Steven Roth

Background: A new preoperative system (SANDPO) was incorporated into our electronic medical record to improve turnover time and patient safety. SANDPO requires the completion of specific tasks by Surgeons (S), Anaesthetists (A) and Nursing staff (N), completion of Documents (D), Patient consent and identification (P) and Operating Room (O, for OR) staff verifications before patients can be taken for surgery. The system was implemented at the same time in our main operating room and the Specialty Care Building, our new outpatient surgical area. Aim: Identify the impact of SANDPO on turnover time as a measure of operating room efficiency. Methods: Pre- and Post-SANDPO data from our Main (1 October 2021 to 26 August 2023) and Specialty Care Operating Rooms (26 September 2022 to 26 August 2023) were analysed to assess turnover time. Results: Compared to Pre-SANDPO, turnover time increased 24.1% in the main operating room and was significantly lower in the Specialty Care versus the main operating room. Adult cases experienced more delays versus paediatric. Simple setup cases showed the largest increases in turnover time. Conclusion: SANDPO, introduced by hospital administration to enhance safety, significantly and unexpectedly decreased operating room efficiency.

To the Editor. We thank authors Babar as well as Abu Fraiha and Leibowitz for their interest in and correspondence about our paper regarding the regalia and symbols worn by medical students and the protests and disruptions at commencement ceremonies.

Introduction: Antisemitism and antisemitic incidents have been increasing in United States medical institutions since the Hamas attack of October 7, 2023. Such incidents include anecdotal reports of antisemitic displays at medical school commencements. This study examined unprofessional behavior observed at the commencement ceremonies of the 25 US medical schools top-ranked for research excellence. This issue is significant since these graduates are expected to become future leaders in the field of medicine. Materials and Methods: Based on publicly available videotaped commencements, we assessed the number of students in the graduating classes wearing non-school-provided regalia, carrying signs, wearing protest buttons, or engaging in verbal protests related to the Israel–terror groups conflict that were either openly antisemitic or potentially offensive or insensitive. Results: Symbols representing antisemitic themes (keffiyehs and three-part graduation stoles conveying antisemitic messages) were worn by students at just under half (12) of the medical schools. The mean number of students in each school wearing keffiyehs or non-official school stoles was 4.0 (95% confidence interval [CI] 2.2–5.8), ranging from 0%–13% of the classes, or 2.5% of the overall graduating cohort. The wearing of buttons, carrying of banners or signs, verbal protests interrupting the ceremony, or students deviating from script ranged from 0% to 22.5% of graduating students, with a mean of 2.7 per school (95% CI -0.8–6.2), or 1.7% of the medical schools graduating cohort. Conclusions: We identified unprofessional behavior at commencements of top-ranked medical schools consisting of antisemitism and displaying offensive and insensitive symbols and messaging. There is an urgent need for medical schools in the US to educate medical trainees about the dangers of antisemitism and all forms of hate and insensitivity.

Introduction. Antisemitism has been increasing in U.S. medicine since the Hamas attack on Israel of October 7, 2023. This included anecdotal reports of antisemitic and anti-Israel displays at medical school commencements. We studied such behavior at the 25 top-ranked U.S. medical schools’ commencements in 2024, which has significance given these graduates are expected to be future leaders. Materials and Methods. Based on publicly-available videotaped 2024 commencements, we determined the number of students in the graduating classes wearing regalia, or carrying signs, wearing buttons, or engaging in verbal protests related to the Israel-terror groups conflict and which were either openly antisemitic, anti-Israel, or could be perceived as offensive or insensitive. Results. At 2024 commencements, symbols representing antisemitic themes (keffiyehs and 3-part graduation stoles conveying antisemitic messages) were worn by students at just under half (12) of the schools. The mean number of students in each school wearing keffiyehs or these stoles was 4.0 (95% confidence interval, CI = 2.2-5.8), ranging from 0-13% of the classes, or 2.5% of the overall graduating cohort. The wearing of buttons, carrying banners, signs, verbal protests interrupting the ceremony, or with students deviating from script ranged from 0-22.5% of graduating students, with a mean of 2.7 per school (95% CI -0.8-6.2), or 1.7% of the graduating cohort. Conclusions. We identified new behavior at commencements of top-ranked medical schools comprised of antisemitism, anti-Israel displays, and displaying offensive and insensitive symbols and messaging. There is an urgent need for medical schools in the U.S. to educate medical trainees about the dangers of antisemitism and all forms of hate and insensitivity.

Conscientious objection is a legally protected right of medical professionals to recuse themselves from patient care activities that conflict with their personal values. Anesthesiology is different from most specialties with respect to conscientious objection in that the focus is to facilitate safe, efficient, and successful performance of procedures by others, rather than to perform the treatment in question. This could give rise to a unique, somewhat indirect ethical tension between the application of conscientious objection and potential infringement upon patient autonomy and well-being. While some situations have clear grounds and precedent for conscientious objection (e.g., abortion, or futile procedures), newer procedures, such as gender-affirming surgery and xenotransplantation, may trigger conscientious objection for complex reasons. This review discusses ethical, legal, and practical aspects of conscientious objection; challenges to anesthesia groups, departments, and healthcare organizations when conscientious objection is invoked by anesthesiologists; and strategies to help mitigate the ethical dilemmas.

Embolism, hyperglycemia, high intraocular pressure-induced increased reactive oxygen species (ROS) production, and microglial activation result in endothelial/retinal ganglion cell death. Here, we conducted in vitro and in vivo ischemia/reperfusion (I/R) efficacy studies of a hybrid antioxidant–nitric oxide donor small molecule, SA-10, to assess its therapeutic potential for ocular stroke. Methods: To induce I/R injury and inflammation, we subjected R28 and primary microglial cells to oxygen glucose deprivation (OGD) for 6 h in vitro or treated these cells with a cocktail of TNF-α, IL-1β and IFN-γ for 1 h, followed by the addition of SA-10 (10 µM). Inhibition of microglial activation, ROS scavenging, cytoprotective and anti-inflammatory activities were measured. In vivo I/R-injured mouse retinas were treated with either PBS or SA-10 (2%) intravitreally, and pattern electroretinogram (ERG), spectral-domain optical coherence tomography, flash ERG and retinal immunocytochemistry were performed. Results: SA-10 significantly inhibited microglial activation and inflammation in vitro. Compared to the control, the compound SA-10 significantly attenuated cell death in both microglia (43% vs. 13%) and R28 cells (52% vs. 17%), decreased ROS (38% vs. 68%) production in retinal microglia cells, preserved neural retinal function and increased SOD1 in mouse eyes. Conclusion: SA-10 is protective to retinal neurons by decreasing oxidative stress and inflammatory cytokines.

5-aminolevulinic acid (ALA) is used during resection of malignant gliomas due to its fluorescence properties and has been shown to render resection more effective than resection without ALA guidance. The aim of this narrative review is to categorize the adverse effects of ALA relevant to anesthesia providers. Intraoperative hypotension, porphyria-related side effects, alterations in blood chemistry and coagulation, photosensitivity, and increased levels of liver enzymes have all been reported. We also sought to examine the impact of dosage and timing of oral administration on efficacy of ALA and on these side effects. Twenty-seven studies met our inclusion criteria of patients undergoing craniotomy for glioma resection using ALA and occurrence of at least one adverse effect. The results of these studies showed that there was heterogeneity in levels of intraoperative hypotension, with some reporting an incidence as high as 32%, and that hypotension was associated with antihypertensive medication use. Clinical symptoms of porphyria, such as gastrointestinal disturbance, were less commonly reported. Photosensitivity of the skin after 5-ALA administration was well documented particularly in patients exposed to light; however, adverse effects on the eye were not adequately studied. Elevation in liver enzymes was a common finding postoperatively but was often clinically insignificant. The timing of oral administration presents practical issues for the preoperative management of patients undergoing resection with ALA. We provide guidance for perioperative management of patients who receive ALA for brain tumor resection. Controlled studies with adequate statistical power are required to further understand and prevent the adverse effects of ALA.