 12 hours later. The IUD for EC should be inserted within 5 days of unprotected intercourse. Most women obtain EC from general practitioners (GPs) or from FP clinics. The availability of EC is not widely publicized, however, and women may have difficulty getting an appointment soon enough. Although many women have heard of EC, they lack detailed knowledge of how it works, the time limits, and how to obtain it. Health professionals also require further education about the use of this method of contraception. The EC guidelines for doctors were recently updated, therefore, and a public information campaign about EC was launched that included the distribution of information packs to GPs, FP clinics, pharmacies, and other National Health Service contacts. The consumer phase of the campaign included radio and magazine advertisements and was covered widely in the media. Access to EC may improve after the campaign, but the biggest impact on access would be to change the prescribing status to "over-the-counter." This possibility is, therefore, being explored as an alternative to (not a replacement of) the free provision of service by GPs or FP clinics. While service delivery is being explored, research is progressing into the use of mifepristone as an EC with fewer side effects than the current hormonal regimen.^ieng

Comment.

PIP: In 1974, FPA's nationwide network of clinics became part of the National Health Service (NHS). A year later, general practitioners (GPs) began offering contraceptive services. Although there had been fierce political debate over the NHS Reorganization Bill which brought family planning into the NHS, and strong opposition to the provision of free contraceptive supplies, free contraception is taken for granted today. Government policy states that the health of the nation calls for services to be appropriate, accessible, and comprehensive in order to reduce the number of unplanned pregnancies, and that people should be freely able to choose between a GP or a clinic. Research published by the FPA and the Contraceptive Alliance offers proof of the cost-effectiveness of the provision. Family planning services, which represent 0.5% of total health care expenditures, prevent an estimated 4 million pregnancies annually, saving nearly 25 billion pounds a year in health and social security budgets. Every pound spent on contraceptive services saves 11 pounds for the public purse. In spite of this, contraception has been placed on the Selected List, and clinic services have been cut in the last 10 years. Access to highly effective, but more expensive, implants and intrauterine systems is restricted because of budget limitations.^ieng