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To evaluate the associations between prescription opioid exposures in community-dwelling older adults and gray and white matter structure by magnetic resonance imaging.

In 2020, the coronavirus disease 2019 (COVID-19) pandemic interrupted the administration of the APPLIED Examination, the final part of the American Board of Anesthesiology (ABA) staged examination system for initial certification. In response, the ABA developed, piloted, and implemented an Internet-based “virtual” form of the examination to allow administration of both components of the APPLIED Exam (Standardized Oral Examination and Objective Structured Clinical Examination) when it was impractical and unsafe for candidates and examiners to travel and have in-person interactions. This article describes the development of the ABA virtual APPLIED Examination, including its rationale, examination format, technology infrastructure, candidate communication, and examiner training. Although the logistics are formidable, we report a methodology for successfully introducing a large-scale, high-stakes, 2-element, remote examination that replicates previously validated assessments.

Electronic cigarettes (e-cigarettes) or vaping use in adolescents has emerged as a public health crisis that impacts the perioperative care of this vulnerable population. E-cigarettes have become the most commonly used tobacco products among youth in the United States. Fruit and mint flavors and additives such as marijuana have enticed children and adolescents. E-cigarette, or vaping, product use–associated lung injury (EVALI) is a newly identified lung disease linked to vaping. Clinical presentation of EVALI can be varied, but most commonly includes the respiratory system, gastrointestinal (GI) tract, and constitutional symptoms. Clinical management of EVALI has consisted of vaping cessation and supportive therapy, including supplemental oxygen, noninvasive ventilation, mechanical ventilation, glucocorticoids, and empiric antibiotics, until infectious causes are eliminated, and in the most severe cases, extracorporeal membrane oxygenation (ECMO). Currently, although there is an insufficient evidence to determine the safety and the efficacy of e-cigarettes for perioperative smoking cessation, EVALI clearly places these patients at an increased risk of perioperative morbidity. Given the relatively recent introduction of e-cigarettes, the long-term impact on adolescent health is unknown. As a result, the paucity of postoperative outcomes in this potentially vulnerable population does not support evidence-based recommendations for the management of these patients. Clinicians should identify “at-risk” individuals during preanesthetic evaluations and adjust the risk stratification accordingly. Our societies encourage continued education of the public and health care providers of the risks associated with vaping and nicotine use and encourage regular preoperative screening and postoperative outcome studies of patients with regard to smoking and vaping use.

To investigate the association between episodes of critical care hospitalizations and delirium with structural brain changes in older adults.

In 2018, the American Board of Anesthesiology (ABA) became the first US medical specialty certifying board to incorporate an Objective Structured Clinical Examination (OSCE) into its initial certification examination system. Previously, the ABA’s staged examination system consisted of 2 written examinations (the BASIC and ADVANCED examinations) and the Standardized Oral Examination (SOE). The OSCE and the existing SOE are now 2 separate components of the APPLIED Examination. This report presents the results of the first-year OSCE administration. A total of 1410 candidates took both the OSCE and the SOE in 2018. Candidate performance approximated a normal distribution for both the OSCE and the SOE, and was not associated with the timing of the examination, including day of the week, morning versus afternoon session, and order of the OSCE and the SOE. Practice-based Learning and Improvement was the most difficult station, while Application of Ultrasonography was the least difficult. The correlation coefficient between SOE and OSCE scores was 0.35 ([95% confidence interval {CI}, 0.30–0.39]; P< .001). Scores for the written ADVANCED Examination were modestly correlated with scores for the SOE (r= 0.29 [95% CI, 0.25–0.34]; P< .001) and the OSCE (r= 0.15 [95% CI, 0.10–0.20]; P< .001). Most of the candidates who failed the SOE passed the OSCE, and most of the candidates who failed the OSCE passed the SOE. Of the 1410 candidates, 77 (5.5%) failed the OSCE, 155 (11.0%) failed the SOE, and 25 (1.8%) failed both. Thus, 207 (14.7%) failed at least 1 component of the APPLIED Examination. Adding an OSCE to a board certification examination system is feasible. Preliminary evidence indicates that the OSCE measures aspects of candidate abilities distinct from those measured by other examinations used for initial board certification.

To elucidate factors that influence opioid prescribing behaviors of key stakeholders after major spine surgery, with a focus on barriers to optimized prescribing.

Smokers are at increased risk for surgical complications. Despite the known benefits of smoking cessation, many perioperative health care providers do not routinely provide smoking cessation interventions. The variation in delivery of perioperative smoking cessation interventions may be due to limited high-level evidence for whether smoking cessation interventions used in the general population are effective and feasible in the surgical population, as well as the challenges and barriers to implementation of interventions. Yet smoking is a potentially modifiable risk factor for improving short- and long-term patient outcomes. The purpose of the Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement on Perioperative Smoking Cessation is to present recommendations based on current scientific evidence in surgical patients. These statements address questions regarding the timing and intensity of interventions, roles of perioperative health care providers, and behavioral and pharmacological interventions. Barriers and strategies to overcome challenges surrounding implementation of interventions and future areas of research are identified. These statements are based on the current state of knowledge and its interpretation by a multidisciplinary group of experts at the time of publication.

The use of buprenorphine, a mixed opioid agonist-antagonist, for the management of chronic pain and/or opioid use disorder is increasing. As such, medical providers will more frequently encounter patients on this therapy. In this paper, we synthesize existing knowledge (derived through keyword searches using MEDLINE databases) in a novel conceptual framework for patients on buprenorphine presenting with acute pain or for those requiring surgical or invasive procedures. This framework is based on three unique domains: the patient, the features of the acute pain insult, and the environment. We discuss important considerations regarding the unique aspects of buprenorphine formulations and dosing, and we describe the importance of multidisciplinary planning and multimodal analgesic strategies. We also highlight important differences in management strategies based upon the presence or absence of opioid use disorder. All medical providers must be prepared to guide the patient on buprenorphine safely through the acute care episode, which includes adequate treatment of acute pain and avoidance of iatrogenic harm, including both short-term complications (eg, respiratory depression) and long-term complications (eg, relapse to opioid use).

With its first administration of an Objective Structured Clinical Examination (OSCE) in 2018, the American Board of Anesthesiology (ABA) became the first US medical specialty certifying board to incorporate this type of assessment into its high-stakes certification examination system. The fundamental rationale for the ABA’s introduction of the OSCE is to include an assessment that allows candidates for board certification to demonstrate what they actually “do” in domains relevant to clinical practice. Inherent in this rationale is that the OSCE will capture competencies not well assessed in the current written and oral examinations—competencies that will allow the ABA to judge whether a candidate meets the standards expected for board certification more properly. This special article describes the ABA’s journey from initial conceptualization through first administration of the OSCE, including the format of the OSCE, the process for scenario development, the standardized patient program that supports OSCE administration, examiner training, scoring, and future assessment of reliability, validity, and impact of the OSCE. This information will be beneficial to both those involved in the initial certification process, such as residency graduate candidates and program directors, and others contemplating the use of high-stakes summative OSCE assessments.

The American Board of Anesthesiology (ABA) has been administering an oral examination as part of its initial certification process since 1939. Among the 24 member boards of the American Board of Medical Specialties, 13 other boards also require passing an oral examination for physicians to become certified in their specialties. However, the methods used to develop, administer, and score these examinations have not been published. The purpose of this report is to describe the history and evolution of the anesthesiology Standardized Oral Examination, its current examination development and administration, the psychometric model and scoring, physician examiner training and auditing, and validity evidence. The many-facet Rasch model is the analytic method used to convert examiner ratings into scaled scores for candidates and takes into account how difficult grader examiners are and the difficulty of the examination tasks. Validity evidence of the oral examination includes that it measures aspects of clinical performance not accounted for by written certifying examinations, and that passing the oral examination is associated with a decreased risk of subsequent license actions against the anesthesiologist. Explaining the details of the Standardized Oral Examination provides transparency about this component of initial certification in anesthesiology.

This study compared anesthesiology residency graduates’ written certification examination performance before and after the American Board of Anesthesiology (ABA) introduced the staged examination system. After equating test scores using common test items, the first 2 cohorts (2013, 2014) in the staged system scored 7.1 points and 8.3 points higher than the 2011 baseline cohort in the former examination system. The 2013 and 2014 cohorts’ pass rates (94.2% and 95.9%) were also higher than the 2011 and 2012 cohorts (91.9% and 92.6%) if a common standard had been applied. The staged examination system may be associated with improved knowledge of anesthesiology graduates.

Although surgical patients who smoke could benefit from perioperative abstinence, few currently receive support. This pilot study determined the feasibility and acceptability of a perioperative text messaging smoking cessation program. One hundred patients (73% of eligible patients approached) enrolled in a surgery-specific messaging service, receiving 1–3 daily messages about smoking and surgical recovery for 30 days. Only 17 patients unenrolled, the majority responded to prompting messages, and satisfaction with the program was high. Surgical patients are amenable to text message–based interventions; a future efficacy trial of text messaging smoking cessation support in surgical patients is warranted.

To investigate whether older adults with mild cognitive impairment (MCI) or dementia have higher rates of procedures requiring general anesthesia or intensive care unit (ICU) admissions compared with cognitively normal (CN) patients.

To compare the indications for hospital admission between current, former, and never smokers and to compare their costs per hospital admission, testing the hypothesis that the cost per hospital admission would be higher for smokers than for former and never smokers.

An urgent need exists to better understand the transition from short-term opioid use to unintended prolonged opioid use (UPOU). The purpose of this work is to propose a conceptual framework for understanding UPOU that posits the influence of 3 principal domains that include the characteristics of (1) individual patients, (2) the practice environment, and (3) opioid prescribers. Although no standardized method exists for developing a conceptual framework, the process often involves identifying corroborative evidence, leveraging expert opinion to identify factors for inclusion in the framework, and developing a graphic depiction of the relationships between the various factors and the clinical problem of interest. Key patient characteristics potentially associated with UPOU include (1) medical and mental health conditions; (2) pain etiology; (3) individual affective, behavioral, and neurophysiologic reactions to pain and opioids; and (4) sociodemographic factors. Also, UPOU could be influenced by structural and health care policy factors: (1) the practice environment, including the roles of prescribing clinicians, adoption of relevant practice guidelines, and clinician incentives or disincentives, and (2) the regulatory environment. Finally, characteristics inherent to clinicians that could influence prescribing practices include (1) training in pain management and opioid use; (2) personal attitudes, knowledge, and beliefs regarding the risks and benefits of opioids; and (3) professionalism. As the gatekeeper to opioid access, the behavior of prescribing clinicians directly mediates UPOU, with the 3 domains interacting to determine this behavior. This proposed conceptual framework could guide future research on the topic and allow plausible hypothesis-based interventions to reduce UPOU.

IMPORTANCE: Cigarette smoking is a risk factor for many perioperative complications, including surgical site infection (SSI). The duration of abstinence from smoking required to reduce this risk is unknown. OBJECTIVES: To evaluate if abstinence from smoking on the day of surgery is associated with a decreased frequency of SSI in patients who smoke cigarettes and to confirm that smoking is significantly independently associated with SSI when adjustment is made for potentially relevant covariates, such as body mass index. DESIGN, SETTING, AND PARTICIPANTS: In this observational, nested, matched case-control study, 2 analyses were performed at an academic referral center in the upper Midwest. Cases included all patients undergoing elective surgical procedures at Mayo Clinic, Rochester, Minnesota, between January 1, 2009, and July 31, 2014 (inclusive) who subsequently developed an SSI. Controls for both analyses were matched on age, sex, and type of surgery. EXPOSURES: Smoking status and preoperative exhaled carbon monoxide level, assessed by nurses in the preoperative holding area. Patients were classified as smoking on the day of surgery if they self-reported smoking or if their preoperative exhaled carbon monoxide level was 10 ppm or higher. MAIN OUTCOMES AND MEASURES: Surgical site infection after a surgical procedure at Mayo Clinic, Rochester, as identified by routine clinical surveillance using National Healthcare Safety Network criteria. RESULTS: Of the 6919 patients in the first analysis, 3282 (47%) were men and 3637 (53%) were women; median age (interquartile range) for control and SSI cases was 60 (48-70). Of the 392 patients in the second analysis, 182 (46%) were men and 210 (54%) were women; median age (interquartile range) for controls was 53 (45-49) and for SSI cases was 51 (45-60). During the study period, approximately 2% of surgical patients developed SSI annually. Available for the first analysis (evaluating the influence of current smoking status) were 2452 SSI cases matched to 4467 controls. The odds ratio for smoking and SSI was 1.51 (95% CI, 1.20-1.90; P &lt; .001), which remained statistically significant after adjusting for covariates. In the second analysis (evaluating the influence of smoking on the day of surgery), there were 137 SSI cases matched to 255 controls. The odds ratio for smoking on the day of surgery and SSI was 1.96 (95% CI, 1.23-3.13; P &lt; .001), which remained statistically significant after adjusting for covariates. Preoperative exhaled carbon monoxide level was not associated with the frequency of SSI, suggesting that the association between smoking on the day of surgery and SSI was not related to preoperative exhaled carbon monoxide levels. CONCLUSIONS AND RELEVANCE: Current smoking is associated with the development of SSI, and smoking on the day of surgery is independently associated with the development of SSI. These data cannot distinguish whether abstinence per se reduces risk or whether it is associated with other factors that may be causative.

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Supplemental Digital Content is available in the text.

During the Fifth Pediatric Anesthesia Neurodevelopmental Assessment Symposium, experts and stakeholders met to present and discuss recent advances made in the study of neurodevelopmental outcomes after exposure to anesthetic drugs in infants and children. This article summarizes the update of 5 ongoing clinical studies: General Anesthesia compared to Spinal Anesthesia, Toxicity of Remifentanil and Dexmedetomidine, Mayo Anesthesia Safety in Kids, the University of California San Francisco human cohort study, and Columbia University Medical Center Neonatal Magnetic Resonance Imaging study. The purpose of this summary is to discuss the contributions and limitations of these studies, how they fit into the published literature, and what questions remain to be answered.

Smoking increases the risk of postoperative morbidity and mortality. Smoking cessation before surgery reduces the risk of complications. The perioperative period may be a “teachable moment” for smoking cessation and provides smokers an opportunity to engage in long-term smoking cessation. Anesthesiologists as the perioperative physicians are well-positioned to take the lead in this area and improve not only short-term surgical outcomes but also long-term health outcomes and costs. Preoperative interventions for tobacco use are effective to reduce postoperative complications and increase the likelihood of long-term abstinence. If intensive interventions (counseling, pharmacotherapy, and follow-up) are impractical, brief interventions should be implemented in preoperative clinics as a routine practice. The “Ask, Advise, Connect” is a practical strategy to be incorporated in the surgical setting. All anesthesiologists should ask their patients about smoking and strongly advise smokers to quit at every visit. Directly connecting patients to existing counseling resources, such as telephone quitlines, family physicians, or pharmacists using fax or electronic referrals, greatly increases the reach and the impact of the intervention.

To examine whether exposure to general anesthesia for operations and procedures after the age of 40 years is associated with incident mild cognitive impairment (MCI) in elderly patients.

Patients who smoke cigarettes are at increased risk for development of complications both during and after surgical procedures, including respiratory, cardiac, and healing-related complications. Abstinence from smoking can considerably reduce these risks. Pharmacotherapy, including nicotine replacement therapy (NRT), is an important component of efficacious tobacco use interventions. However, the use of NRT in the perioperative period is controversial. In this narrative review, we discuss the current evidence for the efficacy and safety of NRT in patients scheduled for surgical procedures, with emphasis on evidence from human studies. We performed a literature search for articles published from January 1, 1990, through May 1, 2015, in the PubMed online database using various permutations of the Medical Subject Headings terms surgery; surgical procedures, operative; nicotine; and smoking cessation. Studies were selected for inclusion according to their relevance to the preclinical and clinical evidence pertaining to how NRT affects surgical outcome and long-term rates of abstinence from tobacco. There is strong evidence that NRT enhances the efficacy of tobacco use interventions. Some preclinical studies suggest that nicotine in high doses that exceed those produced by NRT decreases the viability of skin flaps. Although the available data are limited, there is no evidence from human studies that NRT increases the risk of healing-related or cardiovascular complications. Individual clinical trials of tobacco use interventions that include NRT have revealed either no effect or a reduction in complication rates. Therefore, given the benefits of smoking abstinence to both perioperative outcomes and long-term health and the efficacy of NRT in achieving and maintaining abstinence, any policies that prohibit the use of NRT in surgical patients should be reexamined.

Blood pressure variability (BPV), a modifiable risk factor, can compromise cerebral perfusion in critically ill patients. We studied the association between BPV in the intensive care unit (ICU) and short- and long-term cognitive outcomes.

To determine what proportion of a geographically defined population who receive new opioid prescriptions progresses to episodic or long-term patterns of opioid prescribing and to explore the clinical characteristics associated with patterns of opioid prescribing.

Smokers are at increased risk of postoperative complications. Electronic nicotine delivery systems (ENDS; or electronic cigarettes) could be a useful tool to reduce harm in the perioperative period. This pilot study examined the attitudes, beliefs, and practices of smokers scheduled for elective surgery regarding ENDS. This was a cross-sectional survey of current cigarette smokers who were evaluated in a preoperative clinic before elective surgery at Mayo Clinic. Measures included demographic characteristics, smoking history, 2 indices assessing the perception of how smoking affected health risks, ENDS use history, and 3 indices assessing interest in, perceived benefits of, and barriers to using ENDS in the perioperative period. Of the 112 smokers who completed the survey, 62 (55%) had tried ENDS and 24 (21%) reported current use. The most commonly stated reason for using ENDS was to quit smoking. Approximately 2 in 3 participants would be willing to use ENDS to help them reduce or eliminate perioperative cigarette use, and similar proportions perceived health benefits of doing so. Of the factors studied, only attempted to quit within the last year was significantly associated with increased interest in the perioperative use of ENDS (P=.03). Compared with participants who had tried ENDS (n=62), those who had never tried ENDS (n=50) had a significantly increased interest in the perioperative use of ENDS. A substantial proportion of patients scheduled for elective surgery had tried ENDS and would consider using ENDS to reduce perioperative use of cigarettes.

IMPORTANCE Cigarette smoking adds an estimated $100 billion in annual incremental direct health care costs nationwide. Cigarette smoking increases complication risk in surgical patients, but the potential effects of smoking status on perioperative health care costs are unclear. OBJECTIVE To test the hypothesis that current and former smoking at the time of admission for inpatient surgery, compared with never smoking, are independently associated with higher incremental health care costs for the surgical episode and the first year after hospital discharge. DESIGN, SETTING, AND PARTICIPANTS This population-based, propensity-matched cohort study, with cohort membership based on smoking status (current smokers, former smokers, and never smokers) was performed at Mayo Clinic in Rochester (a tertiary care center) and included patients at least 18 years old who lived in Olmsted County, Minnesota, for at least 1 year before and after the index surgery. EXPOSURE Undergoing an inpatient surgical procedure at Mayo Clinic hospitals between April 1, 2008, and December 31, 2009. MAIN OUTCOMES AND MEASURES Total costs during the index surgical episode and 1 year after hospital discharge, with the latter standardized as costs per month. Costs were measured using the Olmsted County Healthcare Expenditure and Utilization Database, a claims-based database including information on medical resource use, associated charges, and estimated economic costs for patients receiving care at the 2 medical groups (Mayo Clinic and Olmsted Medical Center) that provide most medical services within Olmsted County, Minnesota. RESULTS Propensity matching resulted in 678 matched pairs in the current vs never smoker grouping and 945 pairs in the former vs never smoker grouping. Compared with never smokers, adjusted costs for the index hospitalization did not differ significantly for current or former smokers. However, the adjusted costs in the year after hospitalization were significantly higher for current and former smokers based on regression analysis (predicted monthly difference of $400 [95% CI, $131-$669] and $273 [95% CI, $56-$490] for current and former smokers, respectively). CONCLUSIONS AND RELEVANCE Compared with never smokers, health care costs during the first year after hospital discharge for an inpatient surgical procedure are higher in both former and current smokers, although the cost of the index hospitalization is not affected by smoking status.

To test the hypothesis that exposure to procedures requiring general anesthesia during adulthood is not significantly associated with incident dementia using a retrospective, population-based, nested, case-control study design.

To describe the prevalence of nonacute conditions among patients seeking health care in a defined US population, emphasizing age, sex, and ethnic differences.

This review evaluates the link between perioperative lung atelectasis and postoperative pulmonary complications (PPCs) and how appropriate ventilatory strategies could mitigate this problem.

To study the association between exposure to procedures performed under general anesthesia before age 2 years and development of attention-deficit/hyperactivity disorder (ADHD).

On April 16 and 17, 2016, the Fifth biennial Pediatric Anesthesia & Neurodevelopment Assessment (PANDA) symposium was convened at the Morgan Stanley Children’s Hospital of New York at Columbia University Medical Center. During the symposium, experts in the fields of anesthesiology, neuropsychology, and epidemiology were convened in a small group session to determine the level of confidence in the current clinical evidence and the next steps in anesthetic neurotoxicity clinical research. Among the participants in the discussion, there remained a lack of consensus on whether anesthetic exposure causes long-term neurodevelopmental deficits in children based on the current evidence. This causal relationship between anesthesia exposure and neurodevelopmental deficit is difficult to establish using observational data, and current and future clinical trials are critical for answering this question. It was, however, recognized that the continuum of data that is seen in studies of other toxic environmental exposures, such as lead poisoning, has not been established in the anesthetic neurotoxicity literature, specifically regarding the timing of the exposure, the dose effects, contributing perioperative conditions, or vulnerable populations. As a result, these questions may need to be addressed in observational studies to guide future clinical trials.

Many patients who smoke cigarettes require anesthesia and surgery. Their smoking can have profound consequences for perioperative management. Efforts to help them quit will be rewarded by both improved immediate postoperative outcomes and the long-term health benefits after surgery. This review will introduce basic concepts important to perioperative tobacco control and cover recent advances in the field.

To determine whether there is a reduction in blood loss and blood transfusions associated with radical retropubic prostatectomy (RRP) by measuring the amount of blood loss and incidence of red blood cell (RBC) transfusions over time along with factors that may influence transfusions.

Maximal relaxation of airway smooth muscle (ASM) in response to atrial natriuretic peptide (ANP), which stimulates particulate guanylyl cyclase (pGC), is less than that produced by nitric oxide (NO) and other compounds that stimulate soluble guanylyl cyclase (sGC). We hypothesized that stimulation of pGC relaxes ASM only by decreasing intracellular Ca2+concentration ([Ca2+]i), whereas stimulation of sGC decreases both [Ca2+]iand the force developed for a given [Ca2+]i(i.e., the Ca2+sensitivity) during muscarinic stimulation. We measured the relationship between force and [Ca2+]i(using fura 2) under control conditions (using diltiazem to change [Ca2+]i) and during exposure to ANP, diethylamine-NO (DEA-NO), sodium nitroprusside (SNP), and theSpdiastereoisomer of β-phenyl-1,N2-etheno-8-bromoguanosine-3′,5′-cyclic monophosphorothionate (Sp-8-Br-PET-cGMPS), a cell-permeant analog of cGMP. Addition of DEA-NO, SNP, orSp-8-Br-PET-cGMPS decreased both [Ca2+]iand force, causing a significant rightward shift of the force-[Ca2+]irelationship. In contrast, with ANP exposure, the force-[Ca2+]irelationship was identical to control, such that ANP produced relaxation solely by decreasing [Ca2+]i. Thus, during muscarinic stimulation, stimulation of pGC relaxes ASM exclusively by decreasing [Ca2+]i, whereas stimulation of sGC decreases both [Ca2+]iand Ca2+sensitivity.