Palliative Sedation, Compassionate Extubation, and the Principle of Double Effect: An Ethical Analysis.

Palliative sedation is a well-recognized and commonly used medical practice at the end of life for patients who are experiencing refractory symptoms that cannot be controlled by other means of medical management. Given concerns about potentially hastening death by suppressing patients' respiratory drive, traditionally this medical practice has been considered ethically justifiable via application of the ethical doctrine known as the Principle of Double Effect. And even though most recent evidence suggests that palliative sedation is a safe and effective practice that does not hasten death when the sedative medications are properly titrated, the Principle of Double Effect is still commonly utilized to justify the practice of palliative sedation and any risk-however small-it may entail of hastening the death of patients. One less common clinical scenario where the Principle of Double Effect may still be appropriate ethical justification for palliative sedation is when the practice of palliative sedation is pursued concurrently with the active withdrawal of life-sustaining treatment-particularly the practice of compassionate extubation. This case study then describes an unconventional case of palliative sedation with concurrent compassionate extubation where Principle of Double Effect reasoning was effectively employed to ethically justify continuing to palliatively sedate a patient during compassionate extubation.

Crowdsourced Assessment of Surgical Skill Proficiency in Cataract Surgery.

OBJECTIVE: To test whether crowdsourced lay raters can accurately assess cataract surgical skills. DESIGN: Two-armed study: independent cross-sectional and longitudinal cohorts. SETTING: Washington University Department of Ophthalmology. PARTICIPANTS AND METHODS: Sixteen cataract surgeons with varying experience levels submitted cataract surgery videos to be graded by 5 experts and 300+ crowdworkers masked to surgeon experience. Cross-sectional study: 50 videos from surgeons ranging from first-year resident to attending physician, pooled by years of training. Longitudinal study: 28 videos obtained at regular intervals as residents progressed through 180 cases. Surgical skill was graded using the modified Objective Structured Assessment of Technical Skill (mOSATS). Main outcome measures were overall technical performance, reliability indices, and correlation between expert and crowd mean scores. RESULTS: Experts demonstrated high interrater reliability and accurately predicted training level, establishing construct validity for the modified OSATS. Crowd scores were correlated with (r = 0.865, p < 0.0001) but consistently higher than expert scores for first, second, and third-year residents (p < 0.0001, paired t-test). Longer surgery duration negatively correlated with training level (r = -0.855, p < 0.0001) and expert score (r = -0.927, p < 0.0001). The longitudinal dataset reproduced cross-sectional study findings for crowd and expert comparisons. A regression equation transforming crowd score plus video length into expert score was derived from the cross-sectional dataset (r2 = 0.92) and demonstrated excellent predictive modeling when applied to the independent longitudinal dataset (r2 = 0.80). A group of student raters who had edited the cataract videos also graded them, producing scores that more closely approximated experts than the crowd. CONCLUSIONS: Crowdsourced rankings correlated with expert scores, but were not equivalent; crowd scores overestimated technical competency, especially for novice surgeons. A novel approach of adjusting crowd scores with surgery duration generated a more accurate predictive model for surgical skill. More studies are needed before crowdsourcing can be reliably used for assessing surgical proficiency.

Severe pupil distortion following transchamber repair of a cyclodialysis cleft.

This report describes a potential complication following the repair of a traumatic cyclodialysis cleft in a pediatric patient using a novel technique. A healthy 11-year-old boy suffered a blunt traumatic tennis ball injury to his left eye. He underwent repair of a retinal dialysis with detachment shortly after the injury. Postoperatively, he developed persistent hypotony, shallow anterior chamber, and hypotony maculopathy. An occult cyclodialysis cleft was suspected. Examination under anesthesia revealed a small cyclodialysis deft. The cleft was closed by transchamber placement of prolene sutures across the cleft under direct visualization through a Tano lens. Postoperative course was complicated by severe pupillary distortion despite subsequent suture removal.

Sequential or simultaneous cyclophotocoagulation and glaucoma drainage implant for refractory glaucoma.

PURPOSE: To describe the outcomes of combining cyclophotocoagulation and tube-shunt glaucoma drainage implants, either sequentially or simultaneously, for the control of refractory glaucomas. PATIENTS AND METHODS: A retrospective review was conducted of all patients that had been treated at our institute with both cyclophotocoagulation and a tube-shunt glaucoma drainage implant in the same eye between January 1996 and June 2000. Preoperative and postoperative intraocular pressure, number of glaucoma medications, vision, and complications data were collected for each eye. RESULTS: A total of 10 eyes of 9 patients met the study criteria. The minimum follow-up period after the last surgery was 15 months. Intraocular pressures were reduced from 28.5 +/- 7.2 mm Hg preoperatively to 13.9 +/- 5.4 mm Hg postoperatively at 15 months (P < 0.000, n = 9). Medications were reduced from 2.7 +/- 1.2 preoperatively to 0.3 +/- 0.5 postoperatively at 15 months (P < 0.000, n = 9). Of the eight eyes with measurable Snellen acuity, postoperative vision decreased two or more lines in five eyes (63%). Complications included transient hypotony (one eye), transient serous choroidal detachment (two eyes), cystoid macular edema (two eyes), corneal edema (three eyes), and panuveitis with chronic hypotony and traction retinal detachment (one eye). CONCLUSIONS: Combining cyclophotocoagulation with tube-shunt glaucoma drainage implants can effectively reduce intraocular pressure and number of glaucoma medications needed to achieve target intraocular pressure goals. Further study is needed to determine the safety of this combined approach compared with other available options to manage refractory glaucomas.

Endoscopic evaluation of the small intestine.

Technological achievements in the area of endoscope design and development have resulted in instruments capable of advancing beyond the reach of simple gastroscopes. Such instruments, known as enteroscopes, form the bases of small bowel endoscopy. Recent widespread use of enteroscopes have contributed significantly to the understanding of small intestinal pathology and improved the ability to diagnose and treat patients with intestinal bleeding sources.