NHS Lothian

Pilot randomised-controlled trial of nortriptyline and escitalopram compared to placebo for depressive symptoms in people with Parkinson’s disease (PD). Participants with PD and depressive symptoms received either nortriptyline, escitalopram or placebo with assessments at baseline and 8 weeks. Feasibility of the full trial was assessed using recruitment rate, loss to follow up before the 8-week primary endpoint, adherence to trial medication and rate of clinically significant adverse reactions. Intended efficacy outcomes included the BDI-II, Patient Health Questionnaire (PHQ-9), Parkinson Anxiety Scale (PAS), MDS-UPDRS and adverse effects. The aim was to recruit 46 participants to determine feasibility of the full trial. 52 participants were recruited from 24 NHS sites and randomised to nortriptyline (n = 16), escitalopram (n = 17) or placebo (n = 19). However, despite multiple strategies, recruitment took two years, and the study therefore did not reach its feasibility aim. Exploratory analyses showed that at 8 weeks depressive symptoms decreased significantly in all three arms. There was no difference in BDI-II score changes between the nortriptyline or the escitalopram when compared to the placebo arm, but PHQ-9 scores showed a greater reduction compared to placebo with nortriptyline (-3.4, 95

Background and Objective: Surgical management of bladder outflow obstruction (BOO) caused by benign prostatic enlargement (BPE) has proven challenging, with increased pressure on National Health Service (NHS) resources. Traditionally, transurethral resection of prostate (TURP) was performed requiring an average inpatient stay of 2-4 days. If complications occur, the patient's stay in the urology ward is extended. Limited bed availability can result in the cancellation of elective surgeries. This continues to pose a challenge with the surge of COVID and respiratory infections during the winter season, resulting in a very limited bed availability. In recent decades, multiple new interventions for bladder outflow obstruction have emerged and proven safe and efficacious in multiple large studies. Our study's aim was to demonstrate GreenLight Laser Prostatectomy's (GLLP) feasibility as a 'true' day-case procedure. Materials and methods: Data collection for both GLLP and bipolar TURP was done as a retrospective observational cohort study in a single institution. Both cohorts underwent primary operation; primary GLLP cases were performed in 2021/2022, and primary bipolar TURP between 2023/2024. Greenlight laser prostatectomy was performed using the 180 W GreenLight XPS (TM) laser therapy system, and bipolar TURP using standard Olympus/Richard Wolf resectoscopes. Multiple preoperative, operative, and postoperative parameters were collected, with a primary focus on day-case discharge after the procedure. Results: A total of 180 patients underwent bladder outflow surgery, of which 90 patients (50%) had GLLP and the other 90 patients (50%) had TURP. The mean age for the GLLP group was 73.9 and for the TURP group was 71.9. We have observed a statistically significant difference in prostate volume between the two groups, with a mean volume of 98.9 cc for the GLLP group and 76.9 cc for the TURP group (p = 0.01). Even though prostates in the GLLP group were larger in size, the operation time was significantly shorter in the GLLP group, with a mean of 57.3 minutes, compared to 66.9 minutes for TURP (p = 0.01). In terms of hospital stay postoperatively, we observed a significant difference in the day-case discharge rate: 94.4% of patients in the GLLP group were discharged as day cases compared to only 4.4% in the TURP group (p < 0.001). Both the GLLP group (72 participants, 80%) and the TURP group (83 participants, 92.2%) achieved successful Trial to Void Without Catheter (TWOC), representing a significant difference in favour of TURP (p = 0.018). A survey regarding the patients' experience was conducted with the operative and postoperative processes has shown that 71.1% of participants in the GLLP group were satisfied, compared to 51.1% in the TURP group, which was statistically significant in favour of the GLLP (p < 0.001). Conclusion: Based on our observations, GLLP is a safe day-case operation with a good patient satisfaction rate and an acceptable success rate. It effectively addresses bladder outflow issues in hospitals with limited bed capacity. When implemented via a well-designed pathway, it can help reduce the waiting times in the NHS.

BACKGROUND:Intraoperative hypotension is a common occurrence in patients undergoing anaesthesia, although there is no standardised definition of hypotension. International consensus statements provide some guidelines for the management of intraoperative hypotension, but general clinical practice is unknown. We aimed to survey anaesthesiologists' values and preferences regarding intraoperative blood pressure management, including whether they would support future research on this topic. METHODS:We conducted an international, online survey of routine practice and opinion. The target population was anaesthesiologists who regularly anaesthetise adult patients. Results are reported descriptively and in accordance with the Consensus-Based Checklist for Reporting of Survey Studies (CROSS) checklist. RESULTS:A total of 1640 anaesthesiologists from 11 European countries participated in the survey. The majority of respondents were specialists (1322 of 1640, 80.6%, 95% CI 78.7-82.6). Almost all respondents worked in public hospitals (1613 of 1640, 98.4%). The overall response rate was 22.7%. Most respondents reported using absolute mean arterial pressure as their main unit of measurement to quantify hypotension (1098 of 1640, 67.0%, 95% CI 64.6-69.2). Respondents were most likely to initiate vasoactive treatment at a mean arterial pressure below 60 or 65 mmHg. Chronic arterial hypertension, traumatic brain injury and surgical procedures involving head-up positioning of the patient were the three most common scenarios where respondents would raise their threshold for treatment. Most respondents considered the establishment of safe intraoperative blood pressure thresholds a critical research question, and almost all respondents (1509 of 1640, 92.0%) indicated a willingness to randomise patients to specific blood pressure targets. For 72.9% (1196 of 1640), the lowest acceptable mean arterial pressure for randomisation was 60 mmHg. Respondents were also interested in the comparison of efficacy and safety of vasoactive agents, and the most sought-after comparison was phenylephrine versus noradrenaline (1252 of 1640, 76.3%). The willingness of respondents to administer these agents in peripheral venous access differed according to geography. CONCLUSION:In this international survey, mean arterial pressures of 60 or 65 mmHg were the most commonly reported blood pressure thresholds leading to initiation of treatment with vasoactive agents. Almost all respondents indicated patient groups for whom they would alter their treatment threshold, namely those suffering from chronic arterial hypertension, those undergoing surgery in a head-up position, and patients with traumatic brain injury. The majority of respondents supported future trials establishing optimal mean arterial pressure threshold and choice of vasoactive agent. We noticed a geographical variation in willingness to administer vasoactive agents in peripheral venous access. EDITORIAL COMMENT:This survey of anaesthesiologists from European countries queried practitioner perceptions of blood pressure management in adults during anaesthesia with focus on hypotension. Queries and responses also concerned circumstances and blood pressure levels which clinicians report being willing to treat actively, and how they might do this practically.

Implant-associated infections (IAIs) remain a major challenge in orthopaedic surgery, causing substantial morbidity, mortality, and healthcare costs. Antimicrobial implant coatings have emerged as a promising preventive strategy, but their comparative clinical benefit remains unclear. This study aimed to evaluate the effectiveness of antimicrobial coatings in preventing IAIs and to compare their clinical performance to uncoated implants. A systematic review and network meta-analysis was conducted in accordance with PRISMA guidelines. Medline, Embase, Scopus, and Web of Science were systematically searched for comparative studies evaluating antimicrobial implant coatings for the prevention of orthopaedic IAIs. The primary outcome was the incidence of postoperative IAIs, while secondary outcomes included complications, site-specific infections, causative organisms, use of antibiotic prophylaxis, operative time, time to infection, and implant survival. Random-effects network meta-analysis, subgroup analyses, and assessment of publication bias were performed to synthesize and compare treatment effects across coating types. Twenty-six studies encompassing 3,592 patients were included, of whom 1,576 received coated and 2,016 uncoated implants. Coating technologies included Defensive Antibacterial Coating (DAC) hydrogel, gentamicin, iodine, silver, antibiotic-loaded calcium sulfate, and gold-silver-palladium alloy. Overall, infection rates were lower in coated implants (26.9

Introduction Prehospital emergency anaesthesia is recognised as a high-risk clinical intervention. These updated guidelines consider changes in prehospital practice and parallel changes in the practice of in-hospital emergency anaesthesia, with the aim of encouraging standardised safe anaesthetic practice in a challenging clinical area. Method A working group was set up by the Association of Anaesthetists to include experts and resident doctors working in prehospital emergency medicine, anaesthesia, intensive care medicine and emergency medicine. There was also representation from relevant specialist groups and societies. We used a modified Delphi process and conducted targeted literature reviews to inform recommendations. Results We formulated recommendations in several key areas of prehospital emergency anaesthetic practice including general techniques; sedation before prehospital emergency anaesthesia; personnel and training; equipment and monitoring; prehospital emergency anaesthesia in children; and transport. Discussion Clinical teams that provide prehospital emergency anaesthesia must be well trained and competent to deliver the procedure to the same standards as their colleagues in the receiving emergency department. Although patients requiring prehospital emergency anaesthesia are often physiologically unstable and have pathology associated with a high mortality, there is good evidence that prehospital emergency anaesthesia can be delivered safely and to high standards.