Performance of Residents and Anesthesiologists in a Simulation-based Skill Assessment

Background: Anesthesiologists and anesthesia residents are expected to acquire and maintain skills to manage a wide range of acute intraoperative anesthetic events. The purpose of this study was to determine whether an inventory of simulated intraoperative scenarios provided a reliable and valid measure of anesthesia residents' and anesthesiologists' skill.

Methods: Twelve simulated acute intraoperative scenarios were designed to assess the performance of 64 residents and 35 anesthesiologists. The participants were divided into four groups based on their training and experience. There were 31 new CA-1, 12 advanced CA-1, and 22 CA-2/CA-3 residents as well as a group of 35 experienced anesthesiologists who participated in the assessment. Each participant managed a set of simulated events. The advanced CA-1 residents, CA-2/CA-3 residents, and 35 anesthesiologists managed 8 of 12 intraoperative simulation exercises. The 31 CA-1 residents each managed 3 intraoperative scenarios.

Results: The new CA-1 residents received lower scores on the simulated intraoperative events than the other groups of participants. The advanced CA-1 residents, CA-2/CA-3 residents, and anesthesiologists performed similarly on the overall assessment. There was a wide range of scores obtained by individuals in each group. A number of the exercises were difficult for the majority of participants to recognize and treat, but most events effectively discriminated among participants who achieved higher and lower overall scores.     

Pharmacy customers’ views and experiences of using pharmacies which provide needle exchange services in Aberdeen and Glasgow, Scotland

Community pharmacists contribution to the management of drug problems is considerable. As the use of illicit drugs has increased, pharmacists have come under increasing pressure to offer services to problem drug users. However, there is concern among some pharmacists that offering such services may deter other customers. There is particular concern among some pharmacists about needle exchange services. Only 9.5% of Scottish pharmacies offer needle exchange services compared to 69% which are dispensing methadone (57% of which supervise methadone consumption). Qualitative interviews were used in a purposive sample of 10 pharmacies in Scotland. Eight customers were interviewed in each pharmacy to ascertain pharmacy customers’ views on these services. The majority of customers were supportive of these services. Customers were often unaware that the pharmacy they were interviewed in was offering services for people with drug problems. Pharmacy customers were more knowledgeable about, and more supportive, of needle exchange services than they were of methadone. This was because they believed needle exchange services helped to reduce the amount of discarded needles in public places. Pharmacy customers also recognised that needle exchange helped reduce the spread of disease. These findings should be used to encourage more pharmacists to offer needle exchange services.     

Management of filamentary keratitis associated with aqueous-deficient dry eye.

PURPOSE: To review the incidence, underlying pathophysiology, and clinical features of filamentary keratitis and to identify evidence-based best-practice strategies for managing filamentary keratitis. METHODS: A comprehensive review of published literature was undertaken. Recommendations for best-practice management strategies were based on the available evidence. Three cases are presented to illustrate the clinical findings and management of patients with chronic filamentary keratitis. RESULTS: Although the evidence base is limited by the absence of well-designed studies, current evidence indicates the following: (1) Aqueous-deficient dry eye (keratoconjunctivitis sicca) is the most common ocular condition associated with filamentary keratitis. (2) Current best-practice management of filamentary keratitis involves treating the underlying dry eye and specific treatments for the corneal filaments. Proposed treatments include nonpreserved lubricants, topical steroidal and nonsteroidal anti-inflammatory agents, and punctal plugs for aqueous-deficient dry eye as well as mechanical removal of filaments, hypertonic saline, mucolytic agents, and bandage contact lenses for the filaments. (3) Filamentary keratitis can be induced or exacerbated by contact lens wear and ocular surgical procedures such as cataract surgery and corneal graft surgery. Pre- and postoperative ocular surface management strategies should be considered in the surgical planning of patients with, or who are susceptible to, filamentary keratitis. Filamentary keratitis can also be induced and/or exacerbated by chronic use of ocular and/or systemic medications, and alternate medications or additional measures to manage the tear film and ocular surface may be required in these cases. CONCLUSIONS: Filamentary keratitis can be a chronic, recurrent, and debilitating condition. With a systemic approach to diagnosis and management, the condition can be effectively controlled and the incidence and severity of recurrences minimized.     

Short-term complications and resource utilization in matched subjects after on-pump or off-pump primary isolated coronary artery bypass.

BACKGROUND: Studies suggest that patients who undergo off-pump coronary artery bypass grafting (OPCABG) have fewer short-term complications and use fewer inpatient resources than do patients who undergo standard coronary artery bypass grafting (CABG) with extracorporeal circulation. However, dissimilarity between groups in risk factors for complications has hindered interpretation of results. OBJECTIVES: To compare the prevalence of selected complications (atrial fibrillation, stroke, reoperation, and bleeding) and inpatient resource utilization (length of stay, discharge disposition, total charges) between subjects undergoing primary isolated CABG or OPCABG who were matched with respect to key risk factors. METHODS: Retrospective, causal-comparative survey conducted in 1 center for 18 months. Patients who underwent primary isolated CABG or OPCABG were matched for sex, age (within 2 years), left ventricular ejection fraction (within 0.05), and graft-patient ratio (exact match) and compared for prevalence of new-onset atrial fibrillation, stroke, reoperation within 24 hours, and bleeding. Statistical analysis included Wilcoxon and t tests for paired comparisons. RESULTS: The sample (107 matched pairs) was 63% male, with a mean age of 66 (SD 9.5) years, a mean left ventricular ejection fraction of 0.51 (SD 0.13), and a mean graft-patient ratio of 3.41 (SD 0.74). The 2 groups did not differ significantly in New York Heart Association class (P = .43), Acute Physiology and Chronic Health Evaluation III score (P = .22), postoperative beta-blocker use (P = .73), or comorbid conditions. None of the complications examined differed significantly between pairs. CONCLUSION: Patients with comparable risk profiles have similar prevalences of selected complications after CABG and OPCABG.     

Stereophotogrammetric measurement of the nasolabial fold in repose: a study of age and posture-related changes

The nasolabial fold is a significant facial landmark. Its size, shape, and symmetry are important in facial reanimation surgery, while effacement is an important goal in rejuvenation surgery. However, quantitative data for the nasolabial fold volume (NLFV) and depth is still unavailable. We present a new method of measurement using 3D color speckle stereophotogrammetry and its application in the assessment of NLFV. The VECTRA-3D system was validated to determine its minimum resolution and accuracy. Normal volunteers aged 13–84 years (n = 87) were imaged in repose. Mother–daughter pairs (n = 15, aged 13–61) were imaged in the upright and supine positions. All data were processed using custom software and analyzed by linear regression and nonparametric tests as appropriate. NLFV varied from 0.0026 to 0.2306 ml. There was significant correlation between NLFV and age (r = 0.7269, p < 0.0001). Men had significantly higher NLFV than women across all ages. There was no significant difference between the left and right NLFV. NLFV altered significantly from upright to supine in all subjects (p = 0.0012). However, the mothers increased their NLFV by 32% from supine to upright postures, which was a greater change than observed in their daughters. We have demonstrated a rapid, objective, and non-invasive assessment tool for facial reanimation and rejuvenation surgery. We have quantified the effects of age and posture on NLFV, and the efficacy and longevity of rejuvenation procedures are currently under investigation.