Patient Simulation: A Literary Synthesis of Assessment Tools in Anesthesiology

High-fidelity patient simulation (HFPS) has been hypothesized as a modality for assessing competency of knowledge and skill in patient simulation, but uniform methods for HFPS performance assessment (PA) have not yet been completely achieved. Anesthesiology as a field founded the HFPS discipline and also leads in its PA. This project reviews the types, quality, and designated purpose of HFPS PA tools in anesthesiology. We used the systematic review method and systematically reviewed anesthesiology literature referenced in PubMed to assess the quality and reliability of available PA tools in HFPS. Of 412 articles identified, 50 met our inclusion criteria. Seventy seven percent of studies have been published since 2000; more recent studies demonstrated higher quality. Investigators reported a variety of test construction and validation methods. The most commonly reported test construction methods included "modified Delphi Techniques" for item selection, reliability measurement using inter-rater agreement, and intra-class correlations between test items or subtests. Modern test theory, in particular generalizability theory, was used in nine (18%) of studies. Test score validity has been addressed in multiple investigations and shown a significant improvement in reporting accuracy. However the assessment of predicative has been low across the majority of studies. Usability and practicality of testing occasions and tools was only anecdotally reported. To more completely comply with the gold standards for PA design, both shared experience of experts and recognition of test construction standards, including reliability and validity measurements, instrument piloting, rater training, and explicit identification of the purpose and proposed use of the assessment tool, are required

Respiratory complications during recovery from gastrointestinal endoscopies performed by gastroenterologists under moderate sedation

Background/Aims Data on the incidence of adverse respiratory events during recovery from gastrointestinal endoscopy are limited. The aim of this study was to investigate the incidence of these complications. Methods In this retrospective cohort study, data were obtained from the electronic records of 657 consecutive patients, who underwent gastroenterological procedures under sedation. Results Pulse oximetry oxygen saturation (SpO2) 60 seconds occurred in 79 patients (12.0%) and in 14 patients (2.1%), and SpO2 <75% occurred in four patients (0.6%) and in no patients during the procedure and recovery period, respectively. No major complications were noted. The occurrence of desaturation during recovery was correlated with desaturation during the procedure (p<0.001). Higher American Society of Anesthesiologists score (odds ratio [OR], 1.867; 95% confidence interval [CI], 1.008–3.458), ischemic heart disease (OR, 1.815; 95% CI, 0.649–5.080), hypertension (OR, 1.289; 95% CI, 0.472–3.516), and diabetes mellitus (OR, 2.406; 95% CI, 0.950–6.095) increased the occurrence of desaturation during recovery. Conclusions We found no major complications during recovery after balanced propofol-based sedation administered by a gastroenterologist-nurse team. Patients with the identified risk predictors must be monitored carefully

EMR documentation of physician–patient communication following genomic counseling for actionable complex disease and pharmacogenomic results

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/136350/1/cge12820.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/136350/2/cge12820_am.pd

Respiratory Physiology and the Impact of Different Modes of Ventilation on the Photoplethysmographic Waveform

The photoplethysmographic waveform sits at the core of the most used, and arguably the most important, clinical monitor, the pulse oximeter. Interestingly, the pulse oximeter was discovered while examining an artifact during the development of a noninvasive cardiac output monitor. This article will explore the response of the pulse oximeter waveform to various modes of ventilation. Modern digital signal processing is allowing for a re-examination of this ubiquitous signal. The effect of ventilation on the photoplethysmographic waveform has long been thought of as a source of artifact. The primary goal of this article is to improve the understanding of the underlying physiology responsible for the observed phenomena, thereby encouraging the utilization of this understanding to develop new methods of patient monitoring. The reader will be presented with a review of respiratory physiology followed by numerous examples of the impact of ventilation on the photoplethysmographic waveform

Influence of anesthesia on hemodynamic assessment of mitral stenosis severity

Background: The treatment of choice for severe rheumatic mitral stenosis (MS) is balloon mitral valvuloplasty (BMV). Assessment of MS severity is usually performed by echocardiography. Before performing BMV, invasive hemodynamic assessment is also performed. The effect of anesthesia on the invasive assessment of MS severity has not been studied. The purpose of the present study was to assess changes in invasive hemodynamic measurement of MS severity before and after induction of general anesthesia. Methods: The medical files of 22 patients who underwent BMV between 2014 and 2020 were reviewed. Medical history, laboratory, echocardiographic and invasive measurements were collected. Anesthesia induction was performed with etomidate or propofol. Pre-procedural echocardiographic measurements of valve area using pressure half time, and continuity correlated well with invasive measurements using the Gorlin formula. Results: After induction of anesthesia the mean mitral valve gradient dropped by 2.4 mmHg (p = 0.153) and calculated mitral valve area (MVA) increased by 0.2 cm2 (p = 0.011). A wide variability in individual response was observed. While a drop in gradient was noted in 14 patients, it increased in 7. Gorlin derived MVA rose in most patients but dropped in 4. Assuming a calculated MVA of 1.5 cm2 and below to define clinically significant MS, 4 patients with pre-induction MVA of 1.5 cm2 or below had calculated MVA above 1.5 cm2 after induction. Conclusions: The impact of general anesthesia on the hemodynamic assessment of MS is heterogeneous and may lead to misclassification of MS severity

Prognostic Factors for Distress After Genetic Testing for Hereditary Cancer

The psychological impact of an unfavorable genetic test result for counselees at risk for hereditary cancer seems to be limited: only 10-20 % of counselees have psychological problems after testing positive for a known familial mutation. The objective of this study was to find prognostic factors that can predict which counselees are most likely to develop psychological problems after presymptomatic genetic testing. Counselees with a 50 % risk of BRCA1/2 or Lynch syndrome completed questionnaires at three time-points: after receiving a written invitation for a genetic counseling intake (T1), 2-3 days after receiving their DNA test result (T2), and 4-6 weeks later (T3). The psychological impact of the genetic test result was examined shortly and 4-6 weeks after learning their test result. Subsequently, the influence of various potentially prognostic factors on psychological impact were examined in the whole group. Data from 165 counselees were analyzed. Counselees with an unfavorable outcome did not have more emotional distress, but showed significantly more cancer worries 4-6 weeks after learning their test result. Prognostic factors for cancer worries after genetic testing were pre-existing cancer worries, being single, a high risk perception of getting cancer, and an unfavorable test result. Emotional distress was best predicted by pre-existing cancer worries and pre-existing emotional distress. The psychological impact of an unfavorable genetic test result appears considerable if it is measured as "worries about cancer." Genetic counselors should provide additional guidance to counselees with many cancer worries, emotional distress, a high risk perception or a weak social network

Non invasive prenatal testing for single gene disorders:Exploring the ethics

Non-invasive prenatal testing for single gene disorders is now clearly on the horizon. This new technology offers obvious clinical benefits such as safe testing early in pregnancy. Before widespread implementation, it is important to consider the possible ethical implications. Four hypothetical scenarios are presented that highlight how ethical ideals of respect for autonomy, privacy and fairness may come into play when offering non-invasive prenatal testing for single gene disorders. The first scenario illustrates the moral case for using these tests for ‘information only', identifying a potential conflict between larger numbers of women seeking the benefits of the test and the wider social impact of funding tests that do not offer immediate clinical benefit. The second scenario shows how the simplicity and safety of non-invasive prenatal testing could lead to more autonomous decision-making and, conversely, how this could also lead to increased pressure on women to take up testing. In the third scenario we show how, unless strong safeguards are put in place, offering non-invasive prenatal testing could be subject to routinisation with informed consent undermined and that woman who are newly diagnosed as carriers may be particularly vulnerable. The final scenario introduces the possibility of a conflict of the moral rights of a woman and her partner through testing for single gene disorders. This analysis informs our understanding of the potential impacts of non-invasive prenatal testing for single gene disorders on clinical practice and has implications for future policy and guidelines for prenatal care