Guideline for the management of hip fractures 2020: Guideline by the Association of Anaesthetists.

We convened a multidisciplinary Working Party on behalf of the Association of Anaesthetists to update the 2011 guidance on the peri-operative management of people with hip fracture. Importantly, these guidelines describe the core aims and principles of peri-operative management, recommending greater standardisation of anaesthetic practice as a component of multidisciplinary care. Although much of the 2011 guidance remains applicable to contemporary practice, new evidence and consensus inform the additional recommendations made in this document. Specific changes to the 2011 guidance relate to analgesia, medicolegal practice, risk assessment, bone cement implantation syndrome and regional review networks. Areas of controversy remain, and we discuss these in further detail, relating to the mode of anaesthesia, surgical delay, blood management and transfusion thresholds, echocardiography, anticoagulant and antiplatelet management and postoperative discharge destination. Finally, these guidelines provide links to supplemental online material that can be used at readers' institutions, key references and UK national guidance about the peri-operative care of people with hip and periprosthetic fractures during the COVID-19 pandemic.

Allergic responses induced by goat milk αS1-casein in a murine model of gastrointestinal atopy.

Up to 3% of young children develop milk allergy and this may influence the development of immune-mediated diseases in later life. One protein that has been associated with allergic reactions to ruminant milk is α(S1)-casein (CN). Studies suggest that goat milk with low levels of α(S1)-CN may reduce allergenicity of milk, but the dose response to α(S1)-CN has not been confirmed. In this study, we examined the immune response to varying levels of goat α(S1)-CN in a mouse model of gastrointestinal allergy. BALB/c mice (aged 5 wk) were given intraperitoneal injections with α(S1)-CN and aluminum as adjuvant at 1 and 3 wk to sensitize mice to the antigen. In wk 5, groups of fasting mice (n=8/group) were challenged 4 times on alternate days by intragastric gavage with saline or 2, 10, or 20mg of α(S1)-CN. Serum levels of specific IgE, IgG(1), and IgG(2a) antibodies and mouse mast cell protease-I were determined. Interleukin-4, IL-10, and IFN-γ responses to 48-h activation with antigen were measured in cultured splenocytes. We determined that mice sensitized with α(S1)-CN had higher titers of specific IgG(1) and IgE antibodies compared with controls; however, groups challenged with differing doses of α(S1)-CN did not differ. The group challenged with the highest dose of α(S1)-CN had a 10-fold increase in mouse mast cell protease-I compared with the group challenged with saline. Both IL-4 and IL-10 were produced in a dose-dependent manner by cultured splenocytes incubated with α(S1)-CN. Overall, α(S1)-CN stimulated the production of cytokines associated with allergic disease in a dose-dependent manner. Thus, milk with lower levels of α(S1)-CN should contribute to a lesser antigenic burden.

A comparison of the Glidescope and Karl Storz DCI videolaryngoscopes in a paediatric manikin.

A new paediatric Glidescope (Cobalt GVL Stat) has recently become available. This varies in design from the Karl Storz DCI videolaryngoscope, as it possesses a short curved disposable blade compared with the narrower straighter blade of the Storz. We compared the time taken for tracheal intubation under normal and difficult intubation conditions in a paediatric manikin. A total of 32 anaesthetists completed four intubations in a random order, with each participant blinded to the airway condition. We hypothesised there would be no difference between the devices. The results showed no difference in tracheal intubation time between the Glidescope and the Storz videolaryngoscope. The mean (SD) times under normal conditions were 18.8 (5.2) s vs 19.9 (6.1) s, (p = 0.16), respectively. Under difficult conditions the times were 22.6 (10.5) vs 27.0 (14.2) s, (p = 0.13), respectively. There were no differences in the visual analogue scores for field of view, ease of use, willingness to use in an emergency, and overall satisfaction.

A simulation-based evaluation of two proposed alternatives to Luer devices for use in neuraxial anaesthesia.

The National Patient Safety Agency has issued a Patient Safety Alert with the aim of eliminating Luer connectors from equipment for lumbar puncture and subarachnoid injections by 1 April 2011, and from all neuraxial and regional anaesthesia equipment in 2013. B-link (UK) Ltd and InterVene Ltd have produced non-Luer connectors for neuraxial devices: the Neurax and Spinalok respectively. Using an adult spinal simulator, 59 experienced clinicians performed neuraxial procedures using these devices and reported on specific performance characteristics and overall usability. Cross-connectivity between non-Luer and Luer connectors was also examined. The median (IQR [range]) overall assessment scores (0-10 scale) of usability for the standard, Neurax and Spinalok systems were 8 (8-9 [7-10]), 6 (5-7 [0-8]) and 7 (6-8 [1-9]) for spinal procedures and 8 (8-9 [6-10]), 7 (5-8 [1-9]) and 4 (3-6 [0-9]) for epidural procedures, respectively. Both study systems scored significantly lower than standard equipment for overall performance of spinal and epidural procedures, although the performance of non-Luer devices was mostly rated 'adequate' or better. Both non-Luer connectors could cross-connect with one or more Luer connectors. Following feedback to the manufacturers, both systems have been modified and cross-connectivity apparently has been eliminated. Our results indicate that clinicians may not find non-Luer devices immediately 'user-friendly'. More importantly, some cross-connectivity with Luer devices was possible. Our findings illustrate that introducing equipment that is fully compliant with the National Patient Safety Agency alert poses a significant challenge to manufacturers and clinicians. We conclude that before introducing any non-Luer device into widespread use, independent, formal evaluation should be carried out.

Facilitation of internal locus of control in adolescent alcoholics through a brief biofeedback-assisted autogenic relaxation training procedure.

The purpose of the study was to determine if autogenic relaxation training facilitated through biofeedback promotes an increase in internal levels of locus of control. The participants were residents of two Southwest Missouri alcohol treatment centers and ranged in age from 18 to 21 years. Treatment and control groups were compared on their responses on the Drinking Related Locus of Control Scale (DRIE) and fingertip temperature pre- and posttraining. The training was effective in teaching autogenic relaxation as demonstrated by increased fingertip temperature for the treatment group posttraining, while no differences were observed for the control group. Most importantly, the treatment group was not only significantly more internal in their locus of control after training but were also significantly more internal than the control group posttraining. Given that alcoholics are significantly more external in their locus of control than nonalcoholics, and that an internal locus of control implies an individual's belief that he or she has control and is responsible for his or her behavior, autogenic relaxation facilitated through biofeedback may be a very important component in therapeutic intervention for adolescent alcoholics.

Influence of knowledge and religiousness on attitudes toward organ donation.

There remains a great need for organ donation. Each year thousands of individuals wait for organs to be donated for transplantation. In this study, the Organ Donation Attitude Survey (ODAS) was developed. One hundred ninety undergraduate students (114 women with a mean age of 20.0 and 76 men with a mean age of 20.5 years) enrolled in general education classes at a small midwestern university participated. The present study determined that ODAS is a reliable and valid instrument to assess attitudes regarding organ donation. The data were analyzed by stepwise regression to determine which variables were related to attitudes regarding organ donation. The results indicated the impact of four variables: education regarding organ donation, knowledge of someone who had donated an organ after death, awareness of anyone who received a donated organ, and religious beliefs. These significant variables in the regression analysis explained 24.95% of the ODAS total score variability. The most important results of the present study indicated that the ODAS was psychometrically valid and it could be used to evaluate attitudes regarding organ donation.