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Cardiopulmonary resuscitation (CPR) is a series of lifesaving actions to maintain breathing and blood flow in a person who experiences cardiac or respiratory arrest [1]. It involves manual application of chest compressions and breaths to those in cardiopulmonary arrest and is often conducted to maintain viability in an emergency until help arrives or more comprehensive interventions are accessible [1]. Though certain groups of professionals are trained to perform CPR, the average person can also become certified. In response to guidelines from the American Heart Association, CPR training programs have been implemented nationwide in recent years [2]. It has been found that community CPR training programs save 24 to 56 lives per 100,000 adults every year [2]. Therefore, the quick recognition of cardiopulmonary arrest and early initiation of CPR is critical to preventing loss of life [2]. 

The first step to successful CPR is to check the scene for safety and form a quick assessment of the surroundings [3]. If a person appears unresponsive, check for signs of life such as eye movements, breathing, and pulse [3]. The “shout-tap-shout” method can be used to assess a person’s responsiveness – in which the responder assesses whether the person responds to sound or touch stimulus [3]. Other signs of a person who may be in need of CPR include gasping and seizure activity [4]. If the person is unresponsive or showing other signs of cardiopulmonary arrest, the next step is to call for help [3]. The first responder to the scene should alert nearby people to the emergency, call 9-1-1, and ask for equipment such as an AED [3]. Before starting CPR, the person should be placed on their back on a firm, flat surface if possible [3]. Chest compressions can then begin at a rate of 100 to 120 per minute, alternating between 30 chest compressions and administering 2 breaths of air [3]. To provide breaths, tilt the head backward and lift the chin [3]. Each breath should last about one second and cause the chest wall to rise [3]. Allow the chest to relax before administering the second breath [3]. 

The American Heart Association and the American Red Cross recommend different CPR compression techniques for infants, children, and adults [2]. For an infant, chest compressions are completed by placing two fingers of one hand over the lower half of the infant’s sternum (slightly below the nipple line) and depressing the chest inward about 0.5 to 1 inch with each compression [2]. For a child aged 1 to 8 years, chest compressions are delivered by placing the heel of one hand over the lower half of the sternum and depressing 1 to 1.5 inches per compression. For people aged 8 years and older, the standard CPR resuscitation technique is used [2]. Both hands are centered on the chest, with shoulders directly over hands and elbows locked [3]. The depth of each compression should be at least 2 inches, allowing for the chest wall to return to normal position after each compression [3]. 

When available, an automated external defibrillator (AED) should be incorporated into the CPR effort [1]. AEDs play an important role in the resuscitation of those with dangerously abnormal heart rhythms, such as ventricular fibrillation or pulseless ventricular tachycardia, by monitoring the heart rhythm and administering an electric shock if needed that can aid in restoring a normal rhythm and spontaneous blood circulation [1]. AEDs may be found in certain public areas, such as hospitals, airports, and some commercial spaces [4]. When making the decision to initiate CPR, it is best to ask fellow bystanders to assist with locating a nearby AED so that compressions can begin without delay [4]. 

The key to success for CPR resuscitation is “early-early-early,” meaning early recognition, early chest compressions, and early defibrillation [4]. Appropriate early intervention increases the chance of resuscitation, and earlier return of spontaneous blood circulation improves long-term outcome for the patient [4]. Many organizations offer classes that the average person can take to become trained and certified. 

References 

1. Bhatnagar, V., Jinjil, K., Dwivedi, D., Verma, R., & Tandon, U. (2018). Cardiopulmonary resuscitation: unusual techniques for unusual situations. Journal of emergencies, trauma, and shock, 11(1), 31. doi:10.4103/JETS.JETS_58_17 

2. Wang, J., Ma, L., & Lu, Y. (2015). Strategy analysis of cardiopulmonary resuscitation training in the community. Journal of thoracic disease, 7(7), E160–E165. doi:10.3978/j.issn.2072-1439.2015.06.09 

3. The American Red Cross. (n.d.). CPR steps: Perform CPR. Red Cross. Retrieved from https://www.redcross.org/take-a-class/cpr/performing-cpr/cpr-steps  

4. Truong, H., Low, L. S., & Kern, K. (2015). Current approaches to cardiopulmonary resuscitation. Current problems in cardiology, 40(7), 275-313. doi:10.1016/j.cpcardiol.2015.01.007 

Proper preoperative, intraoperative, and postoperative warming of patients is critical for reducing incidences of perioperative hypothermia, defined as a core body temperature of less than 36°C [1]. Besides being highly uncomfortable, hypothermia can lead to significant adverse events including intraoperative blood loss, coagulation abnormalities, increased post-op infection rates, and prolonged recoveries and hospital stays [1,2]. Several methods using convective and conductive warming techniques have been developed to lower the risk of hypothermia during and after surgery.

Conductive warming techniques involve direct contact of heated materials with exposed skin surfaces. A common example of this is pre- and postoperative warming of patients using heated blankets. This method is generally easy to deploy since most well-resourced hospitals are stocked with warm towels for surgical candidates. Though easy to utilize, this method is limited by the duration for which the material remains warm and the pressure of the material on the patient’s skin. In contrast, convective warming refers to movement of gas or liquids to transfer heat energy to another object. Forms of convective heating include the popular use of forced-air warmers or IV fluid warming devices. Forced-air warmers operate by distributing heated air generated by a power unit through a specifically designed blanket [1]. IV fluid warming involves administering warm fluids through patient IV lines. For both conductive and convective warming, there is a risk of thermal injury if heated material is too hot or placed underneath body regions that create high pressure points between the skin and heated material [1].

Literature demonstrates that conductive warming is generally less efficacious than convective warming [1-4]. Emmert et al’s 2017 study compared conductive and convective warming in patients undergoing video-assisted thoracic surgery. In this study, 60 patients were either warmed using Temp° Jelly blankets and two leg blankets (conductive warming), or with forced-air warmers (convective warming) during surgery. Their baseline assessments revealed no differences in the length of surgery, duration of pre-warming and initial core temperatures between both groups. However, a significant difference was found in core body temperatures between both groups 15 minutes into the surgery and at the end. Seventy-four percent of patients in the conductive group had a core temperature below 36°C within the first 15 minutes of surgery, compared to just 24% of patients in the convective group (p < 0.001). Only 8% of patients in the convective group had a core temperature less than 36°C at the end of surgery, compared to a staggering 56.5% in the conduction group (p < 0.001).

Emmert et al’s study is one of many that highlight the superiority of convective warming over conductive warming intraoperatively. An additional comparison can be made between two forms of convection warming: IV fluids and forced-air heating. A meta-analysis by John et al. (2014), demonstrates that administering warmed IV fluid led to significant reductions in the incidence of accidental perioperative hypothermia in gynecological and abdominal surgeries. However, a clinical trial by Boayam in 2018 found that forced-air warming was clinically more effective than fluid warming at preventing hypothermia in patients undergoing gynecological surgery.

In summary, there are many ways to prevent perioperative hypothermia. Deciding which warming method to use requires careful consideration but should be a high priority in order to minimize postoperative adverse events.

References 

1. John, M., Ford, J., & Harper, M. (2014). Peri‐operative warming devices: performance and clinical application. Anaesthesia, 69(6), 623-638. doi:10.1111/anae.12626 

2. Emmert, A., Franke, R., Brandes, I. F., Hinterthaner, M., Danner, B. C., Bauer, M., & Bräuer, A. (2017). Comparison of conductive and convective warming in patients undergoing video-assisted thoracic surgery: a prospective randomized clinical trial. The Thoracic and Cardiovascular Surgeon, 65(05), 362-366. doi:10.1055/s-0036-1583766. 

3. Convective vs. Conductive Warming. 3M Health Care. (2011). https://multimedia.3m.com/mws/media/905363O/b-8-3-convective-vs-conductive-warming.pdf 

4. Hohn, L., Schweizer, A., Kalangos, A., Morel, D. R., Bednarkiewicz, M., & Licker, M. (1998). Benefits of intraoperative skin surface warming in cardiac surgical patients. British journal of anaesthesia, 80(3), 318-323. 

5. Boayam, W. (2018). Comparison between Forced Air and Intravenous Fluid Warmer in Gynecologic Laparoscopic Surgery: A Randomized Trial (Doctoral dissertation, Department of Anesthesiology Institution Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok). 

Total intravenous anesthesia (TIVA) is anesthesia administered entirely through an IV. Though TIVA is considered a form of general anesthesia, it differs from most approaches in that it excludes the use of volatile agents.

TIVA is typically used to induce temporary analgesia and loss of consciousness in the operating room. A trained anesthesiologist is responsible for determining drug selection, concentration, and infusion rates.^1,2,3 Studies have suggested that TIVA confers several advantages over the use of other general anesthesia techniques. It is particularly useful in scenarios where stress-free conscious extubation is indicated, as TIVA suppresses airway activity, reducing the frequency of bronchospasm and laryngospasm in children.^1,2 TIVA has also been shown to reduce post-operative nausea and vomiting.³ Finally, patients who require wakeup during surgery are significantly less likely to remember the occurrence under TIVA as compared to volatile agents.³ For these reasons and several others, it is the preferred anesthetic approach for a number of specific indications, including:³

• Long QT syndrome 
• Malignant hyperthermia risk 
• History of severe postoperative nausea/vomiting 
• Patients with complicated/compromised airways 
• Neurosurgery or surgery requiring neurophysiological monitoring 
• “Tubeless” ENT or thoracic surgery 
• Cases where neuromuscular blocking is contraindicated: for example, in patients with neuromuscular disorders 

Moreover, TIVA eliminates the risk of environmental leakage of volatile anesthetic agents, making anesthesia delivery more efficient as well as safer for those in the operating room.

TIVA can be delivered manually using a pump; however, nowadays, the standard of care utilizes programmed pumps that display and process pharmacokinetic information.² Such pumps can adjust infusion rates to maintain a certain plasma concentration of anesthetic. This, along with consideration of factors such as age or weight, allows for individualization of dosing. The most frequently used anesthetic cocktail for TIVA is propofol augmented with an opioid, though technically any hypnotic drug could be used in its place.⁴ Notably, infusions of both propofol and remifentanil have been identified as the “gold standard” of TIVA for achieving appropriate depth of sedation and rapid recovery.³

Despite its advantages, there are some risks to TIVA, mainly related to system failure or miscalculation of infusion rate. TIVA is both technically complex and labor-intensive, which is one of the reasons that anesthesiologists often prefer to incorporate volatile agents. All possible measures must be taken to ensure that anesthetic infusion is maintained at a constant and appropriate rate. For example, it is recommended that only dedicated pharmacokinetic pumps be used, and that these pumps be serviced a minimum of once every twelve months. Great care must be taken when programming the pump with patient information, needle size, and drug type/dilution, as input of incorrect information could lead to either dangerous or inadequate drug concentrations. Special training is required to manage the pharmacokinetic pumps, and this training must be specific to pump brand and model.³

These considerations have historically discouraged anesthesiologists from employing TIVA. However, the trend seems to be reversing. Increasingly, programming and technology replaces the need for human calculation and manual intervention. These improving technologies continue to make TIVA safer and more prevalent as an anesthetic technique.

References 

¹ Gaynor, J., & Ansermino, J. M. (2016). Paediatric total intravenous anaesthesia. BJA Education, 16(11), 369-373. https://doi.org/10.1093/bjaed/mkw019 

² Lauder, G. R. (2015). Total intravenous anesthesia will supercede inhalational anesthesia in pediatric anesthetic practice. Pediatric Anesthesia, 25(1), 52-64. 

³ Al-Rifai, Z., & Mulvey, D. (2016). Principles of total intravenous anaesthesia: practical aspects of using total intravenous anaesthesia. British Journal of Anaesthesia, 16(8), 276-280. https://doi.org/10.1093/bjaed/mkv074  

⁴ Anderson, B. J., & Houghton, J. (2018, February 9). Total intravenous anesthesia and target-controlled infusion. A Practice of Anesthesia for Infants and Children (Sixth Edition). https://www.sciencedirect.com/science/article/pii/B9780323429740000082 

Over a year after the beginning of the COVID-19 pandemic, much remains to be elucidated about how the human body responds to the SARS-CoV-2 virus. Some individuals show no symptoms, others recover swiftly, and yet others suffer from a severe or even fatal symptoms. Autoantibodies, which have been found to erroneously target a body’s own tissues across a range of autoimmune diseases, such as lupus and rheumatoid arthritis, may explain some of the clinical heterogeneity seen in COVID-19.

One study of 147 hospitalized COVID-19 patients found that autoantibodies may account for a large proportion of serious or fatal COVID-19 cases ¹. Researchers demonstrated that about half of patients hospitalized for COVID-19 harbored at least one type of autoantibody in their bloodstream. Among the study participants who had their blood drawn on more than one day, about 20% harbored no autoantibodies when they were first admitted but developed them over the course of their COVID-19 infection; in certain individuals, autoantibody levels were extremely high, mirroring levels characteristic of autoimmune diseases. In contrast, only 15% of healthy controls harbored such antibodies. Common targets of these antibodies included immune system proteins, such as the cytokines.

Recent research has also found that some severe cases of COVID-19 could be linked to problems with the important immune system protein required to ward off viral infections, type I interferon (IFN) ^2-3. One study found that an X-linked recessive TLR7 deficiency disrupting IFN production could account for at least 1% of cases of life-threatening COVID-19 in men under 60 ³. More commonly however, patients were found to harbor blood-borne IFN-targeting antibodies. In a large-scale international assessment of patients with severe COVID-19 alongside uninfected participants, researchers found that 10% of patients with COVID-19 pneumonia had high levels of autoantibodies to type I IFNs ², while people with no or mild symptoms had very low levels of these autoantibodies. The likelihood of producing such autoantibodies increased with age: while less than 10% of individuals under 40 with severe COVID-19 harbored these autoantibodies in active form, over 20% of individuals over 80 had them.

Even very low levels of autoantibodies against IFNs can be clinically screened for. Assessing the presence of these autoantibodies may thus help predict disease progression, enabling appropriate preparations.

Following COVID-19, a small number of patients have developed a range of different autoimmune diseases, including Guillain-Barre syndrome ^4,5. Autoimmune symptoms appear to be triggered alongside or immediately after respiratory symptoms.  

To elucidate the link between COVID-19 and autoimmunity, prediction algorithms have been used to identify regions of SARS-CoV-2 proteins that antibodies may recognize and bind to, after which these were compared to all human proteins to search for potential similarities ⁶. Interestingly, many of the human proteins identified were already associated with a number of other diseases, such as multiple sclerosis, rheumatoid arthritis, and lupus, while others were associated with diseases of the cardiovascular and respiratory systems, as well as epilepsy – some of which have been identified as COVID-19 symptoms.

Much remains to be elucidated as regards autoimmune reactions due to COVID-19. Although inflammation is likely to play a role, the precise mechanisms triggering such autoantibody production remain unclear. Research will also need to dissect how these autoantibodies add to or exacerbate COVID-19 symptoms, including in the context of long COVID.

References

1.       Chang, S. E. et al. New-onset IgG autoantibodies in hospitalized patients with COVID-19. Nat. Commun. (2021). doi:10.1038/s41467-021-25509-3

2.       Bastard, P. et al. Autoantibodies against type I IFNs in patients with life-threatening COVID-19. Science (80-. ). (2020). doi:10.1126/science.abd4585

3.       Asano, T. et al. X-linked recessive TLR7 deficiency in ~1% of men under 60 years old with life-threatening COVID-19. Sci. Immunol. (2021). doi:10.1126/sciimmunol.abl4348

4.       Moody, R., Wilson, K., Flanagan, K. L., Jaworowski, A. & Plebanski, M. Adaptive immunity and the risk of autoreactivity in covid-19. International Journal of Molecular Sciences (2021). doi:10.3390/ijms22168965

5.       Toscano, G. et al. Guillain–Barré Syndrome Associated with SARS-CoV-2. N. Engl. J. Med. (2020). doi:10.1056/nejmc2009191

6.       Moody, R. et al. Predicted B Cell Epitopes Highlight the Potential for COVID-19 to Drive Self-Reactive Immunity. Front. Bioinforma. (2021). doi:10.3389/fbinf.2021.709533

7.       Khamsi, R. Rogue antibodies could be driving severe COVID-19. Nature 590, 29–31 (2021). doi:10.1038/d41586-021-00149-1

Spirituality is an important part of medical care that many patients desire. Patients facing major illnesses or injuries are frequently in once-in-a-lifetime situations that they could not have emotionally prepared for and often turn to religion and spirituality as a source of comfort. Religion and spirituality are associated with positive medical and psychiatric outcomes, especially in older adults, which makes it an important part of caring for the patient as a whole in medicine. There has been much published data on how religion and spirituality can improve depression, anxiety, and substance use disorders.¹ While hospitals frequently have chaplains for these discussions, many patients hope that physicians can engage in these conversations as well. In a study with hospital inpatients, 77% of the inpatients said physicians should consider their spiritual needs as it relates to their health, yet 68% of patients said their physician never discussed religious beliefs with them.² This suggests there is a gap between what patients hope to receive from medicine in terms of discussions on spirituality and what physicians are delivering.

In a study investigating the medical community’s opinion of religion and spirituality, a survey with almost 900 resident physician respondents from all clinical specialties demonstrated that 75% of residents believed religion and spirituality was important for patient health and that it was important to discuss with patients.³ However, only 14.4% of residents reported doing so in practice. Reasons for why they did not included concern for maintaining professional neutrality and concern about offending patients. Interestingly, in another study looking at how physicians’ beliefs influence their frequency of religious and spiritual discussions, physicians who self-reported to be religious or spiritual had these discussions with patients more than non-religious/spiritual physicians did.⁴ This suggests physicians who are non-religious/spiritual may be less comfortable initiating these conversations and are at a disadvantage in providing religious and spiritual support to patients. In addition, providers with diverse beliefs can help the field as a whole better address patients’ needs.

The American Association of Medical Colleges (AAMC) publishes objectives for medical students, which includes the ability to ask about spiritual history and understand how spirituality can improve healthcare outcomes.⁵ Because spirituality can affect the patient’s health, all providers should be educated in how to have these discussions in the context of medicine regardless of their own personal beliefs. However, in practice, medical schools and residencies train learners very little in the skills needed to be comfortable with these discussions. There is little to no formal training or practice which would likely increase physicians’ comfort in asking about religion and spirituality. Increased training is necessary in the future to have more holistic medical care that takes into account the religious and spiritual preferences of the patient, in the hopes of improving their healthcare outcomes.

References

1. Koenig HG. Religious attitudes and practices of hospitalized medically ill older adults. Int J Geriatr Psychiatry. 1998 Apr;13(4):213-24. doi: 10.1002/(sici)1099-1166(199804)13:4<213::aid-gps755>3.0.co;2-5. PMID: 9646148.
2. King DE, Bushwick B. Beliefs and attitudes of hospital inpatients about faith healing and prayer. J Fam Pract. 1994 Oct;39(4):349-52. PMID: 7931113.
3. Vasconcelos APSL, Lucchetti ALG, Cavalcanti APR, da Silva Conde SRS, Gonçalves LM, do Nascimento FR, Chazan ACS, Tavares RLC, da Silva Ezequiel O, Lucchetti G. Religiosity and Spirituality of Resident Physicians and Implications for Clinical Practice-the SBRAMER Multicenter Study. J Gen Intern Med. 2020 Dec;35(12):3613-3619. doi: 10.1007/s11606-020-06145-x. Epub 2020 Aug 19. PMID: 32815055; PMCID: PMC7728988.
4. Franzen AB. Influence of Physicians’ Beliefs on Propensity to Include Religion/Spirituality in Patient Interactions. J Relig Health. 2018 Aug;57(4):1581-1597. doi: 10.1007/s10943-018-0638-7. PMID: 29876717.
5. Association of American Medical Colleges (AAMC). Contemporary issues in medicine: communication in medicine. Medical school objectives project, Report III. 1999

Laryngeal mask airway (LMA) facilitates surgeries by providing high airtightness, low stimulation, and easier management of the supraglottic airway [1]. It is widely used to control the airways of pediatric surgical patients [2]. Unfortunately, laryngeal mask airway removal can result in adverse airway events, so anesthetic choice and timing must be carefully considered to prevent such occurrences [1].

Generally, isoflurane and sevoflurane are the anesthetic agents of choice for LMA [3]. This is because they tend to promote faster recovery [3]. However, other agents could reduce the risk of adverse airway-related events and thus merit consideration for use alongside LMA. One such agent is desflurane. Although desflurane does not permit as fast a recovery as other inhaled anesthetic agents, its pharmacokinetic qualities and rapid metabolism can render it appropriate for use in low-flow systems [3]. To address desflurane’s longer laryngeal mask airway removal times, medical teams can administer it in an entropy-guided low-flow context [3]. This technique has demonstrably promoted lower consumption of anesthetics and shorter removal time compared with minimal alveolar concentration-guided anesthesia [3].

Other variations on anesthetic practice that promote better outcomes include the combined use of propofol with isoflurane, or dexmedetomidine with sevoflurane [2, 4]. Kumar and colleagues found that deep anesthesia via a propofol-isoflurane combination resulted in a lower incidence of teeth clenching and airway obstruction, and a shorter emergence duration compared to isoflurane alone [2]. On the other hand, Bhat and colleagues found that dexmedetomidine (1 µg /kg) with sevoflurane decreased emergence agitation and promoted smoother removal of LMA than normal saline or lower dose dexmedetomidine (0.5 1 µg /kg) with sevoflurane [4].

As for timing, physicians looking to remove a patient’s laryngeal mask airway generally contemplate two options: removal during deep anesthesia, or removal following emergence [2]. Significant challenges are associated with each possibility. Removal under deep anesthesia risks events such as glossocoma and pharyngalgia, while removal in the awake state can lead to PACU complications and coughing [1].

Several experiments have sought to determine which option is preferable in different contexts. Sun et al conducted a randomized controlled trial consisting of children undergoing squint correction operations with general anesthesia [1]. They measured adverse airway events such as glossocoma, pharyngalgia, coughing, and laryngeal spasm rates [1]. When lidocaine cream was applied to the LMA cuff prior to insertion, removal in the awake state was generally preferable to deep anesthesia removal [1]. This was also true when hydrosoluble lubricant had been applied to the LMA instead of lidocaine cream [1].

Ramgolam et al found that tonsillectomy patients aged 0 to 16 years old exhibited no significant difference in adverse events overall, regardless of whether removal occurred while they were under deep anesthesia or awake [5]. However, subjects who experienced deep removal were more likely to suffer respiratory adverse events [5]. In a larger pool of subjects, this could mean that deep anesthesia laryngeal mask airway removal results in increased costs, hospital stays, and postsurgical adverse events [6].

On a parallel note, Asahi and colleagues narrowed their focus to pediatric patients with special needs [7]. These patients require extra consideration, given their difficulty complying with instructions during removal [7]. The 80 patients were divided into two groups: removal during the pre-awake state and the deep anesthesia state [7]. The pre-awake states exhibited gross body movement, more clenching, and difficult ventilation, suggesting that deep anesthesia may be preferable for this subsection of patients [7].

The optimal LMA removal technique requires a complex inquiry into anesthetic agents, timing, and patients’ individual abilities to comply with instructions. By accounting for these factors, physicians can provide for easier removal and fewer adverse airway events.

References 

[1] R. Sun et al., “The impact of topical lidocaine and timing of LMA removal on the incidence of airway events during the recovery period in children: a randomized controlled trial,” BMC Anesthesiology, vol. 21, no. 10, p. 410-417, January 2021. [Online]. Available: https://doi.org/10.1186/s12871-021-01235-7. 

[2] D. Kumar et al., “Isoflurane alone versus small dose propofol with isoflurane for removal of laryngeal mask airway in children-a randomized controlled trial,” Journal of Pakistan Medical Association, vol. 69, no. 11, p. 1596-1600, November 2019. [Online]. Available: https://doi.org/10.1186/s12871-021-01235-7. 

[3] S. Mishra et al., “Effect of entropy-guided low-flow desflurane anaesthesia on laryngeal mask airway removal time in children undergoing elective ophthalmic surgery – A prospective, randomised, comparative study,” Indian Journal of Anaesthesia, vol. 63, no. 6, p. 485-490, June 2019. [Online]. Available: http://doi.org/10.4103/ija.IJA_237_19. 

[4] R. Bhat et al., “Study of dose related effects of dexmedetomidine on laryngeal mask airway removal in children -a double blind randomized study,” Anaesthesia, Pain & Intensive Care, vol. 22, no. 3, p. 368-373, July-September 2018. [Online]. Available: https://apicareonline.com/index.php/APIC/article/view/74. 

[5] A. Ramgolam et al., “Deep or awake removal of laryngeal mask airway in children at risk of respiratory adverse events undergoing tonsillectomy—a randomised controlled trial,” British Journal of Anaesthesia, vol. 120, no. 3, p. 571-580, March 2018. [Online]. Available: https://doi.org/10.1016/j.bja.2017.11.094. 

[6] M. Oofuvong et al., “Excess costs and length of hospital stay attributable to perioperative respiratory events in children,” Anesthesia and Analgesia, vol. 120, no. 2, p. 411-419, February 2015. [Online]. Available: https://doi.org/10.1213/ANE.0000000000000557. 

[7] Y. Asahi et al., “Excess costs and length of hospital stay attributable to perioperative respiratory events in children,” Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology, October 2021. [Online]. Available: https://doi.org/10.1016/j.ajoms.2021.09.004. 

Workplace mistreatment is a widespread issue, occurring in all subspecialties in medicine and at all levels of the medical hierarchy. Mistreatment includes discrimination, verbal or physical abuse, and sexual harassment. More subtle forms may include micro-aggressions or gaslighting arising from conscious or unconscious bias. Mistreatment toward medical professionals may lead to burnout, which is defined by the World Health Organization as emotional exhaustion and fatigue. Burnout can contribute to depression and suicidal ideation, which increases the risk for suicide completion. 28% of resident physicians experience a major depressive episode during training compared to 7-8% of similarly aged adults in the U.S. general population¹. An estimated 300 physicians die by suicide every year at nearly twice the rate of the general population¹. Not only is physician mistreatment detrimental to the physicians, but it also negatively impacts patient care. Long-term effects cause suboptimal care practices, medical and medication errors, and decreased patient satisfaction with medical care⁵. It is important to understand the causes and components leading to these statistics in order to prevent them in the future.

Among resident physicians, commonly reported examples of workplace mistreatment include gender discrimination, racial discrimination, verbal abuse and sexual harrassment.² In a 2020 meta-analysis, researchers found 64.1% of resident physicians experienced some form of intimidation, harassment, or discrimination.³ The most common forms of mistreatment were verbal, physical, and sexual abuse. The people who most frequently caused the mistreatment were relatives or friends of patients, nurses, and patients. In another study, researchers found similar results with the additional conclusion that women experienced more gender discrimination and sexual harassment. Patients and their families more often discriminated by gender while attending physicians were reported more for sexual harassment and abuse.²

Even after completion of residency training, attending physicians can experience workplace mistreatment. A 2021 cross-sectional study surveyed nearly 600 attending anesthesiologists about microaggressions. 94% of female physicians reported experiencing sexist microaggressions of hearing or seeing degrading female terms and images. 81% of minority physicians experienced racial and ethnic microaggressions. Of note, levels of burnout were higher among female and minority physicians, associating increased workplace mistreatment with increased levels of burnout.

One way to combat workplace mistreatment in medicine is to educate all levels of healthcare workers about what abuse looks like and empower them to be “upstanders” instead of passive bystanders.⁵ Strategies include educating healthcare workers on how to intervene when they observe abuse or mistreatment, either through direct or indirect intervention. Direct intervention involves acknowledging abuse or micro-aggressions and starting a conversation about it such as saying, “I heard you say this, which makes me feel…”. By addressing the behavior, the perpetrator may realize the behavior is unacceptable in the workplace and can self-reflect on the perspective that led them to behave in that manner. Indirect intervention redirects attention by shifting the conversation to other topics, which may be a valuable tool when bystanders do not feel comfortable directly addressing the perpetrator. With widespread education, time, and cultural change, hopefully, the prevalence of workplace mistreatment will decrease, leading to downstream effects of better mental health for medical professionals in the future.

References

1. American Foundation for Suicide Prevention. (n.d.). 10 Facts About Physician Suicide and Mental Health [Brochure]. New York, NY: Author.
2. Mata DA, Ramos MA, Bansal N, Khan R, Guille C, Angelantonio ED, Sen S. (2015). Prevalence of Depression and Depressive Symptoms among Resident Physicians. JAMA, 314(22), 2373. doi:10.1001/jama.2015.15845. PMID: 26647259; PMCID: PMC4866499.
3. Bahji A, Altomare J. Prevalence of intimidation, harassment, and discrimination among resident physicians: a systematic review and meta-analysis. Can Med Educ J. 2020 Mar 16;11(1):e97-e123. doi: 10.36834/cmej.57019. PMID: 32215147; PMCID: PMC7082478.
4. Sudol NT, Guaderrama NM, Honsberger P, Weiss J, Li Q, Whitcomb EL. Prevalence and Nature of Sexist and Racial/Ethnic Microaggressions Against Surgeons and Anesthesiologists. JAMA Surg. 2021 May 1;156(5):e210265. doi: 10.1001/jamasurg.2021.0265. Epub 2021 May 12. PMID: 33760000; PMCID: PMC7992024.
5. Ehie O, Muse I, Hill L, Bastien A. Professionalism: microaggression in the healthcare setting. Curr Opin Anaesthesiol. 2021 Apr 1;34(2):131-136. doi: 10.1097/ACO.0000000000000966. PMID: 33630771; PMCID: PMC7984763.

SARS-CoV-2, the virus underlying the Covid-19 pandemic, is known to cause a host of symptoms, including fever, cough, dyspnea, sputum production, myalgia, arthralgia, headache, gastrointestinal issues, rhinorrhea, sore throat, and loss of olfactory ability/taste. Olfactory symptoms are common among Covid-19 patients; in fact, one study found that 86 percent of infected individuals experienced detectable olfactory symptoms.¹ Given the prevalence of the virus, it has been of heightened interest to find methods of sino-nasal symptom alleviation. One recently proposed method includes the use of nasal steroids to treat Covid-19.

Nasal steroid sprays are traditionally used to alleviate allergy or, less commonly, non-allergy related inflammation in the nasal cavity. The steroid is suspended within pressurized gas, allowing for dispersion into the nasal cavity upon release from the canister. The effect of the steroid is a reduction in the size of blood vessels and surrounding tissue, therefore treating acute congestion and making respiration easier.

Several studies seem to suggest that chronic use of intranasal steroids can help alleviate some of the olfactory symptoms which characterize Covid-19. A study published by İşlek et al., titled, “Evaluation of effects of chronic nasal steroid use on rhinological symptoms of COVID-19 with SNOT-22 questionnaire,” showed that Covid-19 positive patients who used intranasal mometasone furoate spray once in a day experienced milder olfactory symptoms and had shorter recovery times when it came to post-viral olfactory dysfunction.² Notably, symptoms were not prevented, merely alleviated. However, another slightly contradictory study found that anosmia – one of the most prevalent and characteristic symptoms of Covid-19 – was not alleviated in patients who self-administered intranasal steroids daily for three weeks.³ Alternatively, some researchers have hypothesized that nasal steroids could be used in the fight against Covid-19 infection itself, as opposed to merely the symptoms. It has been shown that SARS-CoV-2 utilizes the host cell’s ACE2 receptor as a point of entry and adhesion.⁴ Given their vital role in regulating blood pressure, wound healing, and inflammation, ACE2 receptors can be found in most cell types throughout the body; however, they are expressed in particularly high levels in epithelial tissue and nasal mucosa.⁵ In fact, studies have shown that higher viral load of SARS-CoV-2 can be found in nasal swabs as compared to throat swabs, a difference which has been attributed to higher levels of ACE2 expression in the nasal mucosa.⁶ Conversely, research has demonstrated that ACE2 expression in nasal epithelial cells in vitro is significantly suppressed by dexamethasone.⁵ Taken together, these findings point towards the possibility that corticosteroids could prevent viral infection and replication in nasal epithelial cells by reducing potential entry points into cells. However, transmission is possible through a number of different avenues, so any protection conferred by nasal corticosteroids would be inherently limited.

In conclusion, the use of nasal corticosteroids is a promising approach for the treatment of Covid-19 nasal symptoms, particularly congestion. However, more remains to be learned as to whether there is a possibility of infection prevention, and the literature on anosmia remains inconsistent. We will likely continue to learn more about intranasal corticosteroids and Covid-19 throughout the course of the pandemic.

References 

¹ Lechien, J. R., Chiesa-Estomba, C. M., De Siati, D. R., Horoi, M., Le Bon, S. D., Rodriguez, A., Dequanter, D., Blecic, S., El Afia, F., Distinguin, L., Chekkoury-Idrissi, Y., Hans, S., Delgado, I. L., Calvo-Henriquez, C., Lavigne, P., Falanga, C., Barillari, M. R., Cammaroto, G., Khalife, M., Leich, P., … Saussez, S. (2020). Olfactory and gustatory dysfunctions as a clinical presentation of mild-to-moderate forms of the coronavirus disease (COVID-19): a multicenter European study. European archives of Oto-rhino-laryngology, 277(8), 2251–2261. https://doi.org/10.1007/s00405-020-05965-1 

² İşlek, A., & Balcı, M. K. (2021). Evaluation of effects of chronic nasal steroid use on rhinological symptoms of COVID-19 with SNOT-22 questionnaire. Pharmacological Reports, 73(3), 781–785. https://doi.org/10.1007/s43440-021-00235-1 

³ Abdelalim, A. A., Mohamady, A. A., Elsayed, R. A., Elawady, M. A., & Ghallab, A. F. (2021). Corticosteroid nasal spray for recovery of smell sensation in COVID-19 patients: A randomized controlled trial. American Journal of Otolaryngology, 42(2), 102884. https://doi.org/10.1016/j.amjoto.2020.102884 

⁴ Hoffmann, M., Kleine-Weber, H., Schroeder, S., Krüger, N., Herrler, T., Erichsen, S., Schiergens, T. S., Herrler, G., Wu, N. H., Nitsche, A., Müller, M. A., Drosten, C., & Pöhlmann, S. (2020). SARS-CoV-2 Cell Entry Depends on ACE2 and TMPRSS2 and Is Blocked by a Clinically Proven Protease Inhibitor. Cell, 181(2), 271–280.e8. https://doi.org/10.1016/j.cell.2020.02.052 

⁵ Saheb Sharif-Askari, F., Saheb Sharif-Askari, N., Goel, S., Fakhri, S., Al-Muhsen, S., Hamid, Q., & Halwani, R. (2020). Are patients with chronic rhinosinusitis with nasal polyps at a decreased risk of COVID-19 infection?. International Forum of Allergy & Rhinology, 10(10), 1182–1185. https://doi.org/10.1002/alr.22672 

⁶ Zou, L., Ruan, F., Huang, M., Liang, L., Huang, H., Hong, Z., Yu, J., Kang, M., Song, Y., Xia, J., Guo, Q., Song, T., He, J., Yen, H. L., Peiris, M., & Wu, J. (2020). SARS-CoV-2 Viral Load in Upper Respiratory Specimens of Infected Patients. The New England Journal of Medicine, 382(12), 1177–1179. https://doi.org/10.1056/NEJMc2001737 

Despite their demonstrated efficacy as sedation and analgesics, propofol and ketamine can result in adverse events [1]. Propofol can lead to hypotension, respiratory depression, hypoventilation, and loss of airway reflexes [2]. Conversely, ketamine does not risk the compromise of a patient’s airway reflexes, but it can cause hypertension, emergence delirium, vomiting, and tachycardia [2]. Ketamine can also impede the central nervous system [1]. To avoid the complications associated with each medication, researchers developed ‘ketofol’ as a combination of propofol and ketamine [1].

At first glance, ketofol appeared to be an effective replacement for ketamine and propofol. In 1999, Friedberg conducted a large meta-analysis of 2,059 operations performed on 1,264 patients anesthetized using combination propofol and ketamine [3]. None of the patients reported hallucinations, uncontrolled pain, vomiting, and nausea, and all of them were satisfied with their anesthetic regimen [3]. The study concluded that ketofol is a safe and effective anesthetic [3]. More recently, Slavik and Zed retrospectively analyzed 23 studies, all of which were centered on the efficacy of propofol and ketamine in combination [1]. They concluded that there was not substantial literature to demonstrate that ketofol evades the adverse cardiovascular events associated with ketamine and propofol [1]. Furthermore, ketamine-propofol did not appear to provide better analgesia than propofol alone [1]. While these findings do not necessarily contradict Friedberg’s conclusion, they certainly demonstrate the need for more research on ketofol.

For anesthesia providers considering using ketofol during an operation, knowledge of the appropriate ratio to administer is essential. Several studies have compared different ratios among themselves, as well as to anesthetic monotherapies, such as propofol alone [4]. One such study drew a comparison between 2:1, 3:1, and 4:1 propofol-ketamine combinations; propofol alone; and a propofol-fentanyl combination [4]. All of the ketofol mixtures provided patients with effective analgesia [4]. However, the 3:1 and 4:1 mixtures led to especially quick recovery and discharge times [4]. Additionally, the 4:1 mixture was responsible for the lowest incidences of postoperative dizziness and respiratory depression among the propofol-ketamine mixtures [4]. While these are the results of only one experiment, they could help guide physicians toward the ideal ratio with which to create ketofol.

Despite its uncertain benefits, ketofol has already found meaningful application in hospital emergency departments (ED). Phillips et al. studied the efficacy of combination ketamine and propofol in an ED during brief procedures, such as fracture manipulation [5]. Of the 28 patients studied, none required intervention or underwent respiratory depression [5]. Compared to the propofol group, the ketofol group was closer to their target bispectral index monitoring score and experienced less hypotension [5]. Willman and Andolfatto also encountered promising results when analyzing the cases of 114 patients who received ketofol in an ED [6]. No patient experienced vomiting or hypotension, and 96.5% of patients did not require additional sedatives [6]. Together, these results suggest there may be cardiovascular benefits, among others, to the use of ketofol as a sedative.

Still, ketofol does not seem so promising in all contexts. One such context is pediatrics. A recent meta-analysis of 29 studies sought to determine the efficacy of ketofol in operations conducted on children [7]. Hayes et al. did identify reduction of some risks due to ketofol–including apnea, hypotension, and bradycardia [7]. Yet, they also found that ketofol may increase children’s risk of respiratory adverse events, hypertension, and tachycardia [7]. Another study did not find a significant difference in sedative quality between ketofol and ketamine, with adverse events occurring at comparable frequencies [2]. Whether these results are the symptoms of imperfect ratios, or indicative of a greater failure on the part of ketofol, warrants continued investigations into the mechanisms of combination propofol and ketamine.

References

[1] V. C. Slavik and P. J. Zed, “Combination Ketamine and Propofol for Procedural Sedation and Analgesia,” Pharmcotherapy, vol. 27, no. 11, p. 1588-1598, January 2012. [Online]. Available: https://doi.org/10.1592/phco.27.11.1588.

[2] Y. Hu, W. Xu, and F. Cao, “A meta-analysis of randomized controlled trials: combination of ketamine and propofol versus ketamine alone for procedural sedation and analgesia in children,” Internal and Emergency Medicine, vol. 14, p. 1159-1165, September 2019. [Online]. Available: https://doi.org/10.1007/s11739-019-02173-6. 

[3] B. L. Friedberg, “Propofol-ketamine technique: Dissociative anesthesia for office surgery (A 5-year review of 1264 cases),” Aesthetic Plastic Surgery, vol. 23, no. 1, p. 70-75, January-February 1999. [Online]. Available: https://doi.org/10.1007/s002669900245.

[4] S. Amornyotin, “Ketofol: A Combination of Ketamine and Propofol,” Journal of Anesthesia & Critical Care, vol. 1, no. 5, p. 1-3, January-February 1999. [Online]. Available: https://doi.org/10.15406/jaccoa.2014.01.00031.

[5] W. Phillips et al., “Propofol Versus Propofol/Ketamine for Brief Painful Procedures in the Emergency Department: Clinical and Bispectral Index Scale Comparison,” Journal of Pain & Palliative Care Pharmacotherapy, vol. 24, no. 4, p. 349-355, December 2010. [Online]. Available: https://doi.org/10.3109/15360288.2010.506503.

[6] E. V. Willman and G. Andolfatto, “A Prospective Evaluation of “Ketofol” (Ketamine/Propofol Combination) for Procedural Sedation and Analgesia in the Emergency Department,” Annals of Emergency Medicine, vol. 49, no. 1, p. 23-30, January 2007. [Online]. Available: https://doi.org/10.1016/j.annemergmed.2006.08.002.

[7] J. A. Hayes et al., “Safety and Efficacy of the Combination of Propofol and Ketamine for Procedural Sedation/Anesthesia in the Pediatric Population: A Systematic Review and Meta-analysis,” Anesthesia & Analgesia, vol. 132, no. 4, p. 979-992, April 2021. [Online]. Available: https://doi.org/10.1213/ANE.0000000000004967.

The intellectual output of an engineer-obstetrician duo, ultrasound was first used clinically as a medical imaging technology in 1956, becoming commonplace in the 1960’s, and has since established itself as a cornerstone medical imaging procedure. Key advantages over other imaging modalities include its low cost of manufacturing and use, noninvasive nature, easy visualization of hemodynamics and tissue properties, compatibility with real-time dynamic assessment, and ease of use in the form of portable ultrasound devices ¹. Recently, a number of advances in musculoskeletal ultrasound imaging, in particular, have galvanized its use across multiple clinical applications ².

First, Doppler ultrasound has been critical for the diagnosis and monitoring of inflammatory arthropathies and the assessment of neoplasms, tendinopathies, and neuropathies. For example, Doppler ultrasound can differentiate between active synovitis and chronic fibrotic synovium, as the former appears as hyperemia ³, and, in oncologic imaging, can clearly distinguish benign from malignant tumors ⁴.

However, traditional Doppler ultrasound remains limited by its inability to clearly visualize microvascular flow, since its algorithm filters lower velocity elements to reduce clutter. Clearly assessing microvascular flow is key, though, to diagnosing early inflammatory processes and neoplastic angiogenesis ^4,5. To this end, multiple advanced ultrasound methods have been developed. First, contrast-enhanced ultrasound, combining microbubble-based intravenous contrast agents with traditional ultrasound, can, unlike previous Doppler ultrasound methods, display blood perfusion and identify capillary-level neovascularization ⁶. Second, another distinct Doppler technique, incorporating a unique motion suppression algorithm that isolates and eliminates clutter, can also enable the visualization of low flow microvasculature ⁷.

Most recently, ultra-high frequency transducers, reaching frequencies of 20-70 MHz, far exceeding the traditional 12-18 MHz range, have also been used to visualize increasingly granular anatomical detail. As such, individual fascicles may now be distinguished using the newest high-frequency ultrasound technology ⁸. Clinically, this first means that ultrasound-guided neurosurgical procedures can spare nerve fascicles, presenting clear advantages over conventional ultrasound or magnetic resonance imaging ⁹. Second, various musculoskeletal features can be accurately measured. Tendons are easily seen, thereby enabling, for example, the identification of pulleys during ultrasound-guided treatments, resulting in safer surgeries ¹⁰. Capsular ligaments, retinacula, and fasciae, all involving millimeter-diameter mesenchymal structures, are now also distinctly visible ². Finally, this new level of precision means that ultrasounds can be used for the early detection of neoplastic masses several millimeters in size. Importantly, however, as the frequency of the ultrasound beams increase, penetration decreases. Thus, these ultrahigh frequency transducers are best suited for assessing for superficial structures.

Finally, elastography can now be used to investigate and possibly heal musculoskeletal system function. To this end, assessing stiffness of nerves and tissue around nerves in fibro-osseous tunnels can be done either by traditional strain or shear-wave elastography techniques ¹¹.

Ultrasound is less physically and economically demanding on patients and has been greatly improving the quality of medical care. Given the rapidity of advances in ultrasound technologies, there is a clear need to standardize the execution and reporting of different associated techniques. Nonetheless, ultrasound continues to represent an indispensable diagnostic imaging modality in clinical settings, with likely many exciting additional future prospects.  

References

1.        Matsuzaki M. The latest technology of musculoskeletal ultrasonography: iterative revolution. J Med Ultrason. 2017. doi:10.1007/s10396-017-0799-0

2.        van Holsbeeck M, Soliman S, van Kerkhove F, Craig J. Advanced musculoskeletal ultrasound techniques: What are the applications? Am J Roentgenol. 2021. doi:10.2214/AJR.20.22840

3.        Aggarwal R, Aggarwal V. High-Resolution musculoskeletal ultrasound in India: The present perspective and the future. Indian J Rheumatol. 2018. doi:10.4103/0973-3698.238196

4.        Jiang Z Zhen, Huang Y Hua, Shen H Liang, Liu X Tian. Clinical Applications of Superb Microvascular Imaging in the Liver, Breast, Thyroid, Skeletal Muscle, and Carotid Plaques. J Ultrasound Med. 2019. doi:10.1002/jum.15008

5.        Arslan S, Karahan AY, Oncu F, Bakdik S, Durmaz MS, Tolu I. Diagnostic performance of superb microvascular imagingand other sonographic modalities in the assessment of lateral epicondylosis. J Ultrasound Med. 2018. doi:10.1002/jum.14369

6.        Qin S, Caskey CF, Ferrara KW. Ultrasound contrast microbubbles in imaging and therapy: Physical principles and engineering. Phys Med Biol. 2009. doi:10.1088/0031-9155/54/6/R01

7.        Yokota K, Tsuzuki Wada T, Akiyama Y, Mimura T. Detection of synovial inflammation in rheumatic diseases using superb microvascular imaging: Comparison with conventional power Doppler imaging. Mod Rheumatol. 2018. doi:10.1080/14397595.2017.1337288

8.        Cartwright MS, Baute V, Caress JB, Walker FO. Ultrahigh-frequency ultrasound of fascicles in the median nerve at the wrist. Muscle and Nerve. 2017. doi:10.1002/mus.25617

9.        Forte AJ, Boczar D, Oliver JD, Sisti A, Clendenen SR. Ultra-high-frequency Ultrasound to Assess Nerve Fascicles in Median Nerve Traumatic Neuroma. Cureus. 2019. doi:10.7759/cureus.4871

10.      Yang TH, Lin YH, Chuang BI, et al. Identification of the Position and Thickness of the First Annular Pulley in Sonographic Images. Ultrasound Med Biol. 2016. doi:10.1016/j.ultrasmedbio.2015.12.007

11.      Ooi CC, Malliaras P, Schneider ME, Connell DA. “Soft, hard, or just right?” Applications and limitations of axial-strain sonoelastography and shear-wave elastography in the assessment of tendon injuries. Skeletal Radiol. 2014. doi:10.1007/s00256-013-1695-3