Patients' expectations of their anesthesiologists.

OBJECTIVES: To determine the patient's perception of the role of an anesthesiologist and the patient's expectations of their anesthesiologist and their anesthesia care. STUDY DESIGN: Questionnaire survey. METHODS: A total of 170 patients attending the preanesthesia clinic answered a survey prior to their clinic interview and another survey the day after their surgery. The questions pertained to their perception of the role of the anesthesia provider, their expectations, and their level of satisfaction. RESULTS: A majority (>75%) of the participants had high expectations of their anesthesia provider. The satisfaction scores were higher among those who felt that their expectations were met and among those who felt that the anesthesiologist explained to them how they would feel after anesthesia. CONCLUSIONS: Because satisfaction is a fulfillment of one's expectations, understanding what the patient expects from their anesthesiologist is the initial step to improve satisfaction scores. The onus is on the anesthesiologist to educate the patient about their role, to set realistic expectations of the postoperative course, and to involve the patient in decisions regarding their anesthesia care.

The American Board of Anesthesiology's Staged Examination System and Performance on the Written Certification Examination After Residency.

This study compared anesthesiology residency graduates' written certification examination performance before and after the American Board of Anesthesiology (ABA) introduced the staged examination system. After equating test scores using common test items, the first 2 cohorts (2013, 2014) in the staged system scored 7.1 points and 8.3 points higher than the 2011 baseline cohort in the former examination system. The 2013 and 2014 cohorts' pass rates (94.2% and 95.9%) were also higher than the 2011 and 2012 cohorts (91.9% and 92.6%) if a common standard had been applied. The staged examination system may be associated with improved knowledge of anesthesiology graduates.

Wrong-site nerve blocks: A systematic literature review to guide principles for prevention.

STUDY OBJECTIVE: Wrong-site nerve blocks (WSBs) are a significant, though rare, source of perioperative morbidity. WSBs constitute the most common type of perioperative wrong-site procedure reported to the Pennsylvania Patient Safety Authority. This systematic literature review aggregates information about the incidence, patient consequences, and conditions that contribute to WSBs, as well as evidence-based methods to prevent them. DESIGN: A systematic search of English-language publications was performed, using the PRISMA process. MAIN RESULTS: Seventy English-language publications were identified. Analysis of four publications reporting on at least 10,000 blocks provides a rate of 0.52 to 5.07 WSB per 10,000 blocks, unilateral blocks, or "at risk" procedures. The most commonly mentioned potential consequence was local anesthetic toxicity. The most commonly mentioned contributory factors were time pressure, personnel factors, and lack of site-mark visibility (including no site mark placed). Components of the block process that were addressed include preoperative nerve-block verification, nerve-block site marking, time-outs, and the healthcare facility's structure and culture of safety. DISCUSSION: A lack of uniform reporting criteria and divergence in the data and theories presented may reflect the variety of circumstances affecting when and how nerve blocks are performed, as well as the infrequency of a WSB. However, multiple authors suggest three procedural steps that may help to prevent WSBs: (1) verify the nerve-block procedure using multiple sources of information, including the patient; (2) identify the nerve-block site with a visible mark; and (3) perform time-outs immediately prior to injection or instillation of the anesthetic. Hospitals, ambulatory surgical centers, and anesthesiology practices should consider creating site-verification processes with clinician input and support to develop sustainable WSB-prevention practices.

A coverage criterion for spaced seeds and its applications to support vector machine string kernels and k-mer distances.

Spaced seeds have been recently shown to not only detect more alignments, but also to give a more accurate measure of phylogenetic distances, and to provide a lower misclassification rate when used with Support Vector Machines (SVMs). We confirm by independent experiments these two results, and propose in this article to use a coverage criterion to measure the seed efficiency in both cases in order to design better seed patterns. We show first how this coverage criterion can be directly measured by a full automaton-based approach. We then illustrate how this criterion performs when compared with two other criteria frequently used, namely the single-hit and multiple-hit criteria, through correlation coefficients with the correct classification/the true distance. At the end, for alignment-free distances, we propose an extension by adopting the coverage criterion, show how it performs, and indicate how it can be efficiently computed.

United States anesthesiologists over 50: retirement decision making and workforce implications.

BACKGROUND: Anesthesiology is among the medical specialties expected to have physician shortage. With little known about older anesthesiologists' work effort and retirement decision making, the American Society of Anesthesiologists participated in a 2006 national survey of physicians aged 50-79 yr. METHODS: Samples of anesthesiologists and other specialists completed a survey of work activities, professional satisfaction, self-defined health and financial status, retirement plans and perspectives, and demographics. A complex survey design enabled adjustments for sampling and response-rate biases so that respondents' characteristics resembled those in the American Medical Association Physician Masterfile. Retirement decision making was modeled with multivariable ordinal logistic regression. Life-table analysis provided a forecast of likely clinical workforce trends over an ensuing 30 yr. RESULTS: Anesthesiologists (N = 3,222; response rate = 37%) reported a mean work week of 49.4 h and a mean retirement age of 62.7 yr, both values similar to those of other older physicians. Work week decreased with age, and part-time work increased. Women worked a shorter work week (mean, 47.9 vs. 49.7 h, P = 0.024), partly due to greater part-time work (20.2 vs. 13.1%, P value less than 0.001). Relative importance of factors reported among those leaving patient care differed by age cohort, subspecialty, and work status. Poor health was cited by 64% of anesthesiologists retiring in their 50s as compared with 43% of those retiring later (P = 0.039). CONCLUSIONS: This survey lends support for greater attention to potentially modifiable factors, such as workplace wellness and professional satisfaction, to prevent premature retirement. The growing trend in part-time work deserves further study.

Perioperative pulmonary embolism: diagnosis and anesthetic management.

All perioperative patients, but especially trauma victims and those undergoing prostate or orthopedic surgery, are at increased risk of venous thromboembolism. Patients at highest risk include those with malignancy, immobility, and obesity; those who smoke; and those taking oral contraceptives, hormone replacement therapy, or antipsychotic medications. Dyspnea, anxiety, and tachypnea are the most common presenting symptoms in awake patients, and hypotension, tachycardia, hypoxemia, and decreased end-tidal CO(2) are the most common findings in patients receiving general anesthesia. The presence of shock and right ventricular failure are associated with adverse outcomes. Helical computed tomographic scanning is the preferred definitive diagnostic study, but transesophageal echocardiography may be valuable in making a presumptive diagnosis in the operating room. Early diagnosis allows supportive therapy and possible anticoagulation (in some cases, to be started before the conclusion of surgery).

A Model for Developing ACGME Competencies in an Academic Anesthesiology Department.

In response to the American College of Graduate Medical Education's Outcomes Project and its mandate for a transition to a competency based curriculum, the Department of Anesthesiology at the Penn State Milton S. Hershey Medical Center executed a focused 18 month program which engaged the entire faculty and effected not only curricular, but cultural change in how anesthesiology residents are taught and evaluated. This article describes the process through which the department leadership educated, engaged, and focused the department's efforts and created an environment that sustained progress and provided incentives for performance. This process also resulted in the development of a novel web based evaluation tool tailored to meet the challenge of evaluating performance in the context of a competency based curriculum. This model, which proved effective for transition to a competency based curriculum, is one which can be applied to any large scale departmental education initiative.

The exact joint distribution of the sum of heads and apparent size statistics of a "tandem repeats finder" algorithm.

Tandem repeats play many important roles in biological research. However, accurate characterization of their properties is limited by the inability to easily detect them. For this reason, much work has been devoted to developing detection algorithms. A widely used algorithm for detecting tandem repeats is the "tandem repeats finder'' (Benson, G., Nucleic Acids Res. 27, 573-580, 1999). In that algorithm, tandem repeats are modeled by percent matches and frequency of indels between adjacent pattern copies, and statistical criteria are used to recognize them. We give a method for computing the exact joint distribution of a pair of statistics that are used in the testing procedures of the "tandem repeats finder'': the total number of matches in matching tuples of length k or longer, and the total number of observations from the beginning of the first such matching tuple to the end of the last one. This allows the computation of the conditional distribution of the latter statistic given the former, a conditional distribution that is used to test for tandem repeats as opposed to non-tandem direct repeats. The setting is a Markovian sequence of a general order. Current approaches to this distributional problem deal only with independent trials and are based on approximations via simulation.