Faculty Bibliography

A 75-year-old male, without relevant medical history and negative HIV1/2 serology, presented at the emergency department with mixed shock (septic - from pleuroparenchymal origin - and hypovolemic due to upper gastrointestinal bleeding [UGIB]). Thoracoabdominal CT scan showed an esophagopleural fistula (EPF), with a large right pleural effusion (lately known to be compatible with exudate - Light's criteria) and right pneumothorax, without active bleeding. The upper gastrointestinal endoscopy (UGIE) showed a severe esophagitis and, in distal oesophagus, an ulcer with an orifice in the center. Biopsies of the edges of the ulcer were performed. Anatomopathological (AP) studies were negative for viral agents but tissue molecular studies (polymerase chain reaction [PCR]) identified cytomegalovirus (CMV) DNA. Despite no immunosuppression condition was identified, CMV severe esophagitis complicated by EPF with right-side empyema and UGIB was diagnosed. An oesophageal fully covered metal stent (FCMS), with anti-migration system, was left in place during 5-weeks and ganciclovir therapy (5mg/kg/day) was maintained for 21-days. Clinical-analytical, radiological and endoscopic improvement was noticed. No recurrence in the following year of follow-up.

BACKGROUND:As higher acuity procedures continue to move from hospital-based operating rooms (HORs) to free-standing ambulatory surgery centers (ASCs), concerns for patient safety remain high. We conducted a contemporary, descriptive analysis of anesthesia-related liability closed claims to understand risks to patient safety in the free-standing ASC setting, compared to HORs. METHODS:Free-standing ASC and HOR closed claims between 2015 and 2022 from The Doctors Company that involved an anesthesia provider responsible for the claim were included. We compared the coded data of 212 free-standing ASC claims with 268 HOR claims in terms of severity of injury, major injuries, allegations, comorbidities, contributing factors, and financial value of the claim. RESULTS:Free-standing ASC claims accounted for almost half of all anesthesia-related cases (44%, 212 of 480). Claims with high severity of injury were less frequent in free-standing ASCs (22%) compared to HORs (34%; P = .004). The most common types of injuries in both free-standing ASCs and HORs were dental injury (17% vs 17%) and nerve damage (14% vs 11%). No difference in frequency was noted for types of injuries between claims from free-standing ASCs versus HORs--except that burns appeared more frequently in free-standing ASC claims than in HORs (6% vs 2%; P = .015). Claims with alleged improper management of anesthesia occurred less frequently among free-standing ASC claims than HOR claims (17% vs 29%; P = .01), as well as positioning-related injury (3% vs 8%; P = .025). No difference was seen in frequency of claims regarding alleged improper performance of anesthesia procedures between free-standing ASCs and HORs (25% vs 19%; P = .072). Technical performance of procedures (ie, intubation and nerve block) was the most common contributing factor among free-standing ASC (74%) and HOR (74%) claims. Free-standing ASC claims also had a higher frequency of communication issues between provider and patient/family versus HOR claims (20% vs 10%; P = .004). Most claims were not associated with major comorbidities; however, cardiovascular disease was less prevalent in free-standing ASC claims versus HOR claims (3% vs 11%; P = .002). The mean ± standard deviation total of expenses and payments was lower among free-standing ASC claims ($167,000 ± $295,000) than HOR claims ($332,000 ± $775,000; P = .002). CONCLUSIONS:This analysis of medical malpractice claims may indicate higher-than-expected patient and procedural complexity in free-standing ASCs, presenting patient safety concerns and opportunities for improvement. Ambulatory anesthesia practices should consider improving safety culture and communication with families while ensuring that providers have up-to-date training and resources to safely perform routine anesthesia procedures.

Health promotion intervention theory must adapt as evidence grows to support the complexities of social and behavioral health fields. Following the COVID-19 pandemic, digital health continues to grow, requiring a re-evaluation of traditional models' applicability to these approaches. The authors propose adapting and integrating the Socio-Ecological Model (SEM) and Diffusion of Innovation (DOI) models for application with digital health to deliver interventions. We also describe the application of the SEM-DOI integration in conjunction with a demonstration project, a digital intervention to improve Metabolic Syndromes (MetS) health outcomes. Future health interventions may consider the proposed SEM-DOI model to account for individual and community-level factors during implementation and use as a guide for meaningful evaluation. Adaptations of theoretical models to current-state interventions and integration of multiple, established models are needed to sustain prevention efforts and efficacy over time.

Within the healthcare sector, especially in the field of nephrology, the matter of gender and racial inequalities continues to be a critical concern that requires immediate focus. Women, particularly those of underrepresented racial groups, face significant challenges due to a lack of representation in research studies, leading to a deficit in knowledge about how kidney diseases affect them differently. These challenges are exacerbated by systemic biases in the healthcare system, which manifest in both gender and racial dimensions, hindering access to and the quality of care for kidney diseases. Addressing these complex disparities requires a recalibration of risk stratification models to include both gender- and race-specific factors and a transformation of healthcare policies to facilitate a more inclusive and sensitive approach. Essential to this transformation is the empowerment of women of all races to actively participate in their healthcare decisions and the strengthening of support systems to help them navigate the complexities of the healthcare environment. Furthermore, education programs must be designed to be culturally competent and address the unique needs and concerns of women across different racial backgrounds. Promoting a collaborative patient-provider relationship is crucial in fostering an environment where equity, dignity, and respect are at the forefront. The path to equitable nephrology care lies in a concerted, collective action from researchers, healthcare providers, policymakers, and patients, ensuring that every individual receives the highest standard of care, irrespective of gender or race.