Propofol infusion syndrome is a rare, potentially fatal condition first described in children in the 1990s and later reported in adults. We provide a narrative review of what is currently known about propofol infusion syndrome, including a structured analysis of all published case reports; child and adult cases were analysed separately as propofol is no longer used for long-term sedation in children. The review contains an update on current knowledge of the pathophysiology of this condition along with recommendations for its diagnosis, prevention, and management. We reviewed 108 publications documenting 168 cases of propofol infusion syndrome. We evaluated clinical features and analysed factors influencing mortality in child and adult cases using separate multivariate analysis models. We used separate multiple linear regression models to analyse relationships between cumulative dose of propofol and the number of features seen and organ systems involved. Lipidaemia, fever, and hepatomegaly occurred more frequently in children than in adults, whilst rhabdomyolysis and hyperkalaemia were more frequent in adults. Mortality from propofol infusion syndrome is independently associated with fever and hepatomegaly in children, and electrocardiogram changes, hypotension, hyperkalaemia, traumatic brain injury, and a mean propofol infusion rate >5 mg kg À1 h À1 in adults. The cumulative dose of propofol was associated with an increased number of clinical features and the number of organ systems involved in adult cases only. Clinicians should consider propofol infusion syndrome in cases of unexplained metabolic acidosis, ECG changes, and rhabdomyolysis. We recommend early consideration of continuous haemofiltration in the management of propofol infusion syndrome.

Many cancer referral guidelines use patient’s age as a key criterium to decide who should be referred urgently. A recent rise in the incidence of colorectal cancer in younger adults has been described in high-income countries worldwide. Information on other cancers is more limited. The aim of this rapid review was to determine whether other cancers are also increasing in younger age groups, as this may have important implications for prioritising patients for investigation and referral. We searched MEDLINE, Embase and Web of Science for studies describing age-related incidence trends for colorectal, bladder, lung, oesophagus, pancreas, stomach, breast, ovarian, uterine, kidney and laryngeal cancer and myeloma. ‘Younger’ patients were defined based on NICE guidelines for cancer referral. Ninety-eight studies met the inclusion criteria. Findings show that the incidence of colorectal, breast, kidney, pancreas, uterine cancer is increasing in younger age groups, whilst the incidence of lung, laryngeal and bladder cancer is decreasing. Data for oesophageal, stomach, ovarian cancer and myeloma were inconclusive. Overall, this review provides evidence that some cancers are increasingly being diagnosed in younger age groups, although the mechanisms remain unclear. Cancer investigation and referral guidelines may need updating in light of these trends.

Background: Older age and frailty increase the risk of morbidity and mortality from cancer surgery and intolerance of chemotherapy and radiotherapy. The effect of old age on diagnostic intervals is unknown. However older adults need a balanced approach to the diagnosis and management of cancer symptoms, considering the benefits of early diagnosis, patient preferences and the likely prognosis of a cancer. Aim: To examine the association between older age and diagnostic processes for cancer and the specific factors which affect diagnosis. Design and setting: Systematic literature review. Method: Electronic databases were searched for studies of patients over 65, presenting with cancer symptoms to primary care considering diagnostic decisions. Studies were analysed using thematic synthesis and according to the Synthesis Without Meta-analysis (SWiM) guidelines. Results: Data from 54 studies with 230729 participants are included. The majority of studies suggest an association between increasing age and prolonged diagnostic interval or deferral of a decision to investigate cancer symptoms. Thematic synthesis highlighted three important factors which resulted in uncertainty in decisions involving older adults: frailty, co-morbidities and cognitive impairment. The data suggested patients wished to be involved in decision making, but the presence of cognitive impairment and the need for additional time within a consultation were significant barriers. Conclusion: This systematic review has highlighted uncertainty in the management of older adults with cancer symptoms. Patients and their family wished to be involved in these decisions. Given the uncertainty regarding optimum management of this group of patients, a shared decision-making approach is important.

Background: The burden of cancer falls predominantly on older adults. Prompt presentation to primary care with cancer symptoms could result in an earlier diagnosis. However patient appraisal and help seeking decisions involving cancer symptoms are complex and may be further complicated in older adults. Aim: To explore the effect of older age on patients’ appraisal of symptoms that may indicate cancer and their decision to seek help for these symptoms. Design: Mixed methods systematic review Method: Electronic databases were searched for studies on the appraisal and help seeking of cancer symptoms by adults aged 65 and over. Studies were analysed using thematic synthesis and according to the Synthesis Without Meta-Analysis (SWiM) guidelines Results: Eighty studies were included in the review with a total of 324995 participants. The studies suggested an association between increasing age and a prolonged appraisal interval. Factors such as reduced knowledge of cancer symptoms and differences in symptom interpretation may contribute to this prolonged interval. In contrast, we found an association between increasing age and prompt help-seeking. Themes affecting help seeking included the influence of family and carers, competing priorities, fear, embarrassment, fatalism, co-morbidities, a desire to avoid doctors, a perceived need to not waste doctor’s time and patient self-management of symptoms. Conclusions: This review suggests that increasing age is associated with delayed symptom appraisal. As a result of this review, policy makers, charities and information from GPs should aim to ensure older adults are able to recognise potential symptoms of cancer and can seek help promptly.

No abstract