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Objectives:. The recent conflicting data on the mortality benefit of neuromuscular blocking agents in acute respiratory distress syndrome and the potential adverse effects of continuous neuromuscular blocking agent necessitates that these medications should be used judiciously with dose reduction in mind. The aims of the study were to improve the process of care by provider education of neuromuscular blocking agent titration and monitoring and to determine the impact of clinical endpoint based neuromuscular blocking agent titration protocol. Design:. We conducted a proof-of-concept historically controlled study of protocol-based intervention standardizing paralytic monitoring and titration using clinical variables. Education of the protocol was provided to ICU staff via bedside teaching and workshops. The primary outcomes were the time to reach goal paralysis and cumulative neuromuscular blocking agent dose. Secondary outcomes included maintenance of deeper sedation (Richmond Agitation and Sedation Scale –5) prior to neuromuscular blocking agent initiation, total time on mechanical ventilation, length of stay, and mortality. Setting:. Medical ICU at a quaternary academic hospital between March 2019 and June 2020. Patients:. Adult severe acute respiratory distress syndrome (Pao2/Fio2

Background: Partial face composite allotransplantation poses a unique aesthetic challenge. Namely, partial face transplants need to resemble the patient’s native skin. The degree of resemblance considered acceptable is a prominent variable and may depend on the gender and underlying skin tone of the recipient. The primary aim of this study was to investigate the degree of skin tone matching deemed aesthetically tolerable, recipient gender, and recipient skin tone. Two populations were queried: (1) the general public and (2) plastic surgeons. Few studies have investigated this topic from either of these standpoints. A secondary aim was to determine whether participant characteristics such as demographics, skin color, and history of having had facial surgery impacted their perceptions. Methods: This was a cross-sectional investigation of perceptions on skin tone matching. Participants from the general public were recruited through Amazon Mechanical Turk and surgeons were recruited through the American Council of Academic Plastic Surgeons. Participants were queried for aesthetic preferences using frontal face photos from age-standardized models. Skin tones of transplanted segments were varied using the Munsell color scale via Adobe Photoshop (Adobe Inc., San Jose, CA). Results: In total, 550 lay participants from Amazon Mechanical Turk and 21 plastic surgeons provided complete survey responses. On average, plastic surgeons tolerated a lesser degree of skin tone discordance than the lay public: 87% of lay participants and 33% of plastic surgeons believed a change of 4 hues was acceptable (p=0.02). Additionally, all survey respondents tolerated less of a degree of skin tone discrepancy on female faces when compared to male faces (mean difference tolerated: 2 hues for females, 4 hues for males). Participants tended to tolerate less skin tone discrepancy in subjects with similar skin tones as their own (mean difference tolerated: 2 hues for own versus 4 hues for different skin tones, p=0.04). Conclusion: This study highlighted the intensely- subjective nature of aesthetic preferences surrounding skin tone matching on the face, which varied by demographics and between surgeons versus the lay public. Surgeons should ensure that they truly elicit their patients’ preferences, especially given that our results demonstrated a greater tolerance for discrepancies among the lay public compared to plastic surgeons. Procuring a graft for facial allotransplantation is challenging; understanding what level of skin tone discrepancy is tolerable to the recipient can help surgeons improve patient satisfaction and may also lessen time-to-transplant by enlarging the potential donor pool for this type of transplant.