Frailty and emergency surgery: identification and evidence-based care for vulnerable older adults.

Frailty is a multidimensional state related to accumulation of age- and disease-related deficits across multiple domains. Older people represent the fastest growing segment of the peri-operative population, and 25-50% of older surgical patients live with frailty. When frailty is present before surgery, adjusted rates of morbidity and mortality increase at least two-fold; the odds of delirium and loss of independence are increased more than four- and five-fold, respectively. Care of the older person with frailty presenting for emergency surgery requires individualised and evidence-based care given the high-risk and complex nature of their presentations. Before surgery, frailty should be assessed using a multidimensional frailty instrument (most likely the Clinical Frailty Scale), and all members of the peri-operative team should be aware of each patient's frailty status. When frailty is present, pre-operative care should focus on documenting and communicating individualised risk, considering advanced care directives and engaging shared decision-making when feasible. Shared multidisciplinary care should be initiated. Peri-operatively, analgesia that avoids polypharmacy should be provided, along with delirium prevention strategies and consideration of postoperative care in a monitored environment. After the acute surgical episode, transition out of hospital requires that adequate support be in place, along with clear discharge instructions, and review of new and existing prescription medications. Advanced care directives should be reviewed or initiated in case of readmission. Overall, substantial knowledge gaps about the optimal peri-operative care of older people with frailty must be addressed through robust, patient-oriented research.

Robust polarization-based quantum key distribution over a collective-noise channel.

We present two polarization-based protocols for quantum key distribution. The protocols encode key bits in noiseless subspaces or subsystems and so can function over a quantum channel subjected to an arbitrary degree of collective noise, as occurs, for instance, due to rotation of polarizations in an optical fiber. These protocols can be implemented using only entangled photon-pair sources, single-photon rotations, and single-photon detectors. Thus, our proposals offer practical and realistic alternatives to existing schemes for quantum key distribution over optical fibers without resorting to interferometry or two-way quantum communication, thereby circumventing, respectively, the need for high precision timing and the threat of Trojan horse attacks.

Anticipatory grief: a psychosocial concept reconsidered.

Formerly anticipatory grief was viewed as a potential coping mechanism for a prospective loss. More recently it has been studied in preventive psychiatry as a determinant of the severity of post-mortem grief. The authors in a critical analysis of methodological and theoretical inconsistencies recommend a reconsideration of the concept within a psychosocial context.

Working through. A process of restitution.

A number of authors, including Freud, have written about the process of working through but have left unsettled what is actually involved. I have attempted to outline the step-by-step process of working through, starting with recollection and repetition and ending with restitution and resolution. I have introduced the term restitution in order to give more importance to an already existing step in the working-throught process; it should not be looked upon as an artificial device. Restitution allows the patient to find appropriate gratification in present reality, and this helps him to relinquish the past. Rather than allowing the patient to "wallow in the muck of guilt," as Eveoleen Rexford suggests society "wallows" in its inability to help its children, restitution gives appropriate direction for change. It is a natural step in the successful resolution of treatment.