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Purpose of Review: The healthcare sector has a substantial environmental footprint, and the delivery of anesthesia contributes significantly. Inhaled anesthetics themselves are potent greenhouse gases, unused intravenous medication exert toxic effects on the environment, and the increasing reliance on single-use devices has led to an ever-growing amount of solid waste produced in operating rooms. This review discusses many of these environmental impacts and suggests practices to mitigate the environmental footprint of anesthetic practice., Recent Findings: The choice of anesthesia maintenance has significant environmental implications, with nitrous oxide and desflurane having the highest carbon footprint of all anesthetic agents. Using low fresh gas flows and supplementing or replacing inhalational agents with propofol leads to a significant reduction in emissions. Many intravenous anesthetic agents pose a risk of environmental toxicity, and efforts should be made to decrease medication waste and ensure appropriate disposal of unused medications to minimize their environmental impacts. Additionally, consideration should be given to replacing single-use devices in the operating rooms with reusable alternatives that are often both environmentally and economically superior. And solid waste generated in the operating room should be segregated thoughtfully, as processing regulated medical waste is a highly energy-intensive process., Summary: Significant opportunities exist to improve the environmental footprint of anesthesia practice, and with the rapidly worsening climate crisis, the importance of implementing changes is greater than ever., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Direct visualization of the eye can be difficult or impossible when there is significant facial burns, trauma, or edema. We present 4 nonresponsive, critically ill children whose pupils could not be directly visualized. Ophthalmic ultrasound revealed pupillary reactivity at presentation and throughout their recovery. Determining pupillary reactivity in these nonresponsive patients impacted their initial triage, resuscitation, and medical management. We propose that ophthalmic point-of-care ultrasonography can assess the pupillary light reflex in critically ill children whose pupils cannot be directly visualized., (© 2024 American Institute of Ultrasound in Medicine.)

Acute brain injury (ABI) increases morbidity and mortality in patients with veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Optimal neurologic monitoring methods have not been well-explicated. We studied the use of Near-infrared Spectroscopy (NIRS) to monitor cerebral regional oxygenation tissue saturation (rSO2) and its relation to ABI in VA-ECMO. In this prospective, observational cohort study of 39 consecutive patients, we analyzed the ability of rSO2 values from continuous bedside NIRS monitoring to predict ABI during VA-ECMO support. ABI occurred in 24 (61.5%) patients. Those with ABI had a lower pre-ECMO Glasgow Coma Scale, more blood product transfusions of pRBCs and FFP, and higher APACHEII score. Baseline rSO2 values were not significantly different between cohorts (54.25 vs 58.50, p = 0.260), while the minimum rSO2 value was lower for patients who experienced an ABI than those who did not (39.75 vs 44.50, p = 0.039). In patients with ABI, 21 (87.5%) had a drop in rSO2 of 25% from baseline, compared to only 7 (46.7%) patients without ABI (p = 0.017). By ROC analysis, we found that desaturations with >25% drop from the baseline rSO2 on VA-ECMO exhibited 86% sensitivity and 55% specificity to predict ABI, with an area under the curve of 0.68. Patients with ABI were more likely to have withdrawal of life sustaining therapy (17 vs 5, p = 0.049), while neurologic outcome and mortality were not statistically different between patients with or without ABI. Our results support that cerebral NIRS is a useful, real-time bedside neuromonitoring tool to detect ABI in VA-ECMO patients. A >25% drop from the baseline was sensitive in predicting ABI occurrence. Further research is needed to assess how to implement this knowledge to utilize NIRS in developing appropriate intervention strategy in VA-ECMO patients.

Introduction: Extracorporeal membrane oxygenation (ECMO) is a life-saving therapy for those in cardiopulmonary failure, including post-cardiac arrest. Despite a high volume of ECMO patients using anti-seizure medication, there is a paucity of data concerning the dosing, levels, and clinical scenarios for their use., Case Report: We present three cases of ECMO patients post-PEA arrest who were on valproic acid (VPA) for treatment of seizure and/or myoclonus. The total and free levels of VPA are reported., Discussion: The trough levels are consistent throughout therapy, suggesting VPA is not significantly removed by the ECMO circuitry. Although the total serum levels remained below the toxic range, the free level was elevated in two patients. These patients did not develop signs of toxicity., Conclusion: VPA may be an effective anti-seizure medication in ECMO patients. Free VPA levels should be more readily available to better quantify efficacy or toxicity, especially in ECMO patients.

Purpose: In light of highly publicized media coverage on breast implant recalls and Food and Drug Administration hearings on breast implant safety, online searches of these topics have surged. It is thus critical to determine whether such searches are providing meaningful information for those who use them. Patient/laywomen-directed online education materials on breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) must not only be comprehensible but also accurate, actionable, and culturally concordant, especially as more diverse populations turn to the internet for breast implant-related information. This study assessed the overall suitability of BIA-ALCL patient-directed educational text and video-based materials online., Methods: This was a cross-sectional, multimetric investigation of online text- and video-based patient-directed educational materials for BIA-ALCL using multiple validated measures. Two reviewers assessed each resource. Kruskal-Wallis and Fisher exact analyses were used as appropriate to compare text- and video-based online resources., Results: In total, 30 websites and 15 videos were evaluated, more than half (56%) of which were from academic/physician or governmental/nonprofit sources. Overall, website and video content, as well as quality, varied by source. Academic/physician or governmental/nonprofit sources tended to be more comprehensive and have higher-quality information than commercial/media outlet sources. Median actionability of websites was 38%, well below the threshold of 70% used in the literature to identify actionable resources. The median suitability score for BIA-ALCL websites was 57%, which is considered "adequate" based on published thresholds. The mean overall Cultural Sensitivity Assessment Tool score for websites was 2.4; Cultural Sensitivity Assessment Tool scores higher than 2.5 are generally regarded as culturally sensitive. In general, videos were more understandable than websites. Substantial interrater reliability across the validated tools used in this study was noted using Pearson correlation coefficients., Conclusions: Online resources varied in content and quality by source. As BIA-ALCL becomes an increasingly salient topic among both providers and patients, it is important to empower women with accurate information about this implant-associated cancer. Of available resources, providers should refer patients or those seeking more information to websites from governmental/academic organizations (".gov" or ".org" domains) and videos from academic/physician or governmental sources, given that among high-quality resources, these were most clear/comprehensible. Overall, there is a need for improved online content on this topic., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

The pandemic of SARS-CoV-2 has led to unprecedented changes to society, causing unique problems that call for extraordinary solutions. We consider one such extraordinary proposal: 'safer infection sites' that would offer individuals the opportunity to be intentionally infected with SARS-CoV-2, isolate, and receive medical care until they are no longer infectious. Safer infection could have value for various groups of workers and students. Health professionals place themselves at risk of infection daily and extend this risk to their family members and community. Similarly, other essential workers who face workplace exposure must continue their work, even if have high-risk household members and live in fear of infecting. When schools are kept closed because of the fear that they will be sites of significant transmission, children and their families are harmed in multiple ways and college students who are living on campus, whether or not they are attending classes in person, are contributing to high rates of transmission and experiencing high rates of exposure. We consider whether offering safer infection sites to these groups could be ethically defensible and identify the empirical unknowns that would need to resolve before reaching definitive conclusions. This article is not an endorsement of intentional infection with the coronavirus, but rather is meant to spark conversation on the ethics of out-of-the-box proposals. Perhaps most meaningfully, our paper explores the value of control and peace of mind for those among us most impacted by the pandemic: those essential workers risking the most to keep us safe., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Phenotypic matching in heart transplantation, where donors and recipients are matched based on physical characteristics, has been previously limited to only analyzing individual variables such as sex and age. This study examines the effects of phenotypic matching utilizing multiple factors simultaneously., Methods: Adult patients undergoing heart transplantation between 2006 and 2016 were identified from the Organ Procurement and Transplantation Network database. Phenotypic matching was defined based on six factors: body mass index difference >30%, age difference >30%, height difference >7%, non-identical ABO blood grouping, race, and sex. A value between 0 and 1 mismatched characteristics was considered phenotypically like matching, whereas 2-6 mismatches was considered phenotypically unlike matching. The primary study endpoint was 1-year survival. Risk-adjusted mortality was examined with multivariable Cox regression models., Results: During the study period, 20,052 adult patients underwent heart transplantation, of whom 9595 (47.9%) were phenotypically like and 10,457 (52.1%) were phenotypically unlike matched. No differences in 1-year survival were seen between like and unlike matched patients (risk-adjusted odds ratio 1.05, 95% confidence interval 0.96-1.15, P = .305) after controlling for clinically relevant covariates. Subgroup analyses did not demonstrate survival differences after stratification based on hospital transplant volume and initial waitlist status. Phenotypically like matched patients had longer waiting times compared with unlike matched patients overall (225 days vs 192 days, P < .001)., Conclusions: Waiting for a phenotypically matched heart provides no survival benefit and exposes patients to prolonged waitlist times. These findings challenge the notion that a perfect donor heart exists, when in fact this concept may be a misnomer., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Despite the 6000 patients treated with extracorporeal membrane oxygenation (ECMO) annually, there is a paucity of data regarding the nutritional management of these patients., Materials and Methods: We performed a prospective, observational study of nutrition in postcardiotomy shock patients at our institution. Over a 3.5-year study period, we identified 50 ECMO patients and 225 non-ECMO patients. We identified type, amount, duration, and disruption of nutritional delivery by cohort. The primary outcome was percent of caloric goal met, and secondary outcome was gastrointestinal complications., Results: ECMO patients met less of their caloric (29% versus 40%, P = 0.017) and protein goals (34% versus 55%, P < 0.001) compared with non-ECMO patients. Tube feeds were administered more slowly (26 versus 37 mL/h, P < 0.001) and held for longer (8.3 versus 4.5 h/d, P < 0.001) in ECMO patients because of procedures (60%) and high-dose pressors (20% versus 7%, P < 0.001). Multivariate analysis demonstrated that ECMO decreased caloric intake by 14%, with no detected increased risk of gastrointestinal complications., Conclusions: -ECMO patients received significantly less nutrition support compared with a non-ECMO population. Tube feed hold deficits could potentially be avoided by utilizing postpyloric tubes to feed through procedures, by eliminating holds for vasopressors/inotropes in hemodynamically stable patients, or by establishing volume-based feeding protocols. Further clinical studies are needed to establish efficacy of these interventions and to understand the impact of nutrition on outcomes in ECMO patients., (Copyright © 2019 Elsevier Inc. All rights reserved.)

In a cross-sectional investigation of the properties of DSM-III-R panic disorder (PD), panic disorder with agoraphobia (PDA), and agoraphobia without history of panic disorder (AWOPD), we analyzed demographic, descriptive, comorbidity, treatment, and course data for 562 subjects with PD, PDA, or AWOPD in a multicenter anxiety-disorders study. In general, AWOPD subjects had the worst functioning and PD subjects the best, as measured by length of intake episodes, education attained, likelihood of receiving financial assistance, depressive comorbidity, and likelihood of having experienced 8 weeks symptom-free. Panic disorder with agoraphobia was the most common disorder and emerged as a condition intermediate in severity between the other two. Treatments received varied little by diagnosis. Most subjects received medication, usually benzodiazepines. Psychodynamic psychotherapy was the most frequently received psychosocial treatment; cognitive and behavioral approaches were less common. Subjects classified with AWOPD were the most likely to have received exposure therapies.

Trauma histories were obtained from 711 subjects in a large study of anxiety disorders, with the intent of determining the prevalence and nature of psychological trauma in this group. Twenty-seven percent of subjects reported significant trauma; 35% of these (10% of all subjects) met DSM-II-R criteria for posttraumatic stress disorder (PTSD). Subjects reporting sexual trauma were significantly more likely to have PTSD. The rate of PTSD was not higher in subjects with panic disorder than in those with other anxiety disorders.