Comparison of a Novel Cadaver Model (Fix for Life) With the Formalin-Fixed Cadaver and Manikin Model for Suitability and Realism in Airway Management Training

BACKGROUND: Manikins are widely used in airway management training; however, simulation of realism and interpatient variability remains a challenge. We investigated whether cadavers embalmed with the novel Fix for Life (F4L) embalmment method are a suitable and realistic model for teaching 3 basic airway skills: facemask ventilation, tracheal intubation, and laryngeal mask insertion compared to a manikin (SimMan 3G) and formalin-fixed cadavers. METHODS: Thirty anesthesiologists and experienced residents ("operators") were instructed to perform the 3 airway techniques in 10 F4L, 10 formalin-fixed cadavers, and 1 manikin. The order of the model type was randomized per operator. Primary outcomes were the operators' ranking of each model type as a teaching model (total rank), ranking of the model types per technique, and an operator's average verbal rating score for suitability and realism of learning the technique on the model. Secondary outcomes were the percentages of successfully performed procedures per technique and per model (success rates in completing the respective airway maneuvers). For each of the airway techniques, the Friedman analysis of variance was used to compare the 3 models on mean operator ranking and mean verbal rating scores. RESULTS: Twenty-seven of 30 operators (90%) performed all airway techniques on all of the available models, whereas 3 operators performed the majority but not all of the airway maneuvers on all models for logistical reasons. The total number of attempts for each technique was 30 on the manikin, 292 in the F4L, and 282 on the formalin-fixed cadavers. The operators' median total ranking of each model type as a teaching model was 1 for F4L, 2 for the manikin and, 3 for the formalin-fixed cadavers (P

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Continuous Popliteal-Sciatic Blocks for Postoperative Analgesia: Traditional Proximal Catheter Insertion Superficial to the Paraneural Sheath Versus a New Distal Insertion Site Deep to the Paraneural Sheath

We tested the hypothesis that during a continuous popliteal-sciatic nerve block, postoperative analgesia is improved with the catheter insertion point "deep" to the paraneural sheath immediately distal to the bifurcation between the tibial and common peroneal branches, compared with the traditional approach "superficial" to the paraneural sheath proximal to the bifurcation. The needle tip location was determined to be accurately located with a fluid bolus visualized with ultrasound; however, catheters were subsequently inserted without a similar fluid injection and visualization protocol (visualized air injection was permitted and usually implemented, but not required per protocol). The average pain (0–10 scale) the morning after surgery for subjects with a catheter inserted at the proximal subparaneural location (n = 31) was a median (interquartile) of 1.5 (0.0–3.5) vs 1.5 (0.0–4.0) for subjects with a catheter inserted at the distal supraparaneural location (n = 32; P = .927). Secondary outcomes were similarly negative. Accepted for publication July 2, 2018. Funding: This work was supported by the Department of Anesthesiology, University California San Diego (San Diego, CA). The authors declare no conflicts of interest. Institutional review board: University of California, San Diego (UCSD) Human Research Protections Program at 9500 Gilman Dr, Mail Code 0052, La Jolla, CA 92093–0052; (858) 657–5100. E-mail: tnelson@ucsd.edu. This report describes human research. This study was conducted with written informed consent from the study subjects. This report describes a prospective randomized clinical trial. The authors state that the report includes every item in the Consolidated Standards of Reporting Trials (CONSORT) checklist for a prospective randomized clinical trial. The study was registered before patient enrollment. This was not an observational clinical study. Registry URL: clinicaltrials.gov NCT02523235. Plain Language Summary: We found no evidence that during a "continuous" popliteal nerve block, postoperative analgesia is improved with the perineural catheter tip deep to the paraneural sheath immediately distal to the sciatic bifurcation, compared with a traditional approach with the catheter tip superficial to the paraneural sheath proximal to the bifurcation. The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the funding entity. Reprints will not be available from the authors. Address correspondence to Brian M. Ilfeld, MD, MS (Clinical Investigation), Department of Anesthesiology, University California, San Diego, 200 W Arbor Dr, MC 8770, San Diego, CA, 92103. Address e-mail to bilfeld@ucsd.edu. © 2018 International Anesthesia Research Society

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Status of Women in Academic Anesthesiology: A 10-Year Update

BACKGROUND: Gender inequity is still prevalent in today's medical workforce. Previous studies have investigated the status of women in academic anesthesiology. The objective of this study is to provide a current update on the status of women in academic anesthesiology. We hypothesized that while the number of women in academic anesthesiology has increased in the past 10 years, major gender disparities continue to persist, most notably in leadership roles. METHODS: Medical student, resident, and faculty data were obtained from the Association of American Medical Colleges. The number of women in anesthesiology at the resident and faculty level, the distribution of faculty academic rank, and the number of women chairpersons were compared across the period from 2006 to 2016. The gender distribution of major anesthesiology journal editorial boards and data on anesthesiology research grant awards, among other leadership roles, were collected from websites and compared to data from 2005 and 2006. RESULTS: The number (%) of women anesthesiology residents/faculty has increased from 1570 (32%)/1783 (29%) in 2006 to 2145 (35%)/2945 (36%) in 2016 (P = .004 and P

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Diagnostic Testing and Decision-Making: Beauty Is Not Just in the Eye of the Beholder

To use a diagnostic test effectively and consistently in their practice, clinicians need to know how well the test distinguishes between those patients who have the suspected acute or chronic disease and those patients who do not. Clinicians are equally interested and usually more concerned whether, based on the results of a screening test, a given patient actually: (1) does or does not have the suspected disease; or (2) will or will not subsequently experience the adverse event or outcome. Medical tests that are performed to screen for a risk factor, diagnose a disease, or to estimate a patient's prognosis are frequently a key component of a clinical research study. Like therapeutic interventions, medical tests require proper analysis and demonstrated efficacy before being incorporated into routine clinical practice. This basic statistical tutorial, thus, discusses the fundamental concepts and techniques related to diagnostic testing and medical decision-making, including sensitivity and specificity, positive predictive value and negative predictive value, positive and negative likelihood ratio, receiver operating characteristic curve, diagnostic accuracy, choosing a best cut-point for a continuous variable biomarker, comparing methods on diagnostic accuracy, and design of a diagnostic accuracy study. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Accepted for publication July 3, 2018. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Thomas R. Vetter, MD, MPH, Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Health Discovery Bldg, Room 6.812, 1701 Trinity St, Austin, TX 78712. Address e-mail to thomas.vetter@austin.utexas.edu. © 2018 International Anesthesia Research Society

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Narrative Review of Decision-Making Processes in Critical Care

Several theories describing the decision-making process in the intensive care unit (ICU) have been formulated. However, none of them appreciate the complexities of the process in an eclectic way by unifying several miscellaneous variables in 1 comprehensive theory. The purpose of this review is to highlight the key intricacies associated with the decision-making process in the ICU, to describe the theoretical frameworks with a special emphasis on gaps of knowledge, and to offer some avenues for improvement. The application of theoretical framework helps us to understand and to modify the structure of the process. Expected utility theory, regret theory, prospect theory, fuzzy-trace theory, construal level theory, and quantum probability theory were formulated over the years to appreciate an increased complexity of the decision-making process in the ICU. However the decision makers engage, these models may affect patient care because each of these frameworks has several benefits and downsides. There are gaps of knowledge in understanding how physicians match the different theoretical frameworks of the decision-making process with the potentially high ICU variability and load, especially when the "best outcome" is often nondiscrete and multidimensional. Furthermore, it is unclear when the preferential application of reflexive, habitual, variable, and biased-prone processes results in patient and staff detriment. We suggest better matching of theoretical frameworks with strengths of the human decision-making process and balanced application computer aids, artificial intelligence, and organizational modifications. The key component of this integration is work to increase the self-awareness of decision-making processes among residents, fellows, and attending physicians. Accepted for publication June 19, 2018. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Krzysztof Laudanski, MD, PhD, AM FCCM, Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, 3620 Hamilton Walk, Philadelphia, PA 19104. Address e-mail to klaudanski@gmail.com. © 2018 International Anesthesia Research Society

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Effects of mandatory salt iodization on breast milk, urinary iodine concentrations, and thyroid hormones: is iodine deficiency still a continuing problem?

Abstract

Purpose

To investigate whether mandatory use of iodized salt in Turkey, since 1999 has sufficient effects on pregnant women and their newborns' urinary iodine concentrations (UIC), maternal and newborns' thyroid function tests and breast milk iodine concentrations (BMIC).

Methods

This cross-sectional analytical-type study was conducted in an obstetrics and gynecology hospital in Konya, Turkey. One hundred and seven pregnant women and their 107 full-term newborns were included into the study. Levels of pregnant women and their newborns' UIC, thyroid-stimulated hormone (TSH), free triiodothyronine (fT3), free thyroxine (fT4), thyroglobulin (Tg), and BMIC were studied.

Results

Of 107 women with term pregnancy, mean TSH value and hypothyroidism frequency were found as 2.34 ± 1.33 mIU/L and 18.7%, respectively. Cord blood TSH level was found higher (≥ 10 mIU/L) in five newborns. Accordingly, the incidence of transient congenital hypothyroidism was 4.7% (5/107). Tg levels were observed to be higher in 50.5% of newborns and 22.4% of pregnant women. Frequency of iodized salt use in pregnancies was detected as 96.3% in general population, 97.5% in urban, and 92.9% in rural areas. Of pregnancies and newborns, 57.9 and 53.3% were found to have deficient urinary iodine, respectively, and BMIC deficiency was detected as 52.0%. There was a significant positive correlation between pregnant women's UIC, and newborns' UIC and BMIC.

Conclusions

Despite the effective struggle with iodine deficiency and salt iodination control program in Konya, we concluded that iodine deficiency still persists as a significant problem in pregnancies.

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Advances in Surgery for Chronic Rhinosinusitis

Abstract

Purpose of Review

Our understanding of chronic rhinosinusitis (CRS) is always evolving with new concepts and technological advancements in order to achieve the best surgical outcomes.

Recent Findings

The extent of surgery has long been debated and current research has provided surgeons indications to create larger openings for the maxillary and frontal sinus. Historical concerns for larger openings impacting outcomes have been resolved with better understanding of post-operative management. Recent literature advocates the mega-antrostomy in the setting of cystic fibrosis or recalcitrant CRS despite previous standard FESS openings. Draf 3 is known to be used in cases of frontal sinus tumors, CSF leaks, mucoceles, and recalcitrant CRS to standard surgery. Technological advances have had impacted rhinology positively, with a number of in-office procedures becoming more common as well as new intra-operative tools to facilitate surgery. Moreover, post-operatively, the advent of a drug-eluting stent has fastened the healing process following FESS leading to better outcomes.

Summary

Advances in sinus surgery are always evolving. What may have been considered a poor approach in the past are being re-visited with better understanding of CRS and technological advancements.

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