Optimizing perioperative analgesia for patients undergoing operative fixation of hip fractures

This PhD thesis describes work carried out on investigation of various interventions with the aim to optimise the anaesthetic management of patients scheduled to undergo operative fixation of hip fractures. We analysed the perioperative effects of continuous femoral nerve block, single preoperative dose of i.v. dexamethasone, the intention to deposit local anaesthetic in different locations around the femoral nerve during ultrasound guided femoral nerve block, continuous spinal anaesthesia and peri-surgical site infiltration with local anaesthetic after surgical fixation of hip fractures. Continuous femoral nerve block provided more effective preoperative analgesia six hours after the insertion of the perineural catheter compared to a standard opiate-based regimen in patients undergoing operative fixation of fractured hip. A single low dose of preoperative dexamethasone in the intervention group decreased pain scores by 75% six hours after the surgery. Both interventions had no major effect on the functional recovery in the first year after the surgical fixation of fractured hip. The results of the ultrasound guided femoral nerve block trial showed no clinical advantage of intending to deposit local anaesthetic circumferentially during performing femoral nerve block. Using the Dixon and Massey’s “up- and-down” method, we demonstrated that intrathecal 0.26 ml of 0.5% bupivacaine provided adequate surgical anaesthesia within 15 minutes in 50% of patients undergoing operative fixation of hip fracture. Finally, we demonstrated that local anaesthetic infiltration had no effect on pain scores 12 hours after the surgical fixation of fractured neck of femur. In addition to this original body of work, a review article was published on femoral nerve block highlighting the use of ultrasound guidance. In conclusion, the results of this thesis offer an insight into interventions aimed at optimising perioperative analgesia in patients scheduled to undergo operative fixation of hip fractures.

Hidden land and changing landscape: Narratives about Mount Khangchendzonga among the Lepcha and the Lhopo

This article explores contemporary ‘hidden land’ narrative constructs of Máyel Lyáng and Beyul Dremojong in Sikkim, India, as conceived by the Lepcha and the Lhopo, two ‘scheduled tribes’. Lepcha and Lhopo narratives about these hidden lands in Mount Khangchendzonga inform us about their contemporary and historical, indigenous and Buddhist contexts and the interactions between these contexts. Lhopo perspectives on the hidden Beyul Dremojong echo classical Tibetan Buddhist ‘revealed treasure’ guidebooks and exist within the complex and reciprocal relationship between the Lhopo and the land they inhabit; development initiatives are understood to have caused illness and death in the Lhopo community of Tashiding, often referred to as the geographical ‘center’ of Beyul Dremojong. Contemporary Lepcha comprehensions of Máyel Lyáng, described in oral narratives within an ethnic community whose cosmology is intimately connected with Mount Khangchendzonga, today show some influence of Lhopo interpretations of Beyul Dremojong and the treasure texts; they also reflect Lepcha fears about cultural dispersion. Present-day narratives about both hidden lands reference notable political events in modern Sikkimese history (encounters with the British; the Chinese occupation of Tibet).

ENVIRON 2011: 21st Irish Environmental Researchers Colloquium

The theme of this year’s colloquium is “Towards 2020: Environmental challenges and opportunities for the next decade” which reflects the many environmental targets that have been set for the year 2020 in areas of climate change, renewable energy, water protection and biodiversity. In relation to the latter, we are delighted to have Professor Michael Depledge (Former Chairman of UK Science Advisory Committee on the Environment & Climate Change) at ENVIRON 2011 to deliver the colloquium keynote address on “Health and the Value of Nature”. The colloquium plenary session has a number of high profile speakers who will address the colloquium theme of environmental challenges and opportunities for the next decade including Professor John Sweeney (NUI Maynooth), Ms Laura Burke (Director of EPA’s Office of Climate, Licensing Research and Resource Use) and Mr John Mullins (CEO of Bord Gais). The research programme has 95 oral presentations and 60 poster presentations in the themes of water quality, energy and climate change, marine and coastal research, environmental management, environmental technologies, environment and health, and biodiversity and ecosystems. In addition, for the first year, poster presenters have the opportunity to make a 1 minute oral presentation on their poster during the oral sessions in the relevant theme. The 2011 colloquium also sees an increase the number of workshops and seminars accompanying the programme with an emphasis on training and development for postgraduates in the environmental area. We are particularly pleased to have a link with the Environment Graduate Programme in the “Ocean Studies Workshop” which illustrates how the ENVIRON colloquium can support and benefit from the various graduate programmes currently being developed within Universities. Finally ENVIRON 2011 and the UCC 2011 Law and the Environment symposium have been deliberately scheduled together at the same time and location to allow delegates from both conferences to benefit from each other’s programmes.

Postoperative analgesic effect, of preoperatively administered dexamethasone, after operative fixation of fractured neck of femur: randomised, double blinded controlled study.

Background: Fractured neck of femur is a common cause of hospital admission in the elderly and usually requires operative fixation. In a variety of clinical settings, preoperative glucocorticoid administration has improved analgesia and decreased opioid consumption. Our objective was to define the postoperative analgesic efficacy of single dose of dexamethasone administered preoperatively in patients undergoing operative fixation of fractured neck of femur. Methods: Institutional ethical approval was granted and written informed consent was obtained from each patient. Patients awaiting for surgery at Cork University Hospital were recruited between July 2009 and August 2012. Participating patients, scheduled for surgery were randomly allocated to one of two groups (Dexamethasone or Placebo). Patients in the dexamethasone group received a single dose of intravenous dexamethasone 0.1 mg kg -1 immediately preoperatively. Patients in the placebo group received the same volume of normal saline. Patients underwent operative fixation of fractured neck of femur using standardised spinal anaesthesia and surgical techniques. The primary outcome was pain scores at rest 6 h after the surgery. Results: Thirty seven patients were recruited and data from thirty patients were analysed. The groups were similar in terms of patient characteristics. Pain scores at rest 6 h after the surgery (the principal outcome) were lesser in the dexamethasone group compared with the placebo group [0.8(1.3) vs. 3.9(2.9), mean(SD) p = 0.0004]. Cumulative morphine consumption 24 h after the surgery was also lesser in the dexamethasone group [7.7(8.3) vs. 15.1(9.4), mean(SD) mg, p = 0.04]. Conclusions: A single dose of intravenous dexamethasone 0.1 mg kg -1 administered before operative fixation of fractured neck of femur improve significantly the early postoperative analgesia. Trial registration: ClinicalTrials.gov identifier: NCT01550146, date of registration: 07/03/2012