Association of Body Surface Area Versus Body Mass Index on Outcomes in Peripheral Arterial Disease.

OBJECTIVE: Numerous studies have indicated that increased obesity in patients with established peripheral artery disease (PAD) is inversely associated with disease prognosis, a phenomenon coined as the "obesity paradox". A major cause of criticism in studies investigating the obesity paradox is the use of body mass index (BMI) as a surrogate marker in defining and quantifying the degree or severity of obesity. We conducted a retrospective review to verify whether the obesity paradox persists in patients with PAD when using body surface area (BSA) as an alternative anthropometric measure. METHODS: Patients undergoing surgery (open or endovascular) for PAD between January 2009 and March 2020 were identified from the Vascular Quality Initiative (VQI) national database. The association between BSA/BMI and risk of post-operative complications was evaluated using logistic regression and restricted cubic spline analysis, both of which adjusted for demographic and comorbid risk predictors. When analyzing BSA and BMI as categorical variables, patients were grouped according to BSA quintiles and the World Health Organization (WHO) BMI categories. RESULTS: A total of 130,428 patients were included based on our eligibility criteria, of which 85,394 (65.5%) were men. Patients were typically hypertensive (87.8%), diabetic (50.4%), and overweight (63.0% over 25 kg/m2). Patients with a high BMI or BSA typically presented at a younger age and with greater pre-operative administration of drugs (statin, ACE-inhibitor, anticoagulant, and beta blocker). Our results indicate that BSA and BMI are inversely associated with post-operative risk of all-cause morbidity, mortality, and cardiac complications. This finding was displayed when analyzing BMI/BSA as a continuous variable, or when indexing patients into BMI/BSA groups. CONCLUSION: Our data suggests that the obesity paradox persists in patients with PAD when using either BMI or BSA as anthropometric measures. Future studies with a prospective design and utilizing newer anthropometric indices should be conducted to fully verify the presence of this phenomenon.

Virtual Reality Training for Central Venous Catheter Placement: An Interventional Feasibility Study Incorporating Virtual Reality Into a Standard Training Curriculum of Novice Trainees.

OBJECTIVES: This study assess the feasibility of integrating virtual reality (VR) simulation into the central venous catheter (CVC) placement training curriculum. DESIGN: The study consists of 3 parts: (1) Evaluating current manikin-based training for CVC placement through surveys for senior first-year anesthesia residents and cardiac anesthesia faculty who supervise resident performing the procedure; (2) Interventional study training novice trainees with VR simulator and assessing their reaction satisfaction; and (3) pilot study integrating VR training sessions into CVC training curriculum for first-year anesthesia residents. SETTING: Conducted at a single academic-affiliated medical center from December 2022 to August 2023. PARTICIPANTS: Junior first-year anesthesia residents. INTERVENTIONS: VR training sessions for CVC placements using the Vantari VR system. MEASUREMENTS AND MAIN RESULTS: Primary outcome: novice trainees' satisfaction with VR training for CVC procedure. Satisfaction of resident and faculty with standard manikin-based training was also collected. Faculty expressed concerns about residents' confidence and perceived knowledge in performing CVC placement independently. Novice trainees showed high satisfaction and perceived usefulness with VR training, particularly in understanding procedural steps and developing spatial awareness. Pilot integration of VR training into the curriculum demonstrated comparable training times and emphasized structured stepwise training modules to ensure completion of vital procedural steps. CONCLUSIONS: This study underscores the potential of VR simulation as a complementary training tool for CVC placement rather than a substitution of standard manikin training. VR is offering immersive experiences and addressing limitations of traditional manikin-based training methods. The integration of VR into training curricula warrants further exploration to optimize procedural proficiency and patient safety in clinical practice.

Implementation of Routine In Situ Simulation in Residency Curriculum Targeting Competency in Technical and Decision-Making Skills.

OBJECTIVE: To describe the development and implementation of a comprehensive in situ simulation-based curriculum for anesthesia residents. DESIGN: This is a prospective study. SETTING: This study was conducted at a university hospital. PARTICIPANTS: This single-center prospective study included all 53 anesthesia residents enrolled in the anesthesia residency program. INTERVENTIONS: Introduction of a routine, high-fidelity, in situ simulation program that incorporates short sessions to train residents in the necessary skill sets and decision-making processes required in the operating room. MEASUREMENTS AND MAIN RESULTS: Our team conducted 182 individual 15-minute simulation sessions over 3 months during regular working hours. All 53 residents in our program actively participated in the simulations. Most residents engaged in at least 3 sessions, with an average participation rate of 3.4 per resident (range, 1-6 sessions). Residents completed an online anonymous survey, with a response rate of 71.7% (38 of 53 residents) over the 3-month period. The survey aimed to assess their overall impression and perceived contribution of this project to their training. CONCLUSIONS: Our proposed teaching method can bridge the gap in resident training and enhance their critical reasoning to manage diverse clinical situations they may not experience during their residency.

Advancing Precision in 3D Echocardiography: Incorporating 3D Markers to Aid Spatial Orientation.

The incorporation of 3D imaging into diagnostic and interventional echocardiography has rapidly expanded in recent years. Applications such as multiplanar reconstruction that were once considered research tools and required off-cart analysis can now readily be performed at the point of image acquisition and in real-time during live image acquisition for procedural guidance. While the application and quality of 3D images have significantly improved in recent years, there remains a noticeable lag in the evolution of artificial intelligence that would further simplify the interpretative processes, both during live sessions and offline analyses. Users are still required to mentally reconstruct sliced images during multiplanar reconstruction based on color-coded planes. While this may be an effortless task for the seasoned echocardiographer, it can be a challenging task for echocardiographers who are less familiar with 3D imaging and multiplanar reconstruction. This article describes the utility of using 3D markers to aid in image interpretation.

Misidentification of the True Aortic Annulus With 2-dimensional Echocardiography: A Critical Appraisal Using 3-Dimensional Imaging.

OBJECTIVES: This study aimed to evaluate the accuracy of identifying the true aortic valve (AV) annulus using 2-dimensional (2D) echocardiography, with the goal of highlighting potential misidentification issues in clinical practice. DESIGN: An observational study employing 3-dimensional (3D) datasets to generate 2D images of the AV annulus for analysis. SETTING: The study was conducted in an academic medical center. PARTICIPANTS: Three-dimensional transesophageal echocardiography datasets were obtained from 11 patients with normal AV and aortic root anatomies undergoing coronary artery bypass surgery. Attending anesthesiologists certified by the National Board of Echocardiography (NBE) were approached subsequently to participate in this study. INTERVENTIONS: Two images per patient were generated from 3D datasets, reflecting the mid-esophageal long-axis view of the AV, a true AV annulus image, and an off-axis image. A survey was distributed to NBE-certified perioperative echocardiographers across 12 academic institutions to identify the true AV annulus from these images. MEASUREMENTS AND MAIN RESULTS: The survey, completed by 45 qualified respondents, revealed a significant misidentification rate of the true AV annulus, with only 36.8% of responses correctly identifying it. The rate of correct identification varied across image sets, with 44.4% of participants unable to correctly identify any true AV annulus image. CONCLUSIONS: The study highlighted the limitations of 2D echocardiography in accurately identifying the true AV annulus in complex 3D structures like the aortic root. The findings suggest a need for greater reliance on advanced imaging modalities, such as 3D echocardiography, to improve accuracy in clinical practice.

Artificial Intelligence for Anesthesiology Board-Style Examination Questions: Role of Large Language Models.

New artificial intelligence tools have been developed that have implications for medical usage. Large language models (LLMs), such as the widely used ChatGPT developed by OpenAI, have not been explored in the context of anesthesiology education. Understanding the reliability of various publicly available LLMs for medical specialties could offer insight into their understanding of the physiology, pharmacology, and practical applications of anesthesiology. An exploratory prospective review was conducted using 3 commercially available LLMs--OpenAI's ChatGPT GPT-3.5 version (GPT-3.5), OpenAI's ChatGPT GPT-4 (GPT-4), and Google's Bard--on questions from a widely used anesthesia board examination review book. Of the 884 eligible questions, the overall correct answer rates were 47.9% for GPT-3.5, 69.4% for GPT-4, and 45.2% for Bard. GPT-4 exhibited significantly higher performance than both GPT-3.5 and Bard (p = 0.001 and p < 0.001, respectively). None of the LLMs met the criteria required to secure American Board of Anesthesiology certification, according to the 70% passing score approximation. GPT-4 significantly outperformed GPT-3.5 and Bard in terms of overall performance, but lacked consistency in providing explanations that aligned with scientific and medical consensus. Although GPT-4 shows promise, current LLMs are not sufficiently advanced to answer anesthesiology board examination questions with passing success. Further iterations and domain-specific training may enhance their utility in medical education.

A Multidisciplinary Protocolized Approach for Ruptured Abdominal Aortic Aneurysm Management: A Retrospective Before-After Study.

OBJECTIVES: To investigate whether implementation of a multidisciplinary protocol for ruptured abdominal aortic aneurysm (rAAA) management reduces rates of adverse complications. DESIGN: A retrospective before-after study. SETTING: A tertiary-care academic hospital. PARTICIPANTS: Adult patients who underwent open or endovascular rAAA repair; data were stratified into before-protocol implementation (group 1: 2015-2018) and after-protocol implementation (group 2: 2019-2022) groups. INTERVENTION: The protocol details the workflow for vascular surgery, anesthesia, emergency department, and operating room staff for a rAAA case; training was accomplished through yearly workshops. MEASUREMENTS AND MAIN RESULTS: The primary outcome was in-hospital mortality. Secondary outcomes included all-cause morbidity and other major complications. Differences in postoperative complication rates between groups were assessed using Pearson's χ2 test. Of the 77 patients included undergoing rAAA repair, 41 (53.2%) patients were in group 1, and 36 (46.8%) patients were in group 2. Patients in group 2 had a significantly shorter median time to incision (1.0 v 0.7 hours, p = 0.022) and total procedure time (180.0 v 160.5 minutes, p = 0.039) for both endovascular and open repair. After protocol implementation, patients undergoing endovascular repair exhibited significantly lower rates of mortality (46.2% v 20.0%, p = 0.048), all-cause morbidity (65.4% v 44.0%, p = 0.050), and renal complications (15.4% v 0.0%, p = 0.036); patients undergoing open repair for a rAAA exhibited significantly lower rates of mortality (53.3% v 27.3%, p = 0.018) and bowel ischemia (26.7% v 0.0%, p = 0.035). CONCLUSIONS: Implementation of a multidisciplinary protocol for the management of a rAAA may reduce rates of adverse complications and improve the quality of care.

Complete and incomplete bridge type double-orifice mitral valve: Diagnosis and characterization with three-dimensional transesophageal echocardiography.

Double orifice mitral valve is a rare congenital anomaly that is often associated with other congenital cardiac abnormalities. Patients may present with valvular dysfunction or may be asymptomatic and have an incidental diagnosis of double outlet mitral valve. Whether symptoms due to this pathology are present or not it is important to accurately characterize this lesion. Three-dimensional imaging is a powerful diagnostic modality for diagnosing and characterizing lesions such as this as highlighted in this case image series where we describe how three-dimensional transesophageal echocardiography was utilized to characterize both complete and incomplete bridge type double orifice mitral valve.

Virtual Reality: The Future of Invasive Procedure Training?

Invasive procedures are associated with adverse events that are both hazardous to patients and expensive to treat. A trainee is expected to perform complex sterile invasive procedures in a dynamic environment under time pressure while maintaining patient safety at the highest standard of care. For mastery in performing an invasive procedure, the automatism of the technical aspects is required, as well as the ability to adapt to patient conditions, anatomic variability, and environmental stressors. Virtual reality (VR) simulation training is an immersive technology with immense potential for medical training, potentially enhancing clinical proficiency and improving patient safety. Virtual reality can project near-realistic environments onto a head-mounted display, allowing users to simulate and interact with various scenarios. Virtual reality has been used extensively for task training in various healthcare-related disciplines and other fields, such as the military. These scenarios often incorporate haptic feedback for the simulation of physical touch and audio and visual stimuli. In this manuscript, the authors have presented a historical review, the current status, and the potential application of VR simulation training for invasive procedures. They specifically explore a VR training module for central venous access as a prototype for invasive procedure training to describe the advantages and limitations of this evolving technology.

Novel Three-Dimensionally Printed Ultrasound Probe Simulator and Heart Model for Transthoracic Echocardiography Education.

Simulation-based training is an essential component in the education of transthoracic echocardiography (TTE). Nevertheless, current TTE teaching methods may be subject to certain limitations. Hence, the authors in this study aimed to invent a novel TTE training system employing three-dimensional (3D) printing technology to teach the basic principles and psychomotor skills of TTE imaging more intuitively and understandably. This training system comprises a 3D-printed ultrasound probe simulator and a sliceable heart model. The probe simulator incorporates a linear laser generator to enable the visualization of the projection of the ultrasound scan plane in a 3D space. By using the probe simulator in conjunction with the sliceable heart model or other commercially available anatomic models, trainees can attain a more comprehensive understanding of probe motion and related scan planes in TTE. Notably, the 3D-printed models are portable and low-cost, suggesting their potential utility in various clinical scenarios, particularly for just-in-time training.

Technical Varieties of Ross Procedure: A Case Series.

Replacement of aortic valve with the pulmonary autograft is carried out through the Ross procedure due to its potential for growth, durability in pediatric population, and absence of anticoagulation. This case series reports the postoperative outcome of two technical variations of Ross procedure in eight patients who underwent surgery from January 2007 to December 2016. The dominant valvular hemodynamic indication was aortic regurgitation. The techniques employed for Ross procedure included free standing root replacement in six patients and modified root replacement with autograft stabilisation using Dacron interposition graft in two patients. Right ventricular outflow tract (RVOT) conduit reconstruction was achieved by utilisation of Contegra bio prosthesis in four patients; and use of manually constructed valved conduit comprising of PTFE (polytetrafluoroethelene) membrane and bovine pericardial tube in remaining four patients. There was no mortality and no re-intervention. The technical varieties of Ross procedure offer freedom from need of anti-coagulation, mortality, and RVOT conduit failure in younger adults.