Invasive Pressure Monitors: Leveling the Playing Field.

Invasive pressure monitors are ubiquitous in cardiothoracic and vascular anesthesia. This technology allows beat-to-beat assessment of central venous, pulmonary, and arterial blood pressures during surgery, procedural interventions, and critical care. Education is commonly focused on the procedural aspects and the complications associated with the initial placement of these monitors without instruction on the technical concepts required for obtaining accurate data. Anesthesiologists must understand the fundamental concepts on which measurements are made to effectively use invasive pressure monitors, including pulmonary artery catheters, central venous catheters, intra-arterial catheters, external ventricular drains, and spinal or lumbar drains. This review will address important gaps in knowledge surrounding leveling and zeroing of invasive pressure monitors, emphasizing the impact of varied practice patterns on patient care.

Local anesthetic systemic toxicity in the pediatric patient.

Lidocaine and prilocaine are local anesthetics, a class of medications which are frequently used in clinical medicine to minimize pain in a variety of procedures. They are commonly found in over-the-counter products such as topical anesthetic creams advertised to relieve localized muscle and joint pain. While safe and well-tolerated when used appropriately, an overdose of these anesthetics increases the risk for local anesthetic systemic toxicity (LAST), which in severe cases can present with seizures, cardiac dysrhythmias, and ultimately cardiovascular collapse. The reduced muscle mass of pediatric patients puts them at an increased risk of LAST due to the depot effect of the systemically absorbed anesthetic. Methemoglobinemia may also be associated with local anesthetic toxicity. Our case involves a previously healthy 15-month-old female who presented to one of our networks' emergency departments in status epilepticus following an accidental ingestion of a tube of 2.5% lidocaine/2.5% prilocaine cream. Her seizure activity was initially resistant to intraosseous benzodiazepine administration, but ultimately resolved following administration of lipid emulsion and sodium bicarbonate. Additionally, the patient had refractory hypoxia on the monitor which resolved shortly after administration of methylene blue. After stabilization, the patient was transferred to the Pediatric ICU and ultimately made a complete recovery. LAST is a life-threatening presentation which requires early recognition by clinicians, as well as an understanding of the appropriate treatment modalities. We review the assessment and management of LAST, with special focus on the pediatric patient.

Versatility in multiple mini-interview implementation: Rater background does not significantly influence assessment scoring.

The medical school admissions process seeks to assess a core set of cognitive and non-cognitive competencies that reflect professional readiness and institutional mission alignment. The standardized format of multiple mini-interviews (MMIs) can enhance assessments, and thus many medical schools have switched to this for candidate interviews. However, because MMIs are resource-intensive, admissions deans use a variety of interviewers from different backgrounds/professions. Here, we analyze the MMI process for the 2018 admissions cycle at the VCU School of Medicine, where 578 applicants were interviewed by 126 raters from five distinct backgrounds: clinical faculty, basic science faculty, medical students, medical school administrative staff, and community members. We found that interviewer background did not significantly influence MMI evaluative performance scoring, which eliminates a potential concern about the consistency and reliability of assessment.

Longitudinal Retinal Perfusion Status in Eyes with Diabetic Macular Edema Receiving Intravitreal Aflibercept or Laser in VISTA Study.

PURPOSE: To evaluate changes in retinal perfusion status with intravitreal aflibercept injection (IAI) and laser treatment in the phase 3 VISTA study of patients with diabetic macular edema (DME). DESIGN: Post hoc analysis of a double-masked, randomized, active-controlled, phase 3 trial. PARTICIPANTS: Patients with center-involved DME in the study eye. METHODS: VISTA randomized 466 patients to laser, IAI 2 mg every 4 weeks (2q4), or IAI 2 mg every 8 weeks after 5 monthly doses (2q8). One eye per patient was enrolled in the study. Retinal perfusion status was evaluated by fluorescein angiography based on the presence or absence of retinal nonperfusion (RNP) in quadrants intersecting at the optic nerve head by a masked independent reading center at weeks 24, 52, 72, and 100. Visual and anatomic outcomes were evaluated at all visits. In patients who received rescue treatment, data were censored from the time rescue treatment was given. MAIN OUTCOME MEASURES: Change in perfusion status from baseline through week 100. RESULTS: At week 100, the proportion of eyes with improvement in retinal perfusion (defined as a reduction from baseline in the total number of quadrants in which RNP is present) in the laser control, 2q4, and 2q8 groups was 14.6%, 44.7%, and 40.0%, respectively. The proportion of eyes that experienced worsening in retinal perfusion (defined as an increase from baseline in the total number of quadrants in which RNP is present) at week 100 in the laser control, 2q4, and 2q8 groups was 25.0%, 9.0%, and 8.6%, respectively. CONCLUSION: Post hoc analysis of the phase 3 VISTA study in patients with DME provides evidence that regular IAI dosing not only can slow worsening of retinal perfusion associated with diabetic retinopathy but also may be able to improve retinal perfusion in some cases by decreasing zones of RNP.

Baseline Factors Affecting Changes in Diabetic Retinopathy Severity Scale Score After Intravitreal Aflibercept or Laser for Diabetic Macular Edema: Post Hoc Analyses from VISTA and VIVID.

PURPOSE: To evaluate whether select baseline systemic and ocular factors influence ≥2-step improvement in the Diabetic Retinopathy Severity Scale (DRSS) score at week 100 in VISTA and VIVID. DESIGN: Post hoc analysis of 2 similarly designed phase 3 trials, VISTA and VIVID. PARTICIPANTS: Total of 456 patients with center-involved diabetic macular edema (DME). METHODS: VISTA and VIVID randomized 872 DME patients to receive intravitreal aflibercept injection (IAI) 2 mg every 4 weeks (2q4), IAI 2 mg every 8 weeks after 5 monthly doses (2q8), or macular laser photocoagulation. This post hoc analysis evaluated the influence of select baseline factors on ≥2-step DRSS score improvement by logistic regression in an integrated VISTA and VIVID dataset using observed cases (n = 456) with patients in each treatment group divided into tertiles based on each characteristic. MAIN OUTCOME MEASURES: Proportion of patients with ≥2-step improvement in DRSS score from baseline at week 100 by age, duration of diabetes, hemoglobin A1c (HbA1c), body mass index (BMI), best-corrected visual acuity (BCVA), central subfield thickness (CST), and DRSS score. RESULTS: At week 100, 10.1%, 34.3%, and 37.6% of patients in the laser, 2q4, and 2q8 groups experienced a ≥2-step DRSS score improvement, respectively. Age, duration of diabetes, HbA1c, BMI, BCVA, and CST had no impact on the ability to achieve ≥2-step improvement in DRSS score. Initial DRSS score was the only factor significantly associated with ≥2-step DRSS score improvement in all treatment groups at weeks 24, 52, 76, and 100. Relatively higher proportions of IAI-treated patients with worse BCVA or thicker CST experienced ≥2-step DRSS score improvement compared with those with better BCVA or thinner CST, respectively, but these associations were not statistically significant. CONCLUSION: A strong association was present between baseline DRSS score and ≥2-step DRSS score improvement at week 100 for DME patients in VISTA and VIVID.

Reducing the Incidence of Substance Use Disorders in Anesthesiology Residents: 13 Years of Comprehensive Urine Drug Screening.

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: The incidence of substance use disorders in the United States among residents in anesthesiology is between 1% and 2%. A recent study reported that the incidence of substance use disorders in U.S. anesthesiology residents has been increasing. There are no reports of effective methods to prevent substance use disorder in residents. A comprehensive drug testing program including a random component may reduce the incidence of substance use disorders. METHODS: The authors initiated a comprehensive urine drug screening program of residents, fellows, faculty physicians, and certified nurse anesthetists. The authors performed 3,190 tests over 13 yr. The authors determined the incidence of substance use disorders among residents in our large anesthesiology residency program during the decade before (January 1, 1994, to December 31, 2003) and for the 13 yr after (January 1, 2004 to December 31, 2016) instituting a random urine drug testing program. A total of 628 residents trained in the program over these 23 yr; they contributed a total of 1,721 resident years for analysis. Fewer faculty and certified nurse anesthetists were studied, so we do not include them in our analysis. RESULTS: The incidence of substance use disorders among trainees in our department during the 10 yr before initiation of urine drug screening was four incidents in 719 resident years or 0.0056 incidents per resident-year. In the 13 yr after the introduction of urine drug screening, there have been zero incidents in 1,002 resident years in our residency program (P = 0.0305). CONCLUSIONS: This single-center, comprehensive program including preplacement and random drug testing was associated with a reduction of the incidence of substance use disorders among our residents in anesthesiology. There were no instances of substance use disorders in our residents over the recent 13 yr. A large, multicenter trial of a more diverse sample of academic, government, and community institutions is needed to determine if such a program can predictably reduce the incidence of substance use disorders in a larger group of anesthesiology residents.

Simulation-based Assessment to Reliably Identify Key Resident Performance Attributes.

BACKGROUND: Obtaining reliable and valid information on resident performance is critical to patient safety and training program improvement. The goals were to characterize important anesthesia resident performance gaps that are not typically evaluated, and to further validate scores from a multiscenario simulation-based assessment. METHODS: Seven high-fidelity scenarios reflecting core anesthesiology skills were administered to 51 first-year residents (CA-1s) and 16 third-year residents (CA-3s) from three residency programs. Twenty trained attending anesthesiologists rated resident performances using a seven-point behaviorally anchored rating scale for five domains: (1) formulate a clear plan, (2) modify the plan under changing conditions, (3) communicate effectively, (4) identify performance improvement opportunities, and (5) recognize limits. A second rater assessed 10% of encounters. Scores and variances for each domain, each scenario, and the total were compared. Low domain ratings (1, 2) were examined in detail. RESULTS: Interrater agreement was 0.76; reliability of the seven-scenario assessment was r = 0.70. CA-3s had a significantly higher average total score (4.9 ± 1.1 vs. 4.6 ± 1.1, P = 0.01, effect size = 0.33). CA-3s significantly outscored CA-1s for five of seven scenarios and domains 1, 2, and 3. CA-1s had a significantly higher proportion of worrisome ratings than CA-3s (chi-square = 24.1, P < 0.01, effect size = 1.50). Ninety-eight percent of residents rated the simulations more educational than an average day in the operating room. CONCLUSIONS: Sensitivity of the assessment to CA-1 versus CA-3 performance differences for most scenarios and domains supports validity. No differences, by experience level, were detected for two domains associated with reflective practice. Smaller score variances for CA-3s likely reflect a training effect; however, worrisome performance scores for both CA-1s and CA-3s suggest room for improvement.

A Feedback and Evaluation System That Provokes Minimal Retaliation by Trainees.

BACKGROUND: Grade inflation is pervasive in educational settings in the United States. One driver of grade inflation may be faculty concern that assigning lower clinical performance scores to trainees will cause them to retaliate and assign lower teaching scores to the faculty member. The finding of near-zero retaliation would be important to faculty members who evaluate trainees. METHODS: The authors used a bidirectional confidential evaluation and feedback system to test the hypothesis that faculty members who assign lower clinical performance scores to residents subsequently receive lower clinical teaching scores. From September 1, 2008, to February 15, 2013, 177 faculty members evaluated 188 anesthesia residents (n = 27,561 evaluations), and 188 anesthesia residents evaluated 204 faculty members (n = 25,058 evaluations). The authors analyzed the relationship between clinical performance scores assigned by faculty members and the clinical teaching scores received using linear regression. The authors used complete dyads between faculty members and resident pairs to conduct a mixed effects model analysis. All analyses were repeated for three different epochs, each with different administrative attributes that might influence retaliation. RESULTS: There was no relationship between mean clinical performance scores assigned by faculty members and mean clinical teaching scores received in any epoch (P ≥ 0.45). Using only complete dyads, the authors' mixed effects model analysis demonstrated a very small retaliation effect in each epoch (effect sizes of 0.10, 0.06, and 0.12; P ≤ 0.01). CONCLUSIONS: These results imply that faculty members can provide confidential evaluations and written feedback to trainees with near-zero impact on their mean teaching scores.

Anesthesia Residents Preferentially Request Operating Room Case Assignments with Complex Cases.

Self-directed learning is associated with knowledge and performance improvements, increased identification and amelioration of knowledge gaps, and heightened critical appraisal of available evidence. We developed and implemented a decision support system that could support self-directed learning for anesthesia residents by soliciting resident input in case selection. We hypothesized that residents would utilize this system to request complex cases, and that more advanced residents would request more complex cases. Prospective, observational study involving 101 anesthesiology residents. We used a web-based interface, RHINOS [Residents Helping in Navigating Operating Room (OR) Scheduling], which allowed residents to share their rank-ordered preferences for OR assignment. Number of cases per OR, anesthesia base units, time units, and proportion of inpatient cases were used as proxies for case complexity. Data were analyzed using a mixed linear model. Residents requested rooms with fewer cases [F(3,22,350) = 194.0; p < 0.001], more base units [F(3,19,158) = 291.4; p < 0.001], more time units [F(3,19,744) = 186.4; p < 0.001], and a greater proportion of cases requiring inpatient preoperative evaluation [F(3,51,929) = 11.3; p < 0.001]. In most cases, these differences were greater for more advanced residents. As hypothesized, residents requested ORs with higher case complexity, and these cases more often required inpatient preoperative evaluation. More advanced residents exhibited a stronger preference for more educational cases than junior residents.

Clinical Performance Scores Are Independently Associated with the American Board of Anesthesiology Certification Examination Scores.

BACKGROUND: It is unknown whether clinical performance during residency is related to the American Board of Anesthesiology (ABA) oral examination scores. We hypothesized that resident clinical performance would be independently associated with oral examination performance because the oral examination is designed to test for clinical judgment. METHOD: We determined clinical performance scores (Zrel) during the final year of residency for all 124 Massachusetts General Hospital (MGH) anesthesia residents who graduated from 2009 to 2013. One hundred eleven graduates subsequently took the ABA written and oral examinations. We standardized each graduate's written examination score (ZPart 1) and oral examination score (ZPart 2) to the national average. Multiple linear regression analysis was used to determine the partial effects of MGH clinical performance scores and ABA written examination scores on ABA oral examination scores. RESULTS: MGH clinical performance scores (Zrel) correlated with both ABA written examination scores (ZPart 1) (r = 0.27; P = 0.0047) and with ABA oral examination scores (ZPart 2) (r = 0.33; P = 0.0005). ABA written examination scores (ZPart 1) correlated with oral examination scores (ZPart 2) (r = 0.46; P = 0.0001). Clinical performance scores (Zrel) and ABA written examination scores (ZPart 1) independently accounted for 4.5% (95% confidence interval [CI], 0.5%-12.4%; P = 0.012) and 20.8% (95% CI, 8.0%-37.2%; P < 0.0001), respectively, of the variance in ABA oral examination scores (ZPart 2). CONCLUSIONS: Clinical performance scores and ABA written examination scores independently accounted for variance in ABA oral examination scores. Clinical performance scores are independently associated with the ABA oral examination scores.

HIF- and non-HIF-regulated hypoxic responses require the estrogen-related receptor in Drosophila melanogaster.

Low-oxygen tolerance is supported by an adaptive response that includes a coordinate shift in metabolism and the activation of a transcriptional program that is driven by the hypoxia-inducible factor (HIF) pathway. The precise contribution of HIF-1a in the adaptive response, however, has not been determined. Here, we investigate how HIF influences hypoxic adaptation throughout Drosophila melanogaster development. We find that hypoxic-induced transcriptional changes are comprised of HIF-dependent and HIF-independent pathways that are distinct and separable. We show that normoxic set-points of carbohydrate metabolites are significantly altered in sima mutants and that these animals are unable to mobilize glycogen in hypoxia. Furthermore, we find that the estrogen-related receptor (dERR), which is a global regulator of aerobic glycolysis in larvae, is required for a competent hypoxic response. dERR binds to dHIFa and participates in the HIF-dependent transcriptional program in hypoxia. In addition, dERR acts in the absence of dHIFa in hypoxia and a significant portion of HIF-independent transcriptional responses can be attributed to dERR actions, including upregulation of glycolytic transcripts. These results indicate that competent hypoxic responses arise from complex interactions between HIF-dependent and -independent mechanisms, and that dERR plays a central role in both of these programs.

The Cognitive Science of Learning: Concepts and Strategies for the Educator and Learner.

Education is the fundamental process used to develop and maintain the professional skills of physicians. Medical students, residents, and fellows are expected to learn considerable amounts of information as they progress toward board certification. Established practitioners must continue to learn in an effort to remain up-to-date in their clinical realm. Those responsible for educating these populations endeavor to teach in a manner that is effective, efficient, and durable. The study of learning and performance is a subdivision of the field of cognitive science that focuses on how people interpret and process information and how they eventually develop mastery. A deeper understanding of how individuals learn can empower both educators and learners to be more effective in their endeavors. In this article, we review a number of concepts found in the literature on learning and performance. We address both the theoretical principles and the practical applications of each concept. Cognitive load theory, constructivism, and analogical transfer are concepts particularly beneficial to educators. An understanding of goal orientation, metacognition, retrieval, spaced learning, and deliberate practice will primarily benefit the learner. When these concepts are understood and incorporated into education and study, the effectiveness of learning is significantly improved.

Venous return and clinical hemodynamics: how the body works during acute hemorrhage.

Venous return is a major determinant of cardiac output. Adjustments within the venous system are critical for maintaining venous pressure during loss in circulating volume. This article reviews two factors that are thought to enable the venous system to compensate during acute hemorrhage: 1) changes in venous elastance and 2) mobilization of unstressed blood volume into stressed blood volume. We show that mobilization of unstressed blood volume is the predominant and more effective mechanism in preserving venous pressure. Preservation of mean circulatory filling pressure helps sustain venous return and thus cardiac output during significant hemorrhage.