Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk

THIS IS THE FIRST OF 2 ARTICLES EVALUATING cardiac events in patients undergoing noncardiac surgery. In this article, we review the magnitude of the problem, the pathophysiology of these events, approaches to risk assessment and communication of risk. The number of patients undergoing noncardiac surgery worldwide is growing, and annually 500 000 to 900 000 of these patients experience perioperative cardiac death, nonfatal myocardial infarction (MI) or nonfatal cardiac arrest. Although the evidence is limited, a substantial proportion of fatal perioperative MIs may not share the same pathophysiology as nonoperative MIs. A clearer understanding of the pathophysiology is needed to direct future research evaluating prophylactic, acute and long-term interventions. Researchers have developed tools to facilitate the estimation of perioperative cardiac risk. Studies suggest that the Lee index is the most accurate generic perioperative cardiac risk index. The limitations of the studies evaluating the ability of noninvasive cardiac tests to predict perioperative cardiac risk reveals considerable uncertainty as to the role of these popular tests. Similarly, there is uncertainty as to the predictive accuracy of the American College of Cardiology / American Heart Association algorithm for cardiac risk assessment. Patients are likely to benefit from improved estimation and communication of cardiac risk because the majority of noncardiac surgeries are elective and accurate risk estimation is important to allow informed patient and physician decision-making.     

Measurement of maximum variability within event related potentials in schizophrenia.

One limitation of averaging individual late component event related potential (ERP) responses is that a single average ERP cannot reflect the variability of responses from epoch to epoch. In this article, we describe a method to quantify this variability and determine if any part of the overall ERP reflects a maximum variance through the use of response variance curves. We then apply this method to one disorder, schizophrenia, in which variability of information processing is hypothesized to underlie aspects of the symptomatology. Response variance curves in a group of unmedicated schizophrenic patients reveal systematic differences, maximal between 190 and 250 ms, compared with those in a group of medicated schizophrenic patients and normal control subjects.     

Resilience in Families with Children and Adult Members with Intellectual Disabilities: Tracing Elements of A Psycho‐Social Model

Aim This paper seeks to illumine how families with children and adult members with intellectual disabilities manage to manifest a buoyant and durable capacity over time. It is therefore concerned centrally with the idea of resilience. Method Drawing from diverse theoretical literatures from child development and protection and gerontology, the paper begins with a review of constructions of resilience. In an attempt to assess where there seems to be support for resilience in families, the core of the paper tests empirical evidence about positive experiences of families supporting children and adults with intellectual disabilities against the theoretical literature on resilience. Result and Conclusions The findings are used to suggest conditions under which resilience is produced and maintained, and to identify emergent elements of a psycho‐social model of resilience in families with children and adult members with intellectual disabilities.     

Impact of a region-wide approach to improving systems for heart attack care: the West Midlands thrombolysis project.

OBJECTIVE: To describe changes in delay to administration of thrombolytic therapy associated with a region-wide audit. DESIGN: Observational study of patients admitted with suspected myocardial infarction (MI) based on continuous audit. SUBJECTS: 18877 patients admitted to 23 hospitals with suspected MI between April 1995 and March 1998. RESULTS: Of 11232 patients with a discharge diagnosis of definite MI, 8802 (46.6%) received thrombolytic therapy during hospitalisation, with 5155 patients eligible for treatment on admission to hospital on the basis of established indications. Call-to-needle time for those eligible for treatment on admission fell from median 105 min in the first year of the project to 85 min in year 3 (P<0.001), and door-to-needle time fell from 45 to 35 min (P<0.001). Forty percent of eligible patients were treated within the then current national standard of 90 min from time of call for help, with nearly 49% in the final year and 20% being treated within the new national standard of 60 min, by the third year. CONCLUSION: The proportion of eligible patients receiving thrombolysis within 1 h of the call for help doubled during the 3-year project but the majority of patients still wait longer than 60-min 'call-to-needle'. New systems to reduce delays to administration of thrombolysis to within 60 min of call for help are required, including consideration of pre-hospital treatment.