The participant-level data set cannot be made publicly available due to German data protection rules and regulations. The statistical code can be made available upon request. Postoperative delirium is a common disorder in older adults that is associated with higher morbidity and mortality, prolonged cognitive impairment, development of dementia, higher institutionalization rates, and rising healthcare costs. Additionally, we will analyze whether the intervention is cost-effective. The study will be conducted at five medical centers with two or three surgical departments each in the southwest of Germany.
Delirium Tanning akron ohio elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. Md State Med J. KapoorHemanshu Prabhakar Juliabe, Charu Mahajan. Support Center Support Center. But now you have brought up a subject that has intrigued me for years. Still, spnak Juliane spank position may be catching on. Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. Participants are required to recall a sequence of spoken digits in reverse order. Supposedly the show just launched this year and Juliane spank has a superb spanking scene in it. Anyone know where the original video Juliane spank
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Post by Marco G. Chicago Spanking Review Forum Discussion of any and all things related to adult spanking Skip to content. Quick links. New Brazilian gem? The cartoons of Dan Rivera. Reader comments strongly desired! Forum rules Only Dan's art and relevant comments should be posted here.
Supposedly the show just launched this year and it has a superb spanking scene in it. Why would it not be mentioned here? According to the Chross message board, a beautiful actress named Juliane Araujo is spanked by Klebber Toledo.
I would love to hear from you guys, to know if you consider it that good. Cheers, Dan. Re: New Brazilian gem? It's very entertaining! Too bad I don't understand the dialog I guess the Brazilians haven't been infected with political correctness.
This scene reminds me of the latest story in Overbarrel's gallery. The ladies watching are all either laughing or nodding in agreement Thanks for calling this to our attention.
Thanks for your reply. Yes, the spanking scene in "Eta Mundo Bom! Just like Phil Overbarrel's latest story. I think it lasts for about 25 smacks, and we can see the man's hand landing on her luscious derriere seventeen 17! Of course, it would be nice to know what they were saying too but I enjoyed it anyway. Thanks, Phil. Thanks, Phil I'm with you on that, Phil. But now you have brought up a subject that has intrigued me for years. I'm a leg-lover, meaning that I totally love seeing a pretty woman lift her skirt to show her legs.
In this context, of course it is the man -- the spanker -- who usually does the lifting, once he has the spankee over his lap. I use that position in all my spank toons, and I notice that you use it too, as does our friend b00m. We always see to it that the skirt is lifted and the legs exposed before the spanking can begin. Now then. Anyone would say that yeah, you guys do that because you're horny and not fit to mingle with polite society. But what about vanilla spankings? Like the one we were discussing, from the Brazilian telenovela.
And those spankings from the few movies and TV shows that dare to show a woman being spanked by a man? Probably there were NO skirts-up spankings in mainstream movies in the 20th century. I'd be happy to be proven wrong. But maybe there is a trend slowly appearing in vanilla entertainment. And Ms. Parker, bless her heart, has excellent legs! In the PBS presentation of "Kiss Me Kate" starring Brent Barrett and Rachel York, Fred does raise Lilli's skirt before starting to spank her, but in this case she is revealed to be wearing pantaloons, or whatever you call those long bloomers, so we got to see no legs.
Still, the skirts-up position may be catching on. I'm already a retired senior citizen, so I may no longer be around when skirts-up spankings become the mainstream norm. But I am very happy that the artists who display their wares on CSR all seem to subscribe to the skirts-up dynamic.
Makes it fun, doesn't it? The spanking extends over 2 episodes, is this a first? Robert Horton was the actor in "Wagon Train". He died this past March at age Whitney Blake was the female lead. Diane Jergens was the spankee. My recollection is that Jergens was madly in love with Dale Robertson and making a nuisance of her self pursuing him around town. Robertson leaves a building through an alley way? He is confronted by her adult brothers who demand to know his intentions toward their sister.
Robertson answers to the effect "this" as he sits on a barrel, turns Jergens over his knee, raises her skirt and petticoats, and begins to spank her on the seat of her bloomers. A chagrined Jergens is seen rubbing her bottom. One of the brothers asks "Why didn't we think of that". I was unable to find a video. The episode does not appear on any of the compilations. I only saw it once, in the mid-sixties.
Marco G. Its THE classic of film spanking! The fine Weeds spanking shows how much TV has changed. The delicious part was the scene next day with actress Jennifer Maxwell sitting on a cushion at breakfast and saying she avoided catching a headcold! Jump to. Who is online Users browsing this forum: No registered users and 0 guests.
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The participant-level data set cannot be made publicly available due to German data protection rules and regulations. The statistical code can be made available upon request. Postoperative delirium is a common disorder in older adults that is associated with higher morbidity and mortality, prolonged cognitive impairment, development of dementia, higher institutionalization rates, and rising healthcare costs.
Additionally, we will analyze whether the intervention is cost-effective. The study will be conducted at five medical centers with two or three surgical departments each in the southwest of Germany. The study employs a stepped-wedge design with cluster randomization of the medical centers. Key aims are the improvement of patient safety and quality of life, as well as the reduction of the long-term risk of conversion to dementia.
Registered on 10 November The online version of this article Delirium is associated with increased morbidity and mortality, cognitive impairment, dementia, and higher institutionalization rates [ 1 ].
The incidence of postoperative delirium POD depends on factors predisposing to delirium such as age, the presence of brain damage, dementia, deficits in cognitive, sensory, or mobility functions, multiple comorbidities, polypharmacy, and frailty [ 2 ]. Early indicators of cognitive deficits, including hyposmia [ 3 ], sleep disorders [ 4 , 5 ], and subjective memory impairment [ 6 , 7 ], are also relevant risk factors for delirium.
The perioperative phase is a major trigger of postoperative delirium because of the administration of anesthesia, the surgical procedures, and other factors related to the operation itself, such as pain and immunological activation [ 2 ].
The incidence of delirium and its severity and duration can be significantly decreased and may be stratified by taking delirium risk factors into account [ 16 ]. Current guidelines for POD management [ 17 ] emphasize the importance of delirium prevention. A multimodal nonpharmacological approach [ 14 , 18 ] is considered the best pathway [ 16 , 19 ].
The study will optimize delirium assessment, establish a cross-sectoral intervention bundle for preventing delirium, and evaluate the effectiveness and cost-efficiency of this all-encompassing approach. To this end, evidence-based delirium diagnoses, neuropsychological tests, and multimodal multiprofessional interventions will be implemented. The project, recruiting a total of patients, has the following objectives:. The evaluation of the perioperative delirium prevalence with the I-Confusion Assessment Method-based scoring system for delirium diagnosis and delirium severity I-CAM-S [ 9 ], which is used for the first time in a large multicenter German sample.
The implementation of a multisector, individualized, multiprofessional and multimodal delirium and POCD prevention program. The evaluation of changes in medication during the pre-admission and perioperative phases, especially with respect to avoidance of anticholinergic drugs and other pharmacologic agents associated with delirium.
The economic evaluation of the multimodal intervention, studying its cost-effectiveness. From the point of view of the hospital departments, initial hospital costs will be evaluated. We have designed a cross-sectoral longitudinal study that aims to include patients undergoing elective surgery. The study employs a stepped-wedge design with cluster randomization of five medical centers.
The consortium leader will manage the project, oversee the financial transfers, monitor the progress according to the planned schedule, and communicate with the study sponsor Innovationsfonds des Gemeinsamen Bundesausschusses. The consortium leader is also part of the steering committee, whose main tasks are dealing promptly with the everyday project issues, monitoring the recruitment progress and the implementation of the intervention modules, and managing the study documentation.
The members of the steering committee are also part of the project committee, which includes two members from each study site. The project committee accompanies the study and coordinates the joint publications as well as the requests for data analysis. An international scientific advisory board of well-established professionals, including a geriatrician, an anesthetist, a gerontologist, and a delirium expert, ensures the scientific quality of the trial. The advisory board is comprised of four delirium and POCD experts.
They may be called upon to deal with ethically difficult issues, and they will also act as a monitoring board for adverse events AEs. As delirium is a high risk in dementia and frailty, we include patients with dementia or frailty who can consent to the trial or whose substitute decision-makers provide consent.
The recruitment procedure is described in Fig. Recruitment procedure. PAWEL Patient safety, cost-effectiveness and quality of life: reduction of delirium risk and post-operative cognitive dysfunction after elective procedures in the elderly. The intervention implements a cross-sectoral all-encompassing multimodal delirium prevention and management approach, and will be carried out in each study center after the center is randomized to take part in the intervention phase of the trial:.
The courses will be adjusted to the specific surgical and anesthesiological departments and special care units in order to ensure comparable levels of knowledge between different study sites.
Environmental orientation support: the hospital environment will be adapted to the special needs of the patients. The decline of sensory function in older adults often leads to additional psychosocial stress, and is exacerbated by cognitive impairment.
Tools for temporal and situational orientation will be made available; for example, whiteboards with personal information, date, season, and year, as well as analog clocks that can be seen from the bed. Special boxes for glasses, hearing aids, and dentures, as well as sleeping masks and ear plugs will be within reach of the patients at all times. These specialists will prescribe meaningful individualized daily activities for preventing delirium, defined in six modules: reorientation, cognitive activation, mobilization, meal companionship, clinical diagnostics and operation room attendance, and nonpharmacological sleep promotion and anxiety reduction.
Patients and their family members will be advised individually about delirium risk and prevention, and will receive information materials leaflets, posters, etc. Given the patient-centered care research implementation goal of this study, the outcomes of patients undergoing the intervention will be compared to the outcomes of patients receiving treatment as usual TAU provided by the centers before the randomized start of the intervention.
Patient group involvement and staff involvement has been implemented in an earlier version of this intervention approach adapting the HELP Hospital Elderly Life Program structure see [ 18 ].
The training modules are expected to play a fundamental role in improving adherence to the intervention protocols. They will be supplemented by additional talks, case discussions, and a web-based knowledge base providing webinars, training videos, and so forth.
Modules prescribed by the intervention team will be monitored, and the time span of the intervention will be daily documented. Adverse events and serious adverse events SAEs will be recorded and documented. Falls, strokes, infections, and other severe perioperative complications death, reoperation, pneumonia, sepsis are to be expected in this patient group independently of the intervention, while SAEs related to the intervention are expected to be very rare.
The assessment of all the outcomes will always be performed by trained assessors, who will be blinded for the intervention. Specifically, delirium raters will be told that the data will be used for validating a delirium risk score. Staff will be instructed not to reveal the nature of the intervention to these assessors. The primary outcome will be delirium prevalence. The CAM [ 32 ], with its four-step diagnostic algorithm, is a widely used screening test for assessing delirium.
It has been operationalized and translated into German [ 33 ], and then revealed a high sensitivity of 0. As the CAM might be confounded by the fluctuating nature of delirium, we use a chart-based review [ 31 ] filled out by trained medical staff at discharge to evaluate for fluctuations in sleep—wake rhythm or psychomotor activity indicating delirium.
The MoCA is a brief cognitive screening test for assessing cognitive impairment among older people. The test assesses multiple cognitive domains including visuospatial ability, executive functions, memory, attention, language, abstraction, and orientation. The MoCA has high sensitivity 0. The digit span backwards is commonly used to assess working memory capacity.
Participants are required to recall a sequence of spoken digits in reverse order. The TMT is a widely used instrument in neuropsychological assessment that measures the speed of scanning and visuomotor tracking, divided attention, and cognitive flexibility [ 36 ].
The test consists of two parts, A and B. TMT A requires an individual to draw lines sequentially connecting consecutive numbers from 1 to TMT B involves drawing a similar line, connecting an ascending sequence of numbers and letters in an alternating manner. In a sample of healthy older adults, Part A had a test—retest reliability of 0. In a sample of elderly volunteers, Part B had a sensitivity of 0. For baseline assessment , the following variables will be evaluated.
Basic sociodemographic patient information to be collected includes age, gender, weight, height, dominant hand, marital status, immigrant background, educational level, occupation, living arrangements, nicotine consumption, alcohol consumption, falls, and statutory level of care dependency.
Hearing and visual integrity will be tested by the whisper and visual acuity tests [ 45 ]. Functional status will be evaluated with the Hamburg Classification Manual [ 54 ] version of the Barthel Index [ 55 ]. The duration and extent of use of physical restraints and patient care attendants will also be assessed. The timelines are summarized in Fig. Standard Protocol Items: Recommendations for Interventional Trials figure of enrollment, intervention, and assessments. The RASS is a simple observational scale that quantifies the level of consciousness, assessing both sedation and agitation.
For analysis of delirium severity , the duration and extent of restraints and one-to-one supervision requirements will be used, in addition to the CAM-S score.
For process analysis , acceptance and feasibility will be evaluated by qualitative assessment using focus groups formed by members of the geriatric centers. For a precise evaluation of the costs, the expense for training and staff carrying out the intervention will be included in the analyses. The study started in November , and the recruitment phase will last until April We plan to complete the evaluations and cost analyses by December Finally, if the patient refuses this option, he or she will be asked for a telephone interview.
Using the adjustment form proposed by Woertman et al. The minimum number of clusters is given by the ratio of the total number of patients to the product between the number of crossing points and the patients per cluster per period, and is We intend to maintain this ratio for every center and for every week interval of the study.
Patient recruitment will be carried out by a medical specialist. Study staff, including doctors and scientists, will provide the necessary information and obtain the written informed consent from the patients, and whenever possible also from one relative to assess the caregiver burden and the cognitive status of the patient. The medical directors and the managers of anesthesia and nursing at the hospitals included in the study have provided a letter of intent expressing their interest in introducing and evaluating preventive procedures, and their willingness to recruit the necessary number of patients.
Hence, the recruiting objective is realistic. In this case, the center will commit either to increase the recruitment in its departments or to include another surgical department. Five months before starting the intervention in a given center, that center and the training team in Stuttgart will be informed about the allocation to prepare for the training and to form the intervention teams. Otherwise, randomization allocation will only be known to the consortium leader and the scientific staff at the University of Potsdam, who will implement the random sequence generation.
All collected data will be checked for reliability and validity every 3 months. Data access will be granted initially to project and data management and consortium leaders.
All the data from scales and neuropsychological tests, as well as the clinical data and the data for the health-economic analysis, will be stored in a pseudonymized fashion. For the primary outcome, logistic regression analyses with cluster adjustment are planned.
Subgroup analyses for specific patient groups e.