Invasive Pressure Monitors: Leveling the Playing Field.

Invasive pressure monitors are ubiquitous in cardiothoracic and vascular anesthesia. This technology allows beat-to-beat assessment of central venous, pulmonary, and arterial blood pressures during surgery, procedural interventions, and critical care. Education is commonly focused on the procedural aspects and the complications associated with the initial placement of these monitors without instruction on the technical concepts required for obtaining accurate data. Anesthesiologists must understand the fundamental concepts on which measurements are made to effectively use invasive pressure monitors, including pulmonary artery catheters, central venous catheters, intra-arterial catheters, external ventricular drains, and spinal or lumbar drains. This review will address important gaps in knowledge surrounding leveling and zeroing of invasive pressure monitors, emphasizing the impact of varied practice patterns on patient care.

Implementing life cycle sustainability assessment for improved space mission design.

Within the space sector, the application of Environmental Life Cycle Assessment (E-LCA) is beginning to emerge as a credible and compelling method for scientifically quantifying environmental impacts of space missions. However, E-LCA does not fully align with the concept of triple-bottom-line sustainability, while the combination of all three sustainability dimensions (environment, society, and economy) within a single life cycle study has thus far never been attempted within the space industry. Moving toward a Life Cycle Sustainability Assessment (LCSA) is, therefore, a logical next step for the space sector to allow these three sustainability dimensions to be addressed. Consequently, this article presents the underlying principles of a new LCSA framework for space missions and demonstrates its applicability for improving system-level design concepts based on the interaction between sustainability dimensions. The framework was formed based on a systematic literature review to analyze the background, issues, and knowledge gaps related to life cycle methodologies, as well as context-specific sustainability aspects. The framework has been implemented within a life cycle database called the Strathclyde Space Systems Database (SSSD). Using the SSSD, the framework was tested on a mission concept called Moon Ice Observation Satellite to demonstrate how changes in the design for a circular economy and other sustainability-based principles will affect the functionality of the mission at the system level. It is envisaged that this framework will enable engineers to create sustainable space systems, technologies, and products that are not only cost-efficient, eco-efficient, and socially responsible, but also ones that can easily justify and evidence their sustainability. Integr Environ Assess Manag 2023;19:1002-1022. © 2022 The Authors. Integrated Environmental Assessment and Management published by Wiley Periodicals LLC on behalf of Society of Environmental Toxicology & Chemistry (SETAC).

Ecospheric life cycle impacts of annual global space activities.

This paper presents a first-order approximation of ecospheric life cycle impacts from annual global space activities across two scenarios using a streamlined Life Cycle Sustainability Assessment (LCSA). The first scenario considers all space missions launched throughout the 2018 calendar year whilst the second is a futuristic scenario where affordable access to space significantly increases the prevalence of space operations. A new space-specific life cycle database and sustainable design tool called the Strathclyde Space Systems Database (SSSD) has been used to compile the inventory of each scenario and generate results across numerous impact categories. The results for each scenario are then compared against normalised values to portray their contribution towards annual worldwide impacts and their severity in terms of planetary boundaries. This allows the relative life cycle sustainability impacts of space activities to be benchmarked for the first time, forming a basis for evaluation and discussion. Overall, the study highlights that despite the relatively small footprint of the space industry at present, this will likely become much more meaningful in the future based on predicted trends. This places an added importance on addressing potential adverse life cycle impacts within the design process of future space technologies and products.

Local anesthetic systemic toxicity in the pediatric patient.

Lidocaine and prilocaine are local anesthetics, a class of medications which are frequently used in clinical medicine to minimize pain in a variety of procedures. They are commonly found in over-the-counter products such as topical anesthetic creams advertised to relieve localized muscle and joint pain. While safe and well-tolerated when used appropriately, an overdose of these anesthetics increases the risk for local anesthetic systemic toxicity (LAST), which in severe cases can present with seizures, cardiac dysrhythmias, and ultimately cardiovascular collapse. The reduced muscle mass of pediatric patients puts them at an increased risk of LAST due to the depot effect of the systemically absorbed anesthetic. Methemoglobinemia may also be associated with local anesthetic toxicity. Our case involves a previously healthy 15-month-old female who presented to one of our networks' emergency departments in status epilepticus following an accidental ingestion of a tube of 2.5% lidocaine/2.5% prilocaine cream. Her seizure activity was initially resistant to intraosseous benzodiazepine administration, but ultimately resolved following administration of lipid emulsion and sodium bicarbonate. Additionally, the patient had refractory hypoxia on the monitor which resolved shortly after administration of methylene blue. After stabilization, the patient was transferred to the Pediatric ICU and ultimately made a complete recovery. LAST is a life-threatening presentation which requires early recognition by clinicians, as well as an understanding of the appropriate treatment modalities. We review the assessment and management of LAST, with special focus on the pediatric patient.

Doing More With Written Feedback: Improving Learner Satisfaction and Reflection With the LEAF (Learner-Engaged Analysis of Feedback) Method.

PROBLEM: Written feedback is often overly positive, nonspecific, and difficult to interpret. Learner satisfaction with written feedback is low and obtaining written feedback that encourages self-reflection is challenging. Improving feedback quality is laborious and only modestly effective. APPROACH: The authors developed the LEAF (Learner-Engaged Analysis of Feedback) method to improve learner satisfaction with, and reflection on, existing written feedback. The method pairs a learner and coach to methodically identify themes in the learner's written feedback. Themes occurring more frequently or less frequently than typical offer areas for reflection, as they may identify learners' relative strengths or weaknesses. The method was introduced at the Massachusetts General Hospital in 2017 during program director (PD) meetings with anesthesiology residents. In 2018, resident satisfaction was measured (1 to 5 Likert-type questions, 1 = "not at all satisfied," 5 = "extremely satisfied") for 4 feedback sources, 2 related to the LEAF method (PD meetings, written feedback) and 2 unrelated (verbal feedback, mentor feedback). Residents' comments were qualitatively assessed to explore the impact on self-reflection. OUTCOMES: Residents who had participated in a LEAF session (n = 54), compared with those who had not (n = 11), reported higher satisfaction with written feedback (mean 3.1 versus 2.5, d = 0.53, P = .03) and PD meeting feedback (mean 3.8 versus 2.8, d = 0.80, P = .03). There were no significant differences between groups for satisfaction with feedback unrelated to the LEAF method. Qualitative analysis of comments suggested that residents found the method useful for providing holistic self-assessment, facilitating goal setting, uncovering blind spots, and improving feedback interpretation. NEXT STEPS: Next steps should include studies determining if the association between increased learner satisfaction with written feedback and the LEAF method is causal, and whether this feedback process changes learners' subsequent behaviors.

A randomized trial comparing physostigmine vs lorazepam for treatment of antimuscarinic (anticholinergic) toxidrome.

BACKGROUND: Toxicity from antimuscarinic agents precipitates a constellation of signs and symptoms; two of the most significant are agitation and delirium. Benzodiazepines are commonly used for treatment; physostigmine is also effective but is underutilized due to concerns for safety and short duration of action. The objective of this study was to compare lorazepam to physostigmine for the treatment of antimuscarinic delirium and agitation. METHODS: This was a blinded, randomized clinical trial in patients presenting for antimuscarinic toxidrome. Inclusion criteria were: ≥10-<18 years old, at least one central and two peripheral antimuscarinic symptoms, delirium and moderate agitation. Subjects were randomized to either (1) lorazepam bolus (0.05 mg/kg) followed by a 4-h normal saline infusion, or (2) physostigmine 0.02 mg/kg bolus followed by a 4-h physostigmine infusion (0.02 mg/kg/h). Primary outcomes were the control of delirium and agitation after bolus and during the infusion. RESULTS: Ten (53%) subjects were enrolled in the lorazepam arm, 9 (47%) in the physostigmine arm. Diphenhydramine was the most common agent ingested (16, 84%). Fewer patients receiving physostigmine had delirium after the initial bolus (44% vs 100%, p = 0.01) and at the 4th hour of infusion (22% vs 100%, p < 0.001) compared to patients who received lorazepam. There was a significant decrease in agitation scores in the physostigmine arm compared to the lorazepam arm after the initial bolus (89% vs 30%, p = 0.02), but no difference at the 4th hour of infusion (p > 0.99). There were no seizures, bradycardia, bronchorrhea, bronchospasm, intubation, or cardiac dysrhythmias. CONCLUSION: Physostigmine was superior to lorazepam in controlling antimuscarinic delirium and agitation after bolus dosing, and control of delirium after a 4-h infusion. There were no serious adverse events in either treatment arm. Physostigmine bolus and infusion should be considered in adolescent patients with significant delirium and agitation from antimuscarinic agents.

Impact of Systemic Dipeptidyl Peptidase-4 Inhibitor Use in Diabetic Macular Edema.

BACKGROUND AND OBJECTIVE: To evaluate impact of baseline systemic dipeptidyl peptidase-4 (DPP-4) inhibitor use in diabetic macular edema (DME). PATIENTS AND METHODS: This was a post hoc exploratory analysis of previously completed randomized, controlled clinical trials (VISTA and VIVID) in patients with DME evaluating intravitreal aflibercept injection (IAI) every 4 weeks (2q4) or every 8 weeks (2q8) or macular laser photocoagulation. RESULTS: Overall, a small number of patients (12.2% [n = 35], 9.7% [n = 28], and 15.4% [n = 44]) in the laser control, 2q4, and 2q8 groups reported baseline DPP-4 inhibitor use. There were no differences in changes from baseline in best-corrected visual acuity, central subfield thickness, or rates of 2-or-greater-step improvement in Diabetic Retinopathy Severity Scale score based on DPP-4 inhibitor use within each treatment group. CONCLUSION: DPP-4 inhibitor use at baseline did not influence the magnitude of visual and anatomic benefit in patients with DME being treated with IAI or laser. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:226-234.].

Versatility in multiple mini-interview implementation: Rater background does not significantly influence assessment scoring.

The medical school admissions process seeks to assess a core set of cognitive and non-cognitive competencies that reflect professional readiness and institutional mission alignment. The standardized format of multiple mini-interviews (MMIs) can enhance assessments, and thus many medical schools have switched to this for candidate interviews. However, because MMIs are resource-intensive, admissions deans use a variety of interviewers from different backgrounds/professions. Here, we analyze the MMI process for the 2018 admissions cycle at the VCU School of Medicine, where 578 applicants were interviewed by 126 raters from five distinct backgrounds: clinical faculty, basic science faculty, medical students, medical school administrative staff, and community members. We found that interviewer background did not significantly influence MMI evaluative performance scoring, which eliminates a potential concern about the consistency and reliability of assessment.

Digoxin Toxicity in a Patient with Pacemaker: A Case Report.

Digoxin is a cardiac myocyte sodium/potassium ATPase inhibitor with a narrow therapeutic index used to treat patients with conditions such as heart failure with reduced ejection fraction and atrial fibrillation. Currently, digoxin-specific antibody fragments serve as a therapeutic option in patients with digoxin toxicity; however, the indications for digoxin-specific antibody fragments are inconsistent, and some sources report a serum digoxin concentration of >12 ng/mL as a treatment indication. We discuss a case of an asymptomatic elevated digoxin level of 13.5 ng/mL secondary to a dosing error, who was managed without digoxin-specific antibody fragments as well as a brief retrospective chart review for patients with a pacemaker presenting with a high digoxin concentration managed with and without digoxin-specific antibody fragments, with equivocal findings.

Resident identification of feedback and teaching on rounds.

Feedback and teaching occur regularly on teaching hospital wards. Although feedback has important implications for resident learning, residents often report that they receive little feedback. The significant overlap of teaching and feedback in clinical education may contribute to resident difficulty with feedback identification. We sent a survey with seven scenarios to internal medicine residents across the country. Two of the scenarios contained teaching, two contained feedback, and three contained combined teaching and feedback. From October 2017 to April 2018, 17% of residents (392/2346) from 17 residency programs completed the survey. Participating residents correctly identified both feedback scenarios 89% of the time, both teaching scenarios 64% of the time, and all three combined teaching and feedback scenarios 38% of the time. Interns were less likely than upper-level residents to correctly identify combined teaching and feedback scenarios (P = 0.005). Residents may have difficulty identifying feedback in the context of teaching. This confusion may contribute to residents' perceptions that they receive little feedback.

Academic Anesthesiologists Perceive Significant Internal Barriers to Intraoperative Teaching in a Cross-Sectional Survey.

BACKGROUND: Academic anesthesiologists have numerous demands on their time, and this can erode teaching quality. Reducing barriers to teaching may ameliorate this. The primary aim of this study is to evaluate the learning environment and identify barriers to clinical teaching using a multicenter survey approach. METHODS: Anesthesiologists at four academic centers were surveyed to understand barriers to clinical teaching. Demographic data and time spent teaching were collected. Faculty attitudes regarding teaching, resident physician perceptions of their teaching, supportiveness of departmental and operating room leadership, whether they enjoyed teaching, and the perceived quality of their own teaching ("self-efficacy") were assessed using Likert scales. Principal component analysis was performed to identify themes in these data. Pearson correlation, t test, and linear regression analyses were used to evaluate interactions between themes. RESULTS: The response rate was 40.6% (230/566). Responding faculty expressed a high level of engagement with the teaching role. Clinical production pressure was a common theme. Faculty who spent more time teaching reported greater enjoyment of teaching, feeling better about their teaching, and were better prepared to teach. Enjoyment of teaching was not independently associated with more time spent teaching. Regression analysis revealed that perceptions of environmental factors (including production pressure) had no independent effect on time spent teaching or on self-efficacy in teaching quality. Faculty self-efficacy was positively related to enjoyment of teaching as well as making teaching a higher priority. CONCLUSIONS: Improving perceptions of the learning environment might be best achieved by mitigating production pressure and improving faculty self-efficacy in their teaching.