The influence of social norms varies with "others" groups: Evidence from COVID-19 vaccination intentions.

The theory that health behaviors spread through social groups implies that efforts to control COVID-19 through vaccination will succeed if people believe that others in their groups are getting vaccinated. But "others" can refer to many groups, including one's family, neighbors, fellow city or state dwellers, or copartisans. One challenge to examining these understudied distinctions is that many factors may confound observed relationships between perceived social norms (what people believe others do) and intended behaviors (what people themselves will do), as there are plausible common causes for both. We address these issues using survey data collected in the United States during late fall 2020 (n = 824) and spring 2021 (n = 996) and a matched design that approximates pair-randomized experiments. We find a strong relationship between perceived vaccination social norms and vaccination intentions when controlling for real risk factors (e.g., age), as well as dimensions known to predict COVID-19 preventive behaviors (e.g., trust in scientists). The strength of the relationship declines as the queried social group grows larger and more heterogeneous. The relationship for copartisans is second in magnitude to that of family and friends among Republicans but undetectable for Democrats. Sensitivity analysis shows that these relationships could be explained away only by an unmeasured variable with large effects (odds ratios between 2 and 15) on social norms perceptions and vaccination intentions. In addition, a prediction from the "false consensus" view that intentions cause perceived social norms is not supported. We discuss the implications for public health policy and understanding social norms.

December Is Coming: A Time Trend Analysis of Monthly Variation in Adult Elective Anesthesia Caseload across Florida and Texas Locations of a Large Multistate Practice.

BACKGROUND: Anesthesia staffing models rely on predictable surgical case volumes. Previous studies have found no relationship between month of the year and surgical volume. However, seasonal events and greater use of high-deductible health insurance plans may cause U.S. patients to schedule elective surgery later in the calendar year. The hypothesis was that elective anesthesia caseloads would be higher in December than in other months. METHODS: This review analyzed yearly adult case data in Florida and Texas locations of a multistate anesthesia practice from 2017 to 2019. To focus on elective caseload, the study excluded obstetric, weekend, and holiday cases. Time trend decomposition analysis was used with seasonal variation to assess differences between December and other months in daily caseload and their relationship to age and insurance subgroups. RESULTS: A total of 3,504,394 adult cases were included in the analyses. Overall, daily caseloads increased by 2.5 ± 0.1 cases per day across the 3-yr data set. After adjusting for time trends, the average daily December caseload in 2017 was 5,039 cases (95% CI, 4,900 to 5,177), a 20% increase over the January-to-November baseline (4,196 cases; 95% CI, 4,158 to 4,235; P < 0.0001). This increase was replicated in 2018: 5,567 cases in December (95% CI, 5,434 to 5,700) versus 4,589 cases at baseline (95% CI, 4,538 to 4,641), a 21.3% increase; and in 2019: 6,103 cases in December (95% CI, 5,871 to 6,334) versus 5,045 cases at baseline (95% CI, 4,984 to 5,107), a 21% increase (both P < 0.001). The proportion of commercially insured patients and those aged 18 to 64 yr was also higher in December than in other months. CONCLUSIONS: In this 3-yr retrospective analysis, it was observed that, after accounting for time trends, elective anesthesia caseloads were higher in December than in other months of the year. Proportions of commercially insured and younger patients were also higher in December. When compared to previous studies finding no increase, this pattern suggests a recent shift in elective surgical scheduling behavior.

Factors Affecting Patient Satisfaction With Their Anesthesiologist: An Analysis of 51,676 Surveys From a Large Multihospital Practice.

BACKGROUND: An increasing focus of health care quality is the assessment of patient-reported outcomes, including satisfaction. Because anesthesia care occurs in the context of perioperative surgical care, direct associations between anesthetic management and patient experience may be difficult to identify. We analyzed anesthesia-specific patient satisfaction survey data from a large private practice group to identify patient, procedure, and anesthetic-specific predictors of patient satisfaction with their anesthesiologist, measured via responses to a validated patient satisfaction survey instrument. We hypothesized that some factors governing satisfaction with an anesthesia provider are beyond their ability to control. METHODS: We retrospectively reviewed responses to the Anesthesia Patient Satisfaction Questionnaire (APSQ), administered online to patients cared for by US Anesthesia Partners, a multistate anesthesia group practice. The APSQ focuses on patient satisfaction with their anesthesiologist and patient-reported outcomes and is administered after discharge. Responses from May to November 2016 were aggregated, and relationships between responses and patient, procedural, and clinician-related factors were assessed using multivariable logistic regression. RESULTS: Out of 629,220 adult patients cared for during the study period, 51,676 responded to the survey request for a 9.3% overall response rate for patients. Nonresponders were slightly older and more likely to be male than responders. After multivariable regression, no patient or procedural factor was associated with patient rating of their anesthesiologist. However, ≥55 years of age, inpatient (versus outpatient) setting, and nighttime surgery (between 6 PM and 6 AM) were associated with lower scores on other satisfaction questions. CONCLUSIONS: Our data suggest that some factors governing satisfaction with an anesthesia provider are beyond their ability to control. Further work is needed to identify elements of patient satisfaction with their anesthesiologist and to optimize these aspects of perioperative care.

Error-checking intraoperative arterial line blood pressures.

Electronic medical records now store a wealth of intraoperative hemodynamic data. However, analysis of such data is plagued by artifacts related to the monitoring environment. Here, we present an algorithm for automated identification of artifacts and replacement using interpolation of arterial line blood pressures. After IRB approval, minute-by-minute digital recordings of systolic, diastolic, and mean arterial pressures (MAP) obtained during anesthesia care were analyzed using predetermined metrics to identify values anomalous from adjacent neighbors. Anomalous data points were then replaced with linear interpolation of neighbors. The algorithm was then validated against manual artifact identification in 54 anesthesia records and 41,384 arterial line measurements. To assess the algorithm's effect on data analysis, we calculated the percent of time spent with MAP below 55 mmHg and above 100 mmHg for both raw and conditioned datasets. Manual review of the dataset identified 1.23% of all pressure readings as artifactual. When compared to manual review, the algorithm identified artifacts with 87.0% sensitivity and 99.4% specificity. The average difference between manual review and algorithm in identifying the start of arterial line monitoring was 0.17, and 2.1 min for the end of monitoring. Application of the algorithm decreased the percent of time below 55 mmHg from 4.3 to 2.0% (2.1% with manual review) and time above 100 mmHg from 8.8 to 7.3% (7.3% manual). This algorithm's performance was comparable to manual review by a human anesthesiologist and reduced the incidence of abnormal MAP values identified using a sample analysis tool.

Amnesia of the Operating Room in the B-Unaware and BAG-RECALL Clinical Trials.

BACKGROUND: Patient memories of the operating room (OR) may serve as the informational basis for assessing satisfaction with individual anesthesiologists. Furthermore, the provision of clinically important information may assume that perioperative memories are retained. Studies assessing the extent of perioperative amnesia and factors associated with perioperative amnesia are sparse. Therefore, we assessed patient amnesia of the OR and of the preoperative holding area in hospitals where midazolam is typically administered in the preoperative holding area and evaluated whether midazolam dose administered in the preoperative holding area and patient age were associated with amnesia of the OR before induction of anesthesia. METHODS: This was a retrospective study among 7750 adult patients who had general anesthesia and participated in the B-Unaware and Bispectral Index or Anesthetic Gas to Reduce Explicit Recall (BAG-RECALL) clinical trials. The last location the patient remembered before induction of anesthesia and the first location they remembered after induction of anesthesia were determined through a modified Brice questionnaire administered over the phone 30 days postoperatively. Regarding the preoperative period, patients were excluded if their last memory was unclear with respect to location before induction of anesthesia or if they were recruited at Winnipeg, where midazolam was typically first administered in the OR. Midazolam dose (mg/kg) administered in the preoperative holding area was divided into quartiles. Poisson regression models were used to calculate age- and multivariable-adjusted odds ratios (95% confidence intervals [CIs]) for the association between midazolam dose and amnesia of the OR before induction of anesthesia. RESULTS: Of the 5339 patients included, 59.5% (95% CI, 58.2­60.9) of patients had amnesia of the OR before induction of anesthesia. In addition, 44.1% (95% CI, 42.8­45.7) last remembered the preoperative holding area, and 15.4% (95% CI, 14.4­16.4) only had preoperative memories before the holding area. The percentages of patients with amnesia of the OR before induction of anesthesia differed according to age groups: 50.7% (95% CI, 47.7%­53.7%) in patients aged 18 to 47 years versus 70.0% (95% CI, 67.0%­72.9%) in patients aged 73 to 99 years. Patients in the highest midazolam quartile had an adjusted prevalence ratio of 1.31 (95% CI, 1.22­1.42) for amnesia of the OR compared with those who did not receive midazolam. CONCLUSIONS: In hospitals where patients typically receive midazolam in the preoperative holding area, the majority of patients do not remember the OR, and a clinically relevant number of patients does not remember the preoperative holding area. If additional studies produce results indicating that a substantial proportion of patients has amnesia of the anesthesiologist, these findings would argue against the validity of assessing patient satisfaction with individual anesthesiologists providing exclusively OR care in such hospitals. Furthermore, if additional studies yield findings suggesting patient amnesia of the preoperative holding area, these results would suggest reconsideration of providing clinically important information only in the preoperative holding area. Older age and midazolam-induced anterograde amnesia are probably associated with impaired perioperative memories.

Advances in awareness monitoring technologies.

PURPOSE OF REVIEW: Initial studies suggested that the use of processed electroencephalogram technology could significantly decrease the incidence of unintended intraoperative awareness events during general anesthesia. Subsequent work has cast doubts on these findings. This review will examine the current state of awareness monitoring. RECENT FINDINGS: Recently published randomized controlled trials examining the use of the bispectral index during general anesthesia have not been able to show superiority over other forms of monitoring depth of anesthesia, such as end-tidal anesthetic-agent concentration. Additionally, there is current interest in utilizing the unprocessed electroencephalogram to ascertain depth of anesthesia and recent studies have demonstrated its use in preventing postoperative delirium. SUMMARY: Although awareness monitors such as the bispectral index monitor may have benefit in patients in whom volatile anesthetic agents must be minimized - such as in hemodynamically unstable patients, or patients undergoing total intravenous anesthesia - these monitors do not appear to be useful for all patients.

The ontology of quantum field theory: Structural realism vindicated?

In this paper I elicit a prediction from structural realism and compare it, not to a historical case, but to a contemporary scientific theory. If structural realism is correct, then we should expect physics to develop theories that fail to provide an ontology of the sort sought by traditional realists. If structure alone is responsible for instrumental success, we should expect surplus ontology to be eliminated. Quantum field theory (QFT) provides the framework for some of the best confirmed theories in science, but debates over its ontology are vexed. Rather than taking a stand on these matters, the structural realist can embrace QFT as an example of just the kind of theory SR should lead us to expect. Yet, it is not clear that QFT meets the structuralist's positive expectation by providing a structure for the world. In particular, the problem of unitarily inequivalent representations threatens to undermine the possibility of QFT providing a unique structure for the world. In response to this problem, I suggest that the structuralist should endorse pluralism about structure.

Corneal abrasion in hysterectomy and prostatectomy: role of laparoscopic and robotic assistance.

BACKGROUND: Radical prostatectomy (RP) is most commonly performed laparoscopically with a robot (robotic-assisted laparoscopic radical prostatectomy, R/PROST). Hysterectomy, which may be open hysterectomy (O/HYST) or laparoscopic hysterectomy (L/HYST), has been increasingly frequently done via robot (R/HYST). Small case series suggest increased corneal abrasions (CAs) with less invasive techniques. METHODS: The authors identified RP (166,942), O/HYST (583,298), or L/HYST (216,890) discharges with CA in the Nationwide Inpatient Sample (2000-2011). For 2009-2011, they determined odds ratios (ORs) and 95% confidence intervals (CIs) for CA, in R/PROST, non-R/PROST, L/HYST, O/HYST, and R/HYST. Uni- and multivariate models studied CA risk depending on surgical procedure, age, race, year, chronic illness, and malignancy. RESULTS: In 2000-2011, 0.18% RP, 0.13% L/HYST, and 0.03% O/HYST sustained CA. Compared with 17,554 non-R/PROSTs (34 abrasions, 0.19%) in 2009-2011, OR was not significantly higher in 28,521 R/PROSTs (99, 0.35%; OR 1.508; CI 0.987 to 2.302; P < 0.057). CA significantly increased in L/HYST (70/51,323; 0.136%) versus O/HYST (70/191,199; 0.037%; OR 3.821; CI 2.594 to 5.630; P < 0.0001), further increasing in R/HYST (63/21, 213; 0.297%; OR 6.505; CI 4.323 to 9.788; P < 0.0001). For hysterectomy, risk of CA increased with age (OR 1.020; CI 1.007 to 1.034; P < 0.003) and number of chronic conditions (OR 1.139; CI 1.065 to 1.219; P < 0.0001). CA risk was likewise elevated in R/HYST with number of chronic conditions. Being African American significantly decreased CA risk in R/PROST and in R/HYST or L/HYST. CONCLUSIONS: L/HYST increased CA nearly four-fold, and R/HYST approximately 6.5-fold versus O/HYST. Identifiable preoperative factors are associated with either increased risk (age, chronic conditions) or decreased risk (race).

The relationship between competition and quality in procedural cardiac care.

BACKGROUND: Anesthesiologists are frequently involved in efforts to meet perioperative quality metrics. The degree to which hospitals compete on publicly reported quality measures, however, is unclear. We hypothesized that hospitals in more competitive environments would be more likely to compete on quality and thus perform better on such measures. To test our hypothesis, we studied the relationship between competition and quality in hospitals providing procedural cardiac care and participating in a national quality database. METHODS: For hospitals performing heart valve surgery (HVS) and delivering acute myocardial infarction (AMI) care in the Hospital Compare database, we assessed the degree of intrahospital competition using both geographical radius and federally defined metropolitan statistical area (MSA) to determine the degree of intrahospital competition. For each hospital, we then correlated the degree of competition with quality measure performance, mortality, patient volume, and per-patient Medicare costs for both HVS and AMI. RESULTS: Six hundred fifty-three hospitals met inclusion criteria for HVS and 1898 hospitals for AMI care. We found that for both definitions of competition, hospitals facing greater competition did not demonstrate better quality measure performance for either HVS or AMI. For both diagnoses, competition by number of hospitals correlated positively with cost: partial correlation coefficients = 0.40 (0.42 for MSA) (P < 0.001) for HVS and 0.52 (0.47 for MSA) (P < 0.001) for AMI. CONCLUSIONS: An analysis of the Hospital Compare database found that competition among hospitals correlated overall with increased Medicare costs but did not predict better scores on publicly reported quality metrics. Our results suggest that hospitals do not compete meaningfully on publicly reported quality metrics or costs.

Intraoperative awareness risk, anesthetic sensitivity, and anesthetic management for patients with natural red hair: a matched cohort study.

PURPOSE: The red-hair phenotype, which is often produced by mutations in the melanocortin-1 receptor gene, has been associated with an increase in sedative, anesthetic, and analgesic requirements in both animal and human studies. Nevertheless, the clinical implications of this phenomenon in red-haired patients undergoing surgery are currently unknown. METHODS: In a secondary analysis of a prospective trial of intraoperative awareness, red-haired patients were identified and matched with five control patients, and the relative risk for intraoperative awareness was determined. Overall anesthetic management between groups was compared using Hotelling's T(2) statistic. Inhaled anesthetic requirements were compared between cohorts by evaluating the relationship between end-tidal anesthetic concentration and the bispectral index with a linear mixed-effects model. Time to recovery was compared using Kaplan-Meier analysis, and differences in postoperative pain and nausea/vomiting were evaluated with Chi square tests. RESULTS: A cohort of 319 red-haired patients was matched with 1,595 control patients for a sample size of 1,914. There were no significant differences in the relative risk of intraoperative awareness (relative risk = 1.67; 95% confidence interval 0.34 to 8.22), anesthetic management, recovery times, or postoperative pain between red-haired patients and control patients. The relationship between pharmacokinetically stable volatile anesthetic concentrations and bispectral index values differed significantly between red-haired patients and controls (P < 0.001), but without clinical implications. CONCLUSION: There were no demonstrable differences between red-haired patients and controls in response to anesthetic and analgesic agents or in recovery parameters. These findings suggest that perioperative anesthetic and analgesic management should not be altered based on self-reported red-hair phenotype.

Prevention of intraoperative awareness in a high-risk surgical population.

BACKGROUND: Unintended intraoperative awareness, which occurs when general anesthesia is not achieved or maintained, affects up to 1% of patients at high risk for this complication. We tested the hypothesis that a protocol incorporating the electroencephalogram-derived bispectral index (BIS) is superior to a protocol incorporating standard monitoring of end-tidal anesthetic-agent concentration (ETAC) for the prevention of awareness. METHODS: We conducted a prospective, randomized, evaluator-blinded trial at three medical centers. We randomly assigned 6041 patients at high risk for awareness to BIS-guided anesthesia (with an audible alert if the BIS value was <40 or >60, on a scale of 0 to 100, with 0 indicating the suppression of detectable brain electrical activity and 100 indicating the awake state) or ETAC-guided anesthesia (with an audible alert if the ETAC was <0.7 or >1.3 minimum alveolar concentration). In addition to audible alerts, the protocols included structured education and checklists. Superiority of the BIS protocol was assessed with the use of a one-sided Fisher's exact test. RESULTS: A total of 7 of 2861 patients (0.24%) in the BIS group, as compared with 2 of 2852 (0.07%) in the ETAC group, who were interviewed postoperatively had definite intraoperative awareness (a difference of 0.17 percentage points; 95% confidence interval [CI], -0.03 to 0.38; P=0.98). Thus, the superiority of the BIS protocol was not demonstrated. A total of 19 cases of definite or possible intraoperative awareness (0.66%) occurred in the BIS group, as compared with 8 (0.28%) in the ETAC group (a difference of 0.38 percentage points; 95% CI, 0.03 to 0.74; P=0.99), with the superiority of the BIS protocol again not demonstrated. There was no difference between the groups with respect to the amount of anesthesia administered or the rate of major postoperative adverse outcomes. CONCLUSIONS: The superiority of the BIS protocol was not established; contrary to expectations, fewer patients in the ETAC group than in the BIS group experienced awareness. (Funded by the Foundation for Anesthesia Education and Research and others; BAG-RECALL ClinicalTrials.gov number, NCT00682825.).

Metaphysical indeterminacy in Everettian quantum mechanics.

The question of whether Everettian quantum mechanics (EQM) justifies the existence of metaphysical indeterminacy has recently come to the fore. Metaphysical indeterminacy has been argued to emerge from three sources: coherent superpositions, the indefinite number of branches in the quantum multiverse and the nature of these branches. This paper reviews the evidence and concludes that those arguments don't rely on EQM alone and rest on metaphysical auxiliary assumptions that transcend the physics of EQM. We show how EQM can be ontologically interpreted without positing metaphysical indeterminacy by adopting a deflationary attitude towards branches. Two ways of developing the deflationary view are then proposed: one where branches are eliminated, and another where they are reduced to the universal quantum state.

Increased risk of intraoperative awareness in patients with a history of awareness.

BACKGROUND: Patients with a history of intraoperative awareness with explicit recall (AWR) are hypothesized to be at higher risk for AWR than the general surgical population. In this study, the authors assessed whether patients with a history of AWR (1) are actually at higher risk for AWR; (2) receive different anesthetic management; and (3) are relatively resistant to the hypnotic actions of volatile anesthetics. METHODS: Patients with a history of AWR and matched controls from three randomized clinical trials investigating prevention of AWR were compared for relative risk of AWR. Anesthetic management was compared with the use of the Hotelling's T statistic. A linear mixed model, including previously identified covariates, assessed the effects of a history of AWR on the relationship between end-tidal anesthetic concentration and bispectral index. RESULTS: The incidence of AWR was 1.7% (4 of 241) in patients with a history of AWR and 0.3% (4 of 1,205) in control patients (relative risk = 5.0; 95% CI, 1.3-19.9). Anesthetic management did not differ between cohorts, but there was a significant effect of a history of AWR on the end-tidal anesthetic concentration versus bispectral index relationship. CONCLUSIONS: Surgical patients with a history of AWR are five times more likely to experience AWR than similar patients without a history of AWR. Further consideration should be given to modifying perioperative care and postoperative evaluation of patients with a history of AWR.

Case report: Volitional delay of self-reported outcomes: insights from a case of intraoperative awareness with explicit recall.

Intraoperative awareness with explicit recall (AWR) is a self-reported outcome of interest in clinical practice, quality assurance initiatives, and clinical trials. Combining structured postoperative interviews with a preoperative description of AWR is assumed to ensure prompt patient disclosure. We describe a volitionally delayed reporting of AWR because of the perceived unimportance of nondistressing awareness experiences, despite preoperative education and 2 postoperative interviews. This delay had implications for a major randomized controlled trial on AWR. Volitionally delayed self-reported outcomes may affect statistical comparisons in clinical trials and quality assurance initiatives, and delay the treatment of subsequent sequelae in clinical practice. This limitation should be considered, even when using structured outcome assessment and preoperative education.

Effects of dose ranging of adenosine infusion on electrocardiographic findings during and after general anesthesia.

PURPOSE: To assess changes in the electrocardiogram (ECG) associated with intraoperative infusion of adenosine in patients undergoing open abdominal gynecological surgery. METHODS: One hundred and sixty-six patients undergoing gynecological surgery were randomly assigned to receive one of four doses of adenosine infusion (25, 50, 100, or 200 µg/kg/min) or matching placebo. Study drug administration was started at skin incision and discontinued at end of surgery. A standardized general anesthetic regimen was used and adjusted based on hemodynamic and bispectral index values. Heart rate and rhythm variables, and PR, QRS, QT, and QTc intervals were recorded from 12-lead ECGs before anesthesia and immediately after patient arrival in the postanesthesia care unit. In addition, a rhythm strip was obtained during administration of the loading dose of the study drug. ECG variables were compared within and between groups. Incidence of ECG and hemodynamic abnormalities was recorded. RESULTS: One hundred and fifty-one subjects had a full set of electrocardiographic data: placebo (n = 38), group adenosine 25 µg/kg/min (n = 31), group adenosine 50 µg/kg/min (n = 29), group adenosine 100 µg/kg/min (n = 28), and group adenosine 200 µg/kg/min (n = 25). Statistically significant postoperative QTc prolongation was observed in all study groups when compared with baseline except for the adenosine 200 µg/kg/min group. However, these changes from baseline were not different among the groups. There were also no significant differences in PR, QRS, and QT intervals between the treatment groups. CONCLUSION: There was no difference in QTc prolongation following intraoperative administration of adenosine infusion compared with placebo during isoflurane general anesthesia. However, QTc prolongation is common following general anesthesia.