Sensory assessment and block duration of transmuscular quadratus lumborum block at L2 versus L4 in volunteers: a randomized controlled trial.

BACKGROUND: The efficacy of an ultrasound guided transmuscular quadratus lumborum block (QLB) for perioperative analgesia of the upper and lower abdomen remain debatable. The purpose of this study was to compare the cutaneous sensory blocked area (CSBA) between QLB blocks performed at the L2 vs. L4 levels. METHODS: Twenty-two healthy volunteers were randomized 1:1 to receive an ultrasound guided right transmuscular QLB at the L2 level (group QL2) or L4 level (group QL4). A cold stimulus was applied for testing of the CSBA at 30 minutes after the blockade was performed. The CSBA was mapped and then calculated. Three hours after the QLB, a cold stimulus was applied once every hour until sensation returned normal and the effective block duration for each volunteer was determined and recorded. RESULTS: The maximum cephalad dermatome level reached was T7 in group QL2 vs. T11 in group QL4, respectively. Caudally, both groups reached the L2 dermatome level. The QL2 block primarily affected dermatomes T9 to L1, while the QL4 block affected T11 to L1. The total CSBA was larger in QL2 group than that in QL4 group (748 [171] cm2 vs. 501 [186] cm2, P=0.004). The effective duration of the QLB was significantly longer in group QL2 than in group QL4 (18.5 [2.0]h vs. 14.1 [4.7]h, P=0.012). The number of affected dermatomes assessed by cold test was significantly larger for the volunteers in groups QL2 (4.6 [0.81] vs. 2.1 [0.30], P<0.001). CONCLUSIONS: Ultrasound guided transmuscular QLB injection of 0.375% 20 mL ropivacaine at the L2 level produced a widespread cutaneous sensory blockade and a prolonged sensory block to cold sensation compared with the L4 level.

Sensory Assessment and Regression Rate of Bilateral Oblique Subcostal Transversus Abdominis Plane Block in Volunteers.

BACKGROUND AND OBJECTIVES: The analgesic effect and duration of a transversus abdominis plane (TAP) block remain controversial. Transversus abdominis plane blocks are effective for somatic/incisional pain but do not provide analgesia for visceral pain from intra-abdominal procedures. The purpose of this study was to assess the area and extent of cutaneous sensory blockade and the regression of dermatomal anesthesia after bilateral oblique subcostal TAP block. METHODS: This observational, prospective clinical study consisted of 12 healthy volunteers. All volunteers received a bilateral oblique subcostal TAP block under real-time ultrasound guidance with 20 mL of 0.375% ropivacaine. The anterior abdominal cutaneous area was divided into 3 parts (midabdomen, left-lateral abdomen, right-lateral abdomen) using 2 lines drawn in a parasagittal fashion 5 cm lateral to the midline. The area of cutaneous sensory blockade involving the anterior abdomen was assessed 30 minutes after institution of the block using a cold stimulus. This was followed by repeated measurements using a cold stimulus applied along parasagittal lines drawn 3 cm lateral to the midline at 0.5, 6, 10, 14, 18, 22, and 26 hours after blockade. RESULTS: The area of cutaneous sensory blockade of the abdomen was 332 (SD, 73) cm; that of the midabdomen was 253 (SD, 29) cm, which represented an average of 90% of the area of the midabdomen; and that of the lateral abdominal wall (combination of left-lateral abdomen and right-lateral abdomen) was 79 (SD, 62) cm, which represented an average of 26% of total lateral abdominal area. Dermatomes T7-T12 of the midabdomen were successfully blocked in all volunteers after using the bilateral oblique subcostal technique. However, T6 and L1 were only variably blocked. The area of cutaneous sensory block of the anterior abdomen regressed over the ensuing 22 hours in the following manner: 90%, 87%, 73%, 50%, 22%, 3%, and 0% at 0.5, 6, 10, 14, 18, 22, and 26 hours, respectively. CONCLUSIONS: Bilateral oblique subcostal TAP block produces a widespread cutaneous sensory blockade with a consistent dermatomal distribution in the midabdomen for a considerable effective duration.

Creating physicians of the 21st century: assessment of the clinical years.

Medical education has been under a constant state of revision for the past several years. The overarching theme of the curriculum revisions for medical schools across the USA has been creating better physicians for the 21st century, with the same end result: graduating medical students at the optimal performance level when entering residency. We propose a robust, thorough assessment process that will address the needs of clerkships, residents, students, and, most importantly, medical schools to best measure and improve clinical reasoning skills that are required for the learning outcomes of our future physicians. The Accreditation Council for Graduate Medical Education (ACGME) evaluates and accredits medical school graduates based on competency-based outcomes and the assessment of specialty-specific milestones; however, there is some evidence that medical school graduates do not consistently meet the Level 1 milestones prior to entering/beginning residency, thus starting their internship year underprepared and overwhelmed. Medical schools should take on the responsibility to provide competency-based assessments for their students during the clinical years. These assessments should be geared toward preparing them with the cognitive competencies and skills needed to successfully transition to residency. Then, medical schools can produce students who will ultimately be prepared for transition to their residency programs to provide quality care.

A Comprehensive Framework for International Medical Programs: A 2017 consensus statement from the American College of Academic International Medicine.

The American College of Academic International Medicine (ACAIM) represents a group of clinicians who seek to promote clinical, educational, and scientific collaboration in the area of Academic International Medicine (AIM) to address health care disparities and improve patient care and outcomes globally. Significant health care delivery and quality gaps persist between high-income countries (HICs) and low-and-middle-income countries (LMICs). International Medical Programs (IMPs) are an important mechanism for addressing these inequalities. IMPs are international partnerships that primarily use education and training-based interventions to build sustainable clinical capacity. Within this overall context, a comprehensive framework for IMPs (CFIMPs) is needed to assist HICs and LMICs navigate the development of IMPs. The aim of this consensus statement is to highlight best practices and engage the global community in ACAIM's mission. Through this work, we highlight key aspects of IMPs including: (1) the structure; (2) core principles for successful and ethical development; (3) information technology; (4) medical education and training; (5) research and scientific investigation; and (6) program durability. The ultimate goal of current initiatives is to create a foundation upon which ACAIM and other organizations can begin to formalize a truly global network of clinical education/training and care delivery sites, with long-term sustainability as the primary pillar of international inter-institutional collaborations.

The Effect of Previous Resident Interactions on the Assessment of Interpersonal and Communication Skills by Teaching Faculty: Are We the Best Evaluators?

BACKGROUND: Evaluating resident interpersonal and communication skills (ICS) presents a significant challenge. Unlike the In-Training-Exam, an objective measure of knowledge, the evaluation of ICS is subjective. Previous interactions could influence how teaching faculty evaluate this competency leading to inaccurate assessment of resident ICS. Faculty groups from other residencies and non-physicians were enlisted to compare assessments with those by teaching faculty. METHODS: A cross-sectional study was conducted comparing how different evaluator groups assessed the ICS of anesthesiology residents. Nine residents participated each in two Standardized Patient (SP) encounters that were video-recorded. The recordings were viewed by eleven evaluators representing four different evaluator groups, one non-blinded teaching faculty group, two blinded anesthesiology faculty groups from separate programs and one blinded non-physician group. They scored each encounter using a modified SEGUE framework evaluation form graded on a Likert scale. RESULTS: The mean score for each resident ICS encounter by evaluator group were as follows: non-blinded teaching faculty (57.89), non-physician group (57.42), and the blinded anesthesiology faculties (53.00) and (53.83) respectively. There was significant difference in how the evaluator groups scored the resident performances (p<0.001). Analysis of ranks showed excellent correlation comparing teaching faculty with the other anesthesiology faculty groups (r=0.764, p=0.017 and r=0.765, p=0.016, respectively). The highest ranked resident overall ranked high across all evaluator groups and the lowest ranked resident was ranked lowest across most evaluator groups. CONCLUSIONS: Though potential for biases from previous interactions exist, teaching faculty assessments of resident ICS are similar to the assessments of other anesthesiology faculty evaluator groups.

Nonconvective forces: a critical and often ignored component in the echocardiographic assessment of transvalvular pressure gradients.

Echocardiography is routinely used to assess ventricular and valvular function, particularly in patients with known or suspected cardiac disease and who have evidence of hemodynamic compromise. A cornerstone to the use of echocardiographic imaging is not only the qualitative assessment, but also the quantitative Doppler-derived velocity characteristics of intracardiac blood flow. While simplified equations, such as the modified Bernoulli equation, are used to estimate intracardiac pressure gradients based upon Doppler velocity data, these modified equations are based upon assumptions of the varying contributions of the different forces that contribute to blood flow. Unfortunately, the assumptions can result in significant miscalculations in determining a gradient if not completely understood or they are misapplied. We briefly summarize the principles of fluid dynamics that are used clinically with some of the inherent limitations of routine broad application of the simplified Bernoulli equation.

Neural network-based real-time prediction of glucose in patients with insulin-dependent diabetes.

BACKGROUND: Continuous glucose monitoring (CGM) technologies report measurements of interstitial glucose concentration every 5 min. CGM technologies have the potential to be utilized for prediction of prospective glucose concentrations with subsequent optimization of glycemic control. This article outlines a feed-forward neural network model (NNM) utilized for real-time prediction of glucose. METHODS: A feed-forward NNM was designed for real-time prediction of glucose in patients with diabetes implementing a prediction horizon of 75 min. Inputs to the NNM included CGM values, insulin dosages, metered glucose values, nutritional intake, lifestyle, and emotional factors. Performance of the NNM was assessed in 10 patients not included in the model training set. RESULTS: The NNM had a root mean squared error of 43.9 mg/dL and a mean absolute difference percentage of 22.1. The NNM routinely overestimates hypoglycemic extremes, which can be attributed to the limited number of hypoglycemic reactions in the model training set. The model predicts 88.6% of normal glucose concentrations (> 70 and < 180 mg/dL), 72.6% of hyperglycemia (≥ 180 mg/dL), and 2.1% of hypoglycemia (≤ 70 mg/dL). Clarke Error Grid Analysis of model predictions indicated that 92.3% of predictions could be regarded as clinically acceptable and not leading to adverse therapeutic direction. Of these predicted values, 62.3% and 30.0% were located within Zones A and B, respectively, of the error grid. CONCLUSIONS: Real-time prediction of glucose via the proposed NNM may provide a means of intelligent therapeutic guidance and direction.

Healthcare access as a right, not a privilege: a construct of Western thought.

Over 45 million Americans are uninsured or underinsured. Those living in poverty exhibit the worst health status. Employment, education, income, and race are important factors in a person's ability to acquire healthcare access. Having established that there are people lacking healthcare access due to multi-factorial etiologies, the question arises as to whether the intervention necessary to assist them in obtaining such access should be considered a privilege, or a right. The right to healthcare access is examined from the perspective of Western thought. Specifically through the works of Aristotle, Immanuel Kant, Thomas Hobbes, Thomas Paine, Hannah Arendt, James Rawls, and Norman Daniels, which are accompanied by a contemporary example of intervention on behalf of the medically needy by the The Johns Hopkins Urban Health Institute. As human beings we are all valuable social entities whereby, through the force of morality, through implicitly forged covenants among us as individuals and between us and our governments, and through the natural rights we maintain as individuals and those we collectively surrender to the common good, it has been determined by nature, natural laws, and natural rights that human beings have the right, not the privilege, to healthcare access.

Stoicism, the physician, and care of medical outliers.

BACKGROUND: Medical outliers present a medical, psychological, social, and economic challenge to the physicians who care for them. The determinism of Stoic thought is explored as an intellectual basis for the pursuit of a correct mental attitude that will provide aid and comfort to physicians who care for medical outliers, thus fostering continued physician engagement in their care. DISCUSSION: The Stoic topics of good, the preferable, the morally indifferent, living consistently, and appropriate actions are reviewed. Furthermore, Zeno's cardinal virtues of Justice, Temperance, Bravery, and Wisdom are addressed, as are the Stoic passions of fear, lust, mental pain, and mental pleasure. These concepts must be understood by physicians if they are to comprehend and accept the Stoic view as it relates to having the proper attitude when caring for those with long-term and/or costly illnesses. SUMMARY: Practicing physicians, especially those that are hospital based, and most assuredly those practicing critical care medicine, will be emotionally challenged by the medical outlier. A Stoic approach to such a social and psychological burden may be of benefit.

The student and the ovum: the lack of autonomy and informed consent in trading genes for tuition.

Rising tuition costs have forced university students to become creative in finding ways to fund their education. Some female university students have decided that ova donation may be an acceptable alternative in which to pay for their tuition. This alternative presents itself because of the insufficient number of ova available for assisted reproduction and emerging stem cell technologies. Young female university students are encouraged by Internet sources and respectable electronic and print media to donate their ova in the cause of assisted reproduction for monetary compensation. While university students generally exhibit autonomy, the constraining influence of their financial predicament compromises the elements of informed consent (voluntariness, competence, capacity, understanding, and disclosure) as to their making an autonomous decision in regard to egg donation. Thus, any moral possibility of giving informed consent is negated. Informed consent can only occur through autonomy. A female university student in need of financial resources to pay for her education cannot make an autonomous choice to trade her genes for tuition. Donated ova are not only needed for assisted reproduction, but for stem cell technologies. While the long-term health of women who donate their ova is of concern (a potential risk of cancer after long term use of ovulation induction), of equal concern is the possibility of a growth in the trade of ova targeting third world and Eastern European women where the precedence for autonomy and informed consent is not well established.

The obligation of physicians to medical outliers: a Kantian and Hegelian synthesis.

BACKGROUND: Patients who present to medical practices without health insurance or with serious co-morbidities can become fiscal disasters to those who care for them. Their consumption of scarce resources has caused consternation among providers and institutions, especially as it concerns the amount and type of care they should receive. In fact, some providers may try to avoid caring for them altogether, or at least try to limit their institutional or practice exposure to them. DISCUSSION: We present a philosophical discourse, with emphasis on the writings of Immanuel Kant and G.F.W. Hegel, as to why physicians have the moral imperative to give such "outliers" considerate and thoughtful care. Outliers are defined and the ideals of morality, responsibility, good will, duty, and principle are applied to the care of patients whose financial means are meager and to those whose care is physiologically futile. Actions of moral worth, unconditional good will, and doing what is right are examined. SUMMARY: Outliers are a legitimate economic concern to individual practitioners and institutions, however this should not lead to an evasion of care. These patients should be identified early in their course of care, but such identification should be preceded by a well-planned recognition of this burden and appropriate staffing and funding should be secured. A thoughtful team approach by medical practices and their institutions, involving both clinicians and non-clinicians, should be pursued.