The modern anesthesiologist's manual: the development and maintenance of an anesthesia case reference application.

Anesthesia clinicians care for patients undergoing a wide range of procedures, making access to reliable references crucial. However, existing resources have key limitations. This technical report describes the development of an in-house anesthesia case reference application designed for use in a tertiary academic hospital. Additionally, it details our experiences in maintaining this system over a 22-month period and compares this system to alternative resources. Utilizing JavaScript and the React library, we developed a cross-platform perioperative reference application. Over fifty articles, encompassing anesthetic considerations for various surgical disciplines, have been created. Furthermore, we conducted a preliminary analysis of analytics data. In the 22 months since the application's inception, the application has garnered over 22,000 views from local users. While there are more than 150 registered users, the number of unregistered users accessing the application on the hospital network remains unknown. Notably, 70% of users accessed the application through a mobile device. The most popular articles centered around procedures with diverse and specific surgeon preferences. Currently, the reported case reference application is routinely utilized by anesthesia clinicians at our institution. Future endeavors will concentrate on establishing a robust content management workflow to broaden the coverage of topics.

Study on the Influence of UV Light on Selective Antibacterial Activity of Silver Nanoparticle Synthesized Utilizing Protein/Polypeptide-Rich Aqueous Extract from The Common Walkingstick, Diapheromera femorata.

Common walkingstick (Diapheromera femorata) aqueous extract (CWSAE) can induce the synthesis of useful bionanomaterials. CWSAE is rich in water-soluble organic compounds such as proteins and polypeptides that function as reducing/stabilizing agents for nanoparticle formation from Ag+ ion precursors. The synthesized AgNPs exhibited a moderately uniform size, with the majority falling within the range of 20-80 nm. These AgNPs were UV-treated and tested as antibacterial agents to inhibit the growth of four pathogenic bacteria (Burkholderia cenocepacia K-56, Klebsiella pneumoniae ST258, Pseudomonas aeruginosa PAO1, and Staphylococcus aureus USA300), as well as one common bacterium (Escherichia coli BW25113). The disk diffusion test demonstrated that the UV-treated AgNPs significantly and selectively inhibited the growth of Staphylococcus aureus USA300 and P. aeruginosa, while showing a small effect on the other two species. This suggests the potential application of green-chemically synthesized AgNPs as selective antibacterial agents. Furthermore, we studied the effects of short-term (1-2 min) and long-term (5-30 min) UV treatment on the selective cytotoxicity of the AgNPs and found that the cytotoxicity of the AgNPs could depend on the duration of UV exposure against certain bacteria.

Repeated Cyclogenesis on Hot-Exoplanet Atmospheres with Deep Heating.

Most current models of hot-exoplanet atmospheres assume shallow heating, a strong day-night differential heating near the top of the atmosphere. Here we investigate the effects of energy deposition at differing depths in a model tidally locked gas-giant exoplanet. We perform high-resolution atmospheric flow simulations of hot-exoplanet atmospheres forced with idealized thermal heating representative of shallow and deep heating (i.e., stellar irradiation strongly deposited at ∼10^{3} Pa and ∼10^{5} Pa pressure levels, respectively). Unlike with shallow heating, the flow with deep heating exhibits a new dynamic equilibrium state, characterized by repeated generation of giant cyclonic storms that move away westward once formed. The formation is accompanied by a burst of heightened turbulence, leading to the production of small-scale flow structures and large-scale mixing of temperature on a timescale of ∼3 planetary rotations. Significantly, while effects that could be important (e.g., coupled radiative flux and convectively excited gravity waves) are not included, over a timescale of several hundred days the simulations robustly show that the emergent thermal flux depends strongly on the heating type and is distinguishable by current observations.

Silver nanoparticles induced with aqueous black carpenter ant extract selectively inhibit the growth of Pseudomonas aeruginosa.

Aqueous black carpenter ant extract (ABCAE) was used to synthesize silver nanoparticles (AgNPs). The ABCAE was rich in water-soluble compounds such as hydrophilic polypeptides that behaved as both reducing and stabilizing agents for generating AgNPs from Ag+ ion precursors. The diameter of the observed AgNPs was mostly in the range of 20-60 nm. The AgNPs were tested as an antibacterial agent for the growth inhibition of two pathogenic bacteria (Pseudomonas aeruginosa ATCC 27853, Staphylococcus aureus ATCC 27661) and one common bacteria (Escherichia coli K12 ATCC 10798). Disk diffusion test showed that the AgNPs selectively inhibited the growth of P. aeruginosa but not for the other two species, suggesting the potential application of the green-chemically synthesized AgNPs as a selective antibacterial agent without harming other beneficial bacteria.

Building Virtual Health Training Tools for Residents: A Design Thinking Approach.

The COVID-19 pandemic drove a rapid transition to virtual care experiences for graduate medical trainees. Core training competencies have expanded to incorporate virtual contexts, however there is limited knowledge of the optimal design of virtual care training tools for learners. In this study, we describe the application of a Design Thinking approach to the identification and co-design of novel training tools to support residents and precepting attending physicians in virtual ambulatory care practice. We applied the model of "Empathize, Define, Ideate, Prototype, and Test" via a mixed methods approach to (1) explore the needs, preferences, and concerns of Internal Medicine residents and outpatient precepting attendings regarding virtual ambulatory care training environments, and (2) evaluate, prototype, and test potential training tools. Eleven residents and eight attending physicians participated. Identified learner needs and problem areas included: improving virtual visit technical skills; acquiring virtual communication skills; adapting to the loss of shared in-person learning space and optimizing virtual learning environments; remediating non-virtual procedural competencies; and educating on new documentation requirements. Key solution areas included: virtual precepting support tools; digital information and education dissemination tools; and strategies for management of technical issues. Several prototypes were proposed, with a single tool (a virtual preceptor tip sheet) deployed in clinical practice. Residents found the workshop program improved their understanding of Design Thinking and its relevance to healthcare. Ultimately, Design Thinking can be deployed to engage medical trainees and precepting attendings in the effective development of novel educational tools for the virtual care learning environment.

Microsporidial Keratitis Related to Water Exposure: A Case Series.

The objective of this retrospective study was to present a series of cases involving the rare ocular disease of microsporidia keratitis treated at a private practice clinic and describe the details regarding specific water exposure, clinical course, voriconazole treatment, and increased prevalence of this infection in Augusta, Georgia, USA. Our analysis was based on the accumulated data from all patients (n=15) diagnosed with microsporidia keratitis at our private practice clinic; the clinical course of three cases is discussed in detail in this article. Specific environmental exposures were documented in 10 patients. All patients self-reported that they had no acquired immunodeficiency. In all cases, patients had complete resolution of active symptoms after receiving treatment with 1-2% topical voriconazole, with an approximate average primary treatment duration of 40.1 ± 17.1 days (median: 40 days, range: 14-70 days). None of the patients reported any clinically significant adverse effects from therapy. There have been increasing reports about this emerging infectious pathogen, particularly in Asia. However, there is limited data in the literature on the etiology, pathogenesis, and treatment of microsporidia-caused ophthalmic diseases. In this case series, we highlight the strong correlation of our patients' condition with specific types of water exposure in the USA as well as the complete resolution of active disease in all our patients as a result of monotherapy with topical voriconazole.

Enhancing Reality: A Systematic Review of Augmented Reality in Neuronavigation and Education.

OBJECTIVE: Augmented reality (AR) is increasingly being explored as an adjunct to conventional neuronavigation systems. AR affords the ability to superimpose 3-dimensional images onto the real environment. A natural extension of this technology is to help guide neurosurgical planning and a means of stereotactic planning and guidance. Here we review the literature on the use of AR in neurosurgery with a focus on current technologies and limitations. Furthermore, we discuss this technology in the context of neurosurgical training as an educational tool. METHODS: PubMed search was performed for "augmented reality and neurosurgery" and "mixed reality and neurosurgery" from 2010. A total of 113 articles written in the last 5 years were retrieved, and 39 were ultimately included in the systematic review. RESULTS: The most common use of AR in neurosurgery was in cranial surgery (n = 26). Other uses included spine surgery (n = 9) and education (n = 2). Devices used for display of AR images varied as did image-to-patient registration methods and overall system accuracy. CONCLUSIONS: Although various AR systems have been successfully utilized across many neurosurgical disciplines, more research is needed to improve accuracy in registration and to assess whether AR-assisted surgery is safe and effective for widespread adoption.

The Mobile Insulin Titration Intervention (MITI) for Insulin Adjustment in an Urban, Low-Income Population: Randomized Controlled Trial.

BACKGROUND: Diabetes patients are usually started on a low dose of insulin and their dose is adjusted or "titrated" according to their blood glucose levels. Insulin titration administered through face-to-face visits with a clinician can be time consuming and logistically burdensome for patients, especially those of low socioeconomic status (SES). Given the wide use of mobile phones among this population, there is the potential to use short message service (SMS) text messaging and phone calls to perform insulin titration remotely. OBJECTIVE: The goals of this pilot study were to (1) evaluate if our Mobile Insulin Titration Intervention (MITI) intervention using text messaging and phone calls was effective in helping patients reach their optimal insulin glargine dose within 12 weeks, (2) assess the feasibility of the intervention within our clinic setting and patient population, (3) collect data on the cost savings associated with the intervention, and (4) measure patient satisfaction with the intervention. METHODS: This was a pilot study evaluating an intervention for patients requiring insulin glargine titration in the outpatient medical clinic of Bellevue Hospital Center in New York City. Patients in the intervention arm received weekday SMS text messages from a health management platform requesting their fasting blood glucose values. The clinic's diabetes nurse educator monitored the texted responses on the platform website each weekday for alarm values. Once a week, the nurse reviewed the glucose values, consulted the MITI titration algorithm, and called patients to adjust their insulin dose. Patients in the usual care arm continued to receive their standard clinic care for insulin titration. The primary outcome was whether a patient reached his/her optimal insulin glargine dose within 12 weeks. RESULTS: A total of 61 patients consented and were randomized into the study. A significantly greater proportion of patients in the intervention arm reached their optimal insulin glargine dose than patients in the usual care arm (88%, 29/33 vs 37%, 10/27; P<.001). Patients responded to 84.3% (420/498) of the SMS text messages requesting their blood glucose values. The nurse reached patients within 2 attempts or by voicemail 91% of the time (90/99 assigned calls). When patients traveled to the clinic, they spent a median of 45 minutes (IQR 30-60) on travel and 39 minutes (IQR 30-64) waiting prior to appointments. A total of 61% (37/61) of patients had appointment copays. After participating in the study, patients in the intervention arm reported higher treatment satisfaction than those in the usual care arm. CONCLUSIONS: MITI is an effective way to help low-SES patients reach their optimal insulin glargine dose using basic SMS text messaging and phone calls. The intervention was feasible and patients were highly satisfied with their treatment. The intervention was cost saving in terms of time for patients, who were able to have their insulin titrated without multiple clinic appointments. Similar interventions should be explored to improve care for low-SES patients managing chronic disease. TRIAL REGISTRATION: Clinicaltrials.gov NCT01879579; https://clinicaltrials.gov/ct2/show/NCT01879579 (Archived by WebCite at http://www.webcitation.org/6YZik33L3).

The Mobile Insulin Titration Intervention (MITI) for Insulin Glargine Titration in an Urban, Low-Income Population: Randomized Controlled Trial Protocol.

BACKGROUND: Patients on insulin glargine typically visit a clinician to obtain advice on how to adjust their insulin dose. These multiple clinic visits can be costly and time-consuming, particularly for low-income patients. It may be feasible to achieve insulin titration through text messages and phone calls with patients instead of face-to-face clinic visits. OBJECTIVE: The objectives of this study are to (1) evaluate if the Mobile Insulin Titration Intervention (MITI) is clinically effective by helping patients reach their optimal dose of insulin glargine, (2) determine if the intervention is feasible within the setting and population, (3) assess patient satisfaction with the intervention, and (4) measure the costs associated with this intervention. METHODS: This is a pilot study evaluating an approach to insulin titration using text messages and phone calls among patients with insulin-dependent type 2 diabetes in the outpatient medical clinic of Bellevue Hospital Center, a safety-net hospital in New York City. Patients will be randomized in a 1:1 ratio to either the MITI arm (texting/phone call intervention) or the usual-care arm (in-person clinic visits). Using a Web-based platform, weekday text messages will be sent to patients in the MITI arm, asking them to text back their fasting blood glucose values. In addition to daily reviews for alarm values, a clinician will rereview the texted values weekly, consult our physician-approved titration algorithm, and call the patients with advice on how to adjust their insulin dose. The primary outcome will be whether or not a patient reaches his/her optimal dose of insulin glargine within 12 weeks. RESULTS: Recruitment for this study occurred between June 2013 and December 2014. We are continuing to collect intervention and follow-up data from our patients who are currently enrolled. The results of our data analysis are expected to be available in 2015. CONCLUSIONS: This study explores the use of widely-available text messaging and voice technologies for insulin titration. We aim to show that remote insulin titration is clinically effective, feasible, satisfactory, and cost saving for low-income patients in a busy, urban clinic. TRIAL REGISTRATION: Clinicaltrials.gov NCT01879579; http://clinicaltrials.gov/ct2/show/NCT01879579 (Archived by WebCite at http://www.webcitation.org/6WUEgjZUO).

Atmospheric dynamics of tidally synchronized extrasolar planets.

Tidally synchronized planets present a new opportunity for enriching our understanding of atmospheric dynamics on planets. Subject to an unusual forcing arrangement (steady irradiation on the same side of the planet throughout its orbit), the dynamics on these planets may be unlike that on any of the Solar System planets. Characterizing the flow pattern and temperature distribution on the extrasolar planets is necessary for reliable interpretation of data currently being collected, as well as for guiding future observations. In this paper, several fundamental concepts from atmospheric dynamics, likely to be central for characterization, are discussed. Theoretical issues that need to be addressed in the near future are also highlighted.

The phase-dependent infrared brightness of the extrasolar planet upsilon Andromedae b.

The star upsilon Andromedae is orbited by three known planets, the innermost of which has an orbital period of 4.617 days and a mass at least 0.69 that of Jupiter. This planet is close enough to its host star that the radiation it absorbs overwhelms its internal heat losses. Here, we present the 24-micrometer light curve of this system, obtained with the Spitzer Space Telescope. It shows a variation in phase with the orbital motion of the innermost planet, demonstrating that such planets possess distinct hot substellar (day) and cold antistellar (night) faces.