Purpose: The purpose of this structured, evidence-based, clinical update was to identify the best evidence comparing general and regional anesthesia and their influence on delirium or cognitive dysfunction (POCD) in the postoperative period. Source:In June 2005 a structured search of MEDLINE from 1966 to present using OVID software was undertaken. Medical subject headings and textwords describing both delirium and POCD were employed. OVID's Therapy (sensitivity) algorithm was used to maximize the detection of randomized trials. The bibliographies of eligible publications were hand-searched to identify trials not identified in the electronic search. Publications enrolling children were excluded. Levels of evidence and grades of recommendations were scored using Centre for Evidence Based Medicine criteria. Principal findings:A total of 18 unique randomized controlled trials were identified: two evaluating delirium; ten evaluating POCD; and six evaluating both. Outcomes for delirium were abstracted from eight trials that enrolled 765 patients (387 regional anesthesia; 378 general anesthesia). Outcomes for POCD were identified from 16 trials that enrolled 2,708 patients (1,313 regional anesthesia; 1,395 general anesthesia). Both delirium (11-43%) and POCD (15-25%) were relatively common in trials actively seeking these outcomes. Consistent Level 2b evidence suggests no significant increase in delirium in patients receiving general anesthesia compared with those receiving regional anesthesia. Similarly, consistent Level 1 evidence indicates that exposure to general anesthesia is not significantly associated with POCD. Conclusion:Available randomized controlled trials suggest that there is no significant difference in the incidence of delirium or POCD when general anesthesia and regional anesthesia are compared. Objectif Source : En juin 2005, une recherche structurée a été entreprise dans MEDLINE, de 1966 à nos jours, en utilisant le logiciel OVID. Les vedettes-matières et les textes décrivant le délire et le DCPO ont été utilisés. Un algorithme thérapeutique (sensibilité) tiré de OVID a servi à optimaliser la détection d'études randomisées. Les bibliographies des études admissibles ont été fouillées manuellement pour découvrir les études non repérées dans la recherche électronique. Les recherches portant sur des enfants ont été exclues. Les niveaux d'évidence et les degrés de recommandations ont été évalués selon les critères du Centre for Evidence Based Medicine. Constatations principales

The majority of elective surgical patients undergo preoperative testing. Non-compliance with guidelines ranged from 5 to 98%. The results of most tests were normal and influenced management in only 2.6% of cases.

Background Patients undergoing major vascular surgery are at high risk of postoperative delirium and postoperative cognitive dysfunction (POCD). Apolipoprotein E (APOE) is involved in central acetylcholine synthesis, and patients bearing the e4 genotype (APOE-e4) are at increased risk of both vascular dementia and peripheral vascular disease. The purpose of this study was to evaluate the associations among delirium, POCD, and APOE-e4 in patients undergoing open aortic repair. Methods Following Research Ethics Board approval and written informed consent, we recruited a cohort of patients C 60 yr of age undergoing open aortic repair. Apolipoprotein E genotyping and a battery of nine neuropsychometric (NP) tests were performed prior to surgery. Delirium was assessed on postoperative days two, four, and discharge using the Confusion Assessment Method. Neuropsychometric testing was repeated at discharge and again three months following surgery. A group of nonsurgical patients was used to adjust NP scores using reliable change index methodology. Logistic regression was used to evaluate independent predictors of both delirium and POCD. Results Eighty-eight patients underwent surgery, 78 completed NP testing on discharge, and sixty-nine completed NP testing at three months. Delirium was noted in 36% of patients after surgery, while POCD was noted in 62% at discharge and 6% at three months. Delirium predicted POCD at discharge (odds ratio 2.86; 95% confidence intervals 0.99 to 8.27) but not at three months. Apolipoprotein E-e4 genotype was not associated with either delirium or POCD following adjustment for covariates. Conclusion Both delirium and POCD are common following open aortic repair; however, the APOE genotype did not predict either condition. This trial has been registered with ClinicalTrials.gov (NCT00911677). RésuméContexte Les patients subissant une chirurgie vasculaire majeure courent un risque e´leve´de manifester du delirium postope´ratoire ainsi qu'un dysfonctionnement cognitif postope´ratoire (DCPO). L'apolipoprote´ine E (APOE) intervient dans la synthe`se centrale de l'ace´tylcholine, et les patients posse´dant le ge´notype e4 (APOE-e4) pre´sentent un risque accru de de´mence vasculaire et de maladie vasculaire pe´riphe´rique. L'objectif de cette e´tude e´tait

Competency-based medical education is gaining traction as a solution to address the challenges associated with the current time-based models of physician training. Competency-based medical education is an outcomes-based approach that involves identifying the abilities required of physicians and then designing the curriculum to support the achievement and assessment of these competencies. This paradigm defies the assumption that competence is achieved based on time spent on rotations and instead requires residents to demonstrate competence. The Royal College of Physicians and Surgeons of Canada (RCPSC) has launched Competence by Design (CBD), a competency-based approach for residency training and specialty practice. The first residents to be trained within this model will be those in medical oncology and otolaryngology-head and neck surgery in July, 2016. However, with approval from the RCPSC, the Department of Anesthesiology, University of Ottawa, launched an innovative competency-based residency training program July 1, 2015. The purpose of this paper is to provide an overview of the program and offer a blueprint for other programs planning similar curricular reform. The program is structured according to the RCPSC CBD stages and addresses all CanMEDS roles. While our program retains some aspects of the traditional design, we have made many transformational changes.