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ASA Monitor Today

Monitor editorial board members share “micro” news stories, research studies, and interesting items with the anesthesiology community.

 

2024 – May 23 | May 8 | May 2 | May 1 | April 25 | April 18 | April 11 | April 4 | March 19 | March 5 | February 27 | February 9 | February 7 |  February 2 | January 26 | January 23 | January 19  | January 18  | January 17  | January 16  | January 12  |  January 11

2023 – December  |  November  |  October  |  September  |  August  |  July  |  June  |  May  |  April  |  March  |  February  |  January


Thoughts on standardizing POCUS training in pediatrics

May 24 

Point-of-care ultrasound (POCUS) is becoming increasingly important in pediatric anesthesia, but the extent of its integration into fellowship training programs in the United States varies. A recent survey assessed the current state of POCUS training within these programs. The findings revealed that while many programs acknowledge the significance of POCUS, there is considerable variability in the training provided. Some programs offer formalized training and dedicated curricula, while others rely on informal or ad hoc instruction. The survey highlights the need for standardized POCUS training to ensure consistent competency among pediatric anesthesia fellows.

 

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bigger not always better

May 8 

 

As anesthesiologists, we experience consolidation in health care in two direct ways – consolidation of anesthesiology groups and consolidation of hospital systems. However, these are only the tip of the iceberg. Vertical integration is resulting in major shifts in how health care is provided and paid for. Many anesthesiologists became more aware of vertical integration with the cyberattack on Change Healthcare (owned by United Health Care).

For further reading:

Ten Things to Know About Consolidation in Health Care Provider Markets (KFF)

Change Healthcare hack shows need for more competition (AMA)
 

 

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A call to reduce physicians’ administrative burden

May 2

The least productive and effective “learning modules” in my professional practice are annual online mandatory compliance training courses. Unlike many hospital employees, as a physician, I am not given work time to complete these courses – and I have to complete them on personal time. A recent report looking at physicians, online compliance training, and burnout highlights that I am not alone! Since I work at a health system that is owned by my university, I only have to complete one set of online training modules. This article highlights that the burdens of these courses are magnified when the physician must complete the same material multiple times for multiple entities each year!
 

 

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Further misadventures in scholarship

May 1

According to the leaderboard at Retraction Watch, three anesthesiologists lead the world in papers retracted. Joachim Boldt, Yoshitaka Fujii, and Hironobu Ueshima account for 194, 172, and 124 retractions, respectively. Having been involved with investigations for all three, I’ve seen first-hand how fraud is often uncovered when fraudsters publish results so implausible that other scientists or, occasionally, journal editors, start asking uncomfortable questions. Four years ago, Nature published a paper about room temperature superconductivity, which would be an enormously consequential discovery. Six additional papers followed, including papers in Nature and Physical Review (which are now retracted). As reported in Nature News, an investigation at the University of Rochester into the work of Ranga Dias identified extensive scientific misconduct. The title says it all: “superconductivity physicist faked blockbuster results.”

A similarly detailed misconduct investigation was reported in Science last month. In March 2020, the French microbiologist Didier Raoult published a “bombshell paper” (as described by Science) claiming that hydroxychloroquine and azithromycin, prescribed together, were effective against COVID-19. Suspicions arose almost immediately, and the massive RECOVERY study eventually confirmed that hydroxychloroquine has no activity against SARS-CoV-2. Because people wanted this to be true, hydroxychloroquine was granted temporary approval in France and by the FDA for treatment of COVID-19. The investigations triggered by the hydroxychloroquine study have led to multiple retractions. Shockingly, Raoult’s institution, University Hospital Institute Mediterranean Infection, not only failed to take any action despite strong evidence of scientific and ethical misconduct, but also initiated lawsuits against the scientific sleuths who uncovered the misconduct. The hospital is now the subject of a criminal investigation.

For further reading:

Superconductivity: The search and the scandal (Chemistry Word)
101 studies flagged as bogus COVID cure pusher sees career unravel (Ars Technica)

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MAO inhibitors and perioperative care – a useful update

April 25

This update provides valuable insights for clinicians managing patients on classic MAO inhibitors. The article emphasizes the safety of continuing MAOI therapy for depression during the perioperative period, as discontinuation preprocedure poses risks of relapse or suicide. To prevent severe serotonin toxicity in MAOI users, clinicians should avoid opioids with SRI activity and select those that do not possess such properties. Similarly, caution is advised in administering vasopressors that release norepinephrine or dopamine to prevent exaggerated hypertension. Furthermore, the article underscores the risk of severe serotonin toxicity if methylene blue is administered to patients concurrently taking an SSRI or SNRI for depression. Alternative approaches to methylene blue are discussed as safer options. Clinicians are encouraged to refer to the publication for comprehensive details on these considerations.

For further reading:

Expert Opinion on Anesthetic Considerations For Patients Receiving a Classic Monoamine Oxidase Inhibitor

 

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surprise!

April 18

Have you heard of unexpected pregnancies among women taking the weight loss drug Ozempic, a GLP-1 agonist? Despite its intended purpose of aiding weight loss, some women with previous fertility struggles or those using birth control have reported unplanned pregnancies while on Ozempic. This trend has sparked online discussions, with affected individuals referring to the babies conceived during Ozempic use as "Ozempic babies." While weight loss is generally associated with improved fertility, the connection between Ozempic and unexpected pregnancies raises concerns about its interaction with birth control and its potential impact on fertility. While further research is needed to understand these effects fully, the first article below emphasizes the broader health benefits of weight loss beyond fertility, including improved mental health, joint health, and reduced risk of chronic diseases like cancer and diabetes.

For further reading:

 

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A practical application for molecular biology

April 17

Propionic acidemia is a rare inborn error of metabolism that results in the accumulation of propionyl-CoA, a metabolite of the amino acids valine, methionine, isoleucine, and threonine. Untreated, it is rapidly fatal. It is treated by diets with very low levels of those amino acids. A recent paper in Nature describes the use of intravenous mRNA coding for the missing propionyl-coenzyme A carboxylase to treat these patients. The nanoparticles are taken up by the liver, where the missing metabolic protein is then synthesized from the mRNA template for several weeks. As described in Nature News, “Eight of the 16 participants had experienced life-threatening episodes connected to their impaired metabolism in the year before starting treatment. For those eight, the likelihood of experiencing another such event decreased by an average of 70%-80% while taking the therapy.”

For further reading: 

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Another huge possibility from GLP-1 agonists

April 11

The blockbuster GLP-1 agonists, heralded for benefits in diabetes and unprecedented efficacy in weight loss, may have another jaw-dropping and unexpected effect: slowing the development of Parkinson’s disease. As described last week in the New England Journal of Medicine, lixisenatide slowed the progression of Parkinson’s disease over 12 months. Not surprisingly, patients in the treatment group also reported more gastrointestinal side effects. As the authors note, the reduced progression of disease needs to be confirmed in phase 3 clinical trials before this can be considered a useful therapy for patients with Parkinson’s disease. 

 

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Show me the money?

April 4

We are a capitalistic society and money is (generally speaking) a huge motivator for us, as American citizens. This concept is especially relevant to physicians right now, as increased demands for care and shortages of professionals have created imbalances in our labor market. As a result, in many places salaries have increased dramatically. Further, traditional models of employment and medical practice are shifting, with individuals now willing to indulge in less stable, more itinerant lifestyles in order to reap maximal financial rewards (e.g., high hourly rates and/or call pay from locum tenens assignments). This article summarizes well the economic principles behind physician compensation, targeted to an audience that has received exhaustive and effective clinical training, but little instruction in business and finance as they relate to health care.
 

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better than counting sheep

March 19

This recent study from Science Advances focused on the development and validation of a metabolomic biomarker to detect sleep deprivation in healthy, young individuals. As we are all aware, sleep deprivation is known to increase the risk of accidents and injuries both on roads and in workplaces. To address this, researchers from Australia, the U.S., and the U.K. conducted three experiments involving extended wake protocols and overnight sleep intervals. They analyzed plasma samples using liquid chromatography–mass spectrometry and utilized a knowledge-based machine learning approach to identify five key variables for predictive modeling. 

The classification models accurately predicted sleep deprivation (24 to 38 hours awake) versus well-rested states (0 to 16 hours) with high accuracy rates (94.7% and 79.3%) and AUC values (99.2% and 89.1%). Regression models also showed promising results for within-participant (R2 = 86.1%) and between-participant (R2 = 47.8%) predictions. The identified metabolites provide insights for future deployment and replication. 

Overall, this approach offers potential applications in reducing accidents through assessments of "fitness for duty" or "post-accident analysis." These results could spark interesting research related to the perioperative care of our patients. 
 
 

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best practices for littlest patients

March 5

The neonatal resuscitation guidelines were recently updated and have been endorsed by the American Heart Association (AHA) and the American Academy of Pediatrics (AAP). This summary provides the updated and important recommendations on umbilical cord management and device selection for administering positive-pressure ventilation (PPV). These guidelines, based on systematic reviews conducted by the International Liaison Committee on Resuscitation (ILCOR) Neonatal Life Support Task Force, were done to translate evidence from the medical literature into practical recommendations for neonatal resuscitation.

Revised guidelines for neonatal resuscitation pertaining to umbilical cord clamping and milking are outlined below:

  • For term and late preterm newborn infants ≥34 weeks’ gestation who do not require immediate resuscitation, delaying cord clamping (≥30 seconds) is deemed advantageous over early cord clamping (<30 seconds).
  • Intact cord milking is not presently recognized as beneficial compared to delayed cord clamping for term and late preterm newborn infants ≥34 weeks’ gestation who do not require immediate resuscitation.
  • In cases of non-vigorous term and late preterm newborn infants at 35-42 weeks’ gestation, opting for intact cord milking over early cord clamping may be considered reasonable.
  • Delaying cord clamping is advised over early cord clamping for preterm newborn infants <34 weeks’ gestation who do not require immediate resuscitation.
  • In situations where delayed cord clamping cannot be carried out for preterm newborn infants between 28-34 weeks’ gestation who do not require immediate resuscitation, intact cord milking may be considered reasonable.
  • Intact cord milking is discouraged for preterm newborn infants <28 weeks’ gestation.

Updated recommendations concerning PPV are as follows:

  • Ensuring effective PPV is given priority for newborn infants requiring support after birth.
  • Preferential use of a T-piece resuscitator for delivering PPV over a self-inflating bag is advised.
  • Given that both T-piece resuscitators and flow-inflating bags rely on a compressed gas source, having a self-inflating bag on hand is recommended in case of compressed gas failure when using either device.
  • Considering the use of a supraglottic airway as the primary interface for PPV administration instead of a face mask for newborn infants delivered at ≥34 weeks’ gestation may be warranted.

These guidelines underwent extensive evaluation by the Neonatal Life Support writing group, consisting of experts, including AAP members. The recommendations are intended for North American health care practitioners seeking up-to-date guidance on neonatal resuscitation and provide insights into current best practices and areas for further research.

 

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what to make of niacin?

February 27

 In a recent study with surprising results, reported recently and published in Nature Medicine, researchers found that niacin metabolism, particularly involving two terminal metabolites, is associated with a significant increase in the risk of major adverse cardiovascular events independent of traditional risk factors. These findings shed light on the potential role of niacin in the pathogenesis of heart disease through inflammatory pathways. The researchers suggest reevaluating the mandate of niacin fortification in food staples due to concerns about excessive intake, especially in the context of modern dietary habits. Despite past use of niacin supplements for cholesterol reduction, current evidence questions its health benefits, prompting a reexamination of its role in cardiovascular disease prevention. The authors conclude that further research is needed to validate these findings across diverse populations and community-based cohorts.

For further details, refer to:

MedPage Today: Could Niacin Actually Induce Heart Disease?
Nature Medicine: A terminal metabolite of niacin promotes vascular inflammation and contributes to cardiovascular disease risk

 

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More bad news for Philips

February 9

More than 500 deaths have been reported to the FDA related to the Philips Respironics devices used for bilevel positive airway pressure and CPAP for the care of patients with sleep disorders. The exact cause cannot be determined from these medical device reports (MDRs), but the company has recalled over 15 million devices, while the details provided in the report are being investigated. The FDA received more than 100,000 MDRs. Initial data suggested that there is a breakdown or suspected breakdown of the polyester-based polyurethane (PE-PUR) foam used in the Philips Respironics ventilators.

 

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Closing the book on a controversial topic

February 7

The last essay in response to the violence gripping the Middle East has been published as a comment to my December editorial “Terrorism Is Terrorism Is Terrorism.” The authors decry the violence and suffering from the current war between Israel and Hamas. However, they note the cycle of violence will continue as long as Hamas controls Gaza. I appreciate the many members of ASA who have written to share their strongly held views about this conflict. I also appreciate the many authors who have written commentaries, adding our physician voices in condemning violence and advocating for compassion, peace, and security. Since this is the ASA Monitor, and not the Journal of Middle East Conflict Resolution, this will be the last essay we will publish on the conflict.
 

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Human growth hormone and neurodegenerative disease

February 2

 A report in Nature offers additional evidence for a causal link between Alzheimer’s disease and human growth hormone injections. Multiple human degenerative diseases are caused by accumulations of misfolded proteins, including Alzheimer’s disease, Parkinson’s disease, Creutzfeldt-Jakob disease, and kuru. 

As described in Nature News, for decades human growth hormone was derived from the pituitary glands of cadavers. Recent analysis of cadaver-derived human growth hormone identified amyloid beta proteins. A remarkably high number of adults who received cadaver-derived human growth hormone have developed early-onset dementia or Creutzfeldt-Jakob disease.
 

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Vaccine hesitancy in a vulnerable population

January 26

Writing for The Atlantic, Daniel Engber looked at COVID vaccination rates for seniors (adults older than 65 years of age). Roughly 70% of seniors have received their influenza vaccination, while only 38% have received a booster for the current wave of COVID-19. As noted by the authors at the CDC, seniors are seven times more likely to die from COVID-19 than from influenza. Writing in JAMA, Robert Califf (FDA Commissioner) and Peter Marks (Director of the FDA Center for Biologics and Research) attribute low vaccination rates to widespread misinformation. The Atlantic suggests that the explanation is more complex, and includes the complexities of vaccination roll-out, availability of vaccines, and failure of providers to alter their yearly recommendations. They also note that the yearly flu shot is an established routine for many seniors, but COVID-19 is sufficiently new that seniors haven’t adjusted to the idea that they also should get a yearly COVID-19 booster. 
 

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Putting the brakes on AI hype

January 23

Two remarkable papers about AI in medicine were published earlier this month.

Writing in Science, an interdisciplinary team developed clinical prediction models for schizophrenia using clinical data from five international randomized controlled trials. As expected, the models predicted the outcomes very well when tested against the data used to fit the model. However, the models performed no better than random chance in predicting outcomes from patients not included in the model fit. Pooling data from all five trials did not improve accuracy. The authors' skepticism about the utility of clinical prediction models is reflected in the study title: “Illusory generalizability of clinical prediction models.”

These results demonstrate an important difference between human cognition and AI algorithms. AI algorithms excel at “big picture” pattern recognition. Humans are good at reaching deep into memory for the rare pattern. It is not uncommon to describe a difficult case to a colleague, who responds, “I had a patient just like that about 10 years ago….”

The paper offers a useful reality check as machine learning algorithms developed from large, pooled data sets are introduced as decision-support tools. As quoted in Nature News, the lead author cautions, “We do have to be really disciplined about how we build these algorithms and how we test them. We can’t just do it once and think it’s real.”

Researchers from Cornell posted a paper on arXiv documenting the accuracy of AMIE, the Articulate Medical Intelligence Explorer. The system was designed to interview patients and capture a full medical history. Using 149 case scenarios, the authors compared the AMIE with primary care physicians. The results were evaluated by specialist physicians and patient actors. As reported in Nature News:

“The AI system matched or surpassed the physicians’ diagnostic accuracy in all six medical specialties considered. The bot outperformed physicians in 24 of 26 criteria for conversation quality, including politeness, explaining the condition and treatment, coming across as honest, and expressing care and commitment.”

 The excellent prospective performance of AMIE contrasts with the relatively poor performance of the clinical prediction model. The take-home message is that such models may provide decision support but cannot yet substitute for physician clinical judgment.

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PROS AND CONS OF THESE NEW MEDICATIONS

January 19

There has been an increasing use of GLP-1 agonists for patients with type 2 diabetes mellitus, and now for weight management. One concern with the use of these agents is the risk of pancreatic cancer. In a recent study from the Gertner Institute for Epidemiology and Health Policy Research at Sheba Medical Center in Israel, the authors report no difference in the risk of pancreatic cancer when compared to those taking insulin. Participants enrolled in this study were followed for five to seven years. However, until further studies are done, this may not apply to those on these agonists for weight management.

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AN ALL-TOO-FAMILIAR TOPIC

January 18

The Centers for Disease Control and Prevention (CDC) tracks SARS-CoV-2 wastewater data throughout the U.S. Currently, the wastewater levels are very high, reflecting widespread COVID-19 infections throughout the country. The current surge is somewhat higher than in the January 2023 surge, but much less than the Omicron-fueled surge of January 2022. 

Because of immunity from infection, vaccination, or (commonly) both, deaths from COVID-19 remain well below the deaths observed in prior surges.



However, over the past few months, deaths from COVID-19 have averaged 1,000-1,500/week. This is an order of magnitude higher than the estimated number of deaths from influenza this fall. The surging death rates, albeit far less than during the peak of the pandemic, speak to the importance of keeping current for vaccination against both viruses. 

 

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An injury that does not appear on surface surveys

January 17

Elizabeth Svoboda describes moral injury as the psychological trauma inflicted when we violate our core principles. Her article in Scientific American describes moral injury to physicians during the first years of the COVID-19 pandemic and moral injury to soldiers who commit immoral acts during war. Moral injury is just as psychologically damaging as PTSD. Moral injury affects millions but remains largely unrecognized by the medical profession. I fear we face increasing risk of moral injury when our professional commitment to patient care is compromised by the corporatization of medicine and surgical demands for clinical shortcuts.

 

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Unintended consequences of BCBS’ termination of commonly used anesthesia services

January 15

On January 1, 2024, Blue Cross Blue Shield of Massachusetts ceased coverage of MAC by anesthesia professionals for patients undergoing colonoscopies and endoscopic, bronchoscopic, or interventional pain procedures. Exceptions may be made for coverage for patients with certain chronic conditions or documented anxiety regarding the medical procedure. Nonetheless, this change is expected to cause significant changes to patient care in Massachusetts, with patients required to undergo procedures with either no anesthesia or sedation provided by the proceduralist.  

There will be significant consequences of this decision affecting such outcomes as screening rates for colon cancer by colonoscopy, adverse events during the covered procedures, and overall perioperative efficiency. Though it is likely a cost-saving measure for the insurance provider, unintended consequences are likely to undo any perceived benefits and will significantly compromise patient safety.

For more reading:

WBUR Radio Boston: Blue Cross colonoscopy policy prompts outrage among Mass. doctors
Becker’s GI and Endoscopy: BCBS Massachusetts anesthesia restriction for GI procedures now in effect: what it means for physicians

 

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A designed risk

January 12

A spilled pill bottle of hydroxychloroquineIn March 2020, I self-prescribed hydroxychloroquine “just in case.” In vitro data suggested it might be helpful. The only clinical evidence was a dismal study from France in which more patients receiving hydroxychloroquine died (these patients were omitted from the results!) than patients who received placebo. Given a case fatality rate >6% in the early days of COVID-19, the risk of hydroxychloroquine seemed a lot less than the risk of COVID-19.

A recent meta-analysis in Biomedicine & Pharmacotherapy suggests that thousands of patients may have died from “compassionate use” of hydroxychloroquine. Prospective studies have since shown that hydroxychloroquine doesn’t work. Although we now know that the benefit-to-risk ratio for hydroxychloroquine is roughly zero, my March 2020 decision was not necessarily the wrong choice in the face of uncertainty.

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The tricky business of health care

January 11

Private equity does not lead to health equity. Running health care as a business has always been tricky. I’m a fan of capitalism in many ways, but it requires thought, consideration, and nuance when it comes to social safety nets such as health care and education. Without regulation, monetary motivators rarely align with serving patients' needs.

For further reading:

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December 2023

Time’s up for latest Apple Watch

December 21

Apple logo on building sign

Apple will stop selling two versions of the Apple Watch following a judgement against the company in a suit brought by Masimo. According to the U.S. International Trade Commission (ITC), Apple incorporated proprietary Masimo technology when it added pulse oximetry to its popular watches in 2020. Apple is contesting a similar previous finding by the ITC.

For further reading:
Apple stops selling latest Apple Watch after losing patent case

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looking abroad for manpower assistance

December 8

Close up on healthcare workers standing in circle holding puzzle pieces in front of themTwenty-five percent of physicians in this country are International Medical Graduates. With a growing shortage of physicians in the United States and the slow expansion of training programs, we need innovative and timely solutions. Our global colleagues are waiting to solve these problems for us if we would just let them in the country.

For further reading:

Opening the Door Wider to International Medical Graduates — The Significance of a New Tennessee Law (This NEJM article may not be accessible to those without a subscription, but there is an audio recording available).

Opening the Door Wider to International Medical Graduates – Harvard Medical School Department of Population Medicine (This press release offers a summary of the NEJM article and further perspective on the upcoming Tennessee law).

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a sad and troubling trend

December 5

After 20 years of declining infant mortality rate, the infant mortality rate increased in 2022 as compared to 2021. The U.S. infant mortality rate rose from 5.44 to 5.60 infant deaths per 1,000 live births from 2021 to 2022. To put this rate in perspective, the infant mortality rate in the European Union is 3.1, in Canada is 4.4, and in Japan is 1.7 (all for 2021, worldbank.org). Further, as this new report shows, disparities in health in the U.S. are also reflected in the infant mortality rate: for Black infants, it is 10.9; for Hispanic infants, 4.9; and for White infants, 4.5.

As anesthesiologists, we may not feel that this statistic is important to us, but I respectfully disagree. As physicians, we should be leading efforts to improve population health and our public health system, even when it does not directly affect our daily work life. In recent years, maternal morbidity and mortality rates have been identified as too high in the U.S. We have been involved with improving maternal care at the time of delivery and support improved access to care throughout the pregnancy and postpartum period. Similarly, we need to advocate for improving care for infants at the time of birth, but also again in the prenatal period.

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November 2023

Paxlovid pro and con

November 30

Close up hand holding a tiny pillA recent article in Archives of Internal Medicine, highlighted in the November 15 ASA Monitor Today, reported rebound Covid-19 infections in about 20% of a small patient sample. It is important to place this into perspective:

  1. Rebound is observed in patients with Covid-19 who do not receive Paxlovid. The incidence of rebound is higher with Paxlovid than without Paxlovid, but Paxlovid unequivocally provides symptomatic improvement while decreasing viral loads.
  2. Paxlovid reduces the incidence of long Covid.
  3. Paxlovid is the only widely available and highly efficacious outpatient treatment for SARS-CoV-2. The efficacy of molnupiravir is modest, and the mechanism of action suggests potential risks. Oral remdesivir is not widely available, and the mechanism of action (similar to molnupiravir) suggests potential risks.
  4. The dosing of Paxlovid is suboptimal. First, the five-day course was chosen in 2020. We were learning about Covid-19 time-course, and it seemed that five days should be long enough. That has proven incorrect. Longer duration of dosing would decrease the incidence of rebound. Second, it isn’t clear that the combination of nirmatrelvir and ritonavir comprising Paxlovid was a good idea. Nirmatrelvir, the antiviral, is potent and effective. Unfortunately, it only lasts about three hours in the plasma. Ritonavir was added to inhibit CYP 3A4, the hepatic enzyme that metabolizes nearly half of all pharmaceuticals. Adding ritonavir permitted Paxlovid to be given twice daily, rather than four times daily. However, ritonavir introduced a host of drug-drug interactions, as would be expected for a drug that inhibits metabolism of nearly half of all drugs. Many patients were denied Paxlovid because physicians were concerned about these drug interactions. Likely some patients denied Paxlovid died from Covid-19. A more logical choice would have been to take nirmatrelvir as a sole drug four times a day.

Patients receiving Paxlovid should be alerted to the possibility of viral rebound. However, Paxlovid effectively reduces symptoms and viral shedding, reduces the risk of long Covid, and hugely decreases the risk of serious illness and death. It should not be withheld in patients with Covid.

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Former CDC director addresses Covid myths

November 28

Close up on healthcare worker giving patient vaccine shot in armIn a recent essay, Tom Frieden, former head of the CDC, addresses three Covid-19 myths:

1. Did Covid-19 really kill 1 million Americans? Yes.

2. Did Covid-19 vaccines save lives? Yes (at least 500,000).

3. Do masks work to slow the spread of Covid-19? Yes.

Dr. Frieden concludes: “We do know with a high degree of certainty that more than 1 million Americans died from Covid, that Covid vaccines save lives, and that masks reduce the risk of infection.”

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Upping the ante: litigating over medical title usage

November 16

Out of focus image of a healthcare worker guiding an empty gurney down a hospital hallwayNurse practitioners who hold doctoral degrees are currently engaged in a legal battle against the state of California, asserting their entitlement to utilize the title “doctor” before their names. They argue that the exclusive use of this title by physicians is unconstitutional. In contrast, physicians contend that this practice could potentially lead to patient confusion, as many patients expect that only medical doctors should bear the “doctor” title in order to ensure clarity and avoid any misunderstandings.

For further reading: Nurse practitioners sue for right to use ‘doctor’ label

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Taking on an epidemic from a new angle

November 15fentanyl testing machine

Fentanyl is now responsible for most opioid deaths. Last year, the FDA approved a point-of-care urine test for fentanyl. As recently highlighted in the New England Journal of Medicine, the point-of-care test approved by the FDA requires a specialized instrument to read the result, limiting use to CLIA-certified laboratories. Urine dipsticks that can be read by visual inspection exist, awaiting FDA approval for use in the U.S.

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The collective labor movement in medicine

November 10Three healtcare workers in full PPE standing next to a car outside

An article in JAMA examined the recent trends toward unionization among physicians-in-training. The article identified 18 private medical hospitals that held votes on unionization from 2011 through 2023. House staff in 16 of these teaching institutions, including Stanford, voted to unionize. According to the authors, no studies have documented the reasons that physicians-in-training seek unionization.

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This just in, from Patrick in Bikini Bottom

November 8

If you find the idea of a disembodied head walking across the ocean floor disturbing, then you should probably not spend too much time hanging out with sea stars (a.k.a., “starfish”). According to a paper recently published in Nature, sea stars are “mostly head-like animals.” The authors looked at gene expression in sea stars and found that each of the five “arms” comprises ectoderm-derived neural tissue, with an endoderm-derived stomach in the center. Genes associated with truncal development are not found in the adult animal, confirming that the sea star is all head.

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Confronting the health complications of a warming world

November 1

Graphics showing world annual hot hours, population, and global warming targetA recent article in Proceedings of the National Academy of Sciences looked at portions of the planet where high heat and humidity will preclude human survival without air conditioning. The “wet-bulb” temperature is the temperature of a thermometer covered by a damp cloth. The evaporation of water cools the thermometer just as the evaporation of sweat cools our bodies. A wet-bulb temperature of 35º C (95º F) has been considered the limit for human survivability. Humans cannot survive more than a few hours at a wet-bulb temperature of 35º C (95º F) because we cannot dissipate the heat of metabolism. The article cites considerable evidence that 35º C is an overestimate, and 31º C (88º F) is probably a better estimate of the limits of survivability. The researchers identify multiple cities in Asia, Africa, and the Middle East that will likely see lethal combinations of heat and humidity with current rates of global warming.

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October 2023

Unintended economic consequences

October 26

Medical form, pen, tablet, and stethoscope sitting together on deskThe federal law commonly known as the “No Surprises Act” (NSA) was created to eliminate balanced billing and protect patients. As seen in multiple lawsuits against the federal government’s implementation rules, without protection for clinicians, these laws can place clinicians in a financial and negotiating peril to the advantage of health care payers. In November's Anesthesiology, Dixit et al. examined the impact of California’s own law against balanced billing. In an accompanying editorial, Tung et al. provided a perspective of how the California experience may not show the whole picture and does not address the federal NSA. However, the study does provide a methodology for future evaluation of these laws on the impact on anesthesiology groups. As the title of the editorial points out, the balance billing laws can really handcuff Smith’s “invisible hand” and stifle free markets if protections for clinicians are not included.

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Leishmaniasis, encephalitis, malaria – Oh my!

October 25

Mosquito close upThis year, I have read more articles about rare infectious diseases, locally acquired, but thought to affect only those in other countries.

Leishmaniasis from infected sand flies and Eastern Equine Encephalitis (EEE) and malaria from infected mosquitos have all been in the news since this summer. Are these reports due to increased travel, climate change, or media frenzy?

Although deadly and difficult to treat, it seems with EEE the cases are no higher than previous annual trends.

Leishmaniasis, also hard to treat, is listed by the WHO as endemic to the U.S.

Malaria is the most treatable of the three, with its rise described by the CDC as "potential," and annual cases in the U.S. approaching 2,000 per year.

For further reading:

Malaria disease basics

Locally acquired malaria case reported in Arkansas

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Not to be taken lightly

October 24

Four bottles of KetaselThe FDA has not approved the use of compounded ketamine for psychiatric disorders. These medications are available for oral or sublingual administration and may be prescribed by telemedicine platforms for at-home use. However, their use in an unmonitored setting may put patients at risk for sedation, dissociation, psychiatric events, abuse, misuse, and physiologic symptoms such as changes to respiration or blood pressure.

Although ketamine has gained favor and exposure as a potential alternative treatment for psychiatric illnesses, great care should be taken by anesthesiologists prior to its use in unapproved settings outside of perioperative care. Further study is required prior to the assessment by the FDA and other regulatory bodies regarding the usage of compounded ketamine.

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The limitations of anesthesia unit productivity metrics

October 19

Two healthcare workers with patient in ORThe article “Measuring and Comparing Clinical Productivity of Individual Anesthesiologists” has been published in this month’s issue of Anesthesiology. The goal of this article is to help anesthesiologists, anesthesiology leaders, and facility leaders understand the limitations of anesthesia unit productivity as a comparative metric of work, and how this metric often devalues actual work.

The challenge of unintended consequences of simply using units per FTE and not understanding the complexity of trying to measure the individual anesthesiologist’s work is described in this passage from the article: “Putting these four factors together, the anesthesiologist who does not take call shifts nor work late ends up being the ‘highest producer’ if no other factors are considered. On the flip side, the ‘lowest producer’ may be an anesthesiologist providing the most complex care, e.g., pediatric cardiac anesthesia, for the exact same reasons. The anesthesiologist takes more calls, the cases are of longer duration, and the staffing ratio is often 1:1 care. If asked which clinician is more valuable and harder to replace, we would pick the anesthesiologist doing more complex cases.”

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The extraordinary burden of long Covid

October 12

Opened box of PaxlovidThe CDC recently released the following reports about long Covid in children and adults:

Long Covid in Children: United States, 2022
Long Covid in Adults: United States, 2022

An astonishing 7% of adults have had long Covid, defined as symptoms persisting for more than three months. Half of these adults (3.5%) have not recovered. Even more astonishing is that 2% of adolescents have had long Covid, and half of those adolescents have still not recovered. This is an extraordinary burden of disease for the United States.

It is known that nirmatrelvir (e.g., Paxlovid) decreases the incidence of long Covid (see papers in JAMA Internal Medicine and the Journal of Medical Virology). As noted in an editorial by Al-Aly in The Lancet Infectious Diseases, “antivirals (nirmatrelvir and molnupiravir) remain massively underused.”

SARS-CoV-2 continues to evolve and infect us. As physicians, we must make every effort to keep our patients healthy. That includes encouraging compliance with vaccination guidelines and liberally prescribing antivirals in patients when they become infected to both mitigate the acute disease and reduce the risk of long Covid.

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Just stand still and they’ll leave you alone – hopefully

October 11

Group of bees flyingRecently a 59-year-old individual died of bee stings despite getting to an emergency room for treatment. Bee stings are usually not fatal, but in this case, they cost him his life. We may be called to the ER to take care of an individual after being exposed to bee stings with dyspnea and airway obstruction needing life support. Bee stings can cause anaphylaxis, delayed immune response, heart attacks, pulmonary hemorrhages, neurological problems, and acute kidney failure. Serum sickness has also been reported to occur. It is best to protect oneself and avoid bee stings, but if stung, the outcome probably depends upon the toxin dose and time to treatment.

For further reading:

MD Linx: A Kentucky man died from bee stings. Here's when bee stings can become life-threatening

The Guardian: Kentucky man dies after swarm of bees attacks him on his porch

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A global community back together again – finally!

October 4

View of SingaporeFor the first time in eight years, the world’s leading anesthesiology stakeholders will be convening in person in Singapore for the World Congress of Anaesthesiologists (WCA), which takes place from March 3-7, 2024. This will be a fantastic opportunity to see old friends and make new ones from the worldwide anesthesiology community!

You can read a September 2023 ASA Monitor article to learn more about collaborations between ASA and the World Federation of Societies of Anaesthesiologists.

Abstract submissions for WCA 2024 in Singapore close on October 15. We are still looking for more submissions from all parts of the world, including North America! Call for Abstracts - 18th World Congress of Anaesthesiologists (WCA2024).

Registration for WCA 2024 is now open through the Congress website.

Discount tickets are available through the early bird ticket program if you register before November 30, 2023.

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September 2023

An achievable global initiative?

September 28

Birdseye view of the UN General AssemblyImagine not receiving oxygen because your family cannot pay. Imagine being on a hospital ward with no blood pressure cuffs or pulse oximeters. Now, imagine surviving emergency surgery only to decompensate on the ward unnoticed. This is a reality for too many resource-constrained settings across much of the world. These are the settings in which 80% of the global population lives. The UN General Assembly took place last week, bringing the world’s leaders together despite these divided times. A major success for global health advocates was achieved through the political declaration and recommitment to universal health coverage, ensuring all people have access to the highest attainable standard of physical and mental health. As inspirational as these lofty goals of policymakers are, they will remain aspirational without the critical foundations needed for health system strengthening. The real gap is between policy and the bedside.

For further reading:

UN General Assembly High-Level Meetings on Health 2023
Political Declaration of the High-level Meeting on Universal Health Coverage (PDF)

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New research brings hope for migraine patients

September 27Older woman sitting in chair holding hand to side of forehead in pain

The latest “In the Know” column in the ASA Monitor discusses the role of CGRP antagonists in treating migraine. An article in JAMA Neurology notes that several lines of experimental evidence suggest that the benefits of CGRP antagonists may be limited to women due to the sexually dimorphic etiology of migraines in women and men. More generally, the article notes that differences in nociception may underlie many pain conditions that disproportionally affect either women or men.

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Updated Covid booster shots

September 21

NHS COVID-19 Vaccination CenterThe FDA approved updated Covid-19 booster shots last week. The updated vaccine is a monovalent, which means that the mRNA encodes the spike protein for just a single variant, XBB.1.5. SARS-CoV-2 is constantly evolving. Fortunately, XBB.1.5 is closely related to EG.5, the currently dominant variant in the U.S.

The CDC recommends the vaccine for everyone 6 months and older. As noted in the CDC announcement, “The benefits of Covid-19 vaccination continue to outweigh any potential risks. Serious reactions after Covid-19 vaccination are rare.”

Nature News has a thoughtful discussion on who should be vaccinated. The article notes that existing immunity from vaccination, infection, or both likely protects most people from severe disease. However, vaccination enhances immunity to currently circulating variants. Enhanced immunity will delay infection, will shorten the duration of illness for those who get infected, and may reduce viral transmission.

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2023 fall vaccine primer

September 21

Close up on person getting bandaid placed on armThere is a new update on the CDC-recommended vaccines for this fall, including the flu shot, an updated Covid-19 vaccine, and an RSV shot.

While the flu shot and Covid-19 vaccine are recommended for all individuals aged 6 months and older, the RSV shot is advised for specific age groups and those with elevated risk factors. With the flu season approaching, the CDC recommends discussing these vaccinations with our patients. The CDC emphasizes the importance of vaccinating against Covid-19, the flu, and RSV, which are the primary causes of hospitalizations during the fall and winter.

The RSV shot is new as of 2023 and is recommended for some adults over 60, infants under 8 months, and older babies with certain risk factors. One needs to check their insurance coverage for RSV shots, review possible potential side effects, and understand the need to space out the vaccines.

For further reading:

MDLinx: These are the top three vaccines you and your patients need this fall
CDC: 2023-2024 CDC flu vaccination recommendations adopted
CDC: CDC recommends updated Covid-19 vaccine for fall/winter virus season
CDC: CDC recommends a powerful new tool to protect infants from the leading cause of hospitalization
KFF Health News: Timing and cost of new vaccines vary by virus and health insurance status

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Wait, I have to take another test?

September 19William Heath, March of Intellect, 1829.

This article from NEJM Journal Watch specifically refers to ABIM processes but is a good read for all physicians, not just internists. Recertification is a hot topic at present. The labor-intensive and at times costly process of maintenance of certification (MOC), which in the not-too-distant past was granted on a one-off, lifetime basis, has inspired exasperation and even anger across many specialties. Critics are vocal that physician MOC status has no correlation with outcomes, is remote from clinical reality, and is in essence a “money-grab.”

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August 2023

Additional modality for treating pain?

August 30Person selecting a happy face with their finger over plain and sad faces

A randomized controlled trial published in The New England Journal of Medicine demonstrated that the selective Nav1.8 inhibitor VX-548 provided 48 hours of analgesia in surgical patients following bunionectomy or abdominoplasty. If these results are reproducible, VX-548 may provide an additional modality for improving pain and decreasing opioid use after surgery.

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Yet another infectious hazard

August 25

Clinician looking at a disease under a microscopeAnesthesiologists have plenty of infectious agents and numerous vectors to worry about, considering respiratory diseases like TB and Covid, the gamut of hospital-acquired and drug-resistant organisms, and the possible infection/contamination risk of our perioperative workspaces. Now, there is a new, potentially very dangerous player in the mix: fungal pathogens. Serious fungal infections will be of particular concern and interest to those of us who practice critical care and/or palliative medicine, but will affect us all as time goes on and their prevalence increases.

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Reducing global inequality – an uphill battle

August 24

An editorial in Nature highlights the benefits to everyone of reducing inequality. The editorial is a follow-up on an open letter written by investigators and economists from 67 different nations to the Secretary-General of the United Nations and the President of the World Bank about the broad benefits of reducing inequality both among and within nations. Inequality between countries has decreased over the past decade, while inequality within countries has been rising.

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Misguided physician presence on social media

August 18

Hands holding a mobile phoneA recent paper in JAMA Network Open investigated the role of physicians in propagating misinformation about Covid-19. The authors identified 52 physicians from 28 different medical specialties who were the primary purveyors of misinformation using social media. Quoting the authors, “Major themes identified included 1) disputing vaccine safety and effectiveness, 2) promoting medical treatments lacking scientific evidence and/or U.S. Food and Drug Administration approval, 3) disputing mask-wearing effectiveness, and 4) other (unsubstantiated claims, e.g., virus origin, government lies, and other conspiracy theories).”

While the motivation for spreading misinformation was beyond the scope of the article, the authors noted that many of the physicians were associated with organizations that propagated medical misinformation for decades. They also noted that “America’s Frontline Doctors,” a group that famously posed in medical attire in front of the U.S. Supreme Court, had netted at least $15 million in consulting fees for promoting ivermectin and hydroxychloroquine for treating Covid-19. There was only one anesthesiologist among the 52 physicians identified. The article did not disclose physician names, but the full data set is available to interested researchers.

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The evolving saga of aspiration risk from GLP-1 agonists

August 17

Person holding a tubeEvidence is still emerging, and ASA is working to develop guidelines regarding GLP-1 agonist medications that act by delaying gastric emptying. The last line of ASA’s recent Guidance on Preoperative Management of Patients (Adults and Children) on Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists is key: “There is no evidence to suggest optimal duration of fasting.”

This week, I anesthetized a patient on a weekly dosing of Ozempic. He had not had a dose in six days and he was NPO for greater than 14 hours – yet there were echogenic materials seen on gastric ultrasound. An endotracheal tube was placed instead of an LMA, and solid food was aspirated from the Profant Ric tube that was placed. The risk of aspiration in these patients may be higher than we recognize currently.

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SARS-Cov-2 has changed, and us along with it

August 16

SARS-CoV-2 variants graphSARS-CoV-2 continues to evolve. This figure, from nextstrain.org, shows how new variants have replaced older variants since the beginning of the pandemic. In each case, novel mutations confer a combination of increased binding to the ACE2 receptor and conformational mutations to the spike protein that escape existing immunity.

According to the CDC, the EG.5 Omicron variant now accounts for 17% of new cases in the U.S. EG.5 evolved from the XBB.1.9 variants that have been dominant for many months. A vaccine booster for XBB is likely to be available by the end of August. It is expected to provide protection against EG.5.

Despite the rise of EG.5, deaths from Covid-19 are continuing to decrease. Vaccination, infection, or both have conferred global immunity. Immunity to infection wanes, which was known before the pandemic. Immunity to serious illness and death remains robust.

SARS-CoV-2 has changed. So have we. This is the new normal.

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Early detection of postpartum hemorrhage

August 10

Illustration of postpartum hemorrhageIn a multinational randomized study from Africa involving 80 hospitals and more than 200,000 patients, investigators looked at the efficacy of a readily implemented strategy for early detection of postpartum hemorrhage following vaginal delivery and rapid, simple interventions to reduce bleeding (uterine massage, oxytocic drugs, tranexamic acid, intravenous fluids, and escalation). The comparison group was conventional peripartum care. Quoting the study conclusion: “Early detection of postpartum hemorrhage and use of bundled treatment led to a lower risk of the primary outcome, a composite of severe postpartum hemorrhage, laparotomy for bleeding, or death from bleeding.” The study was funded by the Bill and Melinda Gates Foundation.

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Unfortunate complications from Covid vaccine

August 3

Doctor working in ORAlthough exceptionally rare, accumulating evidence suggests that some vaccinated patients may have symptoms resembling long-Covid, a condition dubbed “Long-Vax.” As summarized in Science News, this condition is gaining increasing acceptance among physicians and scientists. It is thought that many of the symptoms of long-Covid trace to the spike protein, which is also the antigen introduced by vaccination. Thus, there is a reasonable mechanistic link by which the spike protein could induce long-Covid in highly susceptible individuals. The LISTEN study at Yale is enrolling subjects who may have had vaccine-associated symptoms similar to long-Covid.

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Screen or no screen?

August 2

The New England Journal of Medicine recently published the results of a randomized trial comparing direct laryngoscopy with videolaryngoscopy for endotracheal tube placement in the intensive care unit and emergency ward. Intubation on the first attempt was successful in 85% of patients in the videolaryngoscope group and 71% of patients in the direct laryngoscope group. An accompanying editorial notes that the study demonstrated significant improvement in success with videolaryngoscopy, but cautioned that the results might not be generalizable to other institutions with different training standards for intubation.

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More pharmacotherapy for dementia?

August 1Older woman sitting in chair with hand held to side of head

The protein klotho is an enzyme that suppresses oxidative stress and inflammation. It appears to be involved in the regulation of aging and is associated with enhanced cognition. A recent study in Nature Aging found that low-dose injections of klotho enhanced memory in nonhuman primates. This is quite different from the drugs that delay Alzheimer’s progression which have recently received FDA approval in that klotho appears to enhance cognition rather than just slow cognitive decline.

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July 2023

Covid emergency over, but problems persist

July 28

Now that the SARS-CoV-2 pandemic is waning, a clearer picture is emerging for “long Covid.” About 80% of cases of long Covid have resolved within a year. However, about 10%-20% of patients have not recovered within a year. Recovery is much slower after one year, with about 10% of patients failing to recover. Risk factors for slow recovery include asthma, diabetes, smoking, and high BMI.

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Covid resistance: in the genes?

July 27

Hand holding a covid testI’ve never tested positive for SARS-COV2, which is remarkable considering I am an anesthesiologist and intensivist with plenty of exposure. Yes, I believe in PPE and vaccinations, but I am one of only a few people I know who never contracted Covid. I have a hard time believing it is due to a lack of testing, as I had the same anxiety of infecting friends, family, and patients as others. I tested obsessively. It was also mandatory at work for a period of time. Maybe I hit the genetic jackpot.

For further reading: New studies shed light on how genes might shape a person’s experience with Covid-19

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What is brain death? Not a rhetorical question…

July 26Close up on a person's hand with and IV line in it

A fascinating editorial in Nature explores the uncomfortable topic of brain death. Variations in the definition of brain death among states result in the bizarre situation where a patient would be pronounced dead in California but considered alive in New Jersey, as actually happened in 2013. The Uniform Law Commission is currently drafting legislation to clarify the definition of brain death and harmonize the law among states.

Heat wave continues – and so does the research

July 26

Much has been written about the health risks of the unprecedented heat wave that continues to set records (including the record set on July 4, the hottest day in recorded history). As recently documented in the Journal of Applied Physiology, even moderate heat starts to impose cardiovascular strain during light activity. Not surprisingly, above specific thresholds, rising heat and rising humidity impose similar cardiovascular strain well below the fatal “wet bulb temperature” of 35°C (95°F).

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A new and very rare genetic muscle disease

July 25

Many patients on statins experience significant and unwanted muscle symptoms, making it difficult for them to remain on statins for preventing cardiovascular disease. The enzyme that the statins block is 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase. As a result, there is reduced cholesterol synthesis. Authors from the Mayo Clinic recently published a study titled “Bi-allelic variants in HMGCR cause an autosomal-recessive progressive limb-girdle muscular dystrophy” that provides further evidence of the role of this enzyme during statin therapy. Even more, they identified a very rare muscle disease in nine unrelated individuals who had unexplained limb-girdle-like muscular dystrophy and bi-allelic variants in the HMGCR gene. This is important basic science information for clinicians involved in the care of patients with muscle disease and rare diseases.

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Despite WHO findings, guidance on aspartame unchanged

July 21

Pill box laying on it's side with a few pills laying outside of itDespite considerable media focus on findings by the WHO that the sweetener aspartame is a “possible carcinogen,” the Joint FAO/WHO Expert Committee on Food Additives decided to not change their guidance on the use of aspartame in thousands of consumed products. As quoted in Nature News, the WHO’s Department of Nutrition and Food Safety director stated, “There was no convincing evidence from experimental or human data that aspartame has adverse effects after ingestion, within the limits established by previous committee.”

Things you can’t unsee

July 21

A recent picture in the New England Journal of Medicine shows the bizarre phenomenon of “hairy tongue,” something you don’t want to see on intubation! (Caveat lector: the picture is not recommended for anyone consuming food while reading ASA Monitor Today or those prone to nightmares related to anesthesia practice).

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Risks of cannabis use before surgery

July 20

Tin of cannabis gummiesA new study published in JAMA Surgery found that patients with cannabis use disorder had a higher risk of complications in the perioperative period. With the increasing use of cannabis among the population, it is a general notion that this is harmless.

The authors of the study, who were from the Department of Anesthesiology, Critical Care and Pain Medicine at the McGovern Medical School at UT Health, Houston, propensity-matched 6,211 patients with and without cannabis use disorder and found that the risk of the primary outcome – which was a composite of in-hospital mortality and seven major perioperative complications such as stroke, myocardial ischemia, acute kidney injury, respiratory failure, venous thromboembolism, hospital-acquired infection, and procedure-related complications – was significantly higher in the cannabis use group (adjusted OR 1.19, P value 0.01). The authors discuss some physiologic and pharmacologic effects of cannabis, which could lead to a higher risk of these complications. This study adds evidence to the growing literature regarding the adverse effects of cannabis use in patients undergoing noncardiac surgery.

Based on the fact that regular use of cannabis can potentially lead to poor pain control and nausea after surgery, ASRA Pain Medicine recommends screening all patients for cannabis use disorder before surgery and creating some guidelines for the perioperative care of these patients.

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The avoidable health disaster of smoking

July 19

As highlighted in Nature, the battle against smoking continues. Twenty percent of the world’s population continues to smoke. Fourteen percent of deaths globally are related to smoking. In the United States, the economic costs attributable to smoking exceed $400 billion annually.

Smoking dangers infographic

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Science and care for transgender patients

July 18

Large group from a trans rights rallyIt was Christmas Day 2015 at my new job in a small, private practice hospital. We rarely did pediatrics at this hospital, but on this day, there were three adolescent patients scheduled for mastectomies. One was age 12, one had no parents at bedside, and one had a snuggly stuffed animal in their arms. It was my first introduction to transgender care. Unfortunately, there had been no prior discussion across the hospital or surgical care teams. There was no policy. There were no guidelines. There was no education for providers. I felt in my gut, “first do no harm.” At that time, I did not know what was right. Today, it’s still not entirely clear where the lines of helping and harming lie. I do know that these patients deserve support – familial, social, psychological, and medical. I also knew they needed a center with informed providers, not a small, uninformed private hospital. We owe these patients greater research prioritization – as much as it takes to provide the best care possible. Lives are on the line.

For further reading: European Countries Restrict Trans Health Care for Minors

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The Curious Economist questions national health expenditure projections

July 12

Graph of National Health Expenditure (NHE) Projections (2009-25) and Actuals (2009-21)The figure here shows actual and projected national health expenditures (NHEs) published in the eight years from 2010 to 2017, each being represented by a different colored line and labeled for the year of publication. The actual NHEs in 2009 through 2021 are represented by an X. In each of the eight years shown, the projections have exceeded the actual amounts realized. For example, actual NHEs in 2019 were well below those projected for that year back in 2010 and were also below those projected in 2012. 2013, 2014, and 2017, and the interpolated projections for 2011, 2015, and 2016. Not surprisingly, the difference between projected and actual NHEs for 2019 diminished each year between publication years 2010 and 2017.

I’m curious… Does the CMS Office of the Actuary intentionally project upward-biased NHEs? Do any behaviors or policies change because of these projections?
– The Curious Economist

Acknowledgment: Thanks to Jennifer Rock-Klotz, ASA Analytics and Research Services Manager, for her help with the data analysis used here.

References:

  1. Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group; U.S. Department of Commerce, Bureau of Economic Analysis; and U.S. Bureau of the Census. National Health Expenditures; Aggregate and Per Capita Amounts, Annual Percent Change and Percent Distribution: Calendar Years 1960-2021. Available at https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nationalhealthaccountshistorical. Accessed June 20, 2023.
  2. Keehan SP, Fiore JA, Poisal JA, et al. National health expenditure projections, 2022-31: Growth to stabilize once the Covid-19 public health emergency ends. Health Aff (Millwood). 2023; 101377hlthaff202300403. Online ahead of print.
  3. Martin AB, Hartman M, Benson J, Catlin A, The National Health Expenditure Accounts Team. National health care spending in 2021: Decline in federal spending outweighs greater use of health care. Health Aff (Millwood). 2023;42(1):6-17.
  4. Poisal JA, Sisko AM, Cuckler GA, et al. National health expenditure projections, 2021-30: Growth to moderate as Covid-19 impacts wane. Health Aff (Millwood). 2022;41(4):474-86.
  5. Martin AB, Hartman M, Lassman D, Catlin A, National Health Expenditure Accounts Team. National health care spending in 2019: Steady growth for the fourth consecutive year. Health Aff (Millwood). 2021;40(1):14-24.
  6. Keehan SP, Cuckler GA, Poisal JA, et al. National health expenditure projections, 2019-28: Expected rebound in prices drives rising spending growth. Health Aff (Millwood). 2020;39(4):704-14.
  7. Sisko AM, Keehan SP, Poisal JA, et al. National health expenditure projections, 2018-27: Economic and demographic trends drive spending and enrollment growth. Health Aff (Millwood). 2019;38(3):491-501.
  8. Cuckler GA, Sisko AM, Poisal JA, et al. National health expenditure projections, 2017–26: Despite uncertainty, fundamentals primarily drive spending growth. Health Aff (Millwood). 201-;37(3):482-92.
  9. Keehan SP, Stone DA, Poisal JA, et al. National health expenditure projections, 2016-25: Price increases, aging push sector to 20 percent of economy. Health Aff (Millwood). 2017;36(3):553-63.
  10. Keehan SP, Poisal JA, Cuckler GA, et al. National health expenditure projections, 2015-25: Economy, prices, and aging expected to shape spending and enrollment. Health Aff (Millwood). 2016;35(8):1522-31.
  11. Keehan SP, Cuckler GA, Sisko AM, et al. National health expenditure projections, 2014-24: Spending growth faster than recent trends. Health Aff (Millwood). 2015;34(8):1407-17.
  12. Sisko AM, Keehan SP, Cuckler GA, et al. National health expenditure projections, 2013-23: Faster growth expected with expanded coverage and improving economy. Health Aff (Millwood). 2014;33(10):1841-50.
  13. Cuckler GA, Sisko AM, Keehan SP, et al. National health expenditure projections, 2012-22: Slow growth until coverage expands and economy improves. Health Aff (Millwood). 2013;32(10):1820-31.
  14. Keehan SP, Cuckler GA, Sisko AM, et al. National health expenditure projections: Modest annual growth until coverage expands and economic growth accelerates. Health Aff (Millwood). 2012;31(7):1600-12.
  15. Keehan SP, Sisko AM, Truffer CJ, et al. National health spending projections through 2020: Economic recovery and reform drive faster spending growth. Health Aff (Millwood). 2011;30(8):1594-605.
  16. Sisko AM, Truffer CJ, Keehan SP, Poisal JA, Clemens MK, Madison AJ. National health spending projections: The estimated impact of reform through 2019. Health Aff (Millwood). 2010;29(10):1933-41.
  17. Truffer CJ, Keehan S, Smith S, et al. Health spending projections through 2019: The recession's impact continues. Health Aff (Millwood). 2010;29(3):522-9.

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Independence Day: A time to reflect

July 11

Illustration showing colonists and indigenous peopleI was fortunate to have July 4, 2023, off and enjoyed some quiet time at home and a cookout and fireworks later with family and friends. I am grateful for where I live and work and my many opportunities. We often refer to July 4th as Independence Day, when the colonists declared freedom from Britain. Sometimes we call it America’s birthday, but I have listened to two books recently that helped me to better understand the parts of our history as a nation that many of us, myself included, tend to forget. I highly recommend “An Indigenous Peoples' History of the United States,” written by Roxanne Dunbar-Ortiz, and “Four Hundred Souls,” edited by Ibram X. Kendi and Keisha N. Blain, if you want to learn more about the history of our land and nation.

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The unequal distribution of morphine

July 7

Illustration of world map with numbers showing morphine distributionA new WHO report on worldwide morphine distribution made headlines this week. It indicated that 80% of morphine in the world was distributed in the Americas, primarily in North America. The median defined daily dose of morphine for high-income countries was estimated to be 125.9 per million people per day, while it was 24.9 for upper-middle-income countries, 6.7 for lower-middle-income nations, and 2 in low-income countries.

The problem is not new. Five years ago, The Lancet Commission on Palliative Care and Pain Relief released an impressive map adjusted for morphine consumption.

Recently, there has been greater focus within the specialty on pain control, especially for those with cancer.

The truth is that many patients suffer across the globe every day due to the lack of access to and cultural barriers around opiates. In some places, overconsumption is the problem. In others, lack of access is the great problem. The efforts of ASA, the WFSA, our Committee on Global Health, and many others continue!

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TB vaccine moves into phase 3 clinical trials

July 6Imaging machine screen showing tuberculosis in patient's chest

As described in Nature News, a vaccine for tuberculosis will move into phase 3 clinical trials after receiving funding from the Bill & Melinda Gates Foundation and the Wellcome Trust. Tuberculosis kills about 1.6 million people every year, mostly in low- and middle-income countries. Tuberculosis was one of the first diseases for which a vaccine (BCG) was administered (1921). Unfortunately, BCG is not particularly effective at preventing TB in adults.

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Microbiota matter

July 4

As summarized in Nature News, the microbiome of babies delivered vaginally differs from the microbiome of babies delivered by Cesarean section. These differences have been shown to be consequential for subsequent child development. Scientists have studied transferring the maternal microbiome by applying vaginal fluid to neonatal skin after Cesarean section. Remarkably, a recent randomized controlled trial demonstrated that microbiota transfer following Cesarean section improved infant neurological development at 3 and 6 months.

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June 2023

CDC health alert on malaria

June 29

Malaria seen through a microscopeA few months ago, I had an ICU patient with fever and delirium. He had not traveled in over three months yet turned out to have cerebral malaria. I was contacted this week by a colleague concerned for a friend returning from Tanzania with fever, chills, headache, and body aches – all classic signs of malaria. On Monday, I read a warning from the CDC to doctors and public health officials that locally acquired malaria cases have been identified in the U.S. The cases, identified in Florida and Texas, were Plasmodium vivax and were found to be sensitive to I.V. artesunate, the first-line treatment in the U.S. With severe weather, warmer temperatures, and rising water in some locations, individuals are encouraged to prevent mosquito bites and control mosquitos at home, even as the risk of malaria in the U.S. remains extremely low.

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Coughing, conspiracy, and Covid?

June 28

Wuhan Institute of Virology workerScience must defer to data. Recent articles in The Wall Street Journal and the blog Public suggest that three scientists at the Wuhan Institute of Virology were sickened with a severe respiratory disease requiring hospitalization in November 2019. Could this be the “smoking gun” to prove that SARS-CoV-2 arose from a "lab leak" and not from zoonotic transmission?

Several days ago, the Office of the Director of National Intelligence released a long-anticipated report about the Wuhan Institute of Virology. The possible cases of Covid-19 in the Wuhan Institute of Virology are assessed on page 6. Available evidence suggests that the scientists did not have Covid-19. Science News reached out to one of the supposedly infected individuals, who replied that the claim that he had Covid-19 was “ridiculous.”

The Public blog has several obvious errors. For example, the authors repeat the canard that the SARS-CoV-2 “furin cleavage site” is not seen in nature. That's simply incorrect. You will find exactly the same furin cleavage site, with an identical RNA sequence except for a silent substitution of a cytosine for an alanine, in the sequence of coronavirus HKU9, starting on line 24181. It also states that the EcoHealth Alliance, which is affiliated with the Wuhan Institute of Virology, proposed to "engineer furin cleavage sites." That is false.

If SARS-CoV-2 arose from a lab leak, then a smoking gun may yet be found (e.g., blood tests from November 2019 showing SARS-CoV-2). However, if SARS-CoV-2 traces to a zoonotic origin, then a "smoking gun" may never be found. SARS-CoV-2 will be in good company, as science has not established with certainty the origins of rabies, HIV, H1N1, Ebola Sudan, Ebola Makona, hantavirus, West Nile virus, Zika virus, Lyme disease, yellow fever, avian flu, SARS, or MERS.

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The solemn privilege of caring for patients at the end of their lives

June 15

A blog post I wrote more than six years ago about death and dying still rings true. Losing colleagues is a particularly difficult reflection to consider, perhaps even more so after 7 million people died in the pandemic.

End-of-life stories gained poignancy through this shared global devastation. Physicians and nurses, often helpless to change the clinical course, were more often forced to comfort patients through the end. Emotional resilience, usually an ICU physician’s superpower, faced its greatest challenge. Compartmentalization became ineffective against a wave of struggling and dying patients.

The pandemic was the hardest time in many of our careers, but I will never forget the colleagues who stepped up to care for patients through the fear, exhaustion, and through our own sadness. I have greater determination to honor life before death. I cherish the values we all share to protect our families and communities. I am even more grateful for the trust patients and families place in us. In my career I have been hugged, screamed at, threatened, and sued, but the privilege of caring for others still stands.

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FL governor vetoes medical title bill, despite bipartisan support

June 14

Eye exam machineFlorida’s patients and physicians recently suffered an unexpected set-back when an important medical title bill (S.B. 230, “Health Care Practitioner Titles and Designations”) was vetoed by Governor Ron DeSantis. The bill had broad (and bipartisan) support in the legislature, and enacting it was a priority of Senate President Kathleen Passidomo, who is a high-profile champion of Florida’s physicians and patients. The reasons for the veto were not made public, but discussions are already in the works with the governor and his staff regarding his concerns, and in formulating a plan to get this legislation passed next year.

For further reading:
DeSantis vetoes a bill intended to remove patient confusion over medical titles

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The big deal about small talk

June 8Healthcare workers getting ready to scrub in for surgery

Networking is hard, and meeting new people can be awkward. This short article in TIME gives some great strategies to help you with small talk and making connections. Even an extrovert like me learned some new strategies. And remember, we are meeting new people all the time at the hospital – it’s a great safe place to work on these strategies!

For further reading:
7 ways to get better at small talk – and why you should

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New international network seeks to save lives, improve access to care

June 7

Two healthcare workers moving a patient on a hospital bed through a hallwayThe milestone adoption of a resolution by the WHO at the 76th World Health Assembly that ended May 30, 2023, catapults emergency, critical, and operative care up the global agenda, bringing us closer to incorporating these vital elements into the Universal Health Coverage goals.

For further reading:
WHO announces Acute Care Action Network for emergency, critical and operative care

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May 2023

African nations need ‘oxygen security’

May 26

Person in medical mask moving oxygen tanksOxygen is all around us, yet in some countries over half of Covid-19 patients died without ever receiving oxygen therapy. The World Health Assembly, the decision-making body of the WHO, is expected to vote on a resolution promoting national oxygen plans. Prioritization of oxygen is imperative for the daily needs of health care systems, including safe anesthesia, but is also needed in preparation for epidemics, conflicts, and natural disasters. Oxygen, used medically since 1917, was only deemed an essential medicine by the WHO in 2017.

For further reading: ‘Lives were lost’: how countries across Africa are building ‘oxygen security’

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ASA, WFSA leaders in attendance this week at World Health Assembly

May 24

World Health Assembly large conference roomThe World Health Assembly is the decision-making body of the World Health Organization (WHO). It is attended by delegations from all WHO member states and focuses on a specific health agenda prepared by the Executive Board. The main functions of the World Health Assembly are to determine the policies of the organization, appoint the Director-General, supervise financial policies, and review and approve the proposed program budget. The Assembly is held annually in Geneva, Switzerland, this year from May 21-30, 2023. Michael Champeau, ASA President, will attend along with leadership from the World Federation of Societies of Anaesthesiologists. Look for an update on the Assembly in an upcoming ASA Monitor article.

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Attention is all you need

May 19

Optimus Prime figurineLarge language models, including ChatGPT, are based on a simple neural network structure called a transformer. Computer scientists spent years trying to teach recurrent and convolutional neural networks how to pay attention to the important words in text, and ignore everything else. In 2017, scientists from Google Research, Google Brain, and the University of Toronto identified that attention is all you need. That’s the title of the paper. The paper is explained for non-experts (familiar with vector notation) on the website “towards data science.”

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Long-term sequelae of wet taps

May 18

Multiple retrospective and, more recently, prospective studies have documented increased risk of chronic headaches following unintended dural puncture for labor analgesia. At the 2023 Society for Obstetric Anesthesia and Perinatology (SOAP) meeting, Dr. Ansari presented her work and reviewed the work of others demonstrating that chronic headache is an underappreciated risk of labor analgesia.

There are three obvious implications:

  1. Parturients need to be informed of the risk of chronic headache as part of the informed consent for labor epidural.
  2. In the event of unintended dural puncture, parturients need to be told that they may experience chronic headaches.
  3. Primary care physicians need to ask about recent pregnancy in women of childbearing age who present with headaches, as a history of a recent labor epidural suggests the need to rule out persistent dural leak.

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ASA Monitor Editor-in-Chief shares top 14 uses of ChatGPT in health care

May 17

A recent article in Forbes highlights the applications of ChatGPT in health care. Envisioned uses include telemedicine assistance, medical decision support, recordkeeping, medical translation, medication management, disease surveillance, medical documentation, clinical trial recruitment, patient triage, drug information, mental health support, and remote patient monitoring.

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Physicians have a 1 in 3 chance of being sued

May 16

Distrust in the physician-patient relationship may go both ways. A report from the AMA finds that over 30% of physicians have been sued at least once in their careers, and that increases to 46% for physicians aged 55 and older. Although male physicians are sued more often, a physician’s chosen specialty may be the higher risk. Both obstetricians and surgeons are sued at higher rates, while primary care doctors are much less likely to be sued.

For further reading:

If you’re a doctor, you’ve got a 1 in 3 chance of being sued

  ASA Policy Research Perspectives: Medical Liability Claim Frequency Among U.S. Physicians (PDF)

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See you in Singapore for 2024 WCA!

May 10

Group taking a fun picture at World Congress of AnaesthesiologistsAs anesthesiologists, we have a role to play on the world's stage in advancing our field, advocating for patients, and leading important health care conversations. ASA is a high-value component member of the World Federation of Societies of Anesthesiologists (WFSA), facilitating the mission and values of safe perioperative care across the globe. Engagement in partnership opportunities is invaluable for ASA members to build professional networks, participate in educational exchange, and collaborate across countries. The 2024 World Congress of Anaesthesiologists (WCA) will be held in Singapore on March 3-7. Abstract submissions are now open through October 25, 2023. We will see you there!

Learn more about the WFSA and the WCA.

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I know what you’re thinking, even though you haven’t said a word

May 5

AI can recreate language using fMRI scans. Although a myriad of uses and ethical questions come to mind, the AI technology space is expanding rapidly. How will this impact health care, patients, and anesthesiologists? These are the questions … with unclear answers.

For further reading:
Nature Neuroscience
NPR

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April 2023

Improvements made to organ procurement and transplantation system

April 26

Graphic illustrating equity with three people of different heights being able to reach apples on a branchMany of us are involved in providing anesthesia care to patients needing solid organ transplantation from grateful cadaveric donors who had consented to donating their organs. The allocation of these valuable organs is handled by the Organ Procurement and Transplantation Network (OTPN). In recent reviews of this program, several miscommunications occurred that resulted in significant problems to the recipients. As a result, the HHS Health Resources and Services Administration announced significant improvements to this program. Further details about the problems and updates may be obtained in the following links:

MD Linx:
70 Deaths Linked to the Organ Transplant and Procurement Network, Prompting Reform

U.S. Senate Committee on Finance:
Wyden Statement at Finance Committee Hearing on the Urgent Need to Address Failures in the Organ Transplant System

Health Resources and Services Administration:
HRSA Announces Organ Procurement and Transplantation Network Modernization Initiative

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Feeding patients is critical

April 25

Graphic about patient pre-procedural intakeCritically ill patients are at high risk of malnutrition, yet the default for any procedure is “NPO after midnight.” Most mechanically ventilated patients require tube feeding, often stopped preprocedure due to concerns for aspiration. There is a paucity of literature assessing this risk. Further, guidelines for patients receiving tube feeding are currently lacking. There is evidence that NPO after midnight for ICU patients is harmful, as these patients often have feedings held multiple times due to repeat procedures, delayed procedures, or cancelled procedures. The ASA Committee on Critical Care Medicine is developing a more practical approach to preprocedural fasting of hospitalized patients receiving tube feeding.

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NEJM hosting free webinar on value distribution of clinical AI

April 21

Line graphWhether you are an artificial intelligence (AI) expert or you are wondering what all the fuss is about, you may have wondered how AI will impact clinical care. The New England Journal of Medicine is sponsoring a free virtual event on Thursday, April 27, at 11 a.m. CT called “The Value Distribution of Clinical AI.” There will be a panel of experts offering insight on how AI will be adopted and paid for in medicine.

Learn more and sign up for the event on the NEJM website.

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Key Medicare physician pay reform bill introduced in Congress

April 20

Medicare physician payments is not keeping up with inflation, AMA graphIt is amazing to me that Medicare payments to physicians have not even closely kept up with inflation. In fact, in some years, Medicare actually cuts payments. But when there are no cuts in the payment rate, the fact remains that the payments don’t match the inflation rate, meaning there is a cut in payment.

Recently, bipartisan legislation was introduced in Congress by physician House members that would ensure physicians’ Medicare pay keeps pace with inflation. Get the details on H.R. 2474 from the AMA website.

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Caring for kids with Marfan syndromepatient with Marfan syndrome

April 19

Many of us encounter patients with Marfan syndrome needing surgery. It is one of the rare disorders we see, with an incidence between 1:5,000 to 1:15,000. It affects children and adults, and we see these patients most commonly for musculoskeletal and cardiovascular problems. I found this recent article just published in Pediatrics, and it provides a nice summary worth reading.

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Are hospitals really trying to be “greener”?

April 18

Bags and bags of garbage spilling out of and piled around a buildingWe enthusiastically followed last week’s ASA Monitor Twitter poll on whether hospitals were being proactive about OR waste! Many thanks to those of you who replied. It’s encouraging that the majority of respondents—52.4%—said their hospitals were “working on” ways to decrease OR waste, but this number could be higher.

The health care industry is responsible for approximately 5-8% of global greenhouse gas (GHG) emissions and air pollutants (asamonitor.pub/3KNbof9). The U.S. produces about six billion tons of medical waste, with disposal costs greater than $3 billion, and the ORs contribute to 33% of all hospital waste (asamonitor.pub/43JTR0a).

In an effort to make mankind better, let’s make sure we’re not making Earth worse! This informal poll shows that we’re making some headway in reducing OR waste, and the number of hospitals addressing this should be growing every year.

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Naloxone Saves Lives

April 14

Bonnie Milas, MDThe June “In The Know” feature titled “Naloxone Saves Lives” describes the road to the FDA’s legalization of over-the-counter naloxone on March 29, 2023. This has been a long time coming and one of the biggest proponents has been Dr. Bonnie Milas, an anesthesiologist who lost both of her sons to fentanyl overdoses. Parts of her testimony will appear in the column, and I’d encourage anyone to read her story. As Dr. Milas notes, every use of over-the-counter nasal naloxone to reverse an overdose is another life granted an opportunity at overcoming addiction.

Dr. Milas was instrumental in ASA’s Reviveme initiative and her testimony (start at the 4:40:00 mark) was instrumental in the over-the-counter approval.

I look forward to sharing more insights on this issue in a couple months!

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U.S. officials moving to address growing xylazine crisisDr. Rahul Gupta, director of the White House Office of National Drug Control Policy, speaks at a press conference at the Superior Council of the Judiciary in Bogota, Colombia on Aug. 23, 2022

April 14

Veterinary anesthetics are a new concern for overdose deaths in the U.S. Xylazine, an animal tranquilizer known as “tranq,” is being mixed with fentanyl, fueling overdose deaths across the country. U.S. officials are now rolling out plans to address this new drug crisis, as tranq deaths have increased 1,000% since 2020. Here are two informative articles on the subject:

NPR: Biden administration says fentanyl-xylazine cocktail is a deadly national threat

Politico: White House announces increased sanctions to combat fentanyl trafficking

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Anesthesiology not alone in scope creep challengesGroup of doctors consulting over a chart

April 12

There is growing evidence that unsupervised nonphysician care may worsen patient outcomes and increase the cost of health care delivery. Anesthesiology is not the only specialty fighting scope creep from nonphysicians. Psychiatry and ophthalmology colleagues are facing these same challenges, as bills seeking to expand scope of practice for nonphysicians flood state legislatures and put patient safety at risk.

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Risk factors for post-tonsillectomy bleeding now characterized

April 11

Illustration of human mouth with labelsPost-tonsillectomy bleeding can be devastating for children and their families. Fortunately, it is rare – but it is implicated as the most significant reason for death after this surgery. In a recent report, researchers from UT Southwestern Medical Center created a model using data from the Children’s Hospital Association’s Pediatric Health Information System database to assess bleeding rates following tonsillectomy. The authors found a host of factors responsible for excessive bleeding requiring readmission or a need to come to the emergency department for care. It was found that adolescents, Hispanic people, those living in a high-income ZIP code, and obese children are more likely to have increased rates of bleeding.

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Mountains of OR trash?

April 7

The waste from surgery and anesthesia increases the cost of health care delivery. It also impacts the environment and the fine balance of supply chains. We have long known that operating rooms generate a large percentage of hospital waste. Over three decades ago, OR waste was estimated at 41 tons for a 385-bed hospital, compared to just 11 tons from the wards. Since the 90s, ORs have moved away from reusable items. Imagine the inevitable increases in the last 30 years, especially since Covid-19.

We’ll discuss this and other aspects of perioperative waste more in the upcoming June issue of the ASA Monitor, but invite you to keep this conversation going on our Twitter page. Watch the Twitter poll for real-time information on how practices are (or aren’t) finally taking a closer look at their waste.

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March 2023

Fentanyl vaccine could be a game-changer

March 28Microgram 3-28

A fentanyl vaccine is in development and could be a game-changer in the care of patients with an opioid use disorder. The antibodies are specific to fentanyl and do not alter the pharmacology of morphine and possibly other opioids. The advantage of the vaccine is that, because it prevents fentanyl from entering the brain, the euphoric effects will be absent. I am not sure how this will affect the care of patients who have received this vaccine and are in need of surgery. Perhaps fentanyl will be ineffective in its analgesic effects? Other opioids may need to be used during their surgical care. The study’s abstract can be found here.

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The continuing controversy of doctored clinical titles

March 23

Doctors sitting around a meeting table“MD,” “DO,” “CRNA,” “CAA,” “ARNP,” “PA-C,” “DNP”: This is just a sample of the alphabet soup of licensed professionals in American health care. The ongoing, increasing fights over titles — most critically around the term “doctor” and the designation “-ologist” — suggest that not everyone plays well in our collective sandbox and further suggest that an uninformed patient population may end up the losers in this struggle. Do patients understand who is actually taking care of them when titles and terms overlap (potentially inappropriately) between the practices of medicine and nursing (and even other fields)?

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3-year study of NPs in the ED: Worse outcomes, higher costs

March 22Blurred action shot of patient on hospital bed being rolled into OR

Like many physicians, I know that my medical education, residency training, and experience allow me to make a difference. This is especially true when the patient presents with more subtle symptoms and complaints. So it does not surprise me that in the VA system, where there has been a policy change to allow for nurse practitioners to work with no physician supervision, researchers found worse outcomes and increased costs for nurse practitioner-provided care.

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Mis-Matched: 500 emergency medicine positions left unfilled

March 21

Blurred action shot of patient on gurney being rolled into ERThe number of unmatched positions for emergency medicine residency programs doubled this year with over 500 positions left unfilled and a 26% drop in applications to the specialty. This is very concerning as ER colleagues are part of our frontline workforce. Several drivers are suggested, including burnout from the pandemic, violence from patients, the burden of providing primary care in an emergency setting, and cost-cutting from health care corporations, as well as the growing opioid epidemic. As anesthesiologists are first responders on the wards, in the perioperative settings, and in intensive care units, we must learn from these lessons and recognize we are not immune to these very same factors.

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Positive life-expectancy trend in Africa threatened by noncommunicable diseasesPreemie baby being examed, stethoscope

March 16

Life expectancy in Africa has experienced remarkable increases over the last few decades, a trend now endangered by a growing threat from noncommunicable diseases. Once known for its struggles with infectious diseases such as HIV, tuberculosis, and malaria, the continent now faces different challenges. Globally, seven of the top 10 causes of death are noncommunicable diseases such as ischemic heart disease, stroke, and diabetes. Urbanization, processed food sources, and sedentary lifestyles are all drivers.

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Integrity test of a recent Cochrane mask review

March 15

People in medical masks in a subway carMany were surprised by a recent Cochrane review on masking that concluded, “Wearing masks in the community probably makes little or no difference to the outcome of laboratory‐confirmed influenza/SARS‐CoV‐2.” A similar conclusion was reached for N95 masks, albeit for influenza.

In an interview, the lead author of the study, Dr. Thomas Jefferson (no kidding), also claimed that the evidence for transmission by aerosols was “thin as air” and that the best defense was hand washing. He also claimed in April 2020 that deaths from COVID-19 were just a seasonal viral illness. For what it’s worth, his interviewer, Dr. Maryanne Demasi, had part of her PhD dissertation retracted for image manipulation.

In response to the kerfuffle, the Cochrane Library has issued a statement clarifying the findings. The statement notes that the intent was not to assess mask effectiveness, but to assess interventions promoting mask use. The review only included two studies during the COVID pandemic, and both strongly favored interventions to promote mask use.

The New York Times has an excellent summary of the evidence regarding masks and the misinterpretation of the Cochrane results.

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Medical groups launch effort to battle health misinformation

March 14Close up screen tablet in healthcare provider's lap

A partnership of 50 organizations called the Coalition for Trust in Health & Science made its debut earlier this month at the annual meeting of the American Association for the Advancement of Science (AAAS). Members of the coalition announced a two-year plan to develop resources and create a rapid-response platform to help combat what they call health disinformation. This article discusses the coalition. It's time to speculate on what anesthesiologists and the ASA Monitor could do to dispel common myths about anesthesia.

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Minnesota Rare Disease Day proclamation

March 10

Rare diseases are not that rare for anesthesiologists anymore because newer therapies for successful treatment are becoming more readily available. This increases the number of such patients requiring anesthesia care. There is a significant gap both in education and the delivery of health care to these patient populations. To improve this situation and bring more recognition to the issue, Minnesota Governor Tim Walz proclaimed February 28, 2023, as Rare Disease Day. The Minnesota Rare Disease Council, along with the University of Minnesota School of Pharmacy and Stem Cell Institute, and many other sponsors including patient advocacy groups, conducted a special symposium on March 2, 2023, to highlight medical issues of concern and reviewed scientific updates to improve the care of such patients. There were many takeaways from this special conference, including new knowledge on a cure for sickle cell disease, gene therapy for Gaucher disease, and translational research suggesting future possibilities for the reversal of adrenoleukodystrophy with medications. The conference concluded with a special quote by Caroline Belden: "Equality is leaving the door open for anyone who has the means to approach it; equity is ensuring there is a pathway to that door for those who need it."

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Aren’t you the valet? Tales of Black American surgeons

March 8Group of scrubbed-in surgeons lined up with heads bowed and eyes closed

Although this piece was written by two prominent surgeons, I am sure that there are anesthesiologists who have experienced this same scenario. Posted just after the end of Black History Month, it is a sobering reminder to me that as a profession and a society, we have much work to do. I, for one, know I am not perfect. I need to ask for forgiveness when I stray from the principle of treating all people with respect. There is so much I need to learn. I urge you to read this and join me.

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A world’s first: Scotland bans desflurane

March 7Medical professionals in the operating room

Scotland becomes the first country to ban desflurane for environmental reasons. Desflurane has a warming potential 2,500 times that of carbon dioxide, so more countries may soon follow suit. Global health care is the fifth largest contributor to greenhouse gases. The elimination of harmful inhalational anesthetics is just the beginning of the many steps needed to curb health care’s impact on climate change.

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Why aren’t we making a difference in perinatal medicine?

March 3

Graph from the WHO shows the rise in maternal mortality rate (MMR) from 2000 to 2020As documented this week in The Washington Post, the United States lags well behind other high-income countries in peripartum outcomes (see wapo.st/3ZrKEqa). Quoting the article: “By 2020, nearly all other rich countries saw the number of deaths per 100,000 births dip well below 10, while the U.S. saw a nearly 78% increase to 21 deaths per 100,000 births.” This graph from the WHO shows the rise in maternal mortality rate (MMR) from 2000 to 2020.

My items reported in ASA Monitor Today are in areas where anesthesiologists have little impact. Peripartum maternal mortality is an area where we have profound influence. The past 20 years have seen anesthesiologists bring ever-increasing training, skill, and medical expertise to perinatal medicine. Why aren’t we making a difference? How can maternal mortality have doubled over the past 10 years on our watch?

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Minnesota takes practical step to address physician burnout

March 2

A decision by the Minnesota Board of Medical Practice (MBMP) in support of physician wellness is one that the AMA says can be emulated by all other state medical boards – a nice shout out for a practical approach. Specifically, the MBMP revised a key (and intrusive) question asked of doctors applying for or renewing their license regarding their health and fitness for practice, part of an “encouraging trend” in eliminating barriers to physicians and med students seeking mental health care.

Zoonotic transfer or lab leak?

March 2

Police in street in front of Wuhan Institute of VirologyAs initially reported by The Wall Street Journal, the Department of Energy concluded that SARS-CoV-2 most likely resulted from a “lab leak” at the Wuhan Institute of Virology. The conclusion was reached with “low confidence.” The FBI shares this view, albeit with “medium confidence.” Other intelligence agencies believe it was zoonotic transfer. Confusingly, different government agencies have arrived at different conclusions. Neither the Department of Energy nor the FBI has shared the data that led to a divergent view from other agencies.

The scientific consensus continues to be that SARS-CoV-2 arose by zoonotic transfer at the Huanan Live Animal Market. There is an excellent and authoritative summary in Cell. One of the great pleasures of science is that conclusions are based on data. If either the Department of Energy or the FBI presents convincing data, then scientists will modify their conclusions based on the usual Bayesian approach of weighing new evidence against the prior probability of the conclusion and the quality of the evidence. However, absent either department coming forward with new evidence, quoting Edward Holmes in Cell, “the most parsimonious explanation for the origin of SARS-CoV-2 is a zoonotic event.”

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February 2023

‘Unwavering defense of democracy’: Thoughts on Ukraine after a year of war

February 28

Collage related to Ukraine warIf you want to be proud of our government and our unwavering defense of democracy, I urge you to read the interviews published in Politico about the run-up to the Russian invasion of Ukraine. Our top intelligence, military, and diplomatic officials provided on-record narratives of the intense international efforts to persuade Russia to resolve issues through diplomacy rather than military action, as well as the concurrent preparations for the worst-case scenario of an all-out land war in Europe. It’s an inspiring story to read on the anniversary of Russia’s unprovoked assault on a sovereign country.

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Drug-resistant P. aeruginosa linked to artificial tears

February 24

Close up on liquid drop dripping out of dropper tipped bottleThere is an extremely rare form of drug-resistant P. aeruginosa that has been found in 58 patients across 13 U.S. states, linked to artificial tears. Five people have lost vision and one has died. The CDC recommends immediate discontinuation of EzriCare Artificial Tears and other products until further notice.

From the CDC website:

As of February 21, 2023, CDC, in partnership with state and local health departments, identified 58 patients in 13 states (CA, CO, CT, FL, IL, NJ, NM, NY, NV, TX, UT, WA, WI) with VIM-GES-CRPA, a rare strain of extensively drug-resistant P. aeruginosa. Thirty-five patients were linked to four healthcare facility clusters. One person has died and there have been 5 reports of vision loss. Dates of specimen collection were from May 2022 to January 2023. Isolates have been identified from clinical cultures of sputum or bronchial wash (13), cornea (12), urine (9), other nonsterile sources (4), and blood (2), and from rectal swabs (25) collected for surveillance; some patients had specimens collected from more than one anatomic site.

Most patients reported using artificial tears. Patients reported over 10 different brands of artificial tears and some patients used multiple brands. EzriCare Artificial Tears, a preservative-free, over-the-counter product packaged in multidose bottles, was the brand most commonly reported. This was the only common artificial tears product identified across the four healthcare facility clusters. Laboratory testing by CDC identified the presence of VIM-GES-CRPA in opened EzriCare bottles from multiple lots; these bottles were collected from patients with and without eye infections and from two states. VIM-GES-CRPA recovered from opened products match the outbreak strain. Testing of unopened bottles of EzriCare Artificial Tears is ongoing to assist in evaluating for whether contamination may have occurred during manufacturing. Patients and healthcare providers should immediately stop the use of EzriCare Artificial Tears pending additional information and guidance from CDC and FDA.

FDA encourages health care professionals and patients to report adverse events or quality problems with any medicine to FDA’s MedWatch Adverse Event Reporting program. Consumers may also report adverse reactions by contacting FDA’s Consumer Complaint Coordinators.

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Closed Claims Case Reviews & Anesthesiologist Coverage

February 23

Close up on judge's gavel and two people shaking hands in backgroundA recent article in the APSF Newsletter about closed claims case review has implications for our profession and I wanted to share it with fellow anesthesiologists. “Non-Operating Room Anesthesia: Closed Claim Review and Analysis” offers two important findings on claims that resulted in indemnity payments, including:

  1. “Moreover, some NORA environments are prone to heightened scrutiny concerning production pressures and economic incentives, particularly in outpatient facilities with high procedure volumes. When a claim involves a code or another emergency, plaintiffs’ attorneys commonly examine the facility’s staffing and resources to assess whether appropriate personnel, equipment, and rescue medications were readily available. If they uncover any evidence intimating additional personnel or resources could have prevented a crisis or improved the patient’s outcome, they will fold these allegations into a basic yet effective theme: economic gain took priority over patient safety.”
  2. “Anesthesia professionals are often criticized for failing to appreciate the patient was high risk, or that they tailored the anesthesia plan to the facility’s practice model rather than the individual patient’s needs.”

Furthermore, their first recommendation states, “The easiest decisions to defend are those that are made in the best interest of the patient’s health and safety. To this end, anesthesia professionals should take sufficient time to perform a comprehensive preanesthesia evaluation and develop an anesthesia plan tailored to the patient based on the individual’s medical history and the nature of the planned procedure. Anesthesia professionals should have autonomy to select the anesthesia plan best suited for the patient, and while the proceduralist may provide input, the anesthesia professional should ultimately make the decision.”

But I found the following findings and recommendation important, and in my opinion, another reason that having a CRNA employed by a proceduralist makes implementation much harder than having an anesthesiologist supervising and evaluating each patient before the start of each anesthetic!

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Comparing nurses and physicians in the ER

February 21

Close up on nurse and doctor at patient's bedsideA working paper published in October by the National Bureau of Economic Research (NBER), titled The Productivity of Professions: Evidence from the Emergency Department, looked at around 1.1 million visits to 44 ERs in the VA, where nurses are able to treat patients without physician oversight. The document received a lot of press in major media outlets. The NBER indicated that treatment by a nurse practitioner resulted in an average 7% increase in costs of care and an 11% increase in LOS, which extended time in the ER by minutes for minor visits and hours for longer ones.

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Fighting scope creep in TeXas and beyond

February 17Illustration of politician facing healthcare workers and capitol building

An article on the Texas Medical Association (TMA) website says organized medicine is banding together to oppose a piece of federal legislation that advocates say would expand the scope of practice for nonphysician practitioners like nurses and physician assistants at the expense of Medicare and Medicaid patients. Another article details the TMA’s larger fight against scope creep and why this issue should be medicine’s top priority.

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Getting Paxlovid should not be this difficult

February 16

Paxlovid boxesIn the past week, I have heard from anesthesiologists at Stanford and other institutions who were unable to get Paxlovid after testing positive for Covid. Some were healthy. Others had significant risk factors. Some had mild cases. Others became profoundly ill. All were at risk of long-Covid.

Their experiences echo those described in a recent tirade in JAMAGetting Treated for Covid-19 Shouldn’t Be This Difficult” (Mangurian, 2022). Frustrated by physician reluctance to prescribe Paxlovid, the Department of Health for the State of California issued this advice last December: “The decision to not prescribe Covid-19 treatment should be reserved for situations in which the risk of prescribing clearly outweighs the benefits of treatment in preventing hospitalization, death, and the potential for reduced risk of long Covid.” Restating the above, the only reason to not prescribe Paxlovid is if the risks of taking Paxlovid outweigh the benefits. That assessment is the basis of every therapeutic decision we make as physicians. All of us are at risk from Covid-19.

According to a paper published last week, there were 4,511 excess physician deaths from March 2020 through December 2021 (Kiang et al., JAMA Internal Medicine, 2023). While that is fewer than the rate of excess deaths in the general population during the pandemic, we are nevertheless at risk of serious illness, hospitalization, death, and long Covid.

As I explained previously in ASA Monitor Today, Paxlovid is not in short supply. Nirmatrelvir (the antiviral) has no known interactions with human proteins. It just tastes bad. Ritonavir, the CYP 3A4 inhibitor, has very few potentially consequential interactions with other drugs (e.g., warfarin, beta blockers, possibly anti-epileptics) when taken for just five days. Paxlovid is our only highly effective treatment for Covid-19. If you get Covid-19, get Paxlovid. If your colleagues get Covid-19, prescribe Paxlovid.

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Bad outcomes aren’t always negligence

February 15

CourtroomAn article published recently on the AMA website says that physicians in Oregon are telling the Oregon Supreme Court that doctors can’t guarantee good results for every patient they treat – and this is something juries need to be reminded of in court cases, especially ones that may “pull at the heartstrings.”

But if an Oregon appellate decision is allowed to stand, jurors would no longer hear a longstanding piece of the Oregon’s Uniform Civil Jury Instruction that says “physicians are not negligent merely because their efforts were unsuccessful” and that “a physician does not guarantee a good result by undertaking to perform a service.”

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Aiding the earthquake victims of Turkey and Syria

February 14

Photo at Turkey Earthquake Relief 2023, Helping Hands eventLike many of you watching the news reports about the devastation and loss of life caused by the earthquake in Turkey and Syria, our family is looking for ways to help those affected by the earthquake. Please consider donating to a trusted and verified organization if you are able to contribute. Both the Helping Hand for Relief and Development and the Syrian American Medical Society Foundation are trusted and verified organizations that provide on-the-ground relief (charity navigator ratings of 98% and 100%, respectively). The Syrian American Medical Society has also created a form to gauge interest in deploying as a volunteer on the ground.

Our thoughts and prayers are with family, friends, and their families, and all those affected by the terrible tragedy in Syria and Turkey. May God give them comfort and strength as they go through this ordeal and rebuild their lives.

Can philanthropic agendas worsen health care disparities?

February 14Ana Maria Crawford

The World Economic Forum (WEC) concluded last month under the theme “Cooperation in a Fragmented World” and called on world leaders to address immediate economic, energy, food, and health crises “while laying the groundwork for a more sustainable, resilient world.”

Around the same time, Gates Foundation CEO Mark Suzman was interviewed by Reuters and called for increased governmental spending on health care: “It's not right for a private philanthropy to be one of the largest funders of multinational global health efforts.”

Yet large funders continue their obsession with "technology" and "innovation," while most health care systems lack essentials such as oxygen and electricity. Are western-driven agendas worsening the disparity they are trying to address?

For further reading, you might be interested in the article “Ventilators are not the answer in Africa” by an anesthesiologist from Botswana.

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Syrians need our help

February 10Syrian building crumbling in background with people in streets in foreground

The earthquake in Turkey and Syria has been devastating. The official numbers underestimate the extent of the casualties. The president of the Syrian American Medical Society (SAMS) has issued an appeal for anesthesiologists to help care for thousands of injured Syrians. If you are interested, please contact me at steven.shafer@stanford.edu, and I will direct you toward colleagues who are organizing this effort.

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January 2023

A call to action on global critical care

January 31Ana Maria Crawford

The pandemic has opened an opportunity window for those of us working toward equity in access to critical care. Much like safe surgery, universal health coverage cannot be achieved without it. Unfortunately, solutions remain siloed, and there is a continued obsession with technology when many places lack the very essentials such as oxygen and reliable electricity. This article in Critical Care is important as it represents the perspective of providers living and working in resource-constrained settings. Eleven of the 12 authors are in low- and middle-income countries. All authors have worked together in many capacities over the years to improve critical care capacity for their patients. This narrative outlines several barriers but also offers solutions to make universal critical care a reality.

 

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A call to action on global critical care

January 31Ana Maria Crawford

The pandemic has opened an opportunity window for those of us working toward equity in access to critical care. Much like safe surgery, universal health coverage cannot be achieved without it. Unfortunately, solutions remain siloed, and there is a continued obsession with technology when many places lack the very essentials such as oxygen and reliable electricity. This article in Critical Care is important as it represents the perspective of providers living and working in resource-constrained settings. Eleven of the 12 authors are in low- and middle-income countries. All authors have worked together in many capacities over the years to improve critical care capacity for their patients. This narrative outlines several barriers but also offers solutions to make universal critical care a reality.

 

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