British journal of anaesthesia
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Editorial Review
Attaining expertise in regional anaesthesia training using a multifactorial approach incorporating deliberate practice.
The most effective way of delivering regional anaesthesia training and the best means of demonstrating competency have not been established. Clinical competency, based on the Dreyfus and Dreyfus lexicon, appears unachievable using current training approaches. Lessons should be taken from the worlds of music, chess, and sports. Modern skills training programmes should be built on an explicit and detailed understanding with measurement of a variety of factors such as perception, attention, psychomotor and visuospatial function, and kinesthetics, coupled with quantitative, accurate, and reliable measurement of performance.
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Editorial Review
Predictive modelling for postoperative acute kidney injury: big data enhancing quality or the Emperor's new clothes?
The increased availability of large clinical datasets together with increasingly sophisticated computing power has facilitated development of numerous risk prediction models for various adverse perioperative outcomes, including acute kidney injury (AKI). The rationale for developing such models is straightforward. ⋯ Some of the purported benefits of predictive modelling, particularly when applied to postoperative AKI, might not fare well under detailed scrutiny. Future research should address existing limitations and seek to demonstrate both benefit to patients and value to healthcare systems from implementation of these models in clinical practice.
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Accumulating evidence supports an effect of physician gender (or sex, a surrogate used in many studies) on important patient outcomes such as death, complications, and hospital length of stay. Recent studies suggest that these effects result from the gender diversity of the team rather than individual physician gender. Here, we reflect on the potential mechanisms of an effect of physician gender on patient outcomes.
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Editorial Review
Hyperfibrinolysis: potential guidance for decision-making to avoid futile extracorporeal cardiopulmonary resuscitation.
Out-of-hospital cardiac arrest (OHCA) is associated with very poor outcomes. Extracorporeal cardiopulmonary resuscitation (eCPR) for selected patients is a potential therapeutic option for refractory cardiac arrest. However, randomised controlled studies applying eCPR after refractory OHCA have demonstrated conflicting results regarding survival and good functional neurological outcomes. eCPR is an invasive, labour-intensive, and expensive therapeutic approach with associated side-effects. ⋯ Studies in trauma patients demonstrate a high mortality rate in those with established hyperfibrinolysis upon emergency room admission. Similar findings have now been reported for the first time in OHCA patients. Hyperfibrinolysis upon admission diagnosed by rotational thromboelastometry was strongly associated with mortality and poor neurological outcomes in a small cohort of patients treated with extracorporeal membrane oxygenation.
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Cerebrovascular autoregulation is defined as the capacity of cerebral blood vessels to maintain stable cerebral blood flow despite changing blood pressure. It is assessed using the pressure reactivity index (the correlation coefficient between mean arterial blood pressure and intracranial pressure). The objective of this scoping review is to describe the existing evidence concerning the association of EEG and cerebrovascular autoregulation in order to identify key concepts and detect gaps in the current knowledge. ⋯ There is a paucity of studies evaluating the link between EEG and cerebrovascular autoregulation. The studies identified included a variety of EEG and cerebrovascular autoregulation acquisition methods, age groups, and diseases allowing for few overarching conclusions. However, the preliminary evidence for the presence of an association between EEG metrics and cerebrovascular autoregulation prompts further in-depth investigations.