'How long do you think?' Unresponsive dying patients in a specialist palliative care service: A consecutive cohort study.

BACKGROUND: Predicting length of time to death once the person is unresponsive and deemed to be dying remains uncertain. Knowing approximately how many hours or days dying loved ones have left is crucial for families and clinicians to guide decision-making and plan end-of-life care. AIM: To determine the length of time between becoming unresponsive and death, and whether age, gender, diagnosis or location-of-care predicted length of time to death. DESIGN: Retrospective cohort study. Time from allocation of an Australia-modified Karnofsky Performance Status (AKPS) 10 to death was analysed using descriptive narrative. Interval-censored survival analysis was used to determine the duration of patient's final phase of life, taking into account variation across age, gender, diagnosis and location of death. SETTING/PARTICIPANTS: A total of 786 patients, 18 years of age or over, who received specialist palliative care: as hospice in-patients, in the community and in aged care homes, between January 1st and October 31st, 2022. RESULTS: The time to death after a change to AKPS 10 is 2 days (n = 382; mean = 2.1; median = 1). Having adjusted for age, cancer, gender, the standard deviation of AKPS for the 7-day period prior to death, the likelihood of death within 2 days is 47%, with 84% of patients dying within 4 days. CONCLUSION: This study provides valuable new knowledge to support clinicians' confidence when responding to the 'how long' question and can inform decision-making at end-of-life. Further research using the AKPS could provide greater certainty for answering 'how long' questions across the illness trajectory.

Postoperative pain trajectory and opioid requirements after laparoscopic bariatric surgery: a single-centre historical cohort study.

PURPOSE: Concerns around delayed emergence and opioid-induced ventilatory impairment in bariatric surgery can lead to intraoperative reliance on short-acting opioids and avoidance of long-acting analgesics with potential sedative effects. Nevertheless, an overly-conservative intraoperative analgesic strategy may result in significant pain at emergence and higher opioid requirements in later phases of care. We sought to establish the pattern of intraoperative analgesic use in bariatric surgical patients as well as their postoperative pain trajectory and opioid requirements. METHODS: We undertook a single-centre historical cohort study. We explored associations between intraoperative analgesic interventions and pain scores and opioid requirements in postanesthesia care units (PACUs), and associations between the quality of analgesia at emergence and subsequent pain and patient-centred recovery outcomes. RESULTS: We extracted perioperative data for 939 patients who underwent bariatric metabolic surgery between January 2018 and October 2019. Only 39% of patients received long-acting opioids intraoperatively and there was minimal use of nonopioid analgesic adjuncts. Nearly 80% of patients reported moderate-to-severe pain on PACU arrival; 97% of patients received intravenous opioids for rescue analgesia (mean dose, 31 mg oral morphine equivalents). Lower pain scores at PACU admission and discharge were associated with subsequent lower inpatient pain scores, lower opioid requirements, shorter time to ambulation, and shorter length of hospital stay. CONCLUSION: In bariatric surgical patients, effective intraoperative analgesic strategies that improve early pain control may have an impact on recovery and pain experience. Judicious use of intraoperative opioids coupled with opioid-sparing multimodal analgesic techniques should be considered and balanced against concerns regarding opioid-related adverse effects in this patient population.

RéSUMé: OBJECTIF: Les préoccupations concernant l'émergence retardée et l'insuffisance ventilatoire induite par les opioïdes en chirurgie bariatrique peuvent conduire à une dépendance peropératoire aux opioïdes à courte durée d'action et à l'évitement des analgésiques à action prolongée ayant des effets sédatifs potentiels. Néanmoins, une stratégie analgésique peropératoire trop conservatrice peut entraîner une douleur importante à l'émergence et des besoins en opioïdes plus élevés dans les phases ultérieures des soins. Nous avons cherché à établir le profil d'utilisation des analgésiques peropératoires chez les patient·es en chirurgie bariatrique ainsi que leur trajectoire de douleur postopératoire et leurs besoins en opioïdes. MéTHODE: Nous avons mené une étude de cohorte historique monocentrique. Nous avons exploré les associations entre les interventions analgésiques peropératoires et les scores de douleur et les besoins en opioïdes dans les salles de réveil, ainsi que les associations entre la qualité de l'analgésie à l'émergence et la douleur ultérieure et les résultats de récupération centrés sur les patient·es. RéSULTATS: Nous avons extrait les données périopératoires de 939 patient·es ayant bénéficié d'une chirurgie métabolique bariatrique entre janvier 2018 et octobre 2019. Seulement 39 % des patient·es ont reçu des opioïdes à action prolongée en peropératoire et l'utilisation d'analgésiques auxiliaires non opioïdes a été minimale. Près de 80 % des patient·es ont signalé une douleur modérée à sévère à leur arrivée en salle de réveil; 97 % des patient·es ont reçu des opioïdes par voie intraveineuse pour une analgésie de secours (dose moyenne, équivalents de morphine orale de 31 mg). Des scores de douleur plus faibles à l'admission et à la sortie de la salle de réveil ont été associés à des scores de douleur plus faibles en milieu hospitalier, à des besoins en opioïdes plus faibles, à un délai avant l'ambulation plus court et à une durée d'hospitalisation plus courte. CONCLUSION: Chez la patientèle de chirurgie bariatrique, des stratégies analgésiques peropératoires efficaces qui améliorent le contrôle précoce de la douleur peuvent avoir un impact sur la récupération et l'expérience de la douleur. L'utilisation judicieuse d'opioïdes peropératoires associée à des techniques analgésiques multimodales d'épargne opioïde doit être envisagée et mise en balance avec les préoccupations concernant les effets indésirables liés aux opioïdes dans cette population de patient·es.

Incidence and factors impacting PTSD following the 2005 Eyre Peninsula bushfires in South Australia - A 7 year follow up study.

OBJECTIVES: To identify the incidence and factors impacting post-traumatic stress disorder (PTSD) at 6 months, 2 and 7 years following the 2005 Eyre Peninsula bushfires in South Australia. METHODS: A questionnaire was used to assess symptoms. DESIGN AND SETTING: A longitudinal follow-up study with responses collected from a self-report booklet. PARTICIPANTS: 179 respondents were present at 6 months post bushfires, with 103 and 87 participants at 2 and 7 years, respectively. MAIN OUTCOME MEASURES: PTSD rates and its precipitating factors. RESULTS: The proportion of PTSD cases at times 1, 2 and 3 were 13.4% (24/179), 10.7% (11/103), and 4.8% (4/87), respectively. At 6 months, terrifying experience of fire reduced odds of developing PTSD (Odds Ratio [OR]: 0.45; 95% CI 0.21-0.96) while relocation increased odds (OR: 2.93; 95% CI 1.06-8.08). At 2 years, relocation (OR: 6.81; 95% CI 1.07-43.41) was a positive predictor. At 7 years, personal loss from the fires (OR: 2.82; 95% CI 1.17-6.77) positively predicted PTSD. CONCLUSION: PTSD rates declined over time. Relocation may be a proxy measure of high levels of emotional trauma. Those most traumatised probably decided to relocate, and hence, relocation should be considered a trigger for PTSD in the aftermath of bushfire.

Context and mechanisms that enable implementation of specialist palliative care Needs Rounds in care homes: results from a qualitative interview study.

BACKGROUND: Improving quality of palliative and end of life care in older people's care homes is essential. Increasing numbers of people die in these settings, yet access to high quality palliative care is not routinely provided. While evidence for models of care are growing, there remains little insight regarding how to translate evidence-based models into practice. Palliative Care Needs Rounds (hereafter Needs Rounds) have a robust evidence base, for providing palliative care in care homes, reducing resident hospitalisations, improving residents' quality of death, and increasing staff confidence in caring for dying residents. This study aimed to identify and describe the context and mechanisms of change that facilitate implementation of Needs Rounds in care homes, and enable other services to reap the benefits of the Needs Rounds approach to care provision. METHODS: Qualitative interviews, embedded within a large randomised control trial, were conducted with a purposive sample of 21 staff from 11 care homes using Needs Rounds. The sample included managers, nurses, and care assistants. Staff participated in individual or dyadic semi-structured interviews. Implementation science frameworks and thematic analysis were used to interpret and analyse the data. RESULTS: Contextual factors affecting implementation included facility preparedness for change, leadership, staff knowledge and skills, and organisational policies. Mechanisms of change that facilitated implementation included staff as facilitators, identifying and triaging residents, strategizing knowledge exchange, and changing clinical approaches to care. Care home staff also identified planning and documentation, and shifts in communication. The outcomes reported by staff suggest reductions in hospitalisations and problematic symptoms for residents, improved staff skills and confidence in caring for residents in their last months, weeks and days of life. CONCLUSIONS: The significance of this paper is in offering care homes detailed insights into service contexts and mechanisms of change that will enable them to reap the benefits of Needs Rounds in their own services. The paper thus will support the implementation of an approach to care that has a robust evidence base, for a population under-served by specialist palliative care. TRIAL REGISTRATION: ACTRN12617000080325 .

Reducing time in acute hospitals: A stepped-wedge randomised control trial of a specialist palliative care intervention in residential care homes.

BACKGROUND: Care home residents are frequently transferred to hospital, rather than provided with appropriate and timely specialist care in the care home. AIM: To determine whether a model of care providing specialist palliative care in care homes, called Specialist Palliative Care Needs Rounds, could reduce length of stay in hospital. DESIGN: Stepped-wedge randomised control trial. The primary outcome was length of stay in acute care (over 24-h duration), with secondary outcomes being the number and cost of hospitalisations. Care homes were randomly assigned to cross over from control to intervention using a random number generator; masking was not possible due to the nature of the intervention. Analyses were by intention to treat. The trial was registered with ANZCTR: ACTRN12617000080325. Data were collected between 1 February 2017 and 30 June 2018. SETTING/PARTICIPANTS: 1700 residents in 12 Australian care homes for older people. RESULTS: Specialist Palliative Care Needs Rounds led to reduced length of stay in hospital (unadjusted difference: 0.5 days; adjusted difference: 0.22 days with 95% confidence interval: -0.44, -0.01 and p = 0.038). The intervention also provided a clinically significant reduction in the number of hospitalisations by 23%, from 5.6 to 4.3 per facility-month. A conservative estimate of annual net cost-saving from reduced admissions was A$1,759,011 (US$1.3 m; UK£0.98 m). CONCLUSION: The model of care significantly reduces hospitalisations through provision of outreach by specialist palliative care clinicians. The data offer substantial evidence for Specialist Palliative Care Needs Rounds to reduce hospitalisations in older people approaching end of life, living in care homes.

The impact of introducing Palliative Care Needs Rounds into rural residential aged care: A quasi-experimental study.

OBJECTIVE: This study examined the impact of introducing Palliative Care Needs Rounds (hereafter Needs Rounds) into residential aged care on hospitalisations (emergency department presentations, admissions and length of stay) and documentation of advance care plans. DESIGN: A quasi-experimental study. SETTING: Two residential aged care facilities in one rural town in the Snowy Monaro region of New South Wales, Australia. PARTICIPANTS: The intervention group consisted of all residents who died during the study period (April 2018-March 2019), and included a subgroup of decedents who were discussed in a Needs Round. The control cohort included all residents who died in the three-year period prior to introducing Needs Rounds (2015-2017). INTERVENTION: Needs Rounds are monthly onsite triage/risk stratification meetings where case-based education and staff support help to identify residents most at risk of dying without an adequate plan in place. Needs Rounds were attended by residential aged care staff and led by a palliative medicine physician. MAIN OUTCOME MEASURES: Decedents' hospitalisations (emergency department presentations, admissions and length of stay) in the last three months of life, place of death and documentation of advance care plans. RESULTS: Eleven Needs Rounds were conducted between April and September 2018. The number of documented advance care plans increased (P < .01). There were no statistically significant changes in hospitalisations or in-hospital deaths. CONCLUSION: Needs Rounds are an effective approach to increase the documentation of advance care plans within rural residential aged care. Further studies are required to explore the rural influence on outcomes including hospital transfers and preferred place of death.

Hospital-Based Acute Care Within 7 Days of Discharge After Outpatient Arthroscopic Shoulder Surgery.

BACKGROUND: The rate of hospital-based acute care (defined as hospital transfer at discharge, emergency department [ED] visit, or subsequent inpatient hospital [IP] admission) after outpatient procedure is gaining momentum as a quality metric for ambulatory surgery. However, the incidence and reasons for hospital-based acute care after arthroscopic shoulder surgery are poorly understood. METHODS: We studied adult patients who underwent outpatient arthroscopic shoulder procedures in New York State between 2011 and 2013 using the Healthcare Cost and Utilization Project database. ER visits and IP admissions within 7 days of surgery were identified by cross-matching 2 independent Healthcare Cost and Utilization Project databases. RESULTS: The final cohort included 103,476 subjects. We identified 1867 (1.80%, 95% confidence interval [CI], 1.72%-1.89%) events, and the majority of these encounters were ER visits (1643, or 1.59%, 95% CI, 1.51%-1.66%). Direct IP admission after discharged was uncommon (224, or 0.22%, 95% CI, 0.19%-0.24%). The most common reasons for seeking acute care were musculoskeletal pain (23.78% of all events). Nearly half of all events (43.49%) occurred on the day of surgery or on postoperative day 1. Operative time exceeding 2 hours was associated with higher odds of requiring acute care (odds ratio [OR], 1.28; 99% CI, 1.08-1.51). High-volume surgical centers (OR, 0.67; 99% CI, 0.58-0.78) and regional anesthesia (OR, 0.72; 99% CI, 0.56-0.92) were associated with lower odds of requiring acute care. CONCLUSIONS: The rate of hospital-based acute care after outpatient shoulder arthroscopy was low (1.80%). Complications driving acute care visits often occurred within 1 day of surgery. Many of the events were likely related to surgery and anesthesia (eg, inadequate analgesia), suggesting that anesthesiologists may play a central role in preventing acute care visits after surgery.

A Prospective Randomized Study to Evaluate a New Learning Tool for Ultrasound-Guided Regional Anesthesia.

Objective: To evaluate the effectiveness of a new learning tool for needle insertion accuracy skills during a simulated ultrasound-guided regional anesthesia procedure. Methods: Thirty participants were included in this randomized controlled study. After viewing a prerecorded video of a single, discreet, ultrasound-guided regional anesthesia task, all participants performed the same task three consecutive times (pretest), and needle insertion accuracy skills in a phantom model were recorded as baseline. All participants were then randomized into two groups, experimental and control. The experimental group practiced the task using the new tool, designed with two video cameras, a monitor, and an ultrasound machine where the images from the ultrasound and video of hand movements are viewed simultaneously on the monitor. The control group practiced the task without using the new tool. After the practice session, both groups repeated the same task and were evaluated in the same manner as in the pretest. Results: Participants in both group groups had similar baseline characteristics with respect to previous experience with ultrasound-guided regional anesthesia procedures. The experimental group had significantly better needle insertion accuracy scores ( P < 0.01) than the control group. Using the new learning tool, inexperienced participants had better needle insertion accuracy scores ( P < 0.01) compared with experienced participants. Conclusions: This study demonstrates that the use of this new learning tool results in short-term improvement in hand-eye, motor, and basic needle insertion skills during a simulated ultrasound-guided regional anesthesia procedure vs traditional practice methods. Skill improvement was greater in novices compared with experienced participants.

A manikin-based evaluation of a teaching modality for ultrasound-guided infraclavicular longitudinal in-plane axillary vein cannulation in comparison with ultrasound-guided internal jugular vein cannulation: A pilot study.

BACKGROUND AND AIMS: Ultrasound (US)-guided infraclavicular approach for axillary vein (AXV) cannulation has gained popularity in the last decade. MATERIAL AND METHODS: In this manikin study, we evaluated the feasibility of a training model for teaching AXV cannulation. The learning pattern with this technique was assessed among attending anesthesiologists and residents in training. RESULTS: A faster learning pattern was observed for AXV cannulation among the attending anesthesiologists and residents in training, irrespective of their prior experience with US. It was evident that a training modality for this technique could be easily established with a phantom model and that hands-on training motivates trainees to embrace US-based central venous cannulation. CONCLUSION: A teaching model for US-guided infraclavicular longitudinal in-plane AXV cannulation can be established using a phantom model. A focused educational program would result in an appreciable change in preference in embracing US-based cannulation techniques among residents.

Body Mass Index More Than 45 kg/m(2) as a Cutoff Point Is Associated With Dramatically Increased Postoperative Complications in Total Knee Arthroplasty and Total Hip Arthroplasty.

BACKGROUND: Higher body mass index (BMI) has been associated with postoperative complications in total knee arthroplasty (TKA) and total hip arthroplasty (THA). However, the association of incremental increases of BMI and its effects on postoperative complications has not been well studied. We hypothesize that there is a BMI cutoff at which there is a significant increase of the risk of postoperative complications. METHODS: We studied the American College of Surgeons National Surgical Quality Improvement Program from 2006 to 2013. The final cohort included 77,785 primary TKA and 49,475 primary THA subjects, respectively. Patients were separated into 7 groups based on BMI (18.5-24.9 kg/m(2), 25.0-29.9 kg/m(2), 30.0-34.9 kg/m(2), 35.0-39.9 kg/m(2), 40.0-44.9 kg/m(2), 45.0-49.9 kg/m(2), and >50.0 kg/m(2)). We analyzed data on five 30-day composite complication variables, including any complication, major complication, wound infection, systemic infection, and cardiac and/or pulmonary complication. RESULTS: The odds ratio for 4 (any complication, major complication, wound infection, and systemic infection) of 5 composite complications started to increase exponentially once BMI reached 45.0 kg/m(2) or higher in TKA. Similarly, the odds ratio in 3 (any complication, systemic infection, and wound infection) of 5 composite complications showed similar trends in THA patients. These findings were further confirmed with propensity score matching and entropy balancing. CONCLUSIONS: Our study suggested that there was a positive correlation between BMI and incidences of 30-day postoperative complications in both TKA and THA. The odds of complications increased dramatically once BMI reached 45.0 kg/m(2).

Educational perspectives in cardiothoracic anesthesia in the United States using a survey of educators and learners.

BACKGROUND: Cardiothoracic anesthesiology training presents learners with unique challenges, procedural skills, and the management of high-intensity critical scenarios. An effective relationship between educator and learner can serve as the backbone for effective learning, which is crucial for the development of budding anesthesiologists. Strengthening this educational alliance between teachers and trainees involves understanding the educational values educators and learners find most important to their learning experiences. This study aimed to identify the key educational values related to cardiothoracic anesthesia for both learners and educators. By identifying these values in separate cohorts (learners and educators), the importance of various educational values can be examined and compared between the trainees and teachers. METHODS: Two separate surveys (one for learners and one for teachers) were adapted from the Pratt and Collins Teaching Perspectives Inventory to establish the importance of various educational values related to cardiothoracic anesthesia. Surveys were sent to 165 Accreditation Council for Graduate Medical Education-accredited anesthesiology residency training programs in the United States to trainees (residents and cardiothoracic anesthesiology fellows) and educators (board-certified cardiothoracic anesthesiologists). RESULTS: Analysis of survey results from 19 educators and 57 learners revealed no statistical differences across the two groups, except Q15: "Let trainee perform critical technical steps" (P value = 0.02). CONCLUSIONS: While learners and educators in cardiothoracic anesthesia hold similar values regarding cardiac anesthesia education, they differ in the degree to which critical technical steps should be performed by learners.

Outcomes of percutaneous versus surgical tracheostomy in an Australian Quaternary Intensive Care Unit: An entropy-balanced retrospective study.

Background: Studies comparing percutaneous tracheostomy (PT) and surgical tracheostomy (ST) complications in the critically ill patient population with high acuity, complexity, and severity of illness are sparse. This study evaluated the outcomes of elective PT versus ST in such patients managed at a quaternary referral center. Aims: The primary aim was to detect a difference in hospital mortality between the two techniques. The secondary aims were to compare Intensive Care Unit (ICU) mortality, complications (including stoma site, tracheostomy-related, and decannulation complications), ICU and hospital length of stay, and time to decannulation. Methods: This was a single-center retrospective observational study of ICU admission from August 2018 to August 2021. Patients were included if an elective tracheostomy was performed during their ICU admission. Patients with a pre-existing tracheostomy and those who underwent an obligatory tracheostomy requirement (e.g. total laryngectomy) were excluded. Cohorts were matched using Hainmueller's entropy balancing. Binary data were evaluated using logistic regression and continuous data with ordinary least squares regression. Results: 349 patients with a tracheostomy were managed in the ICU during the observation period. They were predominantly males (75% in PT; 67% in ST), with a mean age in the PT and ST group of (47; SD = 18) and (55; SD = 16), respectively. After exclusion, 135 patients remained, with 63 in the PT group and 72 in the ST group. Patients receiving ST were significantly older with a higher Body Mass Index (BMI) than the PT group. There were no significant differences in gender, Acute Physiological And Chronic Health Evaluation (APACHE) III, and the Australian and New Zealand Risk Of Death (ANZROD) between the two groups. There was no difference in hospital mortality between groups (OR 0.91, CI 0.26-3.18, p = 0.88). There were also no differences in ICU mortality, ICU and hospital length of stay, and time to decannulation. PT was associated with a greater likelihood of complications (OR 4.19; 95% CI 1.73-10.13; p < 0.01). PT was associated with a greater risk of complications in those who had this performed early (<10 days of intubation) as well as late (>10 days of intubation). Conclusions: Percutaneous tracheostomy was associated with higher complications compared to surgical tracheostomy. They were related to tracheostomy cuff deflation, stomal site bleeding and infection, sputum plugging, and accidental and failed decannulation. These findings have identified opportunities to improve patient outcomes.

Characteristics and pathogenicity of Vibrio alginolyticus SWS causing high mortality in mud crab (Scylla serrata) aquaculture in Hong Kong.

Introduction: Vibrio alginolyticus is a Gram-negative, rod-shaped bacterium belonging to the family of Vibrionaceae, a common pathogen in aquaculture animals, However, studies on its impact on Scylla serrata (mud crabs) are limited. In this study, we isolated V. alginolyticus SWS from dead mud crab during a disease outbreak in a Hong Kong aquaculture farm, which caused up to 70% mortality during summer. Methods: Experimental infection and histopathology were used to investigate the pathogenicity of V. alginolyticus SWS in S. serrata and validate Koch's postulates. Comprehensive whole-genome analysis and phylogenetic analysis antimicrobial susceptibility testing, and biochemical characterization were also performed. Results: Our findings showed that V. alginolyticus SWS caused high mortality (75%) in S. serrata with infected individuals exhibiting inactivity, loss of appetite, decolored and darkened hepatopancreas, gills, and opaque muscle in the claw. Histopathological analysis revealed tissue damage and degeneration in the hepatopancreas, gills, and claw muscle suggesting direct and indirect impacts of V. alginolyticus SWS infection. Conclusions: This study provides a comprehensive characterization of V. alginolyticus SWS as an emerging pathogen in S. serrata aquaculture. Our findings underscore the importance of ongoing surveillance, early detection, and the development of targeted disease management strategies to mitigate the economic impact of vibriosis outbreaks in mud crab aquaculture.

Dendritic cell phenotype can be improved by certain chemotherapies and is associated with alterations to p21(waf1/cip1.).

INTRODUCTION: Dendritic cells (DCs) possess the capacity to elicit immune responses against harmful antigens and have been used in DC-vaccines to stimulate the immune system to engage cancer cells. However, a lack of an appreciation of the quality of the DC that is used and/or the monocyte from which it is derived has limited their successful incorporation into treatment strategies. METHODS: In the current study, we explored the relationship between cytokine receptor expression on the monocytes and its subsequent development into DCs. The significance of p21 expression in DCs during differentiation was also studied, as was the effect that manipulating this with chemotherapy may have on DC quality. RESULTS: DCs separated into two groups based on their ability to respond to a maturation stimulus. This quality correlated with a particular receptor profile of granulocyte-macrophage colony-stimulating factor and interleukin 4 expressed on the monocytes from which they were derived. DC quality was also associated with p21 expression, and artificially increasing their levels in DCs by using some chemotherapy improved function. CONCLUSIONS: Overall, these studies have highlighted a role for common chemotherapy in activating p21 in DCs, which is a prerequisite for good DC function.

Erratum: CHL1 suppresses tumor growth and metastasis in nasopharyngeal carcinoma by repressing PI3K/AKT signaling pathway via interaction with Integrin ß1 and Merlin: Erratum.

[This corrects the article DOI: 10.7150/ijbs.34785.].

Analgesic efficacy of ketamine and magnesium after laparoscopic sleeve gastrectomy: A randomized, double-blind, placebo-controlled trial.

Background Ketamine and magnesium are antagonists of the N-methyl-d-aspartate receptor, and are valuable adjuvants for multimodal analgesia and opioid sparing. Data are limited regarding the opioid sparing efficacy of the combined intraoperative application of these agents in laparoscopic bariatric surgery. The objective of this study was to compare the postoperative opioid sparing properties of a single intraoperative dose of ketamine versus a combination of single doses of ketamine and magnesium after laparoscopic gastric sleeve resection in bariatric patients. Methods One hundred and twenty- six patients were randomly assigned to receive single boluses of ketamine alone 0.5 mg kg-1 IV (ketamine group); combined ketamine bolus of 0.5 mg kg-1 IV and magnesium 2 g IV (ketamine and magnesium group); or placebo. Opioid consumption at 24 h (in morphine equivalents); pain at rest; postoperative nausea and vomiting impact score; sedation scores; and trends of transcutaneous carbon-di-oxide values were analysed. Results The median (inter-quartile range [range]) morphine consumption at 24 h were 32 (24-47 [4.8-91]) mg in the ketamine group, 37 (18-53 [1-144]) mg in the ketamine and magnesium group, and 26 (21-36 [5-89]) mg in the control group and were not significantly different between the groups. There were no differences for all other outcomes examined. Conclusion Combined single intraoperative bolus doses of ketamine and magnesium did not result in postoperative opioid sparing after laparoscopic gastric sleeve resection.

Improved Quality of Death and Dying in Care Homes: A Palliative Care Stepped Wedge Randomized Control Trial in Australia.

OBJECTIVES: Mortality in care homes is high, but care of dying residents is often suboptimal, and many services do not have easy access to specialist palliative care. This study examined the impact of providing specialist palliative care on residents' quality of death and dying. DESIGN: Using a stepped wedge randomized control trial, care homes were randomly assigned to crossover from control to intervention using a random number generator. Analysis used a generalized linear and latent mixed model. The trial was registered with ANZCTR: ACTRN12617000080325. SETTING: Twelve Australian care homes in Canberra, Australia. PARTICIPANTS: A total of 1700 non-respite residents were reviewed from the 12 participating care homes. Of these residents, 537 died and 471 had complete data for analysis. The trial ran between February 2017 and June 2018. INTERVENTION: Palliative Care Needs Rounds (hereafter Needs Rounds) are monthly hour-long staff-only triage meetings to discuss residents at risk of dying without a plan in place. They are chaired by a specialist palliative care clinician and attended by care home staff. A checklist is followed to guide discussions and outcomes, focused on anticipatory planning. MEASUREMENTS: This article reports secondary outcomes of staff perceptions of residents' quality of death and dying, care home staff confidence, and completion of advance care planning documentation. We assessed (1) quality of death and dying, and (2) staff capability of adopting a palliative approach, completion of advance care plans, and medical power of attorney. RESULTS: Needs Rounds are associated with staff perceptions that residents had a better quality of death and dying (P < .01; 95% confidence interval [CI] = 1.83-12.21), particularly in the 10 facilities that complied with the intervention protocol (P < .01; 95% CI = 6.37-13.32). Staff self-reported perceptions of capability increased (P < .01; 95% CI = 2.73-6.72). CONCLUSION: The data offer evidence for monthly triage meetings to transform the lives, deaths, and care of older people residing in care homes. J Am Geriatr Soc 68:305-312, 2020.

Correction: Death of a close friend: Short and long-term impacts on physical, psychological and social well-being.

[This corrects the article DOI: 10.1371/journal.pone.0214838.].

Death of a close friend: Short and long-term impacts on physical, psychological and social well-being.

This paper reports the impact of a major life event-death-on the physical, psychological and social well-being of the deceased's close friends. We utilised data from a large longitudinal survey covering a period of 14 years (2002-2015) consisting a cohort of 26,515 individuals in Australia, of whom 9,586 had experienced the death of at least one close friend. This longitudinal cohort dataset comprises responses to the SF-36 (health related quality of life measure) and allowed for analysis of the short and longer-term impacts of bereavement. In order to manage the heterogeneity of the socio-demographics of respondents who did/not experience a death event, we use a new and robust approach known as the Entropy Balancing method to construct a set of weights applied to the bereaved group and the control group (the group that did not experience death). This approach enables us to match the two groups so that the distribution of socio-demographic variables between the two groups are balanced. These variables included gender, age, marital status, ethnicity, personality traits, religion, relative socio-economic disadvantage, economic resources, and education and occupation and where they resided. The data show, for the first time, a range of negative and enduring consequences experienced by people following the death of a close friend. Significant adverse physical and psychological well-being, poorer mental health and social functioning occur up to four years following bereavement. Bereaved females experienced a sharper fall in vitality, suffered greater deterioration in mental health, impaired emotional and social functioning than the male counterparts up to four years after the death. The data show that the level of social connectedness plays an important role in bereavement outcomes. Specifically, we found that less socially active respondents experienced a longer deterioration in physical and psychological health. Finally, we found evidence that the death of a close friend lowered the respondent's satisfaction with their health. Since death of friends is a universal phenomenon, we conclude the paper by reflecting on the need to recognise the death of a close friend as a substantial experience, and to offer support and services to address this disenfranchised grief. Recognising bereaved friends as a group experiencing adverse outcomes can be used internationally to prompt health and psychological services to assist this specific group, noting that there may be substantial longevity to the negative sequelae of the death of a friend. Facilitating bereaved people's support networks may be a fruitful approach to minimising these negative outcomes.

Normalising and planning for death in residential care: findings from a qualitative focus group study of a specialist palliative care intervention.

BACKGROUND: Improving access to palliative care for older adults living in residential care is recognised internationally as a pressing clinical need. The integration of specialist palliative care in residential care for older adults is not yet standard practice. OBJECTIVE: This study aimed to understand the experience and impact of integrating a specialist palliative care model on residents, relatives and staff. METHODS: Focus groups were held with staff (n=40) and relatives (n=17). Thematic analysis was applied to the data. RESULTS: Three major themes were identified. The intervention led to (1) normalising death and dying in these settings, (2) timely access to a palliative care specialist who was able to prescribe anticipatory medications aiding symptom management and unnecessary hospitalisations and (3) better decision-making and planned care for residents, which meant that staff and relatives were better informed about, and prepared for, the resident's likely trajectory. CONCLUSIONS: The intervention normalised death and dying and also underlined the important role that specialists play in providing staff education, timely access to medicines and advance care planning. The findings from our study, and the growing wealth of evidence integrating specialist palliative care in residential care for older adults, indicate a number of priorities for care providers, academics and policymakers. Further work on determining the role of primary and specialist palliative care services in residential care settings is needed to inform service delivery models.