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This paper explores the concept of suitability within applications of Ideal Distribution Models (IDMs). Specifically, we investigate the effectiveness of single measures of suitability in contexts ...

Objectives/hypothesis Video laryngoscopy has grown tremendously in popularity over the last decade for management of the anticipated difficult airway. The use of video laryngoscopy has not been adequately studied in the head and neck pathology patient population, including those with masses, previous head and neck surgery, or radiation. Study design Prospective observational study. Methods This study included 100 patients with head and neck pathology undergoing awake flexible bronchoscopic intubation for nonemergency surgery requiring general anesthesia. After the performance of awake flexible bronchoscopic intubation and induction of anesthesia, video laryngoscopy was performed with the CMAC D blade and Glidescope AVL. The primary outcome was the modified Cormack-Lehane view obtained on video laryngoscopy. Results One hundred patients were enrolled in the study. After exclusions, 92 patients underwent video laryngoscopy with both the CMAC D blade and the Glidescope AVL. Thirty-seven patients (40.2%) had a Cormack-Lehane view ≥3 with the CMAC D blade, and 28 patients (30.4%) had a Cormack-Lehane view ≥3 with the Glidescope AVL. There were no complications from awake flexible bronchoscopic intubation or video laryngoscopy. Conclusions There is a high incidence of inability to obtain a view of the glottis with video laryngoscopy in patients with head and neck pathology, particularly airway masses. Level of evidence 3 Laryngoscope, 131:82-86, 2021.

Simulation-based education (SBE) has become pervasive in health care training and medical education, and is even more important in subspecialty training whereby providers such as otolaryngologists and anesthesiologists share overlapping patient concerns because of the proximity of the surgical airway. Both these subspecialties work in a fast-paced environment involving high-stakes situations and life-changing events that necessitate critical thinking and timely action, and have an exceedingly small bandwidth for error. Team training in the form of interprofessional education and learning involving surgeons, anesthesiologists, and nursing is critical for patient safety in the operating room in general, but more so in otolaryngology surgery.

Regional anesthesia and acute pain management in otolaryngology uses multimodal techniques for perioperative pain control. Multiple methods for regional anesthesia and acute pain management are discussed, including indications and techniques for decreasing perioperative opioid requirements and enhancing recovery.

The perioperative care of adult patients undergoing free tissue transfer during head and neck surgical (microvascular) reconstruction is inconsistent across practitioners and institutions. The executive board of the Society for Head and Neck Anesthesia (SHANA) nominated specialized anesthesiologists and head and neck surgeons to an expert group, to develop expert consensus statements. The group conducted an extensive review of the literature to identify evidence and gaps and to prioritize quality improvement opportunities. This report of expert consensus statements aims to improve and standardize perioperative care in this setting. The Modified Delphi method was used to evaluate the degree of agreement with draft consensus statements. Additional discussion and collaboration was performed via video conference and electronic communication to refine expert opinions and to achieve consensus on key statements. Thirty-one statements were initially formulated, 14 statements met criteria for consensus, 9 were near consensus, and 8 did not reach criteria for consensus. The expert statements reaching consensus described considerations for preoperative assessment and optimization, airway management, perioperative monitoring, fluid management, blood management, tracheal extubation, and postoperative care. This group also examined the role for vasopressors, communication, and other quality improvement efforts. This report provides the priorities and perspectives of a group of clinical experts to help guide perioperative care and provides actionable guidance for and opportunities for improvement in the care of patients undergoing free tissue transfer for head and neck reconstruction. The lack of consensus for some areas likely reflects differing clinical experiences and a limited available evidence base.

The GlueX experiment at Jefferson Lab has been designed to study photoproduction reactions with a 9-GeV linearly polarized photon beam. The energy and arrival time of beam photons are tagged using a scintillator hodoscope and a scintillating fiber array. The photon flux is determined using a pair spectrometer, while the linear polarization of the photon beam is determined using a polarimeter based on triplet photoproduction. Charged-particle tracks from interactions in the central target are analyzed in a solenoidal field using a central straw-tube drift chamber and six packages of planar chambers with cathode strips and drift wires. Electromagnetic showers are reconstructed in a cylindrical scintillating fiber calorimeter inside the magnet and a lead-glass array downstream. Charged particle identification is achieved by measuring energy loss in the wire chambers and using the flight time of particles between the target and detectors outside the magnet. The signals from all detectors are recorded with flash ADCs and/or pipeline TDCs into memories allowing trigger decisions with a latency of 3.3 $\mu$s. The detector operates routinely at trigger rates of 40 kHz and data rates of 600 megabytes per second. We describe the photon beam, the GlueX detector components, electronics, data-acquisition and monitoring systems, and the performance of the experiment during the first three years of operation., Comment: Accepted by Nuclear Instruments and Methods A, 78 pages, 54 figures

From 2016 to 2019, the Indian Pradhan Mantri Ujjwala Yojana (PMUY) distributed over 80 million liquefied petroleum gas (LPG) stoves, making it the largest clean cooking program ever. Yet, evidence shows widespread continued use of the traditional chulha, negating the potential health benefits of LPG. Here we use semi-structured interviews with female and male adults to understand the drivers of LPG usage in Mulbagal, Karnataka, the site of a proto-PMUY program. We find that respondents perceive the main value of LPG to be saving time, rather than better health. We also find that norms of low female power in the household, in addition to costs, delay saving for and ordering LPG cylinder refills. Namely, female cooks controlled neither the money nor the mobile phone required to order a timely refill. These factors together contribute to the ‘refill gap’: the period of non-use between refilling cylinders, which may range from days to even months. Our work reveals how gender norms can amplify affordability challenges in low-income households.

In India, approximately 480,000 deaths occur annually from exposure to household air pollution from the use of biomass cooking fuels. Displacing biomass use with clean fuels, such as liquefied petroleum gas (LPG), can help reduce these deaths. Through government initiatives, most Indian households now own an LPG stove and one LPG cylinder. Many households, however, continue to regularly use indoor biomass-fueled mud stoves (chulhas) alongside LPG. Focusing on this population in rural Maharashtra, India, this study (N = 186) tests the effects of conditioning a sales offer for a spare LPG cylinder on a reversible commitment requiring initially disabling indoor chulhas. We find that almost all relevant households (>98%) were willing to accept this commitment. Indoor chulha use decreased by 90% (95% CI = 80% to 101%) when the sales offer included the commitment, compared to a 23% decrease (95% CI = 14% to 32%) without it. For both treatment groups, we find that 80% purchased the spare cylinder at the end of the study.

IntroductionHealth interventions often target pregnant women and their unborn children. Interventions in rural India targeting pregnant women, however, often do not cover the critical early windows of susceptibility during the first trimester and parts of the second trimester. This pilot seeks to determine if targeting newlyweds could protect entire pregnancies with a clean stove and fuel intervention.MethodsWe recruited 50 newlywed couples who use biomass as a cooking fuel into a clean cooking intervention that included a liquefied petroleum gas (LPG) stove, two gas cylinders, a table to place the stove on and health education. We first evaluated whether community health workers in this region could identify and recruit couples at marriage. We quantified how many additional days of pregnancy could be covered by an intervention if we recruited at marriage versus recruiting after detection of pregnancy.ResultsOn average, we identified and visited newlywed couples within 40 (SD 21) days of marriage. Of the 50 couples recruited, 25 pregnancies and 18 deliveries were identified during this 1-year study. Due to challenges securing fuel from the LPG supply system, not all couples received their intervention prior to pregnancy. Regardless, couples recruited in the marriage arm had substantially more days with the intervention than couples recruited into a similar arm recruited at pregnancy (211 SD 46 vs 120 SD 45). At scale, a stove intervention targeting new marriages would cover about twice as many weeks of first pregnancies as an intervention recruiting after detection of pregnancy.ConclusionsWe were able to recruit in early marriage using existing community health workers. Households recruited early in marriage had more days with clean fuel coverage than those recruited at pregnancy. Our findings indicate that recruitment at marriage is feasible and warrants further exploration for stove and other interventions targeting pregnancy-related outcomes.

IntroductionThere is evidence that the BCG vaccine against tuberculosis also helps prevent other diseases – perhaps including COVD-19. Spain had a program for universal BCG vaccination until 1981.ObjectiveTo see whether cohorts born when Spain had a program of universal BCG vaccination had lower rates of confirmed cases of COVID-19 and mortality (relative to similar cohorts in Italy).MethodsWe compare COVID-19 mortality and confirmed cases for those born roughly a decade before and after 1981. We compare the outcomes to the same age cohorts in Italy, which never had universal BCG vaccination.ResultsThe Spanish cohort that received BCG had a relative risk of 0.962 of having a confirmed case of COVID-19. This risk is statistically significantly below unity (95% CI 0.952 to 0.972, P< 0.001). There is also suggestive evidence the BCG cohort in Spain had lower mortality (relative risk 0.929, CI 0.850 to 1.01, P = 0.11). The small sample size makes this test underpowered.ConclusionThese suggestive results provide a shred of evidence that BCG vaccinations help protect against COVID. I outline many limitations to this study and point how better data can help be more convincing.

Oral rehydration solution (ORS) has the potential to avert almost all deaths from diarrheal diseases. Nevertheless, in poor nations only about half of children with diarrhea receive ORS. Each year since 2014, India has run an Intensified Diarrhea Control Fortnight to increase ORS treatment. A key element of the Fortnight plan is free distribution of ORS to over 100 million homes with young children. We compared ORS usage reported in the 2015/2016 National Family Health Survey in the 3 months before the 2015 and 2016 Fortnights to the 2 months after. We control for state fixed effects and for observable characteristics of the child and household. To reduce data mining, we use a short predetermined set of controls and also use a machine learning method: cross-fit partialing-out lasso logistic regression. ORS usage rose about 4.0 percentage points after the Fortnight, closing about 7% of the gap to universal usage. The increase is not statistically significant at conventional levels. These point estimates are inconsistent with government claims that, in 2015, 63% of homes received free ORS. The Fortnight could benefit from more transparent monitoring, a more rigorous evaluation, and improvements in operations. Funding Statement: IRLE at UC Berkeley funded this research. Declaration of Interests: We declare no conflicts of interest.

Anesthesiologists and otolaryngologists share overlapping patient concerns because of the proximity of the surgical airway. While many surgical environments benefit from a collegial team dynamic, the characteristics of the otolaryngologic environment require a unique interdisciplinary collaboration for optimal patient outcomes. Patients undergoing head and neck surgery are at high risk of potentially devastating events if the airway is distorted due to pathologic conditions. Therefore, both specialties benefit from a shared understanding of each other’s practice. Team training in the form of interprofessional simulation education involving surgeons, anesthesiologists, and nursing is critical for patient safety in the operating room in general but more so in otolaryngology surgery. High-quality ENT anesthesia simulation training should provide clinicians with (1) deliberate practice of procedural skills and/or (2) familiarization with equipment and their failure modes, (3) management of basic and critical events associated with ENT patients and surgery, (4) interdisciplinary crisis resource management skills during head and neck surgery including decision-making under pressure and delegation of roles, and (5) debriefing, reflection, and valuable feedback.

This data in brief article includes estimated time cooking based on temperature sensor data taken every 30 min from three stone fires and introduced fuel-efficient Envirofit stoves in approximately 168 households in rural Uganda. These households were part of an impact evaluation study spanning about six months to understand the effects of fuel-efficient cookstoves on fuel use and pollution. Daily particulate matter (pollution) and fuelwood use data are also included. This data in brief file only includes the weeks prior to, during, and after an in-person measurement team visited each home. The data is used to analyze whether households change cooking patterns when in-person measurement teams are present versus when only the temperature sensor is in the home.

The articles in this symposium describe how advances in information technology present many challenges. I briefly review the other articles. I then conclude with a complementary approach to addressing the challenges. Specifically, a more just and productive society is more likely if more people work together to use artificial intelligence, Big Data, and other tools to further goals they select themselves.

INTRODUCTION Gammatile (GT) is a recently FDA-cleared brachytherapy platform with 131Cs seeds imbedded into a resorbable collagen carrier for surgically targeted radiation delivery. We report the first experience for recurrent glioblastoma patients who underwent GT treatment following surgical resection. METHODS Twenty-two consecutive patients with 23 isocitrate dehydrogenase (IDH) wild-type glioblastomas (14 second; eight third recurrence) who underwent intra-operative MRI/5-ALA guided maximal safe resection followed by GT placement were prospectively followed. There were 6 methylguanine-DNA-methyltransferase promoter methylated (MGMTm) and 17 unmethylated (MGMTu) glioblastomas. RESULTS The median hospital stay was one day (range:1-15 days). There was one 30-day readmission (4.5%) for a cerebrospinal fluid leak from the incision site, which resolved with lumbar drainage. There were no other wound complications. One patient (4.5%) suffered new post-operative seizure. Eight patients experienced worsened neurological deficit (8/22 or 36%). While all deficits improved by the 30-day follow-up, 7 of these 8 patients suffered KPS decline due to persistent deficits. There was one 30-day mortality (4.5%) from intracranial hemorrhage secondary to heparinization for an ischemic limb. The median follow-up after GT placement for the remaining 21 patients was 296 days (range:111-931 days). Six months local control (LC) was achieved in ~75% of the patients irrespective of MGMT status. Median overall survival (OS) was 715 days for the MGMTu patients, and not reached (>1000 days) for MGMTm patients. These outcomes compared favorably to the published literature (LC: 3-49%; OS MGMTu: 135-285 days; OS MGMTm: 174-564 days) and an age, KPS, extent of resection matched glioblastoma cohort who underwent maximal safe resection without GT at our institution (LC: 52%; OS MGMTu: 462 days; OS MGMTm: 821 days; p=0.0089 and p=0.0271, respectively when compared to the GT treated patients). CONCLUSION This clinical experience supports the safety and efficacy of GT brachytherapy as a treatment option for recurrent glioblastomas.

Background We sought to determine whether mannequin-based simulation can reliably characterize how board-certified anesthesiologists manage simulated medical emergencies. Our primary focus was to identify gaps in performance and to establish psychometric properties of the assessment methods. Methods A total of 263 consenting board-certified anesthesiologists participating in existing simulation-based maintenance of certification courses at one of eight simulation centers were video recorded performing simulated emergency scenarios. Each participated in two 20-min, standardized, high-fidelity simulated medical crisis scenarios, once each as primary anesthesiologist and first responder. Via a Delphi technique, an independent panel of expert anesthesiologists identified critical performance elements for each scenario. Trained, blinded anesthesiologists rated video recordings using standardized rating tools. Measures included the percentage of critical performance elements observed and holistic (one to nine ordinal scale) ratings of participant’s technical and nontechnical performance. Raters also judged whether the performance was at a level expected of a board-certified anesthesiologist. Results Rater reliability for most measures was good. In 284 simulated emergencies, participants were rated as successfully completing 81% (interquartile range, 75 to 90%) of the critical performance elements. The median rating of both technical and nontechnical holistic performance was five, distributed across the nine-point scale. Approximately one-quarter of participants received low holistic ratings (i.e., three or less). Higher-rated performances were associated with younger age but not with previous simulation experience or other individual characteristics. Calling for help was associated with better individual and team performance. Conclusions Standardized simulation-based assessment identified performance gaps informing opportunities for improvement. If a substantial proportion of experienced anesthesiologists struggle with managing medical emergencies, continuing medical education activities should be reevaluated.

Objective To determine if pharyngeal packs have an effect on postoperative pain and postoperative nausea and vomiting in functional endoscopic sinus surgery (FESS). Study Design Forty-six patients scheduled for routine endoscopic sinus surgery were recruited into this study. The patients were randomly allocated to have or to not have pharyngeal packing prior to surgery. Methods The placement of pharyngeal packs during FESS is controversial. Theoretically, pharyngeal packs may prevent postoperative nausea and vomiting by preventing ingestion of blood during sinus surgery. However, prior studies have not conclusively demonstrated this to be the case in FESS. Pharyngeal packs have been associated with complications including throat pain, aspiration, and death. The objective of this randomized control trial was to determine if pharyngeal packs have an effect on postoperative throat pain, nausea, and vomiting in order to determine their importance during FESS. Patients were blinded to intervention. Postoperatively, throat pain and nausea/vomiting scores were recorded. Results There was no significant difference in mean throat pain at 4 hours following surgery (P = 0.860). At 24 hours after surgery, patients without pharyngeal packing experienced more pain than those who had a throat pack placed (P = 0.002). There was no significant difference in the level of nausea at 4 hours after surgery (P = 0.315) or at 24 hours after surgery (P = 0.315). Conclusion We recommend against the routine use of placing pharyngeal packs during FESS. Level of Evidence 1b. Laryngoscope, 127:2460–2465, 2017

Basic sanitation and hygiene can prevent roughly a million deaths a year. This study examines the rapid prototyping of a pilot school-based handwashing, safe water, and sanitation program in Chennai, India. Our content analysis identified challenges in the classroom (Localization; Curriculum supplies; Program implementation; Communication and language; and Teacher commitment), factors outside the class but within the school (School administration and support and Hygiene and sanitation facilities and supplies) and factors outside the school such as family and slum conditions. We report on the pilot, the barriers it faced, and the changes we made in pursuit of a sustainable school-based health program. Keywords: Hygiene, School-based health intervention, Sanitation, Behavior change, India

Background Indoor residual spraying (IRS), the coating of interior walls of houses with insecticides, is common in malaria-endemic areas. While important in malaria control, IRS potentially exposes residents to harmful insecticides. The World Health Organization recommends steps to minimize exposure; however, no programme has focused on educating populations. Methods A dramatic presentation and song were developed by study personnel and performed by lay performers in order to spread awareness of the importance of IRS and to minimize insecticide exposure. Performances were staged at 16 sprayed villages in the Vhembe District of Limpopo, South Africa, at which 592 attendees completed short questionnaires before and after the performance about behaviors that might limit insecticide exposure. Overall indices of the attendees’ change in knowledge of precautions to take prior to and after spraying to prevent insecticide exposure were analyzed using hierarchical mixed models to assess the effect of the performance on change in participants’ knowledge. Results Approximately half of attendees lived in homes that had been sprayed for malaria and 62% were female. Over 90% thought it better to allow IRS prior to the presentation, but knowledge of proper precautions to prevent exposure was low. The proportion answering correctly about proper distance from home during spraying increased from 49.4% pre-performance to 62.0% post-performance (RR = 1.26, 95% CI = 1.13, 1.41), and the proportion reporting correctly about home re-entry interval after spraying increased from 58.5 to 91.1% (RR = 1.54, 95% CI 1.35, 1.77). Attendees improved in their knowledge about precautions to take prior to and after spraying from mean of 57.9% correct to a mean of 69.7% (β = 12.1%, 95% CI 10.9, 13.4). Specifically, increased knowledge in closing cupboards, removing food and bedding from the home, covering immoveable items with plastic, and leading animals away from the home prior to spraying were observed, as was increased knowledge in sweeping the floors, proper disposal of dead insects, and discarding dirty washrags after spraying. Conclusions A dramatic presentation and song were able to increase the attendees’ knowledge of precautions to take prior to and after spraying in order to limit their insecticide exposure resulting from IRS. This approach to community education is promising and deserves additional study.

Diarrhoea, the most common disease directly related to water, sanitation, and hygiene (WASH), still remains one of the most significant health problems among children under-five worldwide. In this reality, BRAC, the largest NGO in the world initiated a comprehensive WASH intervention in 50 upazilas (sub-districts) of Bangladesh in 2007 which was later scaled up to cover 150 upazilas in two subsequent phases. The intervention period of the programme was 2007-2011. The present study encompassed 30 upazilas of the first phase of intervention. The aim of the study was to investigate the effectiveness of this intervention on reduction of diarrhoea among under-five children, and to identify the factors associated with childhood diarrhoea. A repeated cross-sectional study design was followed, and a population-based survey was carried out on four occasions: baseline (2007), midline (2009), endline (2011), and post-endline (2015) among 4,775 households. This analysis considers only households having at least one under-five children. Absence of handwashing practice with soap after defecation and before eating food, unclean latrine condition, and unsafe disposal of child faeces were identified as significant risk factors associated with under-five diarrhoea from Log-binomial regression. The prevalence of under-five diarrhoea within the past 2 weeks of the survey declined from 13.7% at baseline to 3.6% at end-line (p 0.001) in the WASH intervention area. However, the progress seemingly stalled after 2011, which may have occurred due to the lack of improvement in unsafe disposal of child faeces and unclean latrine condition after the intervention period. Study findings suggest that, to reduce the prevalence of childhood diarrhoea it is important to promote safe disposal of child faeces, maintaining cleanliness of latrines, and washing hand with soap at critical times, beyond merely increasing the sanitation coverage. Findings also underline the necessity of maintaining a small-scale monitoring component involving local community, such as a WatSan committee (a local committee comprising the user communities for supervising WASH related activities) for periodic monitoring at household level for a certain period after the program intervention works to make the behavioural change more sustainable and to keep the reduction rate of under-five diarrhoeal prevalence steady.

Background Functional endoscopic sinus surgery is a common procedure for sinonasal disease, frequently performed in the outpatient setting. General anesthesia maintained with total intravenous anesthesia (TIVA) with propofol has been shown to give superior surgical conditions compared to inhaled anesthetics. This study evaluated the effects of TIVA versus a predominantly nitrous oxide (N2 O)-based anesthetic with a low-dose propofol and remifentanil infusion on sinus surgery. Methods Patients were randomized to either a N2 O-based (nitrous oxide with propofol and remifentanil) or TIVA (propofol and remifentanil without nitrous oxide) group. The surgeon was blinded to the anesthetic technique. Surgical field grading was performed in real time by the otolaryngologist every 15 minutes with the Boezaart grading system. Results There were no statistically significant differences between the Boezaart scores, duration of surgery, or estimated blood loss between the two anesthetic techniques. However, the use of N2 O provided a statistically significant, 38% reduction in time from surgery end to extubation. The TIVA group had significantly decreased mean and median pain scores in the post-anesthesia care unit (PACU). There was no difference in the rate of postoperative nausea and vomiting between the two groups. Conclusion A N2 O-based anesthetic for functional endoscopic sinus surgery provides similar intraoperative and postoperative conditions when compared to TIVA, while being superior in terms of time to extubation. Although the TIVA group had significantly decreased pain scores, this did not lead to a decrease in pain medicine received in the PACU, and there was no difference between groups in time to discharge. Level of evidence 1b Laryngoscope, 130:E299-E304, 2020.

We study how a regulator can best allocate its limited inspection resources. We direct our analysis to a US Occupational Safety and Health Administration (OSHA) inspection program that targeted dangerous establishments and allocated some inspections via random assignment. We find that inspections reduced serious injuries by an average of 9% over the following five years. We use new machine learning methods to estimate the effects of counterfactual targeting rules OSHA could have deployed. OSHA could have averted over twice as many injuries if its inspections had targeted the establishments where we predict inspections would avert the most injuries. The agency could have averted nearly as many additional injuries by targeting the establishments predicted to have the most injuries. Both of these targeting regimes would have generated over $1 billion in social value over the decade we examine. Our results demonstrate the promise, and limitations, of using machine learning to improve resource allocation. JEL Classifications: I18; L51; J38; J8

Hospitalized patients outside of the operating room frequently require emergency airway management. This study investigates complications of emergency airway management in critically ill adults, including: (1) the incidence of difficult and failed intubation; (2) the frequency of esophageal intubation; (3) the incidence of pneumothorax and pulmonary aspiration; (4) the hemodynamic consequences of emergent intubation, including death, during and immediately following intubation; and (5) the relationship, if any, between the occurrence of complications and supervision of the intubation by an attending physician.Data were collected on consecutive tracheal intubations carried out by the intensive care unit team over a 10-month period. Non-anesthesia residents were supervised by anesthesia residents, critical care attending physicians, or anesthesia attending physicians.Two hundred ninety-seven consecutive intubations were carried out in 238 adult patients. Translaryngeal tracheal intubation was accomplished in all patients. Intubation was difficult in 8% of cases (requiring more than two attempts at laryngoscopy by a physician skilled in airway management). Esophageal intubation occurred in 25 (8%) of the attempts but all were recognized before any adverse sequelae resulted. New infiltrates suggestive of pulmonary aspiration were present on chest radiography after 4% of intubations. Seven patients (3%) died during or within 30 min of the procedure. Five of the seven patients had systemic hypotension (systolic blood pressureor = 90 mmHg), and four of the five were receiving vasopressors to support systolic blood pressure. Patients with systolic hypotension were more likely to die after intubation than were normotensive patients (P0.001). There was no relationship between supervision by an attending physician and the occurrence of complications.In critically ill patients, emergency tracheal intubation is associated with a significant frequency of major complications. In this study, complications were not increased when intubations were accomplished without the supervision of an attending physician as long as the intubation was carried out or supervised by an individual skilled in airway management. Mortality associated with emergent tracheal intubation is highest in patients who are hemodynamically unstable and receiving vasopressor therapy before intubation.

There is considerable controversy as to whether the simulator should die during high-fidelity simulation (HFS). We sought to describe the physiologic and biochemical stress response induced by simulated patient death as well as the impact on long-term retention of Advanced Cardiovascular Life Support (ACLS) knowledge and skills.Twenty-six subjects received an American Heart Association (AHA) ACLS provider course. Following the course, subjects participated in HFS and were randomized to simulated death or survival. Heart rate and salivary cortisol (SC) and dihydroepiandrosterone (DHEA) were collected at this time. Subjects returned six months later for a follow-up simulation in which ACLS knowledge and skills were tested.For all participants, there was an increase in heart rate during simulation compared with baseline heart rate (+ 32 beats/minute), p0.0001. Similarly, SC and DHEA were higher compared with baseline levels (+ 0.115 μg/dL, p0.01 and + 97 pg/mL, p0.001, respectively). However, the only statistically significant difference between groups was an increase in heart rate response at the end of the simulation compared with baseline in the death group (+ 29.2 beats/minute versus + 18.5 beats/minute), p0.05. There was no difference on long-term knowledge or skills.Learners experience stress during high-fidelity simulation; however, there does not appear to be a readily detectable difference or negative response to a simulated patient death compared with simulated survival.

We randomize the insurance premium for the SKY micro-health insurance program in rural Cambodia, allowing us to estimate the causal effects of health insurance on economic, health care utilization, and health outcomes. SKY insurance has its greatest impact on economic outcomes. SKY also changed health-seeking behavior, increasing the use of covered public facilities and decreasing the use of uncovered private care for major illnesses. As expected, due to low statistical power, we did not find statistically significant impacts on health.

There is growing support for an entrepreneurial community health worker (CHW) model, but the benefits of such a design are unclear. We randomly assigned CHWs in Uganda to sell treatment for child diarrhea door-to-door and retain the profits or to deliver treatment to homes for free. We find that, despite stronger financial incentives, the entrepreneurial model led to substantially less effort (fewer household visits) than the free delivery model. Qualitative evidence suggests that selling had a social penalty whereas free distribution was socially rewarding. Our results call into question the notion that an entrepreneurial model necessarily increases CHW effort relative to free distribution.

Background Anaesthetists may fail to recognize and manage certain rare intraoperative events. Simulation has been shown to be an effective educational adjunct to typical operating room-based education to train for these events. It is yet unclear, however, why simulation has any benefit. We hypothesize that learners who are allowed to manage a scenario independently and allowed to fail, thus causing simulated morbidity, will consequently perform better when re-exposed to a similar scenario. Methods Using a randomized, controlled, observer-blinded design, 24 first-year residents were exposed to an oxygen pipeline contamination scenario, either where patient harm occurred (independent group, n=12) or where a simulated attending anaesthetist intervened to prevent harm (supervised group, n=12). Residents were brought back 6 months later and exposed to a different scenario (pipeline contamination) with the same end point. Participants’ proper treatment, time to diagnosis, and non-technical skills (measured using the Anaesthetists’ Non-Technical Skills Checklist, ANTS) were measured. Results No participants provided proper treatment in the initial exposure. In the repeat encounter 6 months later, 67% in the independent group vs 17% in the supervised group resumed adequate oxygen delivery (P=0.013). The independent group also had better ANTS scores [median (interquartile range): 42.3 (31.5–53.1) vs 31.3 (21.6–41), P=0.015]. There was no difference in time to treatment if proper management was provided [602 (490–820) vs 610 (420–800) s, P=0.79]. Conclusions Allowing residents to practise independently in the simulation laboratory, and subsequently, allowing them to fail, can be an important part of simulation-based learning. This is not feasible in real clinical practice but appears to have improved resident performance in this study. The purposeful use of independent practice and its potentially negative outcomes thus sets simulation-based learning apart from traditional operating room learning.

We present a case of a patient with complete tracheal dehiscence and multiple false passages after recent tracheal resection and anastomosis. Loss of tracheal continuity after disruption of anastomosis with distal stump retraction presents a unique anesthetic challenge given lack of access to the trachea and the need for adequate anesthesia and analgesia for surgical neck dissection. Traditional airway management, including awake fiberoptic intubation, intubation via direct laryngoscopy, needle cricothyrotomy, and awake tracheostomy are not viable options. Using total intravenous anesthesia with spontaneous ventilation, surgeons dissected the neck, retrieved the distal tracheal stump, repaired the trachea, and formalized the tracheostomy. We highlight the importance of recognizing the symptoms of a tracheal rupture, understanding the extreme limitation of securing the airway with traditional techniques, and discuss the alternative techniques including use of extracorporeal membrane oxygenation to avoid airway management. Awareness of increased mortality risk with tracheal reoperation and the significance of close communication between the anesthesiologists, the surgeons, and the patient is necessary for successful management.

Consistent adoption of preventive health behaviors could save many lives, but we do not understand how to create consistent adoption. For example, low-cost point-of-use (POU) water treatment technologies such as chlorine and filters can substantially reduce diarrheal disease, a leading cause of child mortality worldwide. Nonetheless, these products are not consistently used anywhere in the developing world, even when available and heavily subsidized. We ran complementary randomized field studies in rural western Kenya and urban Dhaka, Bangladesh in which households received free trials of POU products to test the role of marketing nudges on usage. Health-oriented marketing messages inspired by behavioral economics incrementally increase the use of all products in both countries. We discuss how our findings from these two studies complement and contradict each other, and what we can learn generally about the uptake of these (and potentially other) preventive health goods.

Introduction Training in transesophageal echocardiography (TEE) requires a significant commitment of time and resources on behalf of the trainees and the instructors. Training opportunities may be limited in the busy clinical environment. Medical simulation has emerged as a complementary means by which to develop clinical skills. Transesophageal echocardiography simulators have been commercially available for several years, yet their ability to distinguish experts from novices has not been demonstrated. We used a standardized assessment tool to distinguish experts from novices using a commercially available TEE simulator. Methods Anesthesiologists certified in advanced perioperative TEE and anesthesiology resident physicians were recruited into the expert and novice cohorts, respectively. The cohorts were recruited from 2 academic medical centers. The novice cohort received a structured introduction to the basic TEE examination. Both cohorts then proceeded to perform a basic TEE examination involving normal cardiac anatomy, which was evaluated by blinded raters using a standardized assessment tool. Results The expert cohort consistently demonstrated the ability to obtain standard TEE imaging views in less time and more accurately than the novice cohort during the course of a simulated TEE examination. Conclusions A simulated transesophageal examination of normal cardiac anatomy in concert with a standardized assessment tool permits ample discrimination between expert and novice echocardiographers as defined for this investigation. Future research will examine in detail the role echocardiography simulators should play during echocardiography training including assessment of training level.

Background:Established models for assessment and maintenance of competency in anesthesiology may not be adequate for anesthesiologists wishing to reenter practice. The authors describe a program developed in their institution incorporating simulator-based education, to help determine competency in licensed and previously licensed anesthesiologists before return to practice.Methods:The authors have used simulation for assessment and retraining at their institution since 2002. Physicians evaluated by the authors’ center undergo an adaptable 2-day simulation-based assessment conducted by two board-certified anesthesiologists. A minimum of three cases are presented on each day, with specific core competencies assessed, and participants complete a standard Clinical Anesthesia Year 3 level anesthesia knowledge test. Participants are debriefed extensively and retraining regimens are designed, where indicated, consisting of a combination of simulation and operating-room observership.Results:Twenty anesthesiologists were referred to the authors’ institution between 2002 and 2012. Fourteen participants (70%) were in active clinical practice 1 yr after participation in the authors’ program, five (25%) were in supervised positions, and nine (45%) had resumed independent clinical practice. The reasons of participants not in practice were personal (1 participant) and medico-legal (3 participants); two participants were lost to follow-up. Two of 14 physicians, who were formally assessed in the authors’ program, were deemed likely unfit for safe return to practice, irrespective of further training. These physicians were unavailable for contact 1 yr after assessment.Conclusion:Anesthesiologists seeking to return to active clinical status are a heterogeneous group. The simulated environment provides an effective means by which to assess baseline competency and also a way to retrain physicians.

"More and better jobs" is the underlying theme of this insightful new book. David Levine analyzes the current labor market in the U.S. and concludes that social policy must change to cope with the realities of the new economy. Although market forces are now moving U.S. enterprise toward high-skill and flexible workplaces, there is a shortage of workers with adequate skills in problem solving and teamwork. To combat this problem, the author presents an ambitious agenda of lifelong learning that will enable American workers to take advantage of the opportunities afforded by the new economic realities. Levine's analysis recommends specific government policies to encourage early childhood education, to improve schools, to help parents finance college, and to help students make the transition from school to work. He also discusses policies that will improve the regulation of workplaces. The book concludes with policy recommendations for individuals changing jobs, as well as for the unemployed, the disabled, and the poor.

Background Awake intubation is the standard of care for management of the anticipated difficult airway. The performance of awake intubation may be perceived as complex and time-consuming, potentially leading clinicians to avoid this technique of airway management. This retrospective review of awake intubations at a large academic medical center was performed to determine the average time taken to perform awake intubation, its effects on hemodynamics, and the incidence and characteristics of complications and failure. Methods Anesthetic records from 2007 to 2014 were queried for the performance of an awake intubation. Of the 1,085 awake intubations included for analysis, 1,055 involved the use of a flexible bronchoscope. Each awake intubation case was propensity matched with two controls (1:2 ratio), with similar comorbidities and intubations performed after the induction of anesthesia (n = 2,170). The time from entry into the operating room until intubation was compared between groups. The anesthetic records of all patients undergoing awake intubation were also reviewed for failure and complications. Results The median time to intubation for patients intubated post induction was 16.0 min (interquartile range: 13 to 22) from entrance into the operating room. The median time to intubation for awake patients was 24.0 min (interquartile range: 19 to 31). The complication rate was 1.6% (17 of 1,085 cases). The most frequent complications observed were mucous plug, endotracheal tube cuff leak, and inadvertent extubation. The failure rate for attempted awake intubation was 1% (n = 10). Conclusions Awake intubations have a high rate of success and low rate of serious complications and failure. Awake intubations can be performed safely and rapidly.

article i nfo We conducted a rapid assessment randomized-controlled trial to quantify changes in fuel use, exposure to smoke, and self-reported health attributable to deployment of an improved wood cookstove in the Upper West region of Ghana. Women trainers from neighboring villages taught participants to build an improved cookstove and demonstrated optimal cooking techniques on such stoves. Participants were then randomly assigned to construct improved stoves at their homes immediately (treatments) or in a few months (controls). Several weeks after the treatments built their new stoves, all participants engaged in a cooking test while wearing a carbon monoxide monitor. At that time we surveyed participants on cooking activity, fuel wood gathering, self-reported health, and socioeconomic status. At a subset of homes we also installed stove usage monitors on the improved and traditional stove for the following three weeks. During the cooking tests, treatments used 5% less fuel wood than controls, but the difference was not statistically significant. There were no detectable reductions in a households' weekly time gathering wood or in exposure to carbon monoxide. In contrast, there was a sharp decline in participants' self-reported symptoms associated with cooking, such as burning eyes, and in respiratory symptoms, such as chest pain and a runny nose. Stove usage monitors show that treatments used their new stove on about half of the days monitored and reduced use of their old stoves by about 25%. When we returned to three of the villages eight months after project implementation, about half the improved stoves showed evidence of recent usage. Overall the new stoves were not successful, but the evaluation was. Our methods offer a rigorous modest-cost method for evaluating user uptake, field-based stove performance, and exposure to smoke.

Low-cost point-of-use (POU) safe water products have the potential to reduce waterborne illness, but adoption by the global poor remains low. We performed an eight-month randomized trial of four low-cost household water treatment products in Dhaka, Bangladesh. Intervention households (n = 600) received repeated educational messages about the importance of drinking safe water along with consecutive two-month free trials with each of four POU products in random order. Households randomly assigned to the control group (n = 200) did not receive free products or repeated educational messages. Households' willingness to pay for these products was quite low on average (as measured by bids in an incentive-compatible real-money auction), although a modest share was willing to pay the actual or expected retail price for low-cost chlorine-based products. Furthermore, contrary to our hypotheses that both one's own personal experience and the influence of one's peers would increase consumers' willingness to pay, direct experience significantly decreased mean bids by 18-55% for three of the four products and had no discernible effect on the fourth. Neighbor experience also did not increase bids. Widespread dissemination of safe water products is unlikely until we better understand the preferences and aspirations of these at-risk populations.

The evolution of simulation from an educational tool to an emerging evaluative tool has been rapid. Physician certification has a long history and serves an important role in assuring that practicing physicians are competent and capable of providing a high level of safe care to patients. Traditional assessment methods have relied mostly on multiple-choice exams or continuing medical education exercises. These methods may not be adequate to assess all competencies necessary for excellence in medical practice. Simulation enables assessment of physician competencies in real time and represents the next step in physician certification in the modern age of healthcare. Mt Sinai J Med 79:140–153, 2012.© 2012 Mount Sinai School of Medicine

Using data from a large U.S. retail firm, we examine how racial matches between managers and their employees affect rates of employee quits, dismissals and promotions. We exploit changes in management at hundreds of stores to estimate hazard models with store fixed effects that control for all unobserved differences across store locations. We find a general pattern of own-race bias across all outcomes in that employees usually have better outcomes when they are the same race as their manager. But we do find anomalies in this pattern, particularly when the manager-employee match violates traditional racial hierarchies (e.g. nonwhites managing whites).

Medical Education 2010: 44: 1006–1015 Objectives Advanced cardiac life support (ACLS) skills tend to degrade over time. There is mounting evidence that high-fidelity simulation (HFS) is advantageous to teaching ACLS. The aspects of HFS that enhance learning are not entirely clear, but the anxiety generated by a scenario may enhance retention through well-established learning pathways. We sought to determine whether an HFS with added emotional stress could provoke anxiety and, if so, whether or not participants learning ACLS would demonstrate better written and applied knowledge retention 6 months after their initial course. Methods Twenty-five student volunteers from Year 1 and 2 at Mount Sinai School of Medicine were randomly assigned to a control group or an emotional content (EC) group for a sudden cardiac death management course. All subjects were monitored for heart rate and were assessed using the State-Trait Anxiety Inventory. Control group participants experienced an HFS in which actors were not scripted to add stress, whereas EC group participants were exposed to an emotionally charged environment using the same actors. Results Participants across the two groups were well matched by resting heart rates, baseline anxiety and prior ACLS knowledge. The EC group participants experienced greater anxiety than controls (mean state anxiety score: 35.0 versus 28.2 [p

This study examines the effects of growing manufacturing employment on infant mortality across almost 200 Indonesian districts from 1985 to 1995, a time of rapid industrialization. Overall, we find no relationship between growing manufacturing employment in general and infant mortality. However, when the growth in manufacturing is concentrated in more polluting industries (as measured by the construction of a harm-weighted index of predicted emissions from manufacturing), there were economically and statistically significant increases in infant mortality. Finally, we consider a variety of potential causal channels that may change with industrialization (such as housing quality and access to health care) and whose change may help to explain the observed relationships. Although most of the various factors are correlated with infant mortality and the industrialization measures are correlated with changes in several factors, conditioning on these measures does not change our basic results.

Patient simulation has been widely incorporated into the educational programs of many anesthesiology residencies. These educational tools have been validated by a number of studies and have been recognized by the Accreditation Council for Graduate Medical Education (ACGME) as effective means of teaching domains of competency. The ACGME and the American Board of Medical Specialties (ABMS) have also recognized that these tools are effective devices for competency evaluation of resident and attending physicians. The use of simulation for both retraining and evaluation of a physician for medical licensure is presented.

Several studies have examined how the ISO 9001 quality management systems standard predicts changes in organizational outcomes such as profits. This is the first large-scale study to explore how employee outcomes such as employment, earnings, and health and safety change when employers adopt ISO 9001. We analyzed a matched sample of nearly 1,000 companies in California. ISO 9001 adopters subsequently had far lower organizational death rates than a matched control group of nonadopters. Among surviving employers, ISO adopters had higher growth rates for sales, employment, payroll, and average annual earnings. Injury rates declined slightly for ISO 9001 adopters, although total injury costs did not. These results have implications for organizational theory, managers, and public policy.