2023 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting: Carbohydrate-containing Clear Liquids with or without Protein, Chewing Gum, and Pediatric Fasting Duration-A Modular Update of the 2017 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting.

These practice guidelines are a modular update of the "Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures." The guidance focuses on topics not addressed in the previous guideline: ingestion of carbohydrate-containing clear liquids with or without protein, chewing gum, and pediatric fasting duration.

2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade: A Report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade.

These practice guidelines provide evidence-based recommendations on the management of neuromuscular monitoring and antagonism of neuromuscular blocking agents during and after general anesthesia. The guidance focuses primarily on the type and site of monitoring and the process of antagonizing neuromuscular blockade to reduce residual neuromuscular blockade.

The epidemiology of torture: a case series of 58 survivors of torture.

UNLABELLED: INTRODUCTION/CONTEXT: Torture is widely practiced throughout the world and, yet, the ways by which torture is perpetrated, its regional similarities and differences, is not well understood. Our goal for this cases series was to elucidate the methods of torture practiced within different countries to both add to and expand upon previous research. This knowledge is important since it can buttress efforts to assist with torture survivors' recovery--medically, psychologically, and legally. METHODS: Fifty-eight survivors of torture who presented to a single interviewer over a 15-year period (1990-2005) for purposes of assisting with their claim for political asylum in the U.S. were enrolled into the study. The survivors' legal affidavits were examined and both quantitative and qualitative data were extracted for analysis. This data included the following: (1) duration, condition, and frequency of imprisonment, (2) abductors' affiliation and dress, (3) torture type, method, and frequency (both physical and mental), and (4) qualitative description of above items. RESULTS: Twenty-three countries were represented in the sample covering six major world regions. Women appear to be at greater risk for sexual torture than men. Sub-Saharan Africans tend to have more abuse compared to other world regions. Furthermore, the length of confinement also appears to trend towards longer duration in those survivors from Sub-Saharan African countries. Certain types of torture were almost universal in their application such as threats of death and beatings, but the manner by which survivors were beaten varied considerably, with hitting/kicking and beating with a stick/baton being the most common. There was no correlation between types of torturous acts and religion. CONCLUSION: This case series confirms some earlier findings about regional similarities and differences in torture methodology. Study results built upon previous studies as well as uncovered new findings suggesting that more work needs to be done. Further, our results will help survivors of torture with their recovery both through improved patient care outcomes and by impacting upon the way asylum cases are adjudicated.

Implementing an electronic medical record at a residency site: physicians' perceived effects on quality of care, documentation, and productivity.

BACKGROUND: Electronic Medical Records (EMRs) are quickly becoming a standard component of medical practices. OBJECTIVES: We longitudinally studied the impact of EMR implementation on physician perceptions of quality of care, documentation, and work hours, as well as on measured physician productivity. METHODS: Physicians were surveyed at 3-month intervals regarding perceived impact of the EMR on quality of care, documentation, and productivity. Relative Value Units (RVUs) per clinic hours were used to measure productivity. Paired t-tests were used to compare the mean RVUs per clinic hour in the pre-EMR with the immediate post-EMR time period and the long-term post-EMR time period. RESULTS: RVUs per hour increased significantly from the pre-EMR time period to the immediate post-EMR time period (means 1.49 and 1.82, respectively, P = 0.0007). The long-term post-EMR time period also showed a significant increase over the pre-EMR period (mean 1.79, P = 0.007). Sixty-six percent of physicians perceived that EMR implementation increased their work amount a little or much more. CONCLUSION: Not only did physician production rise immediately, it stayed at the increased level for the duration of our study period. This may be due to improved documentation supporting more appropriate billing. However, physicians also perceived the EMR as taking up more of their time.

Adolescent hospital discharges associated with self-poisonings in Wisconsin, 2000-2002.

OBJECTIVE: This study investigates the Wisconsin adolescent self-poisoning problem, using state discharge data on medication-related self-inflicted injuries, focusing on medications used and risk factors. METHODS: Wisconsin inpatient discharge files for 3 years (January 1, 2000-December 31, 2002) were evaluated. Medication-related injuries were analyzed for intentionality, medications used, discharge status, and risk factors such as mental illness, eating disorders, and alcohol abuse or dependence. RESULTS: There were nearly 3000 medication-related injury hospitalizations--1150 of them self-poisoning hospitalizations--among Wisconsin 12-17 year olds during 2000-2002. Females 12-17 years had twice as many medication-related injuries as males. Sixty percent of medication-related injuries occurred in patients with a mental disorder diagnosis. Non-narcotic analgesics were most commonly used and had one of the highest rates of intentionality (65%). A large proportion of intentional/suicidal medication-related injuries were discharged to another facility (35%), compared to 14% among all medical injuries. Males with medication-related injuries were twice (95% CI: 1.60, 2.75) as likely and females 1.4 (95% CI: 1.2, 1.6) times as likely to have intentional/suicidal injuries if they also abused or depended on alcohol. CONCLUSIONS: Given that a nonfatal suicide attempt is the strongest predictor of eventual suicide, the hundreds of self-poisoning discharges per year in Wisconsin 12-17 year olds is a serious public health concern. Both the medical community and public health community should heed the warnings of these nonfatal suicide attempts and implement educational programs addressing this issue.

Dental status and quality of life in long-term head and neck cancer survivors.

OBJECTIVES: To analyze how the dental status of long-term head and neck cancer survivors affects their subjective quality of life. STUDY DESIGN: Observational case series. METHODS: A convenience sample of 5-year head and neck cancer survivors underwent the following battery of tests: 1) targeted head and neck examination, 2) updated medical history, 3) dental evaluation, 4) standardized quality of life questionnaires. RESULTS: Eighty-six survivors were included in the study. The following associations were identified: 1) those who became edentulous secondary to cancer treatment and those without occlusion at time of the study demonstrated worse Pain, Activity, Recreation/Entertainment, Chewing, Swallowing, Speech, Eating in Public, Normalcy of Diet, Physical Well-Being, Social/Family Well-Being, Functional Well-Being, and Additional Concerns scores; 2) higher Decayed/Missing/Filled scores were associated with worse Pain, Disfigurement, Activity, Recreation/Entertainment, Employment, Chewing, Swallowing, Speech, Eating in Public, Understandability of Speech, Normalcy of Diet, Physical Well-Being, Additional Concerns scores, and weight loss; 3) decreased oral opening measurements were associated with worse Chewing, Swallowing, Eating in Public, Normalcy of Diet, Additional Concerns scores, and weight loss; 4) edentulous survivors who did not use dentures had worse Pain, Activity, Recreation/Entertainment, Understandability of Speech, and Eating in Public scores. CONCLUSIONS: Although previous studies have shown that many of the effects of cancer treatment disappear between 1 and 3 years, this study shows that the dental status has a persistent impact on subjective quality of life.

Psychosocial effects in long-term head and neck cancer survivors.

BACKGROUND: To identify and rate the importance of several psychosocial and physiologic influences on quality of life (QOL) among a cohort of 5-year head and neck cancer survivors, we conducted a cross-sectional study of a convenience sample that used both questionnaires and physiologic evaluations. METHODS: QOL was assessed by the Functional Assessment of Cancer Therapy (FACT) and the FACT Head and Neck additional concerns (FACT-H&N) questionnaires. Psychosocial characteristics (or risk factors) potentially influencing QOL were measured by the Millon Behavioral Health Inventory (MBHI) and the Social Support Questionnaire (SSQSR). Physiologic risk factors were measured in examinations that included shoulder and neck range of motion, whole and stimulated saliva measurements, and oropharyngeal swallowing efficiency. We evaluated the association of selected QOL measures with three groups of potential risk factors: psychosocial factors, consisting of selected MBHI and SSQSR scales; physiologic factors, consisting of selected physical ability measures; and a combination of psychosocial/physiologic factors. RESULTS: The entire study population of 105 subjects completed the FACT and FACT-H&N questionnaires; 86 of these completed the physiologic tests as well. Combined psychosocial/physiologic models best predicted all QOL measures considered. Psychosocial models alone, compared with physiologic models alone, better predicted FACT physical and social/family well-being measures. Physiologic models alone, compared with psychosocial models alone, better predicted FACT-H&N additional concerns measures. Premorbid pessimism (MBHI) was consistently the best predictor of QOL measures. CONCLUSIONS: Both psychosocial and physiologic factors influence QOL in patients with head and neck cancer, but many QOL measures are most strongly influenced by psychosocial considerations. Physicians and surgeons caring for long-term head and neck cancer survivors should be cognizant of the importance of psychosocial risk factors in the QOL of their patients.

Speech intelligibility and quality of life in head and neck cancer survivors.

OBJECTIVE: Poor speech intelligibility adversely affects quality of life self-assessment in long term survivors of head and neck cancer treatment. STUDY DESIGN: Observational case series including both objective clinical speech testing and subjective quality of life questionnaire administration. METHODS: Five-year head and neck cancer survivors were recruited to study the association between speech intelligibility and quality of life. Survivors were analyzed as an entire group, and also subdivided into laryngectomees and non-laryngectomees. Objective testing included sentence and word intelligibility. Subjective testing included quality of life questionnaires (UWQOL, FACT, FACT-head and neck, and PSS-HN) and a locally prepared "cancer concern" question. Associations were sought between intelligibility, quality of life and demographics. RESULTS: Sixty-two survivors underwent testing. Lower sentence intelligibility and word intelligibility scores were associated with diminished self-perceived UWQOL Speech (P = .0001 and P = .0001, respectively) and PSS-HN Understandability of Speech (P = .009 and P = .005). Decreased word intelligibility was additionally associated with decreased UWQOL Chewing (P = .003), UWQOL Swallowing (P = .02), UWQOL Recreation (P = .05), PSS-HN Willingness to Eat in Public (P = .03), and PSS-HN Normalcy of Diet (P = .0001). The associations continued even after patients who had undergone laryngectomy were excluded. CONCLUSIONS: Long-term survivors of head and neck cancer continue to have both objective and subjective deficits in speech parameters five years after treatment. Objective deficits are associated with subjective concerns about speech, eating, and recreation. Understanding how communication deficits affect quality of life in long-term head and neck cancer survivors may allow more effective therapies to modulate these concerns in the recovery period.

Clean indoor air policies in Wisconsin workplaces.

OBJECTIVE: To describe the nature and extent of workplace environmental tobacco smoke exposures in Wisconsin. METHODS: Descriptive data and confidence intervals from the Current Population Survey tobacco supplements of 1995-1996 and 1998-1999 are presented. RESULTS: The percent of indoor workers working under a smoke-free policy increased slightly, from 62% in 1995-1996 to 65% in 1998-1999. Respondents with a college degree were more likely to work under a smoke-free policy than those with a high school education or less. Among respondents with a work policy in 1998-1999, a complete ban on smoking reduced any workplace exposure in the past 2 weeks (4%) compared to a partial ban (26%) or an unrestricted policy (30%). CONCLUSION: Wisconsin has seen a small increase in workplace policies that ban smoking in the workplace. These policies are more likely to protect workers of higher socioeconomic status and may increase health disparities in tobacco-related diseases in the future.

Aspiration, weight loss, and quality of life in head and neck cancer survivors.

OBJECTIVE: To determine associations between objective assessments (swallowing function and weight change) and subjective quality-of-life (QOL) measures. DESIGN: Observational case series using clinical testing and questionnaires. SETTING: University hospital-based tertiary clinical practice. PATIENTS: Convenience sample of 5-year survivors of head and neck cancer (62 nonlaryngectomy survivors were studied). INTERVENTIONS: Objective testing included examination, weight history, videofluoroscopic swallow studies (VFSS), and oropharyngeal swallowing efficiency (OPSE). Subjective testing included QOL questionnaires (University of Washington Quality-of-Life [UWQOL] Scale, Performance Status Scale for Head and Neck Cancer Patients [PSS-HN], Functional Assessment of Cancer Treatment-General [FACT-G] Scales, and Functional Assessment of Cancer Therapy-Head and Neck [FACT-H&N] Scale). MAIN OUTCOME MEASURES: Aspiration (identified by VFSS), weight change, and QOL measures. RESULTS: Aspiration was associated with the decreased QOL scores in chewing, swallowing, normalcy of diet, and additional concerns of the FACT-H&N Scale. No association was found between aspiration and willingness to eat in public, subjective understandability, or any of the FACT-G scales. Of the nonlaryngectomy survivors, 27 (44%) demonstrated some degree of aspiration during VFSS. Associations were found between aspiration, primary tumor T stage, weight change, and OPSE. Aspirators lost a mean of 10.0 kg from precancer treatment weight, while nonaspirators gained a mean of 2.3 kg (P<.001). Mean OPSE scores were 69 for nonaspirators and 53 for aspirators (P =.01). CONCLUSIONS: Almost half of long-term nonlaryngectomy head and neck cancer survivors demonstrated at least some degree of aspiration. The presence of aspiration is associated with substantial weight loss, advanced initial tumor stage, diminished oropharyngeal swallowing efficiency, and lower scores on a variety of QOL scales.

Wisconsin physicians advising smokers to quit: results from the Current Population Survey, 1998-1999 and Behavioral Risk Factor Surveillance System, 2000.

INTRODUCTION: Physicians advising their patients to quit smoking has been recognized as an effective component of smoking cessation treatment, yet evidence suggests that physicians are not consistently providing this type of counseling. METHODS: Data from both the Current Population Survey's (CPS) Tobacco Use Supplements administered September 1998, January 1999, and May 1999 and from the 2000 Behavioral Risk Factor Survey System (BRFSS) were analyzed and compared. The weighted proportions and 95% confidence intervals of Wisconsin and US smokers who had seen a physician in the past year and reported receiving advice from them to quit smoking were calculated. Proportions were analyzed for the total population as well as for subgroups of gender, age, race, educational level, and income level. RESULTS: CPS data showed that Wisconsin smokers who had seen a physician in the past year were significantly more likely to receive smoking cessation advice from their physician (64%) compared to US smokers (59%). Though not significant, a similar trend was seen in the BRFSS data. There were no consistent significant differences in rates analyzed by gender, age, race, educational level, or income level. CONCLUSIONS: Data from the CPS and BRFSS show that less than two thirds of Wisconsin smokers are receiving smoking cessation advice from their physicians. Increasing physician counseling of patients who smoke continues to be a priority public health goal for decreasing morbidity and mortality from tobacco-related illnesses.

Academic ranks and medical schools of underrepresented minority faculty in family medicine departments.

PURPOSE: To examine academic rankings and educational backgrounds of underrepresented minority (URM) family medicine faculty and compare their academic ranks with national trends. The authors also determined the extent to which international and historically black educational institutions contributed URM faculty to family medicine. METHOD: In 1999 questionnaires were sent to 129 family medicine departments asking for academic ranks and educational institutions attended by their URM faculty. Comparisons were made between URM faculty's academic ranks and all family medicine faculty, medical school minority faculty, and medical school faculty. RESULTS: A total of 80% of URM faculty were assistant professors or instructors, and 4.4% were professors. URM family medicine faculty had significantly lower rankings compared with medical school minority faculty and all family medicine faculty. URM family medicine faculty at historically black medical schools were more likely to have received their degrees from historically black undergraduate institutions and medical schools than were URM family medicine faculty at non-historically-black medical schools. CONCLUSIONS: URM family medicine faculty appear to experience a double disadvantage: being minority and working for family medicine departments. Their academic ranks remain far below those of both minority medical school faculty and family medicine faculty, a discouraging finding considering the current shortage of URM faculty in family medicine departments. Historically black medical schools cannot address the shortage alone, so non-historically-black medical schools need to both recruit URM faculty and follow up with appropriate mentoring of those faculty.

Radium in Wisconsin drinking water: an analysis of osteosarcoma risk.

Epidemiological studies of radium dial painters have found an association between exposure to high-dose radium and bone cancers. However, only limited data exist on the relationship between low doses of radium, as are found in some drinking water sources, and osteosarcoma. The authors conducted a population-based case-control study to examine the association between exposure to radium in drinking water and the occurrence of osteosarcoma. Estimates of radium exposure and covariates used were based on subjects' residential ZIP codes. The median radium level was not significantly associated with osteosarcoma (odds ratio = .98; 95% confidence interval = .93, 1.04; p = .56). The authors found no evidence that radium, at current levels in Wisconsin drinking water, resulted in excess cases of osteosarcoma.