Development and Implementation of a Clinician-Educator Track for Residents in Anesthesiology.

Background: Clinician-educators in academic settings have often had no formal training in teaching or in giving feedback to trainees. We implemented a Clinician-Educator Track within the Department of Anesthesiology with the initial goal of improving teaching skills through a didactic curriculum and experiential opportunities for a broad audience of faculty, fellows, and residents. We then assessed our program for feasibility and effectiveness. Methods: We developed a 1-year curriculum focusing on adult learning theory, evidence-based best teaching practices in different educational settings, and giving feedback. We recorded the number of participants and their attendance at monthly sessions. The year culminated in a voluntary observed teaching session using an objective assessment rubric to structure feedback. Participants in the Clinician-Educator Track then evaluated the program through anonymous online surveys. Qualitative content analysis of the survey comments was performed using inductive coding to generate relevant categories and identify the main themes. Results: There were 19 participants in the first year of the program and 16 in the second year. Attendance at most sessions remained high. Participants appreciated the flexibility and design of scheduled sessions. They very much enjoyed the voluntary observed teaching sessions to practice what they had learned throughout the year. All participants were satisfied with the Clinician-Educator Track, and many participants described changes and improvements in their teaching practices due to the course. Conclusions: The implementation of a novel, anesthesiology-specific Clinician-Educator Track has been feasible and successful, with participants reporting improved teaching skills and overall satisfaction with the program.

Logistical Considerations and Clinical Outcomes Associated With Converting Operating Rooms Into an Intensive Care Unit During the Coronavirus Disease 2019 Pandemic in a New York City Hospital.

BACKGROUND: Coronavirus disease 2019 (COVID-19) emerged as a public health crisis that disrupted normal patterns of health care in the New York City metropolitan area. In preparation for a large influx of critically ill patients, operating rooms (ORs) at NewYork-Presbyterian/Columbia University Irving Medical Center (NYP-Columbia) were converted into a novel intensive care unit (ICU) area, the operating room intensive care unit (ORICU). METHODS: Twenty-three ORs were converted into an 82-bed ORICU. Adaptations to the OR environment permitted the delivery of standard critical care therapies. Nonintensive-care-trained staff were educated on the basics of critical care and deployed in a hybrid staffing model. Anesthesia machines were repurposed as critical care ventilators, with accommodations to ensure reliable function and patient safety. To compare ORICU survivorship to outcomes in more traditional environments, we performed Kaplan-Meier survival analysis of all patients cared for in the ORICU, censoring data at the time of ORICU closure. We hypothesized that age, sex, and obesity may have influenced the risk of death. Thus, we estimated hazard ratios (HR) for death using Cox proportional hazard regression models with age, sex, and body mass index (BMI) as covariables and, separately, using older age (65 years and older) adjusted for sex and BMI. RESULTS: The ORICU cared for 133 patients from March 24 to May 14, 2020. Patients were transferred to the ORICU from other ICUs, inpatient wards, the emergency department, and other institutions. Patients remained in the ORICU until either transfer to another unit or death. As the hospital patient load decreased, patients were transferred out of the ORICU. This process was completed on May 14, 2020. At time of data censoring, 55 (41.4%) of patients had died. The estimated probability of survival 30 days after admission was 0.61 (95% confidence interval [CI], 0.52-0.69). Age was significantly associated with increased risk of mortality (HR = 1.05, 95% CI, 1.03-1.08, P < .001 for a 1-year increase in age). Patients who were ≥65 years were an estimated 3.17 times more likely to die than younger patients (95% CI, 1.78-5.63; P < .001) when adjusting for sex and BMI. CONCLUSIONS: A large number of critically ill COVID-19 patients were cared for in the ORICU, which substantially increased ICU capacity at NYP-Columbia. The estimated ORICU survival rate at 30 days was comparable to other reported rates, suggesting this was an effective approach to manage the influx of critically ill COVID-19 patients during a time of crisis.

Initial Clinical Impressions of the Critical Care of COVID-19 Patients in Seattle, New York City, and Chicago.

Since the first recognition of a cluster of novel respiratory viral infections in China in late December 2019, intensivists in the United States have watched with growing concern as infections with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus-now named coronavirus disease of 2019 (COVID-19)-have spread to hospitals in the United States. Because COVID-19 is extremely transmissible and can progress to a severe form of respiratory failure, the potential to overwhelm available critical care resources is high and critical care management of COVID-19 patients has been thrust into the spotlight. COVID-19 arrived in the United States in January and, as anticipated, has dramatically increased the usage of critical care resources. Three of the hardest-hit cities have been Seattle, New York City, and Chicago with a combined total of over 14,000 cases as of March 23, 2020.In this special article, we describe initial clinical impressions of critical care of COVID-19 in these areas, with attention to clinical presentation, laboratory values, organ system effects, treatment strategies, and resource management. We highlight clinical observations that align with or differ from already published reports. These impressions represent only the early empiric experience of the authors and are not intended to serve as recommendations or guidelines for practice, but rather as a starting point for intensivists preparing to address COVID-19 when it arrives in their community.

Critical Care in a Tertiary Hospital in Malawi.

BACKGROUND: The provision of critical care services is essential to healthcare systems and increasingly a global health focus, but many hospitals in sub-Saharan Africa are unable to meet this need. Intensive care unit (ICU) mortality in this region is high, but studies describing the provision of critical care services are scarce. METHODS: This was a retrospective cohort study of all patients admitted to the ICU at Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi, between September 1, 2013, and October 17, 2014. We summarized demographics, clinical characteristics, and outcomes, and analyzed factors associated with mortality. RESULTS: Of 390 patients admitted to ICU during the study, 44.9 % of patients were male, and the median age was 22 years (IQR 6-35) years. Although most patients (73.1 %) were admitted with surgical diagnoses, the highest mortality was among patients admitted with sepsis (59.3 %), or obstetric (44.7 %) or medical (40.0 %) diagnoses. Overall ICU mortality was high (23.6 %). CONCLUSIONS: There is a shortage of data describing critical care in low-resource settings, particularly in sub-Saharan Africa. Surgical disease comprises the majority of ICU utilization in this study site, but medical and obstetric illness carried higher ICU mortality. These data may guide strategies for improving critical care in the region.

The surgical Apgar score is strongly associated with intensive care unit admission after high-risk intraabdominal surgery.

BACKGROUND: Understanding intensive care unit (ICU) triage decisions for high-risk surgical patients may ultimately facilitate resource allocation and improve outcomes. The surgical Apgar score (SAS) is a simple score that uses intraoperative information on hemodynamics and blood loss to predict postoperative morbidity and mortality, with lower scores associated with worse outcomes. We hypothesized that the SAS would be associated with the decision to admit a patient to the ICU postoperatively. METHODS: We performed a retrospective cohort study of adults undergoing major intraabdominal surgery from 2003 to 2010 at an academic medical center. We calculated the SAS (0-10) for each patient based on intraoperative heart rate, mean arterial blood pressure, and estimated blood loss. Using logistic regression, we assessed the association of the SAS with the decision to admit a patient directly to the ICU after surgery. RESULTS: The cohort consisted of 8501 patients, with 72.7% having an SAS of 7 to 10 and <5% an SAS of 0 to 4. A total of 8.7% of patients were transferred immediately to the ICU postoperatively. After multivariate adjustment, there was a strong association between the SAS and the decision to admit a patient to the ICU (adjusted odds ratio 14.41 [95% confidence interval {CI}, 6.88-30.19, P < 0.001] for SAS 0-2, 4.42 [95% CI, 3.19-6.13, P < 0.001] for SAS 3-4, and 2.60 [95% CI, 2.08-3.24, P < 0.001] for SAS 5-6 compared with SAS 7-8). CONCLUSIONS: The SAS is strongly associated with clinical decisions regarding immediate ICU admission after high-risk intraabdominal surgery. These results provide an initial step toward understanding whether intraoperative hemodynamics and blood loss influence ICU triage for postsurgical patients.

Anesthetic-specific electroencephalographic patterns during emergence from sevoflurane and isoflurane in infants and children.

BACKGROUND: Devices that monitor the depth of anesthesia are increasingly used to titrate sedation and avoid awareness during anesthesia. Many of these monitors are based upon electroencephalography (EEG) collected from large adult reference populations and not pediatric populations (Anesthesiology, 86, 1997, 836; Journal of Anaesthesia, 92, 2004, 393; Anesthesiology, 99, 2003, 34). We hypothesized that EEG patterns in children would be different from those previously reported in adults and that they would show anesthetic-specific characteristics. METHODS: This prospective observational study was approved by the Institutional Review Board, and informed written consent was obtained. Patients were randomized to receive maintenance anesthesia with isoflurane or sevoflurane. EEG data collection included at least 10 min at steady-state maintenance anesthesia. The EEG was recorded continuously through emergence until after extubation. A mixed model procedure was performed on global and regional power by pooled data analysis and by analyzing each anesthetic group separately. Statistical significance was defined as P < 0.05. RESULTS: Thirty-seven children completed the study (ages 22 days-3.6 years). Isoflurane and sevoflurane had different effects on global and regional EEG power during emergence from anesthesia, and frontal predominance patterns were significantly different between these two anesthetic agents. CONCLUSIONS: The principal finding of the present study was that there are anesthetic-specific and concentration-dependent EEG effects in children. Depth-of-anesthesia monitors that utilize algorithms based on the EEGs of adult reference populations therefore may not be appropriate for use in children.

Intraoperative reported adverse events in children.

BACKGROUND: Significant intraprocedural adverse events (AE) are reported in children who receive anesthesia for procedures outside the Operating Rooms (NORA). No study, so far, has characterized AE in children who receive anesthesia in the operating rooms (ORA) and NORA when anesthesia care is provided by the same team in a consistent manner. OBJECTIVE/AIM: We used the same patient-specific Quality Assurance questionnaires (QAs), to elucidate incidences of intraoperative reported AE for children receiving anesthesia in NORA and ORA locations. Through multivariate logistic regression analysis, we assessed the association between patient's AE risk and procedure's location while adjusting for American Society of Anesthesiologists (ASA) status, age, and unscheduled nature of the procedure. METHODS/MATERIALS: After Institutional Review Board approval, we used returned QAs of patients under 21 years, who received anesthesia from our pediatric anesthesia faculty from May 1 2006 through September 30, 2007. We analyzed QA data on: service location, unscheduled/scheduled procedure, age, ASA status, presence, and type of AE. We excluded QAs with incomplete information on date, location, age, and ASA status. RESULTS: We included 8707 cases, with 3.5% incidence of reported AE. We had 1898 NORA and 6808 ORA cases with AE incidence of 2.5% and 3.7%, respectively. Multivariate regression analysis revealed that patients with higher ASA status or younger age had higher incidence of reported AE, irrespective of location or unscheduled nature of the procedure. The most common AE type, for both sites, was respiratory related (1.9%). CONCLUSIONS: Pediatric reported AE incidence was comparable for NORA and ORA locations. Younger age or higher ASA status are associated with increased risk of AE.

[Difficulties in identification of human corpses and skeletal remains on the basis of dental records and examinations]. / Trudnosci identyfikacji zwlok i szczatków ludzkich w oparciu o dokumentacje i badania stomatologiczne.

The entire skull-based complex comparative identification procedure consists of several detailed studies from different disciplines of science. The range of the performed studies predominantly depends on the available and collected comparative material pertaining to the examined individual and the final outcome of the complex identification procedure represents the results of individual stages of the studies. Odontological tests involving the comparison of dentition in the examined human skull with the dentition of the typed person, established by the available comparative material, represent a significant element of the identification procedure. The aim of the investigations was the examination of availability and usefulness of dental records during the identification process. The research was based on expert opinions issued in human-skull based identification processes and performed at Department of Forensic Medicine, University of Medical Sciences in Poznan, in the period between 1996 and 2005. A total of 398 identification procedures carried out in 348 sculls was analyzed. The research was mainly identification of an individual through face reconstruction and a skull/photo comparison. An overall number of 206 computer (digital) face-reconstructions and 263 comparison analyses was done in the above-mentioned period. Statistically, in only 22 cases out of 263 comparison analyses some dental records were available. Even then, dental records were not always relevant. In 4 cases, dental records were either incomplete, inaccurate or unreadable.

[Morphology and diagnostics of mechanisms of chest bone fractures and their use in analyzing forensic medicine results]. / Morfologia i diagnostyka mechanizmów zlaman kosci klatki piersiowej -- wykorzystanie w opiniowaniu sadowo-lekarskim.

The study presents the analysis of 343 available protocols of autopsy results. In the reviewed material, the authors noted that of 343 autopsies performed in 2005, in 92 cases, rib fractures were present. The study reviews the articles on the morphology and determination of the mechanism of rib fracturing. The authors describe the majority of factors that influence the type of fracture, as well as the current views on the possibility of applying the knowledge of morphology and mechanisms of rib fracturing in opinionating in traffic accidents, injuries inflicted to victims of assault and battery, in interpreting autopsy findings in victims of falls from high altitude or crushing by heavy objects, as well as in differentiating between primary and secondary injuries, and also identifying fractures occurring during resuscitation. Fractures in children are presented separately. The authors also analyze the issue of establishing the sequence of fractures.

Dose-dependent effects of FK506 on neuroregeneration in a rat model.

This study explored the effects of different doses of FK506 on peripheral nerve regeneration, to determine whether neuroregeneration could be enhanced without the toxicity of systemic immunosuppression. In the first part of the study, subimmunosuppressive doses of FK506 were determined by examining skin allograft survival in a rat model. Full-thickness skin grafts (2 cm2) from Wistar rats were grafted to recipient Lewis rats. The procedure was performed for six groups (n = 6). The control group received no FK506, and the other five groups received daily doses of FK506 of 0.125, 0.25, 0.5, 1.0, or 2.0 mg/kg. Animals that received 2.0 mg/kg FK506 per day exhibited complete skin graft take, whereas all other groups demonstrated complete rejection. After determination of the immunosuppressive dose of FK506, the neuroregenerative effects of different doses of FK506 were explored by assessing nerve regeneration in 80 rats after tibial nerve transection and repair. The control group received no FK506, whereas the other four groups were given daily doses of FK506 of 0.25, 0.5, 1.0, or 2.0 mg/kg. Rats were euthanized at three time points (25, 30, and 35 days), to fully investigate the effects of different FK506 dosing regimens on neuroregeneration. Histomorphometric analyses performed on postoperative days 30 and 35 demonstrated statistically significant improvements in neuroregeneration with subimmunosuppressive FK506 doses of 0.5 and 1.0 mg/kg per day. Therefore, the study demonstrated that neuroregeneration was enhanced at low doses of FK506 that were not sufficient to prevent skin allograft rejection.

Effects of delaying FK506 administration on neuroregeneration in a rodent model.

FK506 is an immunosuppressant drug that has been shown experimentally to stimulate nerve growth and speed functional recovery, when administered immediately after peripheral nerve injury. However, the clinical scenario of a peripheral nerve injury is often associated with either a delayed diagnosis or reconstruction. The purpose of this study was to determine the efficacy of FK506 on neuroregeneration with delayed administration. Thirty-two Lewis rats underwent tibial nerve transection with immediate repair. Animals were left untreated, or were treated with daily injections of FK506 (2 mg/kg), started on the day of surgery, postoperative day 3, or postoperative day 5. Animals underwent walking track analysis to assess functional nerve recovery. Nerves were harvested for histomorphometric analysis on postoperative days 21, 28, and 42. Histomorphometry demonstrated that all treatment groups, regardless of the time of drug initiation, demonstrated evidence of enhanced neuroregeneration, compared to the untreated group. Histomorphometric data from groups harvested on day 21 demonstrated a statistically significant improvement in neuroregeneration in the immediate and 3-day delay groups. Therefore, the beneficial effects of FK506 on neuroregeneration are not restricted to immediate administration, but these effects significantly diminish when FK506 is administered 3 days after nerve injury.