Year two of virtual interviews: longitudinal changes and diverse perspectives.

BACKGROUND: The coronavirus disease (COVID-19) pandemic brought the virtual interview (VI) format to graduate medical education (GME) and the trainee recruitment process. It is unclear if applicants' VI experience is consistent across all demographic groups. Our group collected 2 years of survey data to assess longitudinal changes in applicants' attitudes towards the VI format. In addition, demographic data were collected, and analyses were performed to identify if between-group differences were present amongst a diverse applicant population. METHODS: We distributed an anonymous electronic survey to applicants to the pulmonary disease and critical care medicine fellowship programs at Case Western Reserve University/University Hospitals Cleveland Medical Center and MetroHealth Medical Center for the 2021 and 2022 appointment years. RESULTS: We received 112 responses (20% response rate) for our surveys. Although there was an overall stability of responses between the first 2 years, there were significant gender differences with applicants identifying as female more likely to recommend VI as a future model. Similarly, there were a significant difference in factor importance based on underrepresented minority (URM) status with applicants identifying as URM placing more emphasis on programs' social media presence. CONCLUSIONS: There were no significant change in the responses of applicants between the first 2 years of VI. However, subset analyses revealed multiple significant findings. These differences have implications for future iterations of the VI format.

Ultrasound guided pulmonary artery catheter insertion: An alternative to fluoroscopic guidance.

Pulmonary artery catheters (PACs) can provide extremely valuable objective data in select patients. They are usually advanced by floatation of balloon tip along the normal blood flow and their placement is confirmed under pressure waveform guidance. Imaging such as fluoroscopy is often employed in low flow states and in cardiac catheterization suite to reduce the failure rate and time to wedge; but is not readily available at bedside. In critically ill patient, bedside insertion is feasible but can be complicated by repeated attempts to float the balloon tip through various cardiac chambers. Point of care ultrasound can be used to visualize the balloon tip of PAC inside the cardiac chambers alongside the confirmatory pressure waveform changes.

A 51-year-old man with chronic cough and left hilar prominence.

What is the diagnosis of this man with a chronic dry cough and left hilar prominence on chest radiography? https://bit.ly/3fL7QMx.

Virtual Interviews: Challenges and Opportunities for Pulmonary Disease and Critical Care Medicine Fellowship Programs.

The coronavirus disease (COVID-19) pandemic brought profound change to the medical education system, and residency and fellowship recruitment was not spared. Many of the activities required for recruitment of new fellows (e.g., airline travel and face-to-face meetings) were not able to be safely done. The rapid shift to all-virtual interviewing brought logistical challenges but, as the season concluded, called into question the value and validity of prior protocols. Our institutions (University Hospitals Cleveland Medical Center and MetroHealth Medical Center in Cleveland, Ohio) designed surveys to collect both applicants' and interviewers' perspectives on the virtual interview process for the 2020-2021 recruitment season to identify the challenges virtual interviews may bring to the current paradigm and what that may mean for the value of the traditional in-person model. Our results show that the absence of certain aspects of in-person interviews (e.g., travel costs and time required off-service) were welcome changes to both applicants and interviewers. However, there were new challenges identified, such as lack of formal training for virtual interviews and a shift in applicants' attention to fellowship program websites. We discuss how these observations could inform best practices for programs and applicants in the future.

Pulse Pressure and Carotid Artery Doppler Velocimetry as Indicators of Maternal Volume Status: A Prospective Cohort Study.

BACKGROUND: Narrow pulse pressure has been demonstrated to indicate low central volume status. In critically ill patients, volume status can be qualitatively evaluated using Doppler velocimetry to assess hemodynamic changes in the carotid artery in response to autotransfusion with passive leg raise (PLR). Neither parameter has been prospectively evaluated in an obstetric population. The objective of this study was to determine if pulse pressure could predict the response to autotransfusion using carotid artery Doppler in healthy intrapartum women. We hypothesized that the carotid artery Doppler response to PLR would be greater in women with a narrow pulse pressure, indicating relative hypovolemia. METHODS: Intrapartum women with singleton gestations ≥35 weeks without acute or chronic medical conditions were recruited to this prospective cohort study. Participants were grouped by admission pulse pressure as <45 mm Hg (narrow) or ≥50 mm Hg (normal). Maternal carotid artery Doppler assessment was then performed in all patients before and after PLR using a standard technique where carotid blood flow (mL/min) = π × (carotid artery diameter/2) × (velocity time integral) × (60 seconds). The velocity time integral was calculated from the Doppler waveform. The primary outcome was the change in the carotid Doppler parameters (carotid artery diameter, velocity time integral, and carotid blood flow) after PLR. Outcomes were compared between study groups with univariable and multivariable analyses with adjustment for potential confounding factors. RESULTS: Thirty-three women consented to participation, including 18 in the narrow and 15 in the normal pulse pressure groups (mean and standard deviation initial pulse pressure, 38.3 ± 4.4 vs 57.3 ± 4.1 mm Hg). The 2 groups demonstrated similar characteristics except for initial pulse pressure, systolic and diastolic blood pressure, and race. In response to PLR, the narrow pulse pressure group had a significantly greater increase in carotid artery diameter (0.08 vs 0.02 cm; standardized difference, 2.0; 95% confidence interval [CI], 1.16-2.84), carotid blood flow (79.4 vs 16.0 mL/min; standardized difference, 2.23; 95% CI, 1.36-3.10), and percent change in carotid blood flow (47.5% vs 8.7%; standardized difference, 2.52; 95% CI, 1.60-3.43) compared with the normal pulse pressure group. In multivariable analysis with adjustment for potential confounding factors, women with narrow admission pulse pressure had a significantly larger carotid diameter (0.66 vs 0.62 cm; P < .0001) and greater carotid flow (246.7 vs 219.3 cm/s; P = .001) after PLR compared to women with a normal pulse pressure. Initial pulse pressure was strongly correlated with the change in carotid flow after PLR (r = 0.60; P < .0001). CONCLUSIONS: The hemodynamic response of the carotid artery to autotransfusion after PLR is significantly greater in women with narrow pulse pressure. Pulse pressure correlates with the physiological response to autotransfusion and provides a qualitative indication of intravascular volume in term and near-term pregnant women.

Perioperative Complications in Obstructive Sleep Apnea Patients Undergoing Surgery: A Review of the Legal Literature.

BACKGROUND: Obstructive sleep apnea (OSA) is common in patients undergoing surgery. OSA, known or suspected, has been associated with significant perioperative adverse events, including severe neurologic injury and death. This study was undertaken to assess the legal consequences associated with poor outcomes related to OSA in the perioperative setting. METHODS: A retrospective review of the legal literature was performed by searching 3 primary legal databases between the years 1991 and 2010 for cases involving adults with known or suspected OSA who underwent a surgical procedure associated with an adverse perioperative outcome. OSA had to be directly implicated in the outcome, and surgical mishaps (i.e., uncontrolled bleeding) were excluded. The adverse perioperative outcome had to result in a lawsuit that was then adjudicated in a court of law with a final decision rendered. Data were abstracted from each case regarding patient demographics, type of surgery, type and location of adverse event, associated anesthetic and opioid use, and legal outcome. RESULTS: Twenty-four cases met the inclusion criteria. The majority (83%) occurred in or after 2007. Patients were young (average age, 41.7 years), male (63%), and had a known diagnosis of OSA (96%). Ninety-two percent of cases were elective with 33.3% considered general procedures, 37.5% were ears, nose and throat procedures for the treatment of OSA, and 29.1% were considered miscellaneous interventions. Complications occurred intraoperatively (21%), in the postanesthesia care unit (33%), and on the surgical floors (46%). The most common complications were respiratory arrest in an unmonitored setting and difficulty in airway management. Immediate adverse outcomes included death (45.6%), anoxic brain injury (45.6%), and upper airway complications (8%). Overall, 71% of the patients died, with 6 of the 11 who suffered anoxic brain injury dying at an average of 113 days later. The use of opioids and general anesthetics was believed to play a role in 38% and 58% of cases, respectively. Verdicts favored the plaintiffs in 58% of cases and the defendants in 42%. In cases favoring the plaintiff, the average financial penalty was $2.5 million (±$2.3 million; range, $650,000--$7.7 million). CONCLUSIONS: Perioperative complications related to OSA are increasingly being reported as the central contention of malpractice suits. These cases can be associated with severe financial penalties. These data likely underestimate the actual medicolegal burden, given that most such cases are settled out of court and are not accounted for in the legal literature.

Legal issues encountered when treating the patient with a sleep disorder.

As our understanding of sleep medicine grows, so does our obligation to protect patients and society from the potential harms of sleep disorders. Harm to self and others can take the form of violent behaviors during sleep or from sleep arousals, or from errors in judgment and motor skills due to excessive daytime sleepiness. Motor vehicle accidents and industrial accidents represent the majority of deaths and injuries due to sleep disorders. Errors in judgment and mental capacity can also lead to significant problems in terms of financial costs to businesses, inefficiencies in the workplace, and harm to others (as in the case of medical errors). Sleepiness can be so debilitating to an individual that he or she may qualify for disability compensation. The sleep specialist plays three basic roles in the interaction between the medical and legal fields: the educator, the medical examiner, and the expert witness. The education of the public, court officials, and patients is necessary to increase awareness of sleep disorders and their risks. The medical examination of the patient and subsequent treatment of the sleep disorder can help to minimize the risks of sleep disorders. Finally, if necessary, the sleep specialist may be called upon to provide expert testimony about the medical evidence provided and the likelihood that a sleep disorder contributed to an alleged criminal act.

Impact of upper airway surgery on CPAP compliance in difficult-to-manage obstructive sleep apnea.

OBJECTIVE: To study the role of adjunctive upper airway surgery in obese patients with obstructive sleep apnea (OSA) who were poorly compliant with continuous positive airway pressure (CPAP) therapy. DESIGN: Retrospective study of obese patients with OSA and documented poor CPAP compliance who underwent noncurative upper airway surgery for anatomical obstruction. Data collected included polysomnogram (PSG) parameters, CPAP settings and compliance, and surgical complications. SETTING: An urban academic county hospital with an 8-bed sleep laboratory. Data were collected retrospectively from 2002 through 2005. PATIENTS: Subjects who met the following criteria: (1) documented OSA (apnea-hypopnea index [AHI] > or =5.0) treated with CPAP therapy, (2) poor CPAP compliance (<4 hours per night), (3) subjected to upper airway surgery, (4) repeated PSG after surgery revealed persistent OSA (AHI > or = 5) requiring continued treatment with CPAP, and (5) availability of presurgery and postsurgery CPAP compliance data. MAIN OUTCOME MEASURE: Compliance with CPAP. RESULTS: Data from 11 patients were available for analysis. Their PSG parameters revealed the mean AHI (79.0 before surgery vs 30.2 after surgery; P < .001) and mean CPAP pressure setting (11.8 cm H(2)O before surgery vs 10.4 cm H(2)O after surgery; P = .09) improved following surgery. A mean increase of 48.6 minutes in CPAP compliance was noted after surgery (P = .03). Eight of the 11 patients improved their CPAP compliance following surgical intervention, including 5 who improved by more than 1 hour. CONCLUSION: Upper airway surgery in select patients with OSA may improve CPAP compliance and should be considered as a potential adjunctive therapeutic measure in poorly compliant patients with OSA.

Findings of a Berlin Questionnaire survey: comparison between patients seen in an asthma clinic versus internal medicine clinic.

BACKGROUND: Obstructive sleep apnea (OSA) and asthma are common and share similar nocturnal symptoms. We hypothesized that the prevalence of OSA symptoms would be greater in asthmatics compared to a general internal medicine population. METHODS: Patients in the Asthma Clinics (n=177) and Internal Medicine Clinics (n=328) at MetroHealth Medical Center, an urban academic institution, were surveyed for OSA risk. Patients completed the Berlin Questionnaire, a validated questionnaire with a positive predictive value (ppv) of 0.89 for determining the presence of OSA in primary care populations. All asthmatics had spirometry performed. RESULTS: The asthma group had more females (p=0.01) and a higher mean body mass index (33.2 vs. 31.2 kg/m(2), p=0.02). However, the percentage with a body mass index >30 kg/m(2) was not different between the groups (p=0.19). The internal medicine group had a much higher rate of hypertension (p=0.002) and diabetes (p<0.001). Asthmatics were more likely to report frequent snoring (18.5% vs. 8.0%, p<0.001) and chronic sleepiness (46.1% vs. 34.3%, p=0.01). OSA risk, as determined by the Berlin Questionnaire, was higher in the asthma group than in the internal medicine group (39.5% vs. 27.2%, p=0.004). In the asthma group, risk for OSA did not correlate with asthma severity (p=0.183). CONCLUSIONS: This study suggests a possible association between asthma and OSA. There is a higher prevalence of OSA symptoms in an asthmatic population when compared to a primary care population, independent of the severity of the asthma.

Physician-attributable differences in intensive care unit costs: a single-center study.

RATIONALE: Variation in practice and outcomes, not explained by patient or illness characteristics, is common in health care, including in intensive care units (ICUs). OBJECTIVE: To quantify within-ICU, between-physician variation in resource use in a single medical ICU. METHODS: This was a prospective, noninterventional study in a medical ICU where nine intensivists provide care in 14-d rotations. Consecutive sample consisted of 1,184 initial patient admissions whose care was provided by a single intensivist. Multivariate models were constructed for average daily discretionary costs, ICU length of stay, and hospital mortality, adjusting for patient and illness characteristics, and workload. MEASUREMENTS AND MAIN RESULTS: The identity of the intensivist was a significant predictor for average daily discretionary costs (p < 0.0001), but not ICU length of stay (p = 0.33) or hospital mortality (p = 0.83). The intensivists had more influence on costs than all other variables except the severity and type of acute illness. Average daily discretionary costs varied by 43% across the different intensivists, equating to a mean difference of 1,003 dollars per admission between the highest and lowest terciles of intensivists. CONCLUSIONS: There are large differences among intensivists in the amount of resources they use to manage critically ill patients. Higher resource use was not associated with lower length of stay or mortality.