coronary artery bypass grafting: results from the Stent or Surgery (SoS) trial. Circulation 2004;110:3411e7. 43. Hlatky MA, Bacon C, Boothroyd D, et al. Cognitive function 5 years after randomization to coronary angioplasty or coronary artery bypass graft surgery. Circulation 1997;96. II-11e14. 44. Avidan MS, Evers AS. The fallacy of persistent postoperative cognitive decline. Anesthesiology 2016;124:255e8.

This review on shared decision-making comes at a time when international healthcare policy, domestic law and patient expectation demand a bringing-together of the patient's values and preferences with the physician's expertise to determine the best bespoke care package for the individual. Despite robust guidance in terms of consent, the anaesthetic community have lagged behind in terms of embracing the patient-focused rather than doctor-focused aspects of shared decision-making. For many, confusion has arisen due to a conflation of informed consent, risk assessment, decision aids and shared decision-making. Although they may well be linked, they are discrete entities. The obstacles to delivering shared decisionmaking are many. Lack of time is the most widely cited barrier from the perspective of physicians across specialties, with little time available to the anaesthetist at the day-of-surgery pre-operative visit. A more natural place to start the process may be the pre-operative assessment clinic, especially for the 'high-risk' patient. Yet shared decision-making is for all, even the 'low-risk' patient. Another barrier is the flow and the focus of the typical anaesthetic consultation; the truncated format presents the danger of a cursory, 'timeefficient' and mechanical process as the anaesthetist assesses risk and determines the safest anaesthetic. As patients have already decided to proceed with therapy or investigation and may be more concerned about the surgery than the anaesthesia, it is often assumed they will accept whatever anaesthetic is offered and defer to the clinician's expertisewithout discussion. Furthermore, shared decision-making does not stop at time of anaesthesia for the peri-operative physician. It continues until discharge and requires the anaesthetist to engage in shared decision-making for prescribing and deprescribing peri-operative medicines.

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• Survival rates for patients with neurosurgical pathology are improving, resulting in more of these patients presenting for incidental surgery. The non-specialist can safely anaesthetize neurosurgical patients by adhering to general neurophysiological principles. • Cerebrospinal fluid diversion devices (shunts) used to treat hydrocephalus are not only ventriculoperitoneal, the distal end may be placed into the intrapleural space or the right atrium. The proximal end can also arise from the lumbar spine.

Medical leadership has been a focus of criticism after a number of notable health service failures. In order to address the development of a safe and accountable service for the future, medical trainees should be engaged in learning and participating in medical management from an early stage. We discuss measures we have taken at one hospital in the United Kingdom to embed non-clinical skills training in the natural progression of specialist training. This programme has since been expanded to other hospitals. We aim to disseminate our learning further so that others may consider implementing local training in a similar way.

A recent letter studied different countries' positions in the field of anaesthesia in the period 1991 to year 2000 (Rahman et al. Anaesthesia 2002; 57: 1213-14). Among other things, the analysis elicited the top ranking 20 countries for research in the field of anaesthesia. Also, they revealed countries where research shares went down and up, respectively. The results were interesting, but one sentence puzzled me. The authors write: 'Journals not available in the Medline database for the entire 1991-2000 period were excluded (Acta Anaesthesiologica Scandinavica and Clinical Journal of Pain). To my knowledge, which is substantiated by a recent search in Medline, both journals have been available in the Medline database for the entire period (Table 1). I would be pleased if the authors could explain this difference.

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