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.     

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.     

Peripheral quantitative computed tomography in children and adolescents: the 2007 ISCD Pediatric Official Positions

Peripheral quantitative computed tomography (pQCT) has mainly been used as a research tool in children. To evaluate the clinical utility of pQCT and formulate recommendations for its use in children, the International Society of Clinical Densitometry (ISCD) convened a task force to review the literature and propose areas of consensus and future research. The types of pQCT technology available, the clinical application of pQCT for bone health assessment in children, the important elements to be included in a pQCT report, and quality control monitoring techniques were evaluated. The review revealed a lack of standardization of pQCT techniques, and a paucity of data regarding differences between pQCT manufacturers, models and software versions and their impact in pediatric assessment. Measurement sites varied across studies. Adequate reference data, a critical element for interpretation of pQCT results, were entirely lacking, although some comparative data on healthy children were available. The elements of the pQCT clinical report and quality control procedures are similar to those recommended for dual-energy X-ray absorptiometry. Future research is needed to establish evidence-based criteria for the selection of the measurement site, scan acquisition and analysis parameters, and outcome measures. Reference data that sufficiently characterize the normal range of variability in the population also need to be established.