Peter Raven

The incidence of delirium associated with orthopedic surgery: a meta-analytic review

BACKGROUND The aim of this study was to perform a systematic review and meta-analysis of the literature regarding the incidence of delirium following orthopedic surgery. METHODS Relevant papers were sourced from online databases and gray literature. Included studies used a validated diagnostic method to measure the incidence of delirium in a prospective sample of adult/elderly orthopedic patients. Data were subject to meta-analysis after stratification by type of surgery (elective v. emergency) and inclusion/exclusion of pre-existing cognitive impairment. A funnel plot assessed for publication bias. RESULTS 26 publications reported an incidence of postoperative delirium of 4-53.3% in hip fracture samples and 3.6-28.3% in elective samples. Significant heterogeneity was evident, and this persisted despite stratification. Hip fracture was associated with a higher risk of delirium than elective surgery both when the cognitively impaired were included in the sample (random effects pooled estimate = 21.7% [95% CI = 14.6-28.8] vs. 12.1% [95% CI = 9.6-14.6]), and when the cognitively impaired were excluded (random effects pooled estimate = 25% [95% CI = 15.7-34.7] vs. 8.8% [95% CI = 4.1-13.6]). The funnel plot showed a deficit of small studies showing low risk and large studies showing high risk. In eight hip fracture studies, the proportion of delirium cases with a preoperative onset ranged from 34 to 92%. CONCLUSIONS Delirium occurs more commonly with hip fracture than elective surgery, and frequently has a preoperative onset when associated with trauma. Recommendations are made with the aim of standardizing future research in order to further explore and reduce the heterogeneity and possible publication bias observed.

A systematic review of the scientific evidence for the efficacy of a palliative care approach in advanced dementia

BACKGROUND Patients with dementia often receive poor end-of-life care, with inadequate pain control and without access to the palliative care services that patients with cancer are offered. This has been identified as an area of need in recent UK. Government reports and by the Alzheimers Society (UK). Our objective was to perform a systematic review of the scientific literature regarding the efficacy of a palliative care model in patients with dementia. METHODS A systematic review was carried out to identify controlled trials that investigated the efficacy of palliative care in patients with dementia. Data sources included were Medline, EMBASE, PsycINFO, CINAHL, British Nursing Index, AMED, Cochrane Database of Systematic Reviews, Web of Science, Cochrane Central Register of Controlled Trials, International Standard Randomised Controlled Trial register, the NHS Economic Evaluation Database and the System for Information on Grey Literature in Europe. Other data was sourced from hand searches of papers identified on electronic databases and review articles. RESULTS The search identified 30 review articles, but only four papers were eligible for full appraisal and only two of these met the full criteria for inclusion. These papers gave equivocal evidence of the efficacy for a palliative model of care in dementia. CONCLUSION Despite the increased interest in palliative care for patients with dementia there is currently little evidence on which to base such an approach. This may in part be due to the ethical difficulties surrounding such research, prognostic uncertainty in clinicians and the lack of clear outcome measures for patients who are unable to express their needs or wishes. Further systematic research is urgently needed to educate an important and developing area of clinical practice.

A randomized double-blind placebo-controlled trial of treatment as usual plus exogenous slow-release melatonin (6 mg) or placebo for sleep disturbance and depressed mood.

Sleep disturbance is common in major depressive disorder (MDD), and is often characterized by early-morning waking. Melatonin is a hypnotic and synchronizes circadian rhythms. It may also be an antidepressant. The melatonin agonists, ramelteon and agomelatine, have hypnotic and antidepressant properties, but there is a dearth of trials investigating the use of melatonin in MDD. This randomized, controlled trial aimed to determine whether exogenous melatonin is a sleep promoter and antidepressant. Thirty-three participants with a Diagnostic and Statistical Manual of Mental Disorders (fourth edition) diagnosis of MDD and early-morning waking were selected for a 4-week, randomized, double-blind trial of slow-release melatonin (6 mg; vs. placebo) given at bedtime over 4 weeks. Sleep was measured subjectively using sleep diaries and the Leeds Sleep Evaluation Questionnaire and objectively using wrist actigraphy. Of the 33 participants, 31 completed the trial. General Linear Modelling showed significant improvements in depression and sleep over time, but this was not specific to melatonin. However, there was a trend towards an improvement in mood with melatonin, and no adverse side effects were observed. In conclusion, melatonin may be beneficial for treating MDD, it seems to be safe and well tolerated, but its potential for treating depression in people who do not wish to take antidepressants requires further evaluation.

Supporting students with disability and health issues: lowering the social barriers.

Medical Education 2012: 46:564–574

Supporting students with disabilities using a 'student support card' scheme.

2–4-week experiences that rely on a pool of approximately 125 small-group facilitators who assist students in applying a problem-solving model to the discussion of cases. Groups are comprised of eight or nine students plus one facilitator (preceptor), who is either a basic scientist or a clinician. Why the idea was necessary Student ratings of preceptor performance, although usually favourable, occasionally identify a faculty member who exhibits problematic facilitation skills. In addition, our medical school, which is community-based, is undergoing an expansion of the Year 2 curriculum into one of its communities, which will add 50 students to the class size and require approximately 60 new preceptors. What was done To assure new preceptor competency, and to identify those who may require further faculty development, a ‘certification examination’ was developed. The test relies on a simulated student small group and provides for group, self and faculty ratings of performance of the basic leadership skills that all preceptors should possess. A 20-item scale was developed, focusing on skills in four domains: orientation and preparation of the group (three items); routine group management (nine items); avoiding inappropriate preceptor behaviour (two items) and addressing possible group dysfunction (five items). ‘Overall preceptor performance’ was also rated. A 5-point scale ranging from 1 (= interferes with PBL process) to 5 (= facilitates exemplary PBL process) was used. At least 70% of the rating form items needed to be scored at ‡ 3 for the preceptor to pass the test. Seven Year 2 students in good academic standing volunteered for the simulated group. Students received a 1-hour orientation using a case they had already studied. Students assumed roles that would introduce common leadership challenges encountered during small-group discussions. Two preceptors, one just completing his first PBL assignment and one with 15 years of experience, volunteered for the pilot test. Both had achieved student ratings of ‘overall...excellent’ (4.6 and 4.8 on a 5-point scale) in their most recent preceptor assignments. Both preceptors had a 30-minute orientation session and were shown drafts of the performance rating instrument. The test used simulations of an initial case analysis and a ‘return to the case’ discussion. Institutional review board approval for the examination was obtained in August 2007 and the pilot test was conducted in October 2007. Evaluation of results and impact Overall ratings of 80.1% for the less experienced preceptor and 80.3% for the more experienced preceptor were obtained. These scores provide an important baseline for future certification of preceptor competence of those rated highly by students in the real setting. Student, preceptor and faculty observer comments indicated that the test was a realistic, feasible and enjoyable means of assessing basic preceptor skills. Improvements need to be made to enhance audiorecording of the small-group discussion and a brief break between the two parts of the test will be incorporated in a second pilot test. Certification of the entire preceptor corps is expected to take up to 2 years.