The impact of hindsight bias on the diagnosis of perioperative events by anesthesia providers: A multicenter randomized crossover study.

STUDY OBJECTIVE: Hindsight bias is the tendency to overestimate the predictability of an event after it has already occurred. We aimed to evaluate whether hindsight bias influences the retrospective interpretation of clinical scenarios in the field of anesthesiology, which relies on clinicians making rapid decisions in the setting of perioperative adverse events. DESIGN: Two clinical scenarios were developed (intraoperative hypotension and intraoperative hypoxia) with 3 potential diagnoses for each. Participants completed a crossover study reviewing one case without being informed of the supposed ultimate diagnosis (i.e., no 'anchor' diagnosis), referred to as their foresight case, and the other as a hindsight case wherein they were informed in the leading sentence of the scenario that 1 of the 3 conditions provided was the ultimate diagnosis (i.e., the diagnosis the participant might 'anchor' to if given this information at the start). Participants were randomly assigned to (1) which scenario (hypotension or hypoxia) was presented as the initial foresight case and (2) which of the 3 potential diagnoses for the second case (the hindsight case, which defaulted to whichever case the participant was not assigned for the first case) was presented as the ultimate diagnosis in the leading sentence in a 2 (scenario order) x 3 (hindsight case anchor) between-subjects factorial design (6 possible randomization assignments). SETTING: Two academic medical centers. PARTICIPANTS: Faculty, fellow, and resident anesthesiologists and certified nurse anesthetists (CRNAs). INTERVENTIONS: None. MEASUREMENTS: After reading each clinical scenario, participants were asked to rate the probability (%) of each of three potential diagnoses to have caused the hypotension or hypoxia. Compositional data analysis (CoDA) was used to compare whether diagnosis probabilities differ between the hindsight and the foresight case. MAIN RESULTS: 113 participants completed the study. 59 participants (52%) were resident anesthesiologists. Participants randomized to the hypotension scenario as a hindsight case were 2.82 times more likely to assign higher probability to the pulmonary embolus diagnosis if provided as an anchor (95% CI, 1.35-5.90; P = 0.006) and twice as likely to assign higher probability to the myocardial infarction diagnosis if provided as an anchor (95% CI, 1.12-3.58; P = 0.020). Participants randomized to the hypoxia scenario as a hindsight case were 1.78 times more likely to assign higher probability to the mainstem bronchus intubation diagnosis if provided in the anchor statement (95% CI, 1.00-3.14; P = 0.048) and 3.72 times more likely to assign higher probability to the pulmonary edema diagnosis if provided as an anchor (95% CI, 1.88-7.35; P < 0.001). CONCLUSIONS: Hindsight bias influences the clinical diagnosis probabilities assigned by anesthesia providers. Clinicians should be educated on hindsight bias in perioperative medicine and be cognizant of the effect of hindsight bias when interpreting clinical outcomes.

Variability in Intraoperative Opioid and Nonopioid Utilization During Intracranial Surgery: A Multicenter, Retrospective Cohort Study.

BACKGROUND: Key goals during intracranial surgery are to facilitate rapid emergence and extubation for early neurologic evaluation. Longer-acting opioids are often avoided or administered at subtherapeutic doses due to their perceived risk of sedation and delayed emergence. However, inadequate analgesia and increased postoperative pain are common after intracranial surgery. In this multicenter study, we describe variability in opioid and nonopioid administration patterns in patients undergoing intracranial surgery. METHODS: This was a multicenter, retrospective observational cohort study using the Multicenter Perioperative Outcomes Group database. Opioid and nonopioid practice patterns in 31,217 cases undergoing intracranial surgery across 11 institutions in the United States are described. RESULTS: Across all 11 institutions, total median [interquartile range] oral morphine equivalents, normalized to weight and anesthesia duration was 0.17 (0.08 to 0.3) mg.kg.min-1. There was a 7-fold difference in oral morphine equivalents between the lowest (0.05 [0.02 to 0.13] mg.kg.min-1) and highest (0.36 [0.18 to 0.54] mg.kg.min-1) prescribing institutions. Patients undergoing supratentorial surgery had higher normalized oral morphine equivalents compared with those having infratentorial surgery [0.17 [0.08-0.31] vs. 0.15 [0.07-0.27] mg/kg/min-1; P<0.001); however, this difference is clinically small. Nonopioid analgesics were not administered in 20% to 96.8% of cases across institutions. CONCLUSION: This study found wide variability for both opioid and nonopioid utilization at an institutional level. Future work on practitioner-level opioid and nonopioid use and its impact on outcomes after intracranial surgery should be conducted.

Randomized Secondary Prevention Trials in Participants With Symptomatic Intracranial Atherosclerotic Stenosis.

Intracranial atherosclerotic stenosis is a prevalent cause of ischemic stroke worldwide. Its association with silent cerebral infarcts and its contribution to cognitive impairment and dementia emphasize the critical need for disease prevention and effective management strategies. Despite extensive research on secondary stroke prevention treatment over the past several decades, intracranial atherosclerotic stenosis continues to exhibit a notably higher recurrent stroke rate compared with other causes. This review focuses on randomized secondary prevention trials involving antithrombotic therapy, endovascular treatment, open surgical therapy, and remote ischemic conditioning. It aims to provide an insightful overview of the major findings from each trial and their implications for future research efforts.

Mobile health supported multi-domain recovery trajectories after major arthroplasty or spine surgery: a pilot feasibility and usability study.

BACKGROUND: Recovery after surgery intersects physical, psychological, and social domains. In this study we aim to assess the feasibility and usability of a mobile health application called PositiveTrends to track recovery in these domains amongst participants undergoing hip, knee arthroplasty or spine surgery. Our secondary aim was to generate procedure-specific, recovery trajectories within the pain and medication, psycho-social and patient-reported outcomes domain. METHODS: Prospective, observational study in participants greater than eighteen years of age. Data was collected prior to and up to one hundred and eighty days after completion of surgery within the three domains using PositiveTrends. Feasibility was assessed using participant response rates from the PositiveTrends app. Usability was assessed quantitatively using the System Usability Scale. Heat maps and effect plots were used to visualize multi-domain recovery trajectories. Generalized linear mixed effects models were used to estimate the change in the outcomes over time. RESULTS: Forty-two participants were enrolled over a four-month recruitment period. Proportion of app responses was highest for participants who underwent spine surgery (median = 78, range = 36-100), followed by those who underwent knee arthroplasty (median = 72, range = 12-100), and hip arthroplasty (median = 62, range = 12-98). System Usability Scale mean score was 82 ± 16 at 180 days postoperatively. Function improved by 8 and 6.4 points per month after hip and knee arthroplasty, respectively. In spine participants, the Oswestry Disability Index decreased by 1.4 points per month. Mood improved in all three cohorts, however stress levels remained elevated in spine participants. Pain decreased by 0.16 (95% Confidence Interval: 0.13-0.20, p < 0.001), 0.25 (95% CI: 0.21-0.28, p < 0.001) and 0.14 (95% CI: 0.12-0.15, p < 0.001) points per month in hip, knee, and spine cohorts respectively. There was a 10.9-to-40.3-fold increase in the probability of using no medication for each month postoperatively. CONCLUSIONS: In this study, we demonstrate the feasibility and usability of PositiveTrends, which can map and track multi-domain recovery trajectories after major arthroplasty or spine surgery.

The Acute Effects of Theragun™ Percussive Therapy on Viscoelastic Tissue Dynamics and Hamstring Group Range of Motion.

Handheld percussive therapy (PT) massage guns have seen a rapid rise in use and with-it increased attention within injury prevention and sport performance settings. Early studies have proposed beneficial effects upon range of motion (ROM), however the mechanism behind these increases remains unreported. This study aimed to determine the influence of a minimal frequency PT dose upon ROM and myotonometry outcomes. Twenty participants (N = 20; 13 males and 7 females, height 1.78cm ± 9.62; weight 77.35kg ± 8.46) participants were allocated to either a PT group receiving 2 x 60-seconds (plus 30-seconds rest) via a Theragun™ Pro4 to the hamstrings covering a standardised 20 lengths from proximal to distal via the standard ball attachment at 1 bar of pressure or a control group (CON) of 2-minutes 30-seconds passive supine rest. Pre and post intervention outcomes were measured for ROM via passive straight leg raise (PSLR) and tissue dynamics via MyotonPro (Tone, Stiffness, Elasticity, Relaxation Time). Results showed significant within-group increases (p < 0.0001, ηp2 0.656, +11.4%) in ROM following PT and between group difference against CON (P < 0.026). Significant within-group differences in stiffness (p < 0.016, ηp2 0.144, -6%), tone (p < 0.003, ηp2 0.213, +2%) and relaxation time (p < 0.002, ηp2 0.232, +6.3%) were also reported following PT. No significant difference was reported in elasticity (P > 0.05) or any other between group outcomes. PT therapy can provide an acute increase in hamstring group ROM following a resultant decrease in tissue stiffness.

Daily Quantity and Kinematic Characteristics of Leg Movement in a Child With SMA (2 Copies SMN2).

PURPOSE: This case report describes daily leg movement quantity and kinematic characteristics of a child with spinal muscular atrophy (SMA) with 2 copies of SMN2, who was symptomatic at the time of treatment with disease-modifying therapies. KEY POINTS: Compared with infants with typical development, this child had differing values for leg movement quantity, duration, average acceleration, and peak acceleration measured across full days in the natural environment by wearable sensors. In addition, movement quantity and clinician-rated outcomes increased with age. CONCLUSIONS: Wearable sensors recorded movement quantity and kinematic characteristics in a treated infant with SMA (2 copies SMN2). These movement parameters were consistently different compared anecdotally with published data from infants with typical development, demonstrating their potential to add unique and complementary information to the assessment of motor function in SMA. RECOMMENDATIONS: Larger longitudinal studies are needed to determine the utility of wearable sensors as an assessment tool and an early predictor of motor outcomes in children with SMA.

Comparison of oral versus intravenous methadone on postoperative pain and opioid use after adult spinal deformity surgery: A retrospective, non-inferiority analysis.

OBJECTIVE: To compare efficacy of oral versus intravenous (IV) methadone on postoperative pain and opioid requirements after spine surgery. METHODS: This was a retrospective, single-academic center cohort study evaluating 1010 patients who underwent >3 level spine surgery from January 2017 to May 2020 and received a one-time dose of oral or intravenous methadone prior to surgery. The primary outcome measured was postoperative opioid use in oral morphine equivalents (ME) and verbal response scale (VRS) pain scores up to postoperative day (POD) three. Secondary outcomes were time to first bowel movement and adverse effects (reintubation, myocardial infarction, and QTc prolongation) up to POD 3. RESULTS: A total of 687 patients received oral and 317 received IV methadone, six patients were excluded. The IV group received a significantly greater methadone morphine equivalent (ME) dose preoperatively (112.4 ± 83.0 mg ME versus 59.3 ± 60.9 mg ME, p < 0.001) and greater total (methadone and non-methadone) opioid dose (119.1 ± 81.4 mg ME versus 63.9 ± 62.5 mg ME, p < 0.001), intraoperatively. Although pain scores for the oral group were non-inferior to the IV group for all postoperative days (POD), non-inferiority for postoperative opioid requirements was demonstrated only on POD 3. Based on the joint hypothesis for the co-primary outcomes, oral methadone was non-inferior to IV methadone on POD 3 only. No differences in secondary outcomes, including QTc prolongation and arrhythmias, were noted between the groups. CONCLUSIONS: Oral methadone is a feasible alternative to IV methadone for patients undergoing spine surgery regarding both pain scores and postoperative opioid consumption.

Pro-Con Debate: Role of Methadone in Enhanced Recovery After Surgery Protocols-Superior Analgesic or Harmful Drug?

Enhanced recovery after surgery (ERAS) protocols are standardized and designed to provide superior analgesia, reduce opioid consumption, improve patient recovery, and reduce hospital length of stay. Yet, moderate-to-severe postsurgical pain continues to afflict over 40% of patients and remains a major priority for anesthesia research. Methadone administration in the perioperative setting may reduce postoperative pain scores and have opioid-sparing effects, which may be beneficial for enhanced recovery. Methadone possesses a multimodal profile consisting of µ-opioid agonism, N-methyl-d-aspartate (NMDA) receptor antagonism, and reuptake inhibition of serotonin and norepinephrine. Furthermore, it may attenuate the development of chronic postsurgical pain. However, caution is advised with perioperative use of methadone in specific high-risk patient populations and surgical settings. Methadone's wide pharmacokinetic variability, opioid-related adverse effects, and potential negative impact on cost-effectiveness may also limit its use in the perioperative setting. In this PRO-CON commentary article, the authors debate whether methadone should be incorporated in ERAS protocols to provide superior analgesia with no increased risks.

Triplication of the interferon receptor locus contributes to hallmarks of Down syndrome in a mouse model.

Down syndrome (DS), the genetic condition caused by trisomy 21, is characterized by variable cognitive impairment, immune dysregulation, dysmorphogenesis and increased prevalence of diverse co-occurring conditions. The mechanisms by which trisomy 21 causes these effects remain largely unknown. We demonstrate that triplication of the interferon receptor (IFNR) gene cluster on chromosome 21 is necessary for multiple phenotypes in a mouse model of DS. Whole-blood transcriptome analysis demonstrated that IFNR overexpression associates with chronic interferon hyperactivity and inflammation in people with DS. To define the contribution of this locus to DS phenotypes, we used genome editing to correct its copy number in a mouse model of DS, which normalized antiviral responses, prevented heart malformations, ameliorated developmental delays, improved cognition and attenuated craniofacial anomalies. Triplication of the Ifnr locus modulates hallmarks of DS in mice, suggesting that trisomy 21 elicits an interferonopathy potentially amenable to therapeutic intervention.

The Impact of Physician Race and Sex on Patient Ranking of Physician Competence and Perception of Leadership Ability.

Background Biases affect patient perceptions of their physician and influence the physician-patient relationship. While racial disparities in care and inequities in the healthcare workforce are well-documented, the impact of physician race on patient perceptions remains unclear. We aimed to investigate the association of physician race and sex on patient perceptions during simulated preoperative encounters. Methods Three hundred patients recruited consecutively in the Preanesthesia Evaluation and Testing Center viewed pictures of 4 anesthesiologists (black male, white male, black female, white female) in random order while listening to a set of paired audio recordings describing general anesthesia. Participants ranked each anesthesiologist on confidence, intelligence, and likelihood of choosing the anesthesiologist to care for their family member, and chose the one anesthesiologist most like a leader. Results Compared to white anesthesiologists, black anesthesiologists had greater odds of being ranked more confident (OR, 1.45; 95% CI, 1.10 to 1.89; P=0.008) and being considered a leader (OR, 2.06; 95% CI, 1.50 to 2.84; P<0.0001). Among white participants, black anesthesiologists had greater odds of being ranked more intelligent (OR, 2.08; 95% CI, 1.54 to 2.81; P<0.0001) and were more likely to be chosen to care for a family member (OR, 2.26; 95% CI, 1.66 to 3.08; P<0.0001). Female anesthesiologists had greater odds of being ranked more intelligent (OR, 1.36; 95% CI, 1.08 to 1.71; P=0.009) and were more likely to be chosen to care for a family member (OR, 1.58; 95% CI, 1.27 to 1.97; P<0.001) compared with male anesthesiologists. Conclusions Contrary to our hypothesis, patients ranked black physicians more highly on multiple competence and leadership quality metrics. Our data likely highlight the role social desirability bias may play in studies of racial disparities within medicine.

Incremental Cost-effectiveness Analysis on Length of Stay of an Enhanced Recovery After Spine Surgery Program: A Single-center, Retrospective Cohort Study.

BACKGROUND: Enhanced recovery after spine surgery (ERAS) is increasingly utilized to improve postoperative outcomes and reduce cost. There are limited data on the monetary benefits of ERAS when incorporating the costs of developing, operationalizing, and maintaining ERAS programs. The objective of this study was to calculate the incremental cost-effectiveness of a spine surgery ERAS program, modeling hospital and operational cost and length of stay (LOS). METHODS: The study included adult patients undergoing spine surgery before and after implementation of an ERAS program. Variables included individual patient-level and ERAS personnel costs, with LOS as the outcome utility of interest. Propensity score matching was used to create a quasi-experimental design to equate the standard care and ERAS groups. RESULTS: Four hundred and nine patients were included in the unmatched group, with 54 patients each in the standard care and ERAS groups after matching. In the matched cohort, the only imbalance in predictors (standard mean difference [SMD] >0.2) were race (SMD, 0.21), American Society of Anesthesiologist (ASA) physical status (SMD, 0.32), fluid balance in the operating room (SMD, 0.21), median (interquartile range) LOS (standard care, 2.0 [1.0, 3.75] days vs. ERAS, 4.0 [3.0, 5.0]; SMD, 0.81) and mean (±SD) total cost (standard care, $19,291.57±13,572.24 vs. ERAS, $24,363.45±26,352.45; SMD, 0.24). In the incremental cost effectiveness analysis, standard care was the dominant strategy in both 1-way and 2-way sensitivity analysis. CONCLUSIONS: We report a real-world, cost-effectiveness analysis following implementation of an ERAS program for spine surgery at a quaternary medical center. Our study demonstrated that considering LOS as the sole determinant, standard care is the dominant cost-effective strategy compared with the ERAS protocol.

Enhanced Recovery Protocol Associated With Decreased 3-Month Opioid Use After Thoracic Surgery.

BACKGROUND: Enhanced recovery protocols (ERPs) have been shown to decrease inhospital opioid use after thoracic surgery. However, the impact on opioid use after discharge has not been reported. We hypothesized that prolonged opioid use would decrease after implementation of a comprehensive ERP. METHODS: Records from all patients undergoing elective pulmonary, pleural, and mediastinal operations at a single institution (2015-2018) were abstracted from a prospective ERP database and The Society of Thoracic Surgeons institutional database. Records were reviewed for documentation of opioid use at 3-month and 6-month postoperative visits. Patients with preoperative chronic opioid use were excluded. Univariate analysis compared patients with and patients without 3-month opioid use, and a multivariable logistic regression evaluated independent predictors of prolonged opioid use. RESULTS: A total of 499 patients was included: 160 pre-ERP, and 339 post-ERP. Three-month opioid use rates were decreased after implementation of an ERP (44% vs 30%, P = .01); 6-month opioid use rates were not significantly different (25% vs 18%, P = .10). Univariate analysis demonstrated increased 3-month opioid use rates among patients with preoperative tobacco use (38% vs 27%, P = .05) and chronic pain disorder (88% vs 32%, P < .01), with no impact from surgical incision (video-assisted thoracoscopic surgery 33%; open 37%, P = .49). On multivariable analysis, participation in an ERP was independently associated with decreased opioid use at 3 months (odds ratio 0.53; 95% CI, 0.31-0.89; P = .02). CONCLUSIONS: There is a high burden of prolonged opioid use after elective thoracic surgery. Participation in a comprehensive ERP is associated with decreased opioid use 3 months postoperatively.

Voluntary commitments made by the world's largest companies focus on recycling and packaging over other actions to address the plastics crisis.

Plastic pollution has caused significant environmental and health challenges. Corporations that contribute to the make, use, and distribution of plastics can play a vital role in addressing global plastic pollution and many are committing to voluntary pledges. However, the extent to which corporation voluntary commitments are helping solve the problem remains underexplored. Here we develop a novel typology to characterize voluntary commitments to reduce plastic pollution made between 2015-2020 by 974 companies including the top 300 of the Fortune Global. We find that 72% of these companies have made commitments to reduce plastic pollution. About 67% of companies participating in voluntary environmental programs (VEPs) and 17% of non-VEPs participants made measurable and timebound commitments. However, rather than tackle virgin plastics, most companies target general plastics and frequently emphasize end-of-life controls with a primary focus on recycling. Growing commitments on plastic pollution are made by large and important companies, but significantly more efforts beyond plastic recycling are required to effectively address plastic pollution challenges.

Resting and Recharging: A Narrative Review of Strategies to Improve Sleep During Residency Training.

Background: Residency involves demanding training with long hours that may cause fatigue and sleep deprivation and adversely impact residents and patients under their care. Objective: To identify, using a narrative review, evidence-based interventions to reduce the physiologic effects of fatigue and sleep deprivation from overnight and night shift work. Methods: A PubMed literature search was conducted through August 30, 2021, using the terms "resident" and "sleep" in the title or abstract and further narrowed using a third search term. Observational studies, randomized controlled trials, systematic reviews, and meta-analyses of human subjects written and published in English were included. Studies that were not specific to residents or medical interns or did not investigate an intervention were excluded. Additional studies were identified by bibliography review. Due to the heterogeneity of study design and intervention, a narrative review approach was chosen with results categorized into non-pharmacological and pharmacological interventions. Results: Initially, 271 articles were identified, which were narrowed to 28 articles with the use of a third search term related to sleep. Bibliography review yielded 4 additional articles. Data on interventions are limited by the heterogeneity of medical specialty, sample size, length of follow-up, and reliance on self-report. Non-pharmacological interventions including strategic scheduling and sleep hygiene may improve sleep and well-being. The available evidence, including randomized controlled trials, to support pharmacological interventions is limited. Conclusions: Non-pharmacological approaches to mitigating fatigue and sleep deprivation have varying effectiveness to improve sleep for residents; however, data for pharmacological interventions is limited.

Carbon Dioxide, Blood Pressure, and Perioperative Stroke: A Retrospective Case-Control Study.

BACKGROUND: The relationship between intraoperative physiology and postoperative stroke is incompletely understood. Preliminary data suggest that either hypo- or hypercapnia coupled with reduced cerebrovascular inflow (e.g., due to hypotension) can lead to ischemia. This study tested the hypothesis that the combination of intraoperative hypotension and either hypo- or hypercarbia is associated with postoperative ischemic stroke. METHODS: We conducted a retrospective, case-control study via the Multicenter Perioperative Outcomes Group. Noncardiac, nonintracranial, and nonmajor vascular surgical cases (18 yr or older) were extracted from five major academic centers between January 2004 and December 2015. Ischemic stroke cases were identified via manual chart review and matched to controls (1:4). Time and reduction below key mean arterial blood pressure thresholds (less than 55 mmHg, less than 60 mmHg, less than 65 mmHg) and outside of specific end-tidal carbon dioxide thresholds (30 mmHg or less, 35 mmHg or less, 45 mmHg or greater) were calculated based on total area under the curve. The association between stroke and total area under the curve values was then tested while adjusting for relevant confounders. RESULTS: In total, 1,244,881 cases were analyzed. Among the cases that screened positive for stroke (n = 1,702), 126 were confirmed and successfully matched with 500 corresponding controls. Total area under the curve was significantly associated with stroke for all thresholds tested, with the strongest combination observed with mean arterial pressure less than 55 mmHg (adjusted odds ratio per 10 mmHg-min, 1.17 [95% CI, 1.10 to 1.23], P < 0.0001) and end-tidal carbon dioxide 45 mmHg or greater (adjusted odds ratio per 10 mmHg-min, 1.11 [95% CI, 1.10 to 1.11], P < 0.0001). There was no interaction effect observed between blood pressure and carbon dioxide. CONCLUSIONS: Intraoperative hypotension and carbon dioxide dysregulation may each independently increase postoperative stroke risk.

Anesthetic management during transsphenoidal pituitary surgery.

PURPOSE OF REVIEW: Pituitary adenoma resections comprise a large proportion of intracranial tumor surgeries. This patient population is medically and physiologically complex and requires careful perioperative planning and management on the part of the anesthesiologist. This review will summarize anesthetic considerations for pre, intra, and postoperative management of patients undergoing transsphenoidal pituitary surgery. RECENT FINDINGS: An endoscopic approach is favored for patients undergoing transsphenoidal pituitary surgery. Hemodynamic monitoring is important to maintain cerebral perfusion and avoid risk of bleeding; however, 'controlled' hypotension may have adverse effects. Multimodal analgesia is effective for the management of postoperative pain and may reduce the risk of postoperative complications, including respiratory depression and postoperative nausea and vomiting. SUMMARY: Transsphenoidal pituitary surgery is a preferred approach for the surgical management of nonfunctioning pituitary macroadenomas with symptoms of mass effect and functioning adenomas that cannot be otherwise managed medically. Understanding tumor pathologies and systemic effects are essential for preoperative planning and providing safe anesthetic care during the perioperative period.