Remote Monitoring and Artificial Intelligence: Outlook for 2050.

Remote monitoring and artificial intelligence will become common and intertwined in anesthesiology by 2050. In the intraoperative period, technology will lead to the development of integrated monitoring systems that will integrate multiple data streams and allow anesthesiologists to track patients more effectively. This will free up anesthesiologists to focus on more complex tasks, such as managing risk and making value-based decisions. This will also enable the continued integration of remote monitoring and control towers having profound effects on coverage and practice models. In the PACU and ICU, the technology will lead to the development of early warning systems that can identify patients who are at risk of complications, enabling early interventions and more proactive care. The integration of augmented reality will allow for better integration of diverse types of data and better decision-making. Postoperatively, the proliferation of wearable devices that can monitor patient vital signs and track their progress will allow patients to be discharged from the hospital sooner and receive care at home. This will require increased use of telemedicine, which will allow patients to consult with doctors remotely. All of these advances will require changes to legal and regulatory frameworks that will enable new workflows that are different from those familiar to today's providers.

Informed consent for invasive procedures in the emergency department.

BACKGROUND: Informed consent for procedures in the emergency department (ED) challenges practitioners to navigate complex ethical and medical ambiguities. A patient's altered mental status or emergent medical problem does not negate the importance of his or her participation in the decision-making process but, rather, necessitates a nuanced assessment of the situation to determine the appropriate level of participation. Given the complexities involved with informed consent for procedures in the ED, it is important to understand the experience of key stakeholders involved. METHODS: For this review, we searched Medline, the Cochrane database, and Clinicaltrials.gov for studies involving informed consent in the ED. Inclusion and exclusion criteria were designed to select for studies that included issues related to informed consent as primary outcomes. The following data was extracted from included studies: Title, authors, date of publication, study type, participant type (i.e. adult patient, pediatric patient, parent of pediatric patient, patient's family, or healthcare provider), number of participants, and primary outcomes measured. RESULTS: Fifteen articles were included for final review. Commonly addressed themes included medical education (7 of 15 studies), surrogate decision-making (5 of 15 studies), and patient understanding (4 of 15 studies). The least common theme addressed in the literature was community notification (1 of 15 studies). CONCLUSIONS: Studies of informed consent for procedures in the ED span many aspects of informed consent. The aim of the present narrative review is to summarize the work that has been done on informed consent for procedures in the ED.

The effect of an organ procurement experience on preclinical medical student perceptions of transplant surgery.

Transplant surgery is a predominantly male specialty with high burnout rates. There are currently limited data regarding how programs can attract a diverse applicant pool to the field of transplant surgery. This study evaluated the effect of an Organ Procurement Experience elective on preclinical medical students' perceptions of transplant surgery in a prospective, longitudinal study. Preclinical medical students were anonymously surveyed before and after attending a deceased donor organ procurement. Questions focused on the following themes: Personal Beliefs, Personal/Professional Life, Diversity, and Gender Equality. Responses were rated on a five-point Likert scale. Ninety-nine and 45 students completed pre/post-procurement survey, respectively. Post-procurement responses demonstrated increased education about the field (2.1/5 vs 3.89/5, P < 0.001) and perceptions of the personalities and collegiality between surgeons (3.06/5 vs 3.73/5, P = 0.005). Post-procurement, women were less likely to feel that female transplant surgeons are treated differently (3.98/5 vs. 3.45/5, P < 0.017). Post-procurement, 19% agreed that transplant surgeons have a high quality of life. One percent of respondents felt the current gender distribution in transplant surgery is satisfactory. The Organ Procurement Experience significantly improved preclinical students' perceptions of the field. However, there remains a strong concern about quality of life and gender diversity within the field.

Comparison between pars plana and anterior endoscopic cyclophotocoagulation for the treatment of glaucoma.

IMPORTANCE: This is the first study to compare the efficacy and safety of endocyclophotocoagulation (ECP) via pars plana (ECP-plus) with ECP via limbus (anterior ECP) for treating glaucoma. BACKGROUND: There is no direct comparison of treatment outcomes between ECP-plus and anterior ECP. DESIGN: Retrospective study. PARTICIPANTS: Fifty-four consecutive patients. METHODS: Fifty-eight eyes from 54 consecutive patients underwent anterior ECP (33 eyes) or ECP-plus (25 eyes) with 2-year follow-up. Linear mixed model was used to analyse the surgical outcomes. MAIN OUTCOME MEASURES: Intraocular Pressure (IOP) was the primary outcome. Secondary outcomes were best-corrected visual acuity, number of glaucoma medications, complications and success rate. RESULTS: Compared to anterior ECP, patients in the ECP-plus group had lower IOP (estimate of effect size [EES] = -3.7 mmHg, P = 0.023) and used fewer number of glaucoma medications (EES = -1.11, P = 0.003), after adjusting for degrees of treatment, preoperative IOP, and presence of combined ECP and phacoemulsification procedure. Patients with ECP-plus achieved a higher success rate at 2 years postoperatively (80% vs 33.3%, P < 0.001). The decrease in IOP between the preoperative and last follow-up visit was greater in the ECP-plus group compared to the anterior ECP group (14.3 mmHg (52%) vs 5.2 mmHg (24%), P = 0.001). There was no significant difference in complication rates between the two groups (28% vs 33%, P = 0.561). CONCLUSIONS AND RELEVANCE: Anterior ECP and ECP-plus have a similar safety profile, and ECP-plus may offer superior IOP control for the management of glaucoma.

Informed Consent in Pediatric Anesthesia: A Narrative Review.

Informed consent for pediatric anesthesia challenges practitioners to navigate complex ethical, medical, and legal ambiguities. A patient's status as a minor does not negate the importance of his or her participation in the decision-making process but, rather, necessitates a nuanced evaluation of age and development to involve the patient to an appropriate extent. Given the complexities involved with pediatric informed consent in anesthesia practice and research, it is important to understand the experience of key stakeholders involved. For this review, we searched Medline, the Cochrane database, PROSPERO, and Clinicaltrials.gov for studies involving pediatric anesthesia informed consent. Inclusion and exclusion criteria were designed to select for studies that included issues related to informed consent as primary outcomes. The following data were extracted from included studies: title, authors, date of publication, study type, intervention, data collection method, participant type (ie, parent, pediatric patient, anesthesia provider), number of participants, pediatric patient age range, and primary outcome measures. Twenty-two articles were included for final review: studies of informed consent in pediatric anesthesia span many aspects of informed consent. Parental understanding has been studied most often (7/22 studies), followed by parental preferences (5/22 studies) and provider-related outcomes (5/22 studies) such as time spent interacting with patients, subjective reporting on amount of training related to informed consent, and provider satisfaction with the informed consent process. Outcomes pertaining to pediatric patients themselves constitute the smallest number of studies, including child anxiety (1/22), child understanding (1/22), and child refusal (1/22). Among the parties involved, parents have been most frequently identified as the subjects of these studies (2719/3805 subjects across all included studies, or 71% of all subjects). Pediatric patients are the least frequently involved subjects of studies that investigate informed consent in pediatric anesthesia (493/3805, or 13% of all subjects). Anesthesia providers and investigators have been study subjects (593/3805, or 16% of all subjects) for a range of topics including time spent interacting with patient, nature of informed consent conversation in relation to trainee status, satisfaction with informed consent process, and priorities for informed consent content. The aim of the present narrative review is to summarize the work that has been done on informed consent for pediatric anesthesia.

Frequency of medication error in pediatric anesthesia: A systematic review and meta-analytic estimate.

BACKGROUND: Clinical evidence shows that pediatric anesthesia patients are subject to a higher rate of life-threatening medical errors than their adult counterparts. Medication error in adult anesthesia is estimated to occur to 1 in 133 anesthetic administrations, but such a figure has not been determined for pediatric anesthesia patients. Individual studies of medication error in pediatric anesthesia have ranged from rates of 0.01% to 1.92% of anesthetic uses. The present study is a systematic review that employs a meta-analytic estimate to determine the rate of medication error in pediatric anesthesia. METHODS: A systematic review of the literature on pediatric anesthesia medication error was conducted using Medline, Cochrane Database, PROSPERO, and Clinicaltrials.gov. A meta-analytic estimate was used to determine the medication error rate for all of the included studies. Subgroup sensitivity analysis was used to evaluate possible sources of heterogeneity in included studies. RESULTS: Of the 433 initially screened records, 13 studies met inclusion criteria. Meta-analytic estimate of medication error rate across all studies was 0.08% (95% CI 0.05%-0.10%), or 1 out of 1250 anesthetics. Ten different countries were represented in the studies. Sample size of anesthetics reported on ranged from 296 to 2 316 635. Data collecting periods ranged from 3 months to 15 years. Six included studies individually reported higher rates of medication error in patients under 1 year of age. CONCLUSION: The present systematic review revealed a medication error rate of 1 per 1250 anesthetic administrations in pediatric anesthesia. This result is significantly lower than would be expected given reported rates of medication error in adult anesthesia, which raises questions regarding the validity of research methods and reporting of medication error in pediatric anesthesia. Future investigations of medication error should employ methodologies other than self-reporting of error, such as retrospective chart review.

Choriocapillaris Changes in Myopic Macular Degeneration.

PURPOSE: Myopic macular degeneration (MMD) can cause irreversible vision loss. Thinner choroid is associated with increased MMD severity. This cross-sectional study analyzed choriocapillaris (CC) alterations in MMD. METHODS: Axial length (AL), best-corrected visual acuity (BCVA), fundus photography, and swept-source optical coherence tomography angiography (SS-OCTA) were assessed in controls and high myopes (spherical equivalent ≤ -6 diopters). Myopic patients with grade 2 MMD (macular diffuse chorioretinal atrophy [MDCA]), high axial myopia (AL ≥ 26.5 mm), and BCVA ≥ 20/40 were compared with controls without MMD. CC mean thickness was measured from 3 × 3-mm SS-OCTA scans by identifying CC peaks in A-scan intensity profiles. CC flow deficit percent (CC FD%) was quantified using a fuzzy C-mean local thresholding method on en face OCTA images. Multivariate regressions compared CC thickness and CC FD% between myopic patients and controls, correcting for age and other confounders. RESULTS: Sixteen eyes with MDCA (AL, 26.96-33.93 mm; ages, 40-78 years) were compared with 51 control eyes (AL, 21.65-25.84 mm; ages, 19-88 years). CC thickness in patients with MDCA was 66% lower than that in controls (5.23 ± 0.68 µm [mean ± SD] vs. 15.46 ± 1.82 µm; P < 0.001). CC FD% in patients with MDCA was 237% greater than in controls (26.5 ± 4.3 vs. 11.2 ± 4.6; P < 0.001). CONCLUSIONS: Patients with MDCA with good visual acuity had thinner CC and increased CC FD%, or reduced CC flow, compared with controls. Patients with grade 2 MMD and good visual acuity demonstrated significant choriocapillaris alterations, suggesting that choriocapillaris perfusion defects contribute to the pathogenesis of MMD. TRANSLATIONAL RELEVANCE: Given the potential vascular etiology for MMD, current research about revascularization of ischemic retina likely has implications for the treatment of MMD.

Interactions Between Opioids and Dextroamphetamine on Locomotor Activity: Influence of an Opioid's Relative Efficacy at the Mu Receptor.

Opioids and stimulants are often used in combination for both recreational and non-recreational purposes. High-efficacy mu opioid agonists generally increase the behavioral effects of stimulants, whereas opioid receptor antagonists generally attenuate the behavioral effects of stimulants; however, less is known regarding the interactions between stimulants and opioids possessing low to intermediate efficacy at the mu receptor. The purpose of this study was to examine the role of an opioid's relative efficacy at the mu receptor in altering the behavioral effects of dextro(d-)amphetamine. To this end, opioids possessing a range of relative efficacy at the mu receptor were examined alone and in combination with cumulative doses of d-amphetamine on a test of open-field, locomotor activity in male rats. Levorphanol, buprenorphine, butorphanol, nalbuphine, (-)-pentazocine, (-)-metazocine, (-)-cyclazocine, (-)-NANM, and nalorphine increased the locomotor effects of d-amphetamine in either an additive or greater-than-additive manner according to an effect-additive model. Only the selective, high-efficacy kappa agonist, spiradoline, and the non-selective opioid receptor antagonist, naloxone, failed to increase the effects of d-amphetamine under the conditions examined. These data indicate that opioids possessing a large range of relative efficacy at the mu receptor, including those possessing very low relative efficacy, significantly increase the locomotor effects of d-amphetamine.

Barriers to emergency department usage during the COVID-19 pandemic.

OBJECTIVE: The objective of this study was to determine the public's likelihood of being willing to use an emergency department (ED) for urgent/emergent illness during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: An institutional review board-approved, cross-sectional survey of a non-probability sample from Amazon Mechanical Turk was administered May 24-25, 2020. Change in self-reported willingness to use an ED before and during the pandemic (primary outcome) was assessed via McNemar's test; COVID-19 knowledge and perceptions were secondary outcomes. RESULTS: There were 855 survey participants (466 [54.5%] male; 699 [81.8%] White; median age 39). Proportion reporting likelihood to use the ED pre-pandemic (71% [604/855]) decreased significantly during the pandemic (49% [417/855]; P < 0.001); those unlikely to visit the ED increased significantly during the pandemic (41% [347/855] vs 22% [417/855], P < 0.001). Participants were unlikely to use the ED during the pandemic if they were unlikely to use it pre-pandemic (adjusted odds ratio, 4.55; 95% confidence interval, 3.09-6.7) or correctly answered more COVID-19 knowledge questions (adjusted odds ratio, 1.37; 95% confidence interval, 1.17-1.60). Furthermore, 23.4% (n = 200) of respondents believed the pandemic was not a serious threat to society. Respondents with higher COVID-19 knowledge scores were more likely to view the pandemic as serious (odds ratio, 1.57; 95% confidence interval, 1.36-1.82). CONCLUSIONS: This survey study investigated the public's willingness to use the ED during the COVID-19 pandemic. Only 49% of survey respondents were willing to visit the ED during a pandemic if they felt ill compared with 71% before the pandemic.

Histologic Changes Following Continuous Wave and Micropulse Transscleral Cyclophotocoagulation: A Randomized Comparative Study.

Purpose: To compare the macroscopic and microscopic histologic changes in eyes treated with micropulse transscleral cyclophotocoagulation (MP-TCP) versus continuous wave transscleral cyclophotocoagulation (CW-TCP). Methods: Twelve halves of globes from three pairs of adult cadaveric eyes were randomly assigned to nontreated control, CW-TCP, single MP-TCP treatment, or double MP-TCP treatments, and then sectioned for histologic analysis. Presence or absence of the following four unique histologic changes was recorded: splitting within the ciliary process epithelium (splitting), separation of the pigmented ciliary process epithelium from the stroma (separation), coagulation of collagen and destruction of ciliary process stroma (coagulation), and full-thickness destruction of ciliary process epithelium (destruction). Results: A total of 498 slides were analyzed, and laser scars in all treated specimens were located in the pars plana. Logistic regression analysis showed that compared with controls, CW-TCP-treated specimens were significantly more likely to experience separation (odds ratio [OR] = 11.1, P = 0.02), coagulation (OR = 24.3, P = 0.002), and destruction (OR = 11.1, P = 0.03). Destruction of the ciliary process epithelium was observed exclusively in CW-TCP-treated sections. No significant differences in histologic features were observed between controls and MP-TCP. Conclusions: MP-TCP does not produce significant histologic changes in cadaveric eyes, whereas CW-TCP treatment does. Translational Relevance: These findings improve understanding of the mechanism of MP-TCP, help explain the increased rates of adverse effects following CW-TCP treatment compared with MP-TCP, and describe effects of MP-TCP at various doses.

Association of Doximity Ranking and Residency Program Characteristics Across 16 Specialty Training Programs.

BACKGROUND: Residency program prestige is an important variable medical students consider when creating their rank list. Doximity Residency Navigator is a ranking system that previous reports have shown significantly influences medical student application decisions. Doximity's use of peer nomination as a central component of its methodology for determining program rank has drawn criticism for its lack of objectivity. Doximity has not published information regarding how peer nomination and more objective measures are statistically weighted in reputation calculation. OBJECTIVE: This study assesses whether a strong negative correlation exists between residency program size and Doximity ranking. METHODS: A cross-sectional study of Doximity residency rankings from the 2018-2019 academic year was conducted. Data extracted from Doximity included program rank, size, and age. Data were additionally collected from the Blue Ridge Institute for Medical Research, National Institutes of Health, funding in 2018 and the US News & World Report Best Medical Schools 2019-2020. A multivariable linear regression model was used that included Doximity ranking as the outcome variable and residency program size as the predictor variable with adjustment for the aforementioned variables. RESULTS: Sixteen of the 28 specialties on Doximity were included in the analysis, representing 3388 unique residency programs. After adjustment for covariates, residency program size was a significant predictor of Doximity ranking (ß = -1.84; 95% CI -2.01 to -1.66, P < .001). CONCLUSIONS: These findings support the critique that the Doximity reputation ranking system may favor larger residency programs. More transparency for Doximity reputation ranking algorithm is warranted.

How to Predict Intraocular Pressure Reduction after Cataract Surgery? A Prospective Study.

Purpose/Aim: To evaluate the best formula to predict intraocular pressure (IOP) reduction after cataract surgery. Materials and methods: In this prospective longitudinal study, we included consecutive patients with or without glaucoma, either with open or with narrow angles but without peripheral anterior synechiae, who underwent phacoemulsification. Clinical factors and anterior segment parameters measured with optical biometry and optical coherence tomography were evaluated as preoperative predictors for IOP reduction at 6 months postoperatively. To find the best combinations of predictors, model selection was conducted using least absolute selection and shrinkage operator regression with cross-validation. Results: A total of 156 eyes from 109 patients were enrolled. The mean age of the patients was 74.89 (±8.54) years and the average preoperative IOP was 15.6 (±3.68) mmHg with 0.7 (range 0-4) glaucoma medications. The mean IOP reduction after phaco was 3.1 (±2.49) mmHg at postoperative month 6. After multivariate analysis, preoperative IOP (ß = 0.49 [0.4-0.59] P < .0001), gonioscopy score (ß = -0.14 [-0.23 to -0.06] P = .0001), anterior chamber depth (ß = -0.85 [-1.64 to -0.07] P = 0.033), lens thickness (LT) (ß = 0.87 [0.12-1.62] P = .024), and angle open distance 750 (ß = -2.2 [-3.96 to -0.44] P = 0.014) were associated with IOP reduction. The best formula to correlate with IOP reduction was -4.76 + (0.46 × preoperative IOP) - (0.42 × LT) - (0.1 × gonioscopy score) - (0.66 × glaucoma status). Conclusion: Different formulas were developed and were able to improve the predictive value of the preoperative IOP. When used in combination, these formulas may help the clinician to know how much IOP reduction to expect after cataract surgery at 6 months postoperatively.

Clinical and economic impact of generic versus brand name meropenem use in an intensive care unit in Colombia.

BACKGROUND: Recent studies suggest that sustained use of generic antibiotics may be associated with clinical failure and emergence of antibacterial resistance. The present study was designed to determine the clinical outcome between the use of generic meropenem (GM) and brand-name meropenem (BNM). Additionally, this study evaluated the economic impact of GM and BNM to determine if the former represents a cost-effective alternative to the latter. METHODS: Patients treated between January 2011 and May 2014 received GM while patients treated between June 2014 and March 2017 received BNM. Mortality was compared between groups. Total infection cost was defined by the cost of antimicrobial consumption, length of stay, and laboratory and imaging exams until infection resolution. FINDINGS: A total of 168 patients were included; survival rate for the 68 patients treated with GM was 38% compared to 59% in the patients treated with BNM. Multivariate analysis showed that the variables most strongly-associated with mortality were cardiovascular disease (OR 18.18, 95% CI 1.25-262.3, p = 0.033) and treatment with generic meropenem (OR 18.45, 95% CI 1.45-232.32, p = 0.024). On the other hand, total infection cost did not show a significant difference between groups (BNM $10,771 vs. GM $11,343; p = 0.91). INTERPRETATION: The present study suggests that patients treated with GM have a risk of death 18 times higher compared to those treated with BNM. Furthermore, economic analysis shows that GM is not more cost effective than BNM. SUMMARY: More studies measuring clinical outcomes are needed to confirm the clinical equivalence of brand-name versus generic antibiotics, not only for meropenem but also for other molecules.

Physician and patient determinants of prognostic counseling in idiopathic REM sleep-behavior disorder.

OBJECTIVES/BACKGROUND: Prognostic counseling about the risk for developing overt neurodegenerative disorders for patients with idiopathic REM sleep-behavior disorder (iRBD) and isolated REM sleep without atonia (iRSWA) is difficult, given lack of disease-modifying interventions and uncertainty in accurate prognostication for individuals. We aimed to analyze patient and physician characteristics associated with documented prognostic discussions for patients with iRBD and iRSWA. PATIENTS/METHODS: We retrospectively reviewed the medical records for 138 (112 iRBD and 26 iRSWA) patients seen at the Mayo Clinic between 2012 and 2015. We analyzed physician and patient demographics, initial complaint, and other information discussed during office visits. We then comparatively analyzed the impact of physician and patient characteristics on documented prognostic discussions using Chi Square or Fischer's exact test. RESULTS: Mean iRBD patient age was 65.0 ± 13.0, and mean iRSWA age was 58 ± 15 years. Seventy-eight (69.6%) iRBD and 22 (84.6%) iRSWA patients were men. Sixty-two (55%) iRBD and three (12%) iRSWA patients received prognostic counseling about phenoconversion risk. iRBD was a secondary complaint in 67 (59.8%). Patients over age 60 years and those having iRBD as a chief complaint more frequently received prognostic discussions than those with opposite characteristics (all p < 0.05). Patient sex and antidepressant use were not associated with counseling. Sleep neurologists disclosed prognostic information most frequently, with male more likely than female clinicians to disclose prognoses. CONCLUSIONS: Several patient and physician characteristics appear to influence documented prognostic counseling for iRBD/RSWA patients. Future studies of iRBD/RSWA patients' preferences are needed to clarify ethically appropriate physician-patient communication concerning prognosis.

Ab Interno Tube Occlusion for Postoperative Hypotony in a Patient With an Ahmed Glaucoma Drainage Device.

PURPOSE: To report a case of Ahmed glaucoma valve-induced hypotony that was successfully managed with postoperative intraluminal stenting of the aqueous shunt tube. PATIENT AND METHODS: We describe a 68-year-old man with advanced uveitic glaucoma with an intraocular pressure (IOP) of 25 mm Hg in the left eye. The patient initially responded well to an Ahmed glaucoma valve implant, but at 10 weeks postimplantation, the patient underwent cataract surgery and developed persistent hypotony, choroidal folds, and decreased vision. RESULTS: Before partial occlusion of the aqueous shunt tube, the patient had an IOP of 3 mm Hg and a best-corrected visual acuity (BCVA) of 20/60. Following intraluminal stenting of the aqueous shunt tube with 4-0 polypropylene suture (Prolene; Ethican), IOP rose from 7 to 10 mm Hg, BCVA improved to 20/30, and the choroidal folds resolved; IOP and BCVA remained stable through 1 year of follow-up and no additional surgical or pharmacological interventions were required. CONCLUSIONS: Aqueous shunt-induced hypotony can be successfully managed with intraluminal stenting and should be considered before tubal ligation or shunt removal.