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Study Objective: To evaluate the association between pretransfusion and posttransfusion hemoglobin concentrations and the outcomes of children undergoing noncardiac surgery., Design: Retrospective review of patient records. We focused on initial postoperative hemoglobin concentrations, which may provide a more useful representation of transfusion adequacy than pretransfusion hemoglobin triggers (the latter often cannot be obtained during acute surgical hemorrhage)., Setting: Single-center, observational cohort study., Patients: We evaluated all pediatric patients undergoing noncardiac surgery who received intraoperative red blood cell transfusions from January 1, 2008, through December 31, 2018., Interventions: None., Measurements: Associations between pre- and posttransfusion hemoglobin concentrations (g/dL), hospital-free days, intensive care unit admission, postoperative mechanical ventilation, and infectious complications were evaluated with multivariable regression modeling., Main Results: In total, 113,713 unique noncardiac surgical procedures in pediatric patients were evaluated, and 741 procedures met inclusion criteria (median [range] age, 7 [1-14] years). Four hundred ninety-eight patients (68%) with a known preoperative hemoglobin level had anemia; of these, 14% had a preexisting diagnosis of anemia in their health record. Median (IQR) pretransfusion hemoglobin concentration was 8.1 (7.4-9.2) g/dL and median (IQR) initial postoperative hemoglobin concentration was 10.4 (9.3-11.6) g/dL. Each decrease of 1 g/dL in the initial postoperative hemoglobin concentration was associated with increased odds of transfusion within the first 24 postoperative hours (odds ratio [95% CI], 1.62 [1.37-1.93]; P < .001). No significant relationships were observed between postoperative hemoglobin concentrations and hospital-free days (P = .56), intensive care unit admission (P = .71), postoperative mechanical ventilation (P = .63), or infectious complications (P = .74)., Conclusions: In transfused patients, there was no association between postoperative hemoglobin values and clinical outcomes, except the need for subsequent transfusion. Most transfused patients presented to the operating room with anemia, which suggests a potential opportunity for perioperative optimization of health before surgery., Competing Interests: Declaration of competing interest No conflicts of interest declared., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Study Objective: This study sought to understand the timing and important factors identified by residents regarding their decision to pursue a career in anesthesiology, training areas deemed important to their future success, perceived greatest challenges facing the profession of anesthesiology, and their post-residency plans., Design: The American Board of Anesthesiology administered voluntary, anonymous, repeated cross-sectional surveys to residents who began clinical anesthesia training in the U.S. from 2013 to 2016 and were subsequently followed up yearly until the completion of their residency. The analyses included data from 12 surveys (4 cohorts from clinical anesthesia years 1 to 3), including multiple-choice questions, rankings, Likert scales, and free text responses. Free responses were analyzed using an iterative inductive coding process to determine the main themes., Main Results: The overall response rate was 36% (6480 responses to 17,793 invitations). Forty-five percent of residents chose anesthesiology during the 3rd year of medical school. "Nature of the clinical practice of anesthesiology" was the most important factor influencing their decision (average ranking of 5.93 out of 8 factors, 1 [least important] to 8 [most important]), followed by "ability to use pharmacology to acutely manipulate physiology" (5.75) and "favorable lifestyle" (5.22). "Practice management" and "political advocacy for anesthesiologists" (average rating 4.46 and 4.42, respectively, on a scale of 1 [very unimportant] to 5 [very important]) were considered the most important non-traditional training areas, followed by "anesthesiologists as leaders of the perioperative surgical home" (4.32), "structure and financing of the healthcare system" (4.27), and "principles of quality improvement" (4.26). Three out of 5 residents desired to pursue a fellowship; pain medicine, pediatric anesthesiology, and cardiac anesthesiology were the most popular choices, each accounting for approximately 20% of prospective fellows. Perceived greatest challenges facing the profession of anesthesiology included workforce competition from non-physician anesthesia providers and lack of advocacy for anesthesiologist values (referenced by 96% of respondents), changes and uncertainty in healthcare systems (30%), and personal challenges such as psychological well-being (3%)., Conclusions: Most residents identified anesthesiology as their career choice during medical school. Interest in non-traditional subjects and fellowship training was common. Competition from non-physician providers, healthcare system changes, and compromised psychological well-being were perceived concerns., Competing Interests: Declaration of Competing Interest Dandan Chen is a former staff member of the American Board of Anesthesiology (ABA); Huaping Sun and Emily Toutkoushian are staff members of the ABA; Stacie G. Deiner, Mark T. Keegan, and Alex Macario are ABA Directors and receive a stipend for their participation in ABA activities. David O. Warner is a former ABA Director., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Exposure to general anaesthesia in children might increase the risk of long-term behavioural problems. It is unclear if any behavioural changes in the short term after anaesthesia could be associated with long-term problems. The goal of the current study was to evaluate the short-term trajectory of parent-reported behaviour measured by the Behaviour Assessment System for Children, third edition (BASC-3) amongst children aged 2.5-6 yr who underwent general anaesthesia for elective surgery., Methods: Children who were undergoing general anaesthesia for surgery were recruited for assessment of behaviour on two occasions: preoperatively (from 1 week to 1 day before anaesthesia), and 3 months postoperatively. To assess longitudinal changes in the parent-reported behaviour measured by BASC-3, linear mixed models were built with visit number included as a categorical variable and subject-specific random intercepts., Results: Sixty-eight children (37 girls [54%]) were enrolled in the study and completed both assessments. At 3 months after anaesthesia, statistically significant improvements (decrease in T scores) in internalising problems (-2.7 [95% confidence interval -4.2 to -1.1]), anxiety (-2.5 [-4.4 to -0.5]), and somatisation (-3.0 [-5.2 to -0.9]) were found. There were no significant differences in scores between visits for other composites or scales. The pattern of results did not depend upon prior anaesthesia exposure., Conclusions: Anaesthesia for elective surgery in young children was associated with a small decrease in internalising problems but no changes in other areas of behavioural problems when assessed at 3 months postoperatively, including in children with prior exposure to anaesthesia., (Copyright © 2022 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Background: Exposure to general anaesthesia in children may be related to deficits in certain areas of cognition. It is unclear if these deficits could be measured in the immediate postoperative period in young children. The goal of the current study was to evaluate the trajectory of cognitive function in the domains of processing speed, working memory, and fine motor skills amongst children aged 2.5-6 yr who underwent general anaesthesia for elective surgery., Methods: Children who were scheduled to receive general anaesthesia for surgery were recruited for assessment of cognitive function at three times: preoperatively, 1-2 weeks postoperatively, and 3 months postoperatively. Assessments included processing speed, working memory, and fine motor skills. To assess longitudinal changes in the cognitive outcomes, linear mixed models were built with visit number included as a categorical variable and subject-specific random intercepts., Results: Sixty-one children (33 girls [54%]) enrolled in the study. Twenty-three children (38%) had received general anaesthesia previously. Significant improvements in picture memory, cancellation, and the processing speed composite were found at Visit 2. The improvement in cancellation and processing speed composite remained significant at Visit 3. Statistically significant improvement in Mullen fine motor score was noticed at Visit 3 compared with Visit 1. The pattern of results did not depend upon prior anaesthesia exposure., Conclusions: General anaesthesia for elective surgery in young children was not associated with declines in working memory, processing speed, and fine motor skills in the first 3 months postoperatively, including in children with prior exposure to anaesthesia., (Copyright © 2021 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Study Objective: To describe how the introduction of an Objective Structured Clinical Examination (OSCE) by the American Board of Anesthesiology (ABA) to its initial certification impacted anesthesiology residencies in the United States., Design and Setting: A sequential mixed-methods design with focus groups and online survey among program directors of Accreditation Council for Graduate Medical Education-accredited anesthesiology residencies., Patients: No patients were included., Intervention: None., Measurements: A convenience sample of 34 program directors were interviewed to understand their perceptions of the ABA OSCE. Subsequently, an online survey, based on major themes identified from the focus groups, was sent to all 156 program directors., Main Results: Several themes emerged from the focus group discussions: (1) a mock OSCE was most common for preparing residents for the ABA OSCE; 2) the ABA OSCE led to changes in residency curriculum; 3) the ABA OSCE assessed communication and professionalism skills well, and how well it assessed technical skills was less agreed on. Survey results from 87 program directors (response rate = 56%) were mostly consistent with the themes generated by the focus groups. Eight-one out of 87 programs (93%) specifically prepared their residents for the ABA OSCE. Fifty-two out of 81 program directors (64%) reported the introduction of the ABA OSCE led to curricular changes. Out of 79 program directors, 45 (57%) agreed the ABA OSCE assesses skills essential to anesthesiology practice, and 40 (51%) considered it added value to board certification., Conclusions: The introduction of the OSCE by the ABA for board certification has affected the curriculum of many residencies. Approximately 3 in 5 program directors perceived the ABA OSCE measures skills essential to anesthesiologists' practice. Future studies should assess residency graduates' perspective on the usefulness of both mock OSCE preparation and the ABA OSCE, and whether the ABA OSCE performance predicts future clinical practice., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Children's exposure to anaesthesia has been associated with risk of developing attention-deficit/hyperactivity disorder (ADHD). The goal of this study was to determine if selected patient characteristics moderate the association between exposure to anaesthesia and ADHD., Methods: In a cohort of children born in between 2006 and 2012, exposure to anaesthesia before the age of 5 yr was categorised into unexposed, singly, or multiply exposed. Weighted proportional hazard regression was performed to evaluate the hazard ratios (HRs) of ADHD diagnosis related to anaesthesia exposure. Interaction analyses were performed to evaluate potential moderators., Results: Among 185 002 children in the cohort, 9179 were diagnosed with ADHD. Compared with unexposed children, a single exposure to anaesthesia was associated with a HR of 1.39, (95% confidence interval [CI], 1.32-1.47) for ADHD. Multiple exposures were associated with a HR of 1.75 (95% CI, 1.62-1.87). In the analyses evaluating moderators of the association between exposure and ADHD, only the interaction for race was statistically significant (P=0.006); exposure increased the incidence of ADHD to a greater extent in non-White compared with White children. Among children with a single exposure, the age at exposure did not affect the relationship between exposure and incidence of ADHD (P=0.78)., Conclusions: Exposure of young children to anaesthesia and surgery is associated with an increased incidence of ADHD, with more exposures associated with greater risk. Compared with White children, non-White children are at greater risk for reasons that are unknown but need to be further explored., (Copyright © 2021 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Background: Whether exposure to a single general anaesthetic (GA) in early childhood causes long-term neurodevelopmental problems remains unclear., Methods: PubMed/MEDLINE, Embase, CINAHL, Web of Science, and the Cochrane Library were searched from inception to October 2019. Studies evaluating neurodevelopmental outcomes and prospectively enrolling children exposed to a single GA procedure compared with unexposed children were identified. Outcomes common to at least three studies were evaluated using random-effects meta-analyses., Results: Full-scale intelligence quotient (FSIQ); the parentally reported Child Behavior Checklist (CBCL) total, externalising, and internalising problems scores; and Behavior Rating Inventory of Executive Function (BRIEF) scores were assessed. Of 1644 children identified, 841 who had a single exposure to GA were evaluated. The CBCL problem scores were significantly higher (i.e. worse) in exposed children: mean score difference (CBCL total: 2.3 [95% confidence interval {CI}: 1.0-3.7], P=0.001; CBCL externalising: 1.9 [95% CI: 0.7-3.1], P=0.003; and CBCL internalising problems: 2.2 [95% CI: 0.9-3.5], P=0.001). Differences in BRIEF were not significant after multiple comparison adjustment. Full-scale intelligence quotient was not affected by GA exposure. Secondary analyses evaluating the risk of these scores exceeding predetermined clinical thresholds found that GA exposure was associated with increased risk of CBCL internalising behavioural deficit (risk ratio [RR]: 1.47; 95% CI: 1.08-2.02; P=0.016) and impaired BRIEF executive function (RR: 1.68; 95% CI: 1.23-2.30; P=0.001)., Conclusions: Combining results of studies utilising prospectively collected outcomes showed that a single GA exposure was associated with statistically significant increases in parent reports of behavioural problems with no difference in general intelligence., (Copyright © 2020 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Background: Exposure to surgery with general anaesthesia (surgery/GA) is associated with cortical atrophy, but the aetiology remains unknown. Amyloid-β (Aβ) deposition is one of the hallmark pathological characteristics of Alzheimer's disease (AD). We examined brain Aβ burden in study participants exposed to surgery/GA., Methods: We performed a cross-sectional analysis of residents of Olmsted County, MN, USA, in the Mayo Clinic Study of Aging who were aged 70-97 yr and underwent measurement of (i) brain Aβ with Pittsburgh compound B positron emission tomography (PiB PET), (ii) brain glucose metabolism with 18-fluorodeoxyglucose (FDG) PET, and (iii) temporal cortical thickness with MRI. Separate analyses were performed with exposure to surgery/GA, defined as occurring after age 40 yr, and with exposure to surgery/GA, defined as occurring within 20 yr before neuroimaging. Imaging measurements were compared between participants who were exposed to surgery/GA vs not exposed., Results: Of the 2563 participants, 585 had PET scans. Regardless of the definition used to quantify exposure, no significant associations were detected between exposure and either global PiB PET or FDG PET. In contrast, exposure to surgery/GA was associated with an increased likelihood of abnormal cortical thinning: odds ratio (OR)=1.98 (95% confidence interval [CI]: 1.19-3.31); P=0.010 in those exposed after age 40 yr, and OR=1.64 (95% CI: 1.05-2.55); P=0.029 in those exposed in the prior 20 yr., Conclusions: Exposure to surgery/GA is not associated with increases in cortical amyloid deposition. This finding suggests that the modest cortical thinning associated with surgery/GA is not related to AD pathology, but rather is caused by other processes., (Copyright © 2020 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Background: Preclinical studies suggest that exposure to general anaesthesia (GA) could cause neurodegeneration consistent with Alzheimer's disease (AD) pathology. Brain magnetic resonance imaging (MRI) is useful to study structural brain changes. We tested the hypothesis that exposure to surgery with GA (surgery/GA) is associated with greater cortical thinning and increased frequency of white matter lesions., Methods: This is a cross-sectional analysis of 70-91-yr-old participants enrolled in the Mayo Clinic Study of Aging who had baseline MRI. The thickness of selected cortical regions, the volume of white matter hyperintensities, and the frequency of cortical infarctions were compared in participants who were and were not exposed to surgery/GA within 20 yr before the first MRI obtained after enrolment., Results: Of 1410 participants with MRI scans, 932 were exposed to surgery/GA before scanning. In adjusted analyses, cortical thickness in regions vulnerable to AD was significantly less in those exposed to surgery/GA in the prior 20 yr (difference -0.023 mm, [95% confidence interval (CI) -0.041 to -0.005], P=0.014). Those with surgery in the prior 20 yr were more likely to have 'abnormal thickness' compared with those without surgery (odds ratio=1.45, [95% CI 1.10-1.90], P=0.009). Exposure was not associated with white matter hyperintensities or the presence of brain infarcts., Conclusions: This study suggests that exposure of older adults to surgical anaesthesia is associated with thinning in cortical regions implicated in AD. The pathogenesis and mechanisms driving these neurodegenerative changes, and the potential clinical significance of these findings, require further study., (Copyright © 2019 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Background: We hypothesised that exposure to multiple, but not single, procedures requiring general anaesthesia before age 3 yr is associated with a specific pattern of deficits in processing speed and fine motor skills., Methods: A secondary analysis (using factor and cluster analyses) of data from the Mayo Anesthesia Safety in Kids study was conducted, in which unexposed, singly exposed, and multiply exposed children born in Olmsted County, MN, USA from 1994 to 2007 were sampled using a propensity-guided approach and underwent neuropsychological testing at ages 8-12 or 15-20 yr., Results: In the factor analysis, the data were well fit to a five factor model. For subjects multiply (but not singly) exposed to anaesthesia, a factor reflecting motor skills, visual-motor integration, and processing speed was significantly lower [standardised difference of -0.35 (95% confidence interval {CI} -0.57 to -0.13)] compared with unexposed subjects. No other factor was associated with exposure. Three groups were identified in the cluster analysis, with 106 subjects (10.6%) in Cluster A (lowest performance in most tests), 557 (55.9%) in Cluster B, and 334 (33.5%) in Cluster C (highest performance in most tests). The odds of multiply exposed children belonging to Cluster A was 2.83 (95% CI: 1.49-5.35; P=0.001) compared with belonging to Cluster B; there was no other significant association between exposure status and cluster membership., Conclusions: Multiple, but not single, exposures to procedures requiring general anaesthesia before age 3 yr are associated with a specific pattern of deficits in neuropsychological tests. Factors predicting which children develop the most pronounced deficits remain unknown., (Copyright © 2019 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Background: It is not known whether the neurotoxicity produced by anaesthetics administered to young animals can also occur in children. Exposure of infant macaques to ketamine impairs performance in selected domains of the Operant Test Battery (OTB), which can also be administered to children. This study determined whether a similar pattern of results on the OTB is found in children exposed to procedures requiring general anaesthesia before age 3 yr., Methods: We analysed data from the Mayo Anesthesia Safety in Kids (MASK) study, in which unexposed, singly-exposed, and multiply-exposed children born in Olmsted County, MN, USA, from 1994 to 2007 were sampled using a propensity-guided approach and prospectively underwent OTB testing at ages 8-12 or 15-20 yr, using five tasks that generated 15 OTB test scores., Results: In primary analysis, none of the OTB test scores depended upon anaesthesia exposure status when corrected for multiple comparisons. Cluster analysis identified four clusters of subjects, with cluster membership determined by relative performance on the OTB tasks. There was no evidence of association between exposure status and cluster membership. Exploratory factor analysis showed that the OTB scores loaded onto four factors. The score for one factor was significantly less in multiply-exposed children (mean standardised difference -0.28 [95% confidence interval, -0.55 to -0.01; P=0.04]), but significance did not survive a sensitivity analysis accounting for outlying values., Conclusions: These findings provide little evidence to support the hypothesis that children exposed to procedures requiring anaesthesia show deficits on OTB tasks that are similar to those observed in non-human primates., (Copyright © 2019 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Study Objective: The initial developmental standards for Maintenance of Certification programs proposed by the American Board of Medical Specialties included the administration of patient and peer surveys by the diplomate every 5 years. The aim of this pilot study was to determine the feasibility of Maintenance of Certification in Anesthesiology Program (MOCA) patient and peer surveys in a selected group of American Board of Anesthesiology (ABA) diplomates., Design: The design was a pilot test of survey instruments-MOCA Patient Care Survey and MOCA Peer Survey., Setting: The setting was the ABA, Raleigh, NC., Subjects: The subjects were ABA-certified anesthesiologists who were active examiners for the primary certification oral examination as of January 2013., Measurements: Fifty-one participating physicians in the patient survey group distributed brochures, which included a link to the MOCA Patient Care Survey, to up to 100 consecutive patients at the point of care. Fifty-one participating physicians in the peer survey group distributed invitations to MOCA Peer Survey via e-mail to 20 peers in a variety of roles. Participants developed and evaluated a practice improvement plan based on survey results. Participants were also surveyed on their opinions on the feasibility of implementing the piloted survey instrument in their practices., Main Results: Response rates for the patient care and the peer surveys were 15% and 75%, respectively. Both surveys indicated a high level of satisfaction with the diplomates; approximately two-thirds of physicians could not identify practice areas in need of improvement., Conclusions: These results suggest that threats to the validity of these surveys include distribution bias for peer surveys and response bias for patient surveys and that surveys often do not provide actionable information useful for practice improvement. Alternative approaches, such as including anesthesiologists within an integrated institutional evaluation system, could be explored to maximize the benefits of physician assessments provided by peers and patients., (Copyright © 2015 Elsevier Inc. All rights reserved.)

There is increasing evidence that exposure of developing brains in animals, including nonhuman primates, to commonly-utilized anesthetic agents may cause adverse effects on cognition and behavior. In this paper, we summarize our methodology for a population-based, propensity-matched study to evaluate possible anesthesia-related sequelae in preschool children when evaluated in elementary or high school. A cohort of all children born in Olmsted County, Minnesota between the years 1994 and 2007 who are currently local residents has been identified. Existing medical records are being used to identify all episodes of exposure to general anesthesia prior to the age of 3 years (i.e., prior to their 3rd birthday). Children with multiple, single, and no anesthesia exposure are sampled for testing between the ages of 8 and 12 years or 15 and 19 years during the period 2012-2016. To match children in different exposure groups as closely as possible, sampling is guided by propensity-matching for the likelihood of receiving anesthesia. Selected children are invited to participate in a single 4-hour session of neuropsychological testing, including the National Center for Toxicological Research-Operant Test Battery, which has been used to study anesthetic neurotoxicity in nonhuman primates. The results of this testing will be compared among children with different anesthetic exposure histories. The expected products of this research will be a detailed phenotype of possible anesthetic-associated neurotoxicity in humans, utilizing a robust patient database and neuropsychological testing battery, and the first comparison of effects of anesthetic exposure in children and nonhuman primates performing nearly identical behavioral tasks., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Study Objective: The aim of this study was to determine the independent factors associated with performance on the Maintenance of Certification in Anesthesiology Program (MOCA) examination., Design: Cross-sectional study., Setting: The American Board of Anesthesiology, Raleigh, NC., Subjects: The American Board of Anesthesiology (ABA) diplomates who were certified between 2000 and 2006 and had taken the MOCA examination at least once by July 2013., Measurements: MOCA examination score for the first attempt., Main Results: Independent positive predictors for MOCA examination score in multiple regression analysis included passing the ABA Part 1 and Part 2 certification examinations on the first attempt and male sex, whereas negative predictors included history of action(s) taken against any medical license, taking the examination later in the MOCA cycle and older age at primary certification., Conclusions: Several factors in addition to performance on the written examination for primary certification (Part 1 Examination) are independently associated with performance on the MOCA examination. Because many of these factors are not modifiable, those diplomates who possess unfavorable risk factors should pay special attention to engaging in continuing learning to prepare for the MOCA examination., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Study Objective: To ascertain current knowledge, attitudes, and practices of anesthesiology residents regarding tobacco control, and to determine the characteristics of current residency training offered in tobacco control., Design: Electronically distributed survey instrument of anesthesiology residency program directors and residents., Setting: University medical center., Measurements and Main Results: The program director and resident response rates were 75/131 (57.3%) and 490/1182 (41.4%), respectively. Programs currently provide education regarding the perioperative consequences of smoking and, with the exception of the effect of smoking cessation shortly before surgery, resident knowledge reflected this curricular emphasis. However, the strong majority of programs did not offer education on how to ask about smoking status and advise cessation (79.5%) or help tobacco users quit before surgery (89.0%), though both program directors and residents felt these topics should be covered. A strong majority of residents (87.8%) felt the perioperative period was an effective time to assist in long-term smoking cessation, and desired education on tobacco control. Barriers to helping patients quit preoperatively included lack of time and low confidence in counseling abilities., Conclusions: A need exists for expanded formal education on perioperative tobacco cessation interventions for anesthesiology residents., (Published by Elsevier Inc.)

Study Objective: To determine the attitudes and perceptions of diplomates of the American Board of Anesthesiology (ABA) regarding the value of Board certification, Maintenance of Certification (MOC),and the specific components., Design: Survey instrument., Setting: American Board of Anesthesiology, Raleigh, NC, USA., Subjects: Diplomates of the ABA., Measurements: A SurveyMonkey link was sent to 3,000 randomly selected 1) non-time-limited diplomates who were not enrolled in MOC, 2) non-time-limited diplomates who were enrolled in MOC, and 3) time-limited diplomates of the ABA (1,000 survey requests per group). The surveys queried demographics, attitudes about the value of Board certification, and attitudes and knowledge about Maintenance of Certification in Anesthesiology (MOCA)., Main Results: 17% to 27% of diplomates from each group completed the survey. The majority of these diplomates perceived Board certification to be of value in demonstrating competence, although fewer believed that Board certification reflected competence. The elements of Professional Standing and Lifelong Learning and Self-Assessment were perceived to be significantly more relevant to the practice of the diplomates than were the Cognitive Examination and Practice Performance Assessment and Improvement activities. Diplomates demonstrated concerns about the cost and complexity of MOC, a lack of evidence that it improves practice, and a belief that the Cognitive Examination covered topics that were not relevant to their current practice., Conclusions: Although diplomates of the ABA highly value Board certification and report that the components of the MOCA program have potential relevance to their practices, they expressed significant concerns about the program as it is currently implemented., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Recent work has indicated that prolonged treatment with nitric oxide (NO) donors results in tissue storage of NO as S-nitrosothiols and N-nitrosamines. The possibility thus exists that NO treatment may result in the development of tissue stores of NO with functionally significant effects following removal of the original NO source. In these studies, the effects of 10 min treatment with two chemically distinct NO sources, S-nitrosoglutathione (GSNO) and (Z)-1-(N,N-diethylamino)diazen-1-ium-1,2-diolate (DEA-NO) were determined in canine pulmonary artery using a superfusion system that permitted continuous isometric force recording during addition and removal of the NO donors. Relaxation that persisted for up to 1 h after removal of the NO source, was demonstrated for both NO sources, but at lower concentrations relative to the relaxant EC(50) for GSNO versus DEA-NO. Persistent relaxation with both NO sources was fully reversed by both the sGC inhibitor, ODQ, and an inhibitor of cGMP-dependent protein kinase, Rp-8-Br-PET-cGMPS, indicating that persistent relaxation was consistent with persistent activation of the sGC-cGMP signaling pathway. In separate measurements, a GSNO-induced persistent increase in both tissue cGMP ([cGMP](i)) and relaxation were fully reversed by both ODQ and the thiol reducing agent dithiothreitol (DTT). The results indicate that vascular smooth muscle is capable of converting short-lived NO responses following short term exposure to NO donors by a mechanism consistent with prolonged sGC activation, resulting in persistent relaxation. Reversal of this cGMP-dependent process with DTT suggests that it occurs via mechanisms that are thiol redox sensitive.

Study Objective: To determine the postoperative outcome of narcolepsy patients, a population that may be at increased risk of perioperative complications, including postoperative hypersomnia, prolonged emergence after general anesthesia, and apnea., Design: Retrospective chart review., Setting: Academic medical center., Measurements: The perioperative outcome of pharmacologically treated narcolepsy patients, diagnosed at the Mayo Clinic sleep laboratory between January 1, 1965, and December 31, 2001, was studied. A total of 37 narcolepsy patients was identified. Charts were reviewed for the following perioperative (intraoperative time plus recovery room time) events: time for extubation, duration of stay in the Postanesthesia Care Unit (PACU), and duration of stay in the hospital. Furthermore, any of the following complications were noted: electrocardiographic (ECG) changes, postoperative nausea and vomiting, hypotension, subjective reports of pain, decreasing oxygen saturation (SpO(2)) levels, respiratory complications, postoperative fever, agitation in the PACU, and hypersomnolence in PACU. In addition, patient hospital stay and major morbidity and mortality during hospital stay were recorded., Main Results: Ten patients pharmacologically treated for their narcolepsy symptoms that underwent 27 noncardiac surgical procedures under general anesthesia. We found no evidence that the pharmacologically treated narcolepsy patients were at any increased risk for perioperative complications. Furthermore, their time for endotracheal extubation, length of stay in the PACU and hospital did not differ from nonnarcolepsy patients., Conclusion: Pharmacological therapy for narcolepsy should be continued during the perioperative period. In addition, treated narcolepsy patients are at no increased risk for postoperative complications.