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Since 1965, Medicare has been the United States’ federally funded health insurance program primarily offered to citizens who are 65 years and older, have a disability, or suffer from End-Stage Renal Disease (ESRD) [1]. Medicare has four parts: A (hospital insurance), B (medical insurance), C (Medicare Advantage), and D (prescription drug coverage) [2]. 

Medicare Part A covers medically necessary services, including inpatient hospital visits, some lab tests, surgeries, nursing facility care, and certain home healthcare services [1]. Nearly all costs incurred during the first 60 days of a hospital visit will be covered by Medicare Part A [2]. Because it is oriented toward treating emergency conditions rather than preventing them, Part A does not include preventative healthcare, such as diagnostic screenings, yearly wellness visits, and influenza vaccinations [2, 3]. People will automatically receive these benefits if they have been receiving Social Security or Railroad Retirement Board benefits at least four months before they turn 65, or if they have a disability, amyotrophic lateral sclerosis (ALS), or ESRD [4]. 

While most Part A beneficiaries do not have to pay a premium, those who have not paid Medicare taxes for ten years before enrollment and/or have certain disabilities will have to pay a premium [2, 5]. In 2021, monthly premium rates start at $259 for those who have contributed to Medicare taxes for 30 quarters or are married to someone who has [5]. People who do not meet either of those stipulations will face a starting premium rate of $471 [5]. 

To receive preventative healthcare, Medicare beneficiaries must enroll in Part B. Part B covers many services that Part A does not, including disease screenings, shots, and ambulance transportation [2, 3]. Because of these additional benefits, Medicare enrollees generally opt to pay more for their healthcare [2]. The monthly premium for Part B begins at $148.50 [2]. Part B members also have to pay an annual deductible, which has been set at $203 for 2021, as well as 20% of bills for primary care physician and outpatient visits [2]. 

Despite Part B’s preventative healthcare benefits, it does not cover certain key services, such as most vision and dental care, hearing aid services, and long-term care [1]. Alongside these benefits, Part C, known as Medicare Advantage (MA), covers everything that Parts A and B cover [2]. Eligibility for Part C is similar to that for Parts A and B; however, enrollees must also reside within the coverage area of their insurance provider and not have ESRD [6]. 

People who wish to receive Medicare Advantage benefits must enroll in Medicare A and B, pay the Part B monthly premium, and buy an MA plan from a private insurer [2]. 40% of Part C enrollees pay other premiums in addition to Part B premiums [7]. In 2021, the average monthly charge for an MA plan that includes prescription drug coverage is $21 [1]. 

Part D offers enrollees prescription drug coverage [1]. It is administered via private companies and requires an additional application to enroll [1]. Different monthly premiums and out-of-pocket costs apply to individual plans [2]. If a beneficiary’s drug costs amount to at least $4,130 in 2021, they will be personally responsible for only 25% of any additional cost of prescription drugs for the rest of the year [2]. Likewise, if drug costs reach $6,550, a beneficiary will need to pay only 5% of additional costs [2]. 

Medicare plan suitability is dependent on various factors, including an individual’s current health status, hospital care, prescription drug costs, and finances.  

References 

[1] M. Rubin, “An Introductory Guide to Medicare Parts A, B, C, and D,” The Balance, Updated January 5, 2021. [Online]. Available: https://www.thebalance.com/an-introductory-guide-to-medicare-parts-a-b-c-and-d-2894259. 

[2] D. Bunis, “Understanding Medicare’s Options: Parts A, B, C and D,” AARP, Updated January 1, 2021. [Online]. Available: https://www.aarp.org/health/medicare-insurance/info-01-2011/understanding_medicare_the_plans.html. 

[3] Medicare, “Preventive & screening services,” Medicare.gov. [Online]. Available: https://www.medicare.gov/coverage/preventive-screening-services/. 

[4] Medicare, “How do I get Parts A & B?,” Medicare.gov. [Online]. Available: https://www.medicare.gov/sign-up-change-plans/how-do-i-get-parts-a-b. 

[5] CMS, “2021 Medicare Parts A & B Premiums and Deductibles,” Centers for Medicare & Medicaid Services, Updated November 6, 2020. [Online]. Available: https://www.cms.gov/newsroom/fact-sheets/2021-medicare-parts-b-premiums-and-deductibles. 

[6] Journal of Oncology Practice, “Overview of Medicare Parts A-D,” Journal of Oncology Practice, vol. 5, no. 2, p. 86-90, March 2009. [Online]. Available: https://doi.org/10.1200/JOP.0922502. 

[7] M. Freed, A. Damico, and T. Neuman, “A Dozen Facts About Medicare Advantage in 2020,” KFF, Updated April 22, 2020. [Online]. Available: https://www.kff.org/medicare/issue-brief/a-dozen-facts-about-medicare-advantage-in-2020/. 

While anesthesia, such as volatile anesthetics, has been used in clinical practice since the end of the 19^th century, their mechanism of action is not well understood. This presents a problem in clinical practice; without an understanding of the mechanism of action of such ubiquitously used pharmacological agents, it can be difficult to control their effects. An earlier theory, the Meyers-Overton theory, postulated that anesthesia bonds to and dissolves lipids in biological membranes¹. While this theory would explain why lipid solubility is so interrelated with anesthesia potency, it is not well supported by current evidence.  

Today, a significant body of research backs the claim that anesthetics work by acting directly on target proteins, particularly two-pore domain potassium proteins⁴. This class of receptors works to maintain cell membrane potential in both excitable and non-excitable cells all over the body, which could explain why some types of anesthesia have such non-specific effects, some of which are related to post-operative complications⁴.  

An acute clinical post-operative complication caused by anesthesia is postoperative hypoxemia, in which the body’s reflex to hyperventilate in low oxygen states is inhibited². This reflex is mediated by two pore-domain potassium channels, specifically by TWIK-related –acid-sensitive (TASK) receptors in the carotid bodies. TASK receptors are constitutively active in normal physiological states. A drop in pH or P_O2 (as occurs in states of low O₂) inhibits these receptors, triggering hyperventilation². 

Current research on the mechanism of volatile anesthetics has shown that volatile anesthetics act on TASK-1 and TASK-3 receptors in the carotid bodies, hyperactivating them to inhibit the hyperventilation reflex⁵. This is required during surgery to stop the patient from fighting intubation; the problem occurs because the inhibition of TASK-1 and TASK-3 can persist long after surgery, resulting in hypoxemia and further complications². There are no widely accepted theories as to the how this effect occurs, but recent publications propose a hybrid between the earlier lipid theory and the receptor model: lipid raft disruption^3,5. Many target receptors being investigated are hydrophobic, only accessible to anesthesia molecules dissolved in lipid. Such dissolution could lead to a perturbation of the lipid rafts that make up membranes and affect membrane protein function and possibly inhibit the hyperventilation reflex³.

Because volatile anesthetics act on specific targets, the natural conclusion is that they compete for binding sites. Until now, these competitive interactions have been additive, as measured by the degree of anesthesia-induced paralysis. However, a recent study has recorded antagonizing effects between two volatile anesthetics — the administration of halothane and isoflurane caused a lesser effect than halothane alone⁵. The proposed mechanism of this antagonism lies in the fact that such two pore-domain proteins have multiple binding sites, and not all copies of the proteins have the same specific sites. Isoflurane and halothane likely bind to the same binding site, isoflurane binding with a lesser efficacy than halothane. Thus, when both agents are introduced, they compete for the same binding site, and isoflurane acts as a competitive antagonist on halothane⁵. If confirmed, this phenomenon may result in more targeted prevention against postoperative hypoxemia with fewer side effects than the current therapies⁵. 

References  

1. Borghese CM: Molecular Pharmacology of Volatile Anesthetics. International Anesthesiology Clinics 2015; 53: 28-39. doi: 10.1097/AIA.0000000000000060 

2. Forman SA: New evidence of receptor-based pharmacology underlying a volatile anesthetic effect. Anesthesiology 2020; 133: 973-75. doi: 10.1097/ALN.0000000000003559 

3. Mahmud AP, Petersen EN, Wang H, Lerner RA, Hansen SB: Studies on the mechanism of general anesthesia. PNAS 2020; 117: 13757-66. doi: 10.1073/pnas.2004259117 

4. Mathie A, Veale EL, Cunningham KP, Holden RG, Wright PD: Two-Pore Domain Protein Channels as Drug Targets: Anesthesiology and Beyond. Annual Review of Pharmacology and Toxicology 2021. doi: 10.1146/annurev-pharmtox-030920-111536 

5. Pandit JJ, Huskens N, O’Donohoe PB, Buckler KJ: Competitive interactions between halothane and isoflurane at the carotid body and TASK channels. Anesthesiology 2020; 133:1046–59. doi: 10.1097/ALN.0000000000003520 

In the past decade, artificial intelligence (AI) and other smart technologies have permeated almost every area of society. At the same time, the concept of deep learning (DL) has revolutionized AI to make it more effective in its applications. Now, when given extensive samples of data, computers are able to make meaningful predictions and estimates which account for underlying patterns not yet recognized or coded for by humans. Therefore, fields that produce a lot of data—such as oncology— are the most attractive for DL applications. Currently, deep-learning AI is being used within oncology to improve diagnostic techniques, treatment methods, and disease management. 

One area of oncology where AI has been especially successful is in image analysis. Given that imaging is a common practice in tumor detection and monitoring, a significant amount of oncological data is visual. While the field of visual data analysis is still relatively new, there have already been promising breakthroughs. For example, the Convolutional Neural Network (CNN), a newly-developed DL model, has been developed to analyze the orientation of each pixel within images, which leads to the appreciation of larger-scale objects.^[1],[2] It was found that after being trained on 130,000 images, a CNN was able to detect malignant skin cancer with more sensitivity and specificity than a panel of 21 board-certified dermatologists.^[3] Various CNNs have also been successful at segmenting tumor volumes, automating lung nodule detection/classification, and detecting breast cancer malignancy using radiographic imaging.^{[4],[5],[6],[7],[8]}

AI has also shown a lot of clinical promise in the analysis of non-visual information. For example, DL algorithms have been able to predict genetic mutations from histopathological data— an assessment which may be useful in increasing detection of anomalies in oncogenes.^[9] AI has also used information from the electronic health record to predict the development of diseases such as prostate, rectum, and liver cancer with 93 percent accuracy.^[10] Since prognosis often depends on the stage in which cancer is detected, these predictive algorithms have the potential to improve the chances of survival and quality of life for future cancer patients. However, these algorithms have more than just preventative applications: they can also inform treatment plans. Artificial neural networks have been able to predict an individual’s likelihood to respond favorably to various treatments given genetic and chemical information.^[11]

Given the host of applications for which AI has proven to be effective, including oncology, it is likely that DL algorithms will continue to be increasingly integrated as a part of cancer research as well as treatment. 

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^[1] Krizhevsky A, Sutskever I, Hinton GE. ImageNet classification with deep convolutional neural networks. In: Pereira F, Burges CJC, Bottou L, Weinberger KQ, editors. Advances in neural information processing systems 25. Curran Associates, Inc; 2012. pp. 1097–105. http://papers.nips.cc/paper/4824-imagenet-classification-with-deep-convolutional-neural-networks.pdf.

^[2] Russakovsky O, Deng J, Su H, et al. ImageNet large scale visual recognition challenge. Int J Comput Vis. 2015;115:211-52.

^[3] Esteva A, Kuprel B, Novoa RA, et al. Dermatologist-level classification of skin cancer with deep neural networks. Nature. 2017;542:115-8.

^[4] Data Science Bowl 2017. https://www.kaggle.com/c/data-science-bowl-2017.

^[5] Wang S, Zhou M, Gevaert O, et al. A multi-view deep convolutional neural networks for lung nodule segmentation. Conf Proc IEEE Eng Med Biol Soc. 2017;2017:1752-5.

^[6] Sage Bionetworks. Digital Mammography DREAM Challenge. http://sagebionetworks.org/research-projects/digital-mammography-dream-challenge/.

^[7] Ribli D, Horváth A, Unger Z, et al. Detecting and classifying lesions in mammograms with deep learning. Sci Rep. 2018;8:4165.

^[8]  Trister AD, Buist DSM, Lee CI. Will machine learning tip the balance in breast cancer screening? JAMA Oncol. 2017;3:1463

^[9] Coudray N, Ocampo PS, Sakellaropoulos T, et al. Classification and mutation prediction from non-small cell lung cancer histopathology images using deep learning. Nat Med. 2018;24:1559-67.

^[10] Miotto R, Li L, Kidd BA, Dudley JT. Deep patient: an unsupervised representation to predict the future of patients from the electronic health records. Sci Rep. 2016;6:26094.

^[11] Menden MP, Iorio F, Garnett M, et al. Machine learning prediction of cancer cell sensitivity to drugs based on genomic and chemical properties. PLOS One. 2013;8:e61318.

The World Health Organization (WHO) defines health as “not merely the absence of disease or infirmity, but a state of complete physical, mental, and social well-being.”¹ However, the definition of quality of life (QOL) is more complex.¹ According to the WHO, quality of life is defined as “individuals’ perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns.”¹ It can be summarized as the feeling of overall life satisfaction.² The evaluation of QOL involves a complex set of interacting objective and subjective factors.¹ 

The past few decades have seen an increasing predominance of chronic disorders.³ In general, chronic diseases are slow in progression, long in duration, and require medical treatment.³ The majority of chronic diseases hold the potential to worsen the overall health of patients by limiting their capacity to live well and their functional status.³ Among the most common chronic conditions are cancer, heart disease, stroke, diabetes, HIV, bowel disease, renal disease, and diseases of the central nervous system.³ The literature in health psychology generally supports the claim that chronic disease disrupts an individual’s day-to-day living and that this disruption can be measured in terms of its impact on an individual’s quality of life.³  

Quality of life is assessed either by interview or questionnaire.³ Interview methods utilize open-ended or semi-structured methods that can be helpful in uncovering the experiences of the patients.³ Questionnaires typically fall into two main categories: (1) generic questionnaires, which are used to evaluate QOL in different populations or (2) specific ones, which are used to analyze QOL in patients with specific conditions.³ Some assessments that are commonly used in studies of chronic disease are the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), the Nottingham Health Profile (NHP), and the EuroQol (EQ-5D).^3,4 

In the context of chronic disease, quality of life can be studied as either a primary or secondary outcome.³ It is an important metric in evaluating the impact of a disease and any medical intervention.⁴ An improvement is considered to be an essential primary outcome and determinant of therapeutic benefit.^3,4 However, this metric is also a useful secondary outcome of research studies that provide data on the impact of therapeutic interventions.⁴ 

In studies of breast cancer survivors, researchers  have generally found a lower reported quality of life compared to control participants.⁵ This trend is associated with more limitations in activities of daily living, issues with sexual functioning, decreased self-esteem, and unhealthy coping strategies.^5,6 One factor that was found to have an influence on the QOL of breast cancer survivors was the type of surgery, with mastectomies  being associated with poorer outcomes compared to breast conserving treatment.⁷ 

Moreover, a number of researchers have investigated the quality of life in patients with heart failure.³ Patients with heart failure have frequently reported significant impairments beyond physical functioning.⁸ Importantly, quality of life measurements in patients with heart failure is a predictor of mortality and morbidity after cardiac procedures.⁸ This metric should be a key consideration in clinical settings when making treatment decisions.

References 

1. Megari K. (2013). Quality of Life in Chronic Disease Patients. Health psychology research, 1(3), e27. doi:10.4081/hpr.2013.e27 

2. Meeberg, G. (1993). Quality of life: a concept analysis. Journal of Advanced Nursing, 18(1), 32-38. doi:10.1046/j.1365-2648.1993.18010032.x 

3. Staquet, M. J., Hays, R. D., & Fayers, P. M. (1998). Quality of life assessment in clinical trials: methods and practice. 

4. EuroQol – a new facility for the measurement of health-related quality of life. (1990). Health Policy, 16(3), 199-208. doi:10.1016/0168-8510(90)90421-9 

5. Richardson, L., Wingo, P., Zack, M., Zahran, H., & King, J. (2008). Health-related quality of life in cancer survivors between ages 20 and 64 years. Cancer, 112(6), 1380-1389. doi:10.1002/cncr.23291 

6. Hewitt, M., Rowland, J., & Yancik, R. (2003). Cancer Survivors in the United States: Age, Health, and Disability. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 58(1), M82-M91. doi:10.1093/gerona/58.1.m82 

7. Ohsumi, S., Shimozuma, K., Morita, S., Hara, F., Takabatake, D., & Takashima, S. et al. (2009). Factors Associated with Health-related Quality-of-life in Breast Cancer Survivors: Influence of the Type of Surgery. Japanese Journal of Clinical Oncology, 39(8), 491-496. doi:10.1093/jjco/hyp060 

8. Fukuoka, Y., Lindgren, T., Rankin, S., Cooper, B., & Carroll, D. (2007). Cluster analysis: a useful technique to identify elderly cardiac patients at risk for poor quality of life. Quality of Life Research, 16(10), 1655-1663. doi:10.1007/s11136-007-9272-7

Millions of healthcare professionals (HCPs) are at risk for negative mental health outcomes as they work during the COVID-19 pandemic, under distressing conditions.¹  A review of physician mental health, published in the Journal of Internal Medicine prior to the onset of COVID-19, found that reported rates of burnout symptoms exceeded 50% in practicing and in-training physicians.^2,3  These rates only stand to increase as physicians are exposed to greater physical, emotional, and psychological strain.  Although there has been limited opportunity to quantitatively measure the effect that the pandemic has had on HCPs in the United States, preliminary statistics from China and Italy have suggested that levels of depression, anxiety, and insomnia are significantly elevated.^4,5  Further, data obtained after the original SARS pandemic determined that, in the short and long-term, essential frontline HCPs are at higher risk of developing anxiety, depressive, or post-traumatic stress disorders.^6,7 

In order to better understand which measures, policies, and resources must be deployed in order to combat the development of mental illness in HCPs, it is necessary to identify the key contributors to stress and negative mental health outcomes.  Research on the current conditions produced by COVID-19 and previous epidemics such as SARS and H1N1 have determined that there are several mental and emotional stressors that are disproportionately responsible for acute stress reactions and adverse long-term mental health outcomes.^1,8  These stressors include longer hours, increased risk of exposure to the virus and subsequent social isolation, concern about infecting one’s family, and moral injury from being required to make ethically fraught decisions regarding the distribution of time and resources as hospitals fill to capacity.^1,8,9,10,11 

In order to mitigate the negative effects of the current situation, healthcare systems must implement efficient and effective evidence-based strategies to maximize already over-stretched resources.¹  Adequate PPE is the first and most powerful step that any healthcare organization can take as a preventative measure against negative mental health outcomes in their HCPs.  This basic measure is also linked to nearly all of the previously mentioned risk factors for distress.^6,8,12  

Secondly, although mental health resources have traditionally been allocated to supporting HCPs who have already developed a mental health pathology, this focus needs to be broadened.  It is crucial that HCPs are educated about available evidence-based self-help programs, such as those developed by the WHO, as well as proactive coping methods and ways to monitor their personal stress reaction.^8,10,13  Monitoring and early intervention reduce the strain on HCPs as well as healthcare systems, especially with the current difficulty of conducting face-to-face psychotherapy.¹ 

Thirdly, although there are limitations on the administration of individualized psychosocial services, these services are nevertheless essential in the treatment of HCPs who are experiencing distress.  Further, it is essential that team leaders and administrators receive instruction on how to identify and intervene when colleagues are experiencing high-risk symptoms such as social withdrawal, anhedonia, depression, anxiety, or insomnia.¹⁰  HCPs experiencing these symptoms should be referred to qualified mental health professionals; fortunately, mental health services are increasingly being made available by telemedicine, in addition to socially distanced in-person settings.^3,8 

Finally, it is also necessary to plan for long-term mental health interventions.⁹  Studies conducted after the SARS epidemic demonstrated that emotional distress among HCPs who treated SARS, was frequently long-lasting, with levels of stress, burnout, and substance use remaining elevated among HCPs for up to two years after the epidemic.^9,14  Thus, while action to protect the psychological and emotional health of HCPs must begin immediately, the healthcare system must also make long-term provisions in order to protect provider mental health. 

References

1. Yang L, Yin J, Wang D, Rahman A, Li X. Urgent need to develop evidence-based self-help interventions for mental health of healthcare workers in COVID-19 pandemic [published online ahead of print, 2020 Apr 28]. Psychol Med. 2020;1-2. doi:10.1017/S0033291720001385. 

2. West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors, consequences and solutions. J Intern Med. 2018 Jun;283(6):516-529. doi:10.1111/joim.12752.  

3. Santarone K, McKenney M, Elkbuli A. Preserving mental health and resilience in frontline healthcare workers during COVID-19. Am J Emerg Med. 2020;38(7):1530-1531. doi:10.1016/j.ajem.2020.04.030.

4. Rossi R, Socci V, Pacitti F, Di Lorenzo G, Di Marco A, Siracusano A, et al. Mental health outcomes among front and second line health workers associated with the COVID-19 pandemic in Italy. JAMA Netw Open. 2020;3(5):e2010185. doi:10.1001/jamanetworkopen.2020.10185. 

5. Lai J, Ma S, Wang Y, et al. Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019. JAMA Netw Open. 2020;3:e203976.32202646. doi:10.1001/jamanetworkopen.2020.3976.

6. Gold JA. Covid-19: adverse mental health outcomes for healthcare workers. BMJ. 2020 May 5;369:m1815. doi:10.1136/bmj.m1815. 

7. Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet. 2020;395:912-20. doi:10.1016/S0140-6736(20)30460-8 32112714. 

8. Pfefferbaum B, North CS. Mental health and the Covid-19 pandemic. N Engl J Med. 2020. doi:10.1056/nejmp2008017. 

9. Pearman A, Hughes ML, Smith EL, Neupert SD. Mental Health Challenges of United States Healthcare Professionals During COVID-19. Front Psychol. 2020 Aug 13;11:2065. doi:10.3389/fpsyg.2020.02065. 

10. Walton M, Murray E, Christian MD. Mental health care for medical staff and affiliated healthcare workers during the COVID-19 pandemic. Eur Heart J Acute Cardiovasc Care. 2020 Apr;9(3):241-247. doi:10.1177/2048872620922795.  

11. Greenberg N, Docherty M, Gnanapragasam S, Wessely S. Managing mental health challenges faced by healthcare workers during Covid-19 pandemic. BMJ. 2020 Mar 26;368:m1211. doi:10.1136/bmj.m1211.  

12. Jun J, Tucker S, Melnyk BM. Clinician Mental Health and Well-Being During Global Healthcare Crises: Evidence Learned From Prior Epidemics for COVID-19 Pandemic. Worldviews Evid Based Nurs. 2020 Jun;17(3):182-184. doi:10.1111/wvn.12439. 

13. Epping-Jordan JE, Harris R, Brown FL, Carswell K, Foley C, García-Moreno C, Kogan C, van Ommeren M. Self-Help Plus (SH+): a new WHO stress management package. World Psychiatry. 2016 Oct;15(3):295-296  doi:10.1002/wps.20355. 

14. Maunder RG, Lancee WJ, Balderson KE, et al. Long-term psychological and occupational effects of providing hospital healthcare during SARS outbreak. Emerg Infect Dis. 2006;12(12):1924-1932. doi:10.3201/eid1212.060584. 

The intersection between technology and health has been one that has recently attracted much attention from researchers, corporations, and consumers alike. Wearable fitness technology, such as FitBits and smartwatches, has especially erupted into the mainstream, and their use has more than tripled from 9% of US consumers in 2014 to 33% in 2018 [4]. These devices allow users to engage more with their own health while also providing a convenient avenue to read their notifications, send simple messages, make phone calls, or do other tasks previously limited to their smartphones [4].  

Health-wise, smartwatches and other wearables are able to make 250,000 measurements per day on the user’s vital signs [2]. As Scott Burgett, the director of Garmin health engineering, says, “the more you know about your body and what your ‘baseline’ is,” the easier it becomes to “track trends and notice deviations” when they occur [3]. By constantly monitoring and measuring, wearable devices are able to alert users when changes are seen in their heart rate, skin temperature, or other physiological factors based on preprogrammed algorithms [2]. As many of these fluctuations can be indicative of a viral infection, wearable devices can be especially useful during the COVID-19 pandemic.  

Since December of 2019, the SARS-CoV-2 virus has spread COVID-19, a respiratory disease, around the world [1]. The virus, which is correlated with fevers, radiographic evidence of pneumonia, and low white-cell or lymphocyte counts, does not yet have a rigorously tested vaccine or antiviral treatment [1]. Thus, current efforts on containing the spread focuses on fast, accurate, and available testing for all [1]. Testing, however, has not been able to curb the severity of the virus as it takes time for hosts to show symptoms and, consequently, many people spread the virus to others before realizing that they are infected. An estimated 25 to 50% of the US population is asymptomatically carrying the coronavirus, and this percentage will only increase without new methods of containment [1].  

Wearable devices can be utilized to detect early cases and identify imminent outbreaks. One of the easiest and most useful measurements wearables can take is a user’s heart rate; viral illnesses put physiological stress on the human body, which will increase resting heart rates [1]. According to a Scripps epidemiologist, changes in heart rate can occur 4 days before a fever develops when a person contracts COVID-19 [2]. In addition, 40% of people with COVID-19 do not ever develop a fever, so wearable technology may even be more indicative than public temperature checks [2]. Wearables can also measure sleep patterns by analyzing heart rate data – elevated sleep duration partnered with worsened sleep quality are also signs of a physiological stress, possibly due to viral infections [1]. As a respiratory disease, COVID-19 also affects the efficiency of the lungs; thus, devices that can detect changes in respiratory function, such as shallow breathing, wheezing, or shortness of breath, are also very informative [1]. Together, these factors can help detect early cases of coronavirus and encourage asymptomatic or mildly symptomatic people to stay home once they have evidence that their bodies are undergoing stress. 

In addition, consistently monitoring the population and recording the data can help patients who need more medical assistance receive it earlier and can help identify communities where potential outbreaks are imminent [1]. When people are more aware of their own health, hospital visits may also be reduced, which can both save hospital resources for those in dire need and lower the risks of transmission to health workers [1]. Finally, moderate intensity activity has been shown to reduce inflammation and improve immune responses, and wearable sensors may prompt physical activity in users by handing them more agency to their own health [1]. 

Although wearable devices and smartwatches are in no way replacements for telehealth or in person health visits, they can help significantly in identifying early, pre-symptomatic cases of COVID-19 and helping the world control the spread of the virus. Current issues remain with mass adoption of wearable tracking devices in privacy, data sharing, and underreporting [1]. Additionally, even if mass adoption of wearable technology is reached, caution should be taken to not over-interpret the data or unnecessarily cause distress [3]. Testing is still the best way to know if an individual has COVID-19, but the ability of wearable devices to detect pre-symptomatic cases and encourage isolation or other measures should be further examined.  

References 

[1] Seshadri, D., Davies, E., Harlow, E., Hsu, J., et al. (2020, June 11). Wearable Sensors for COVID-19: A Call to Action to Harness Our Digital Infrastructure for Remote Patient Monitoring and Virtual Assessments. Retrieved August 20, 2020, from https://www.frontiersin.org/articles/10.3389/fdgth.2020.00008/full 

[2] Could wearable tech work as a Covid early warning system? (2020, June 09). Retrieved August 21, 2020, from https://www.scmp.com/lifestyle/health-wellness/article/3088137/your-wearable-tech-could-be-used-covid-19-virus-early 

[3] Steger, Andrew. (2019, May 01). Can Wearable Tech Spot COVID-19 Symptoms? Retrieved August 21, 2020, from https://healthtechmagazine.net/article/2020/08/can-wearable-tech-spot-covid-19-symptoms-perfcon 

[4] Phaneuf, A. (2020, January 31). Latest trends in medical monitoring devices and wearable health technology. Retrieved August 21, 2020, from https://www.businessinsider.com/wearable-technology-healthcare-medical-devices 

Anaphylaxis, a severe, potentially life-threatening allergic reaction, can occur during surgery in response to anesthesia or other medications used during an operation. The most common causes of intraoperative anaphylaxis are neuromuscular blocking agents (NMBAs), antibiotics, disinfectants, and latex (1). Evaluating the type of reaction and understanding the subsequent allergy evaluation of possible causes are crucial for the management of a patient experiencing perioperative anaphylaxis and for the prevention of additional episodes.  

During the perioperative timeframe, the occurrence of anaphylaxis can vary, based on comorbidities, medications, surgical procedures, and anesthetics. In addition, delay in diagnosis can occur because of the setting – the patient is usually intubated, sedated, and draped, and so early signs and symptoms are not easily observed. Furthermore, anesthetics can cause cardiovascular changes that can mimic early anaphylaxis by increasing heart rate or causing a decrease in arterial pressure, making early recognition even more challenging (2).  

Clinical manifestations of anaphylactic response to anesthesia or other perioperative medications can vary from a mild rash to cardiovascular collapse. Early symptoms of anaphylaxis include low blood pressure and an abnormally high heart rate. The identification of the culprit can sometimes be deduced according to the timing between the administration of the suspected allergen and the clinical signs and symptoms that erupt. For instance, when symptoms occur within the first 30 minutes of anesthesia, a suspected culprit is NMBAs, whereas when symptoms occur after 30 minutes of anesthesia, latex is considered as a possible inducer (3). 

Management of anaphylaxis should first and foremost consider a careful and complete review of the clinical and perioperative history before any procedure in patients with previous perioperative reaction, especially because these patients are more likely to experience a reaction during subsequent exposures. Thus, it is crucial for concerns to be discussed between the anesthesia and surgical teams and that an allergy consult be obtained if there is an allergic reaction (3). 

The management of anaphylaxis should also involve a careful review of the treatment administered and the response of the patient. It is important to document even the substances used in the procedure that are not typically allergenic, including antiseptics, gels, dyes, and hemostatic agents.  

There are no randomized studies that have evaluated the use of a specific protocol of premedication for the prevention of perioperative anaphylaxis (4). So, most importantly, anesthesiologists and allergist teams should evaluate at-risk patients before any surgical procedure and identify any potential causes of anaphylaxis. Prevention is the most important component to decrease the incidence of anaphylaxis, which begins with recognition and documentation. 

Sources: 

1. Mertes PM, Lambert M, Gueant-Rodriguez RM, Aimone-Gastin I, MoutonFaivre C, Moneret-Vautrin DA, et al. Perioperative anaphylaxis. Immunol Allergy Clin N Am 2009;29:429-51. 

2. Bailey JM. Context-sensitive half-times and other decrement times of inhaled 

anesthetics. Anesth Analg 1997;85:681-6. 

3. Volcheck GW, Hepner DL. Identification and Management of Perioperative Anaphylaxis. J Allergy Clin Immunol Pract. 2019;7(7):2134-2142. doi:10.1016/j.jaip.2019.05.033 

4. Mertes PM, Malinovsky JM, Jouffroy L, Working Group of the SFAR and SFA, Aberer W, Terreehorst I, et al. Reducing the risk of anaphylaxis during anesthesia: 2011 updated guidelines for clinical practice. J Investig Allergol Clin Immunol 2011;21:442-53. 

When the body’s protective barriers (such as the skin) are breached, the body responds by activating the innate immune system. Affected tissues and cells release chemical messengers to call innate immune cells to action. On the other hand, the adaptive immune system responds to infection, which can occur in the exposed wound, by recruiting T-cells and B-cells. Surgical trauma can simultaneously activate both innate and adaptive immune systems. During and immediately after surgery, a sharp increase in proinflammatory cytokines at the surgical site initiates healing. To maintain homeostasis, anti-inflammatory cytokines increase in number and control the proinflammatory response. Regulatory balance between proinflammatory and anti-inflammatory responses determines the patient’s prognosis, i.e. whether a patient develops postoperative complications such as sepsis, tumor recurrence, or multiple organ failure. Anesthesia may directly and indirectly influence this balance via sustained suppression of the immune response; this may predispose patients to sepsis or, in the case of cancer patients, tumor metastasis.[1]

Volatile anesthetics seem to suppress and impair immune function; they may be linked to tumor growth and to aggregation of neurodegenerative proteins.[2–3] For instance, sevoflurane decreases neutrophil count[4], inhibits neutrophil activation and adhesion[5], decreases macrophage levels[6], decreases cytokine release in macrophages and in natural killer cells[7], suppresses natural killer cell cytotoxicity[8], and increases microglial activation leading to cognitive decline[9]. Isoflurane shares many of these effects on the immune system, as well as additional immunosuppressive effects; overall effects of several volatile anesthetics (including desflurane, isoflurane, sevoflurane, and the discontinued halothane) on innate and adaptive immunity were compiled in a comprehensive 2016 review article by Stollings et al in 2016.[10]

Effects of various anesthetics may also be immune activating. One in vitro study showed that sevoflurane compensated for the immunosuppressive effect of nitrous oxide, namely decreased production of peripheral blood mononuclear cells; sevoflurane also compensates for thiopental’s effects, including decreased release of soluble interleukin-2 receptor and decreased cell proliferation.[11] Another example of potential benefits of sevoflurane is the increased release of cytokines such as interleukin-1?, interferon-?, and tumor necrosis factor-? in macrophages.[12] Because volatile anesthetics have complex effects on the immune response, both in vitro and in vivo models of research continue to address this new concern of the long-term impact of anesthetics in postoperative complications.

Indirect effects of anesthesia were also demonstrated, in prospective clinical research with differences in hormone production throughout the perioperative period. Compared to isoflurane, sevoflurane led to significantly lower glucocorticoid and cortisol levels in the blood at the end of the laparoscopic surgery; this was shown to coincide with lower levels of growth hormone and higher levels of prolactin. Overall, sevoflurane may generate a better stress response and thereby a better immune response than isoflurane.[13] More research on the impact of anesthesia on hormone levels will elucidate indirect impact on immune response.

Consideration of the impact of anesthesia on immune function is especially critical in oncologic surgeries, because the balance of immunosuppression and immune activation will have a direct impact on the regrowth or removal of cancerous cells.[14] For such surgeries, several clinical studies indicate that regional anesthesia may be a better option than general anesthesia, for select types of cancer.[15-20] While much more research is needed regarding the mechanisms of anesthetic effect on perioperative immune response, the profound impact is evident and should play a role in the customized course of anesthesia for all patients, particularly those that are immune-compromised, for the best possible outcome; anesthesiologists have a large role to play in regulating the immune response and optimizing the long-term outcome of patients after surgery.

1. Dąbrowska AM, Słotwiński R. The immune response to surgery and infection. Cent Eur J Immunol. 2014;39(4):532‐537. doi:10.5114/ceji.2014.47741

2. Kurosawa S, Kato M. Anesthetics, immune cells, and immune responses. J Anesth. 2008;22(3):263‐277. doi:10.1007/s00540-008-0626-2

3. Homburger JA, Meiler SE. Anesthesia drugs, immunity, and long-term outcome. Curr Opin Anaesthesiol. 2006;19(4):423‐428. doi:10.1097/01.aco.0000236143.61593.14

4. Fröhlich, D, Rothe, G, Schwall, B, Schmid, P, Schmitz, G, Taeger, K, Hobbhahn, J Effects of volatile anaesthetics on human neutrophil oxidative response to the bacterial peptide FMLP.. Br J Anaesth. (1997). 78 718–23

5.  Möbert, J, Zahler, S, Becker, BF, Conzen, PF Inhibition of neutrophil activation by volatile anesthetics decreases adhesion to cultured human endothelial cells. Anesthesiology. (1999). 90 1372–81

6. Möbert, J, Zahler, S, Becker, BF, Conzen, PF Inhibition of neutrophil activation by volatile anesthetics decreases adhesion to cultured human endothelial cells. Anesthesiology. (1999). 90 1372–81

7. Cho, EJ, Yoon, JH, Hong, SJ, Lee, SH, Sim, SB The effects of sevoflurane on systemic and pulmonary inflammatory responses after cardiopulmonary bypass. J Cardiothorac Vasc Anesth. (2009). 23 639–45

8. Mitsuhata, H, Shimizu, R, Yokoyama, MM Suppressive effects of volatile anesthetics on cytokine release in human peripheral blood mononuclear cells. Int J Immunopharmacol. (1995). 17 529–34

9. Shen, X, Dong, Y, Xu, Z, Wang, H, Miao, C, Soriano, SG, Sun, D, Baxter, MG, Zhang, Y, Xie, Z Selective anesthesia-induced neuroinflammation in developing mouse brain and cognitive impairment. Anesthesiology. (2013). 118 502–15

10. Lindsay M. Stollings, Li-Jie Jia, Pei Tang, Huanyu Dou, Binfeng Lu, Yan Xu; Immune Modulation by Volatile Anesthetics. Anesthesiology 2016;125(2):399-411. doi: https://doi.org/10.1097/ALN.0000000000001195.

11. Schneemilch CE, Hachenberg T, Ansorge S, Ittenson A, Bank U. Effects of different anaesthetic agents on immune cell function in vitro. Eur J Anaesthesiol. 2005;22(8):616‐623. doi:10.1017/s0265021505001031

12. Flondor, M, Hofstetter, C, Boost, KA, Betz, C, Homann, M, Zwissler, B Isoflurane inhalation after induction of endotoxemia in rats attenuates the systemic cytokine response. Eur Surg Res. (2008). 40 1–6

13. Marana E, Annetta MG, Meo F, et al. Sevoflurane improves the neuroendocrine stress response during laparoscopic pelvic surgery. Can J Anaesth. 2003;50(4):348‐354. doi:10.1007/BF03021031

14. Gottschalk, A, Sharma, S, Ford, J, Durieux, ME, Tiouririne, M Review article: The role of the perioperative period in recurrence after cancer surgery. Anesth Analg. (2010). 110 1636–43

15. Lin, L, Liu, C, Tan, H, Ouyang, H, Zhang, Y, Zeng, W Anaesthetic technique may affect prognosis for ovarian serous adenocarcinoma: A retrospective analysis. Br J Anaesth. (2011). 106 814–22

16. Christopherson, R, James, KE, Tableman, M, Marshall, P, Johnson, FE Long-term survival after colon cancer surgery: A variation associated with choice of anesthesia. Anesth Analg. (2008). 107 325–32

17. Exadaktylos, AK, Buggy, DJ, Moriarty, DC, Mascha, E, Sessler, DI Can anesthetic technique for primary breast cancer surgery affect recurrence or metastasis?. Anesthesiology. (2006). 105 660–4

18. Biki, B, Mascha, E, Moriarty, DC, Fitzpatrick, JM, Sessler, DI, Buggy, DJ Anesthetic technique for radical prostatectomy surgery affects cancer recurrence: A retrospective analysis. Anesthesiology. (2008). 109 180–7

19. Gupta, A, Björnsson, A, Fredriksson, M, Hallböök, O, Eintrei, C Reduction in mortality after epidural anaesthesia and analgesia in patients undergoing rectal but not colonic cancer surgery: A retrospective analysis of data from 655 patients in central Sweden. Br J Anaesth. (2011). 107 164–70

20. de Oliveira, GSJr, Ahmad, S, Schink, JC, Singh, DK, Fitzgerald, PC, McCarthy, RJ Intraoperative neuraxial anesthesia but not postoperative neuraxial analgesia is associated with increased relapse-free survival in ovarian cancer patients after primary cytoreductive surgery. Reg Anesth Pain Med. (2011). 36 271–7

Surgery and anesthesia are essential health services, but they are unavailable in many parts of the world.¹ An estimated one third of the world’s population does not have access to essential surgical resources, and even more people are exposed to unsafe anesthesia practices.¹ Low- and middle-income countries face shortages in human resources, technical resources, education systems and other utilities that prevent them from achieving the same standards of anesthesia care as high-income countries.² When anesthesiology practitioners from high-income countries travel to low-resource settings to provide care, they are often confronted by a lack of resources and different health issues among their patients.³ Anesthesia providers should consider the low anesthetic capacity in low- and middle-income countries, the importance of safe anesthesia and future strategies to approach global anesthesia care.¹

Anesthesia is necessary for the management of a variety of situations, including obstetric surgery,⁴ childbirth,⁵ abdominal surgery,⁶ injuries⁵ and other surgical conditions. However, providers in low-resource settings are unable to give proper anesthesia care to patients due to shortages of personnel, drugs, equipment and training.⁷ For example, a study by Hodges et al. found that in Uganda, only 23 percent, 13 percent and 6 percent of anesthetists had the facilities to deliver safe anesthesia to an adult, to a child and for a Cesarean section, respectively.⁷ Additionally, many educated clinicians in low-income settings emigrate to places with more opportunities for growth and better resources.⁸ As a result, anesthesia providers in low-resource areas have few role models, low wages, inadequate equipment and limited professional development opportunities.^5,8 Overall, an insufficiency of technological supplies, medications and training combined with a small workforce makes anesthesia care low in quality, if existent at all, in low-resource settings.

Yet anesthesia care is highly important to health care and general success of low-income regions.¹ Conservative estimates show that conditions requiring surgery and anesthesia contribute to 11 percent of the global burden of disease, and poor anesthetic care could result in further morbidity or mortality.⁹ For example, the inability to provide safe anesthesia for women in childbirth, whether for Cesarean section or vaginal delivery, contributes to high fetal and maternal mortality rates in low-resource settings.¹⁰ Anesthetic shortages also contribute to disparities in global mortality rates from injuries, as 90 percent of deaths from injuries occur in low- or middle-income countries.¹¹ The Global Burden of Disease Study estimates that by 2030, injuries will be the fifth leading cause of death in low- and middle-income countries, ahead of HIV, tuberculosis and malaria.¹² This is especially concerning given the role anesthesia and surgery play in preventing injury-related deaths. Evidently, anesthesia is crucial to preventing issues such as maternal, fetal and injury-related morbidity and mortality, all of which are common in low-resource regions.¹

Anesthesiology professionals and other health providers can work towards better anesthesia care in low-resource settings. Walker et al. suggest that nurses or clinical officers be provided with effective anesthesia training programs in settings without anesthesiologists.⁸ Hodges et al. encourage local structural changes, such as improvements in local management, finances and logistics.⁷ In their review, Bharati et al. mention that use of local or epidural anesthetics may lower risk of mortality in cases where resuscitation equipment, vital signs monitors and mechanical ventilators are unavailable.² The authors also make a variety of suggestions for enhancing anesthesia provision in low-resource settings, including continuous education for nurse anesthetists, simulation training for medical students, adequate resuscitation equipment, changes in prescription practices and development of transportation infrastructure.² However, these improvements all require contributions by high-income countries and global organizations.² Education and local infrastructure changes may be helpful in low-resource settings, but these advances—along with technological development, proper equipment and improved transportation—may be difficult to achieve without a global effort.

Anesthesia and surgery are crucial to maintaining a healthy population. However, safe anesthesia care is sorely lacking in low-resource settings. A lack of supplies, technology, infrastructure and health professionals makes anesthesiology extremely difficult in low-resource regions. This can contribute to obstetric, injury-related and other surgical complications and mortality. Global health policymakers should shift focus and funding to anesthesia provision in low-resource regions to work toward a healthy global population.¹

1.         Li V, Neuen BL. Access to safe anesthesia: A global perspective. The Journal of Global Health. April 1, 2014.

2.         Bharati SJ, Chowdhury T, Gupta N, Schaller B, Cappellani RB, Maguire D. Anaesthesia in underdeveloped world: Present scenario and future challenges. Nigerian Medical Journal. 2014;55(1):1–8.

3.         University of Oxford Nuffield Department of Clinical Neurosciences. Anaesthesia in Developing Countries. Continuing Professional Development 2020; https://www.ndcn.ox.ac.uk/study-with-us/continuing-professional-development/anaesthesia-in-developing-countries.

4.         Grady K. Building capacity for anaesthesia in low resource settings. BJOG: An International Journal of Obstetrics & Gynaecology. 2009;116(s1):15–17.

5.         Cherian M, Choo S, Wilson I, et al. Building and retaining the neglected anaesthesia health workforce: Is it crucial for health systems strengthening through primary health care? Bulletin of the World Health Organization. May 10, 2010;88:637–639.

6.         Khan FA, Merry AF. Improving Anesthesia Safety in Low-Resource Settings. Anesthesia & Analgesia. 2018;126(4):1312–1320.

7.         Hodges SC, Mijumbi C, Okello M, McCormick BA, Walker IA, Wilson IH. Anaesthesia services in developing countries: Defining the problems. Anaesthesia. 2007;62(1):4–11.

8.         Walker I, Wilson I, Bogod D. Anaesthesia in Developing Countries. Anaesthesia. 2007;62(s1):2–3.

9.         Ozgediz D, Riviello R. The “other” neglected diseases in global public health: Surgical conditions in sub-Saharan Africa. PLoS Medicine. 2008;5(6):e121.

10.       Dyer RA, Reed AR, James MF. Obstetric anaesthesia in low-resource settings. Best Practice & Research Clinical Obstetrics & Gynaecology. 2010;24(3):401–412.

11.       Bae JY, Groen RS, Kushner AL. Surgery as a public health intervention: Common misconceptions versus the truth. Bulletin of the World Health Organization. 2011;89(6):394.

12.       Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet (London, England). 2012;380(9859):2095–2128.

A diverse workforce is more productive and more representative of the American population.¹ Factors such as race, ethnicity, gender, sexual orientation and religion are frequently considered aspects of diversity, while disability is largely ignored.² Indeed, only 15 percent of top-ranked companies include disability in their definitions of diversity.³ Lack of awareness of the various forms of disability can contribute to conflict and mistrust between employees.⁴ It is unlawful to discriminate against an employee for having a disability,⁵ yet employees with disabilities often face prejudice.⁶ Though the literature on physician disability is limited, health professionals of all types—ranging from clinical psychologists⁷ to nurses⁸—may face disability throughout their lives.⁹ While some guidelines exist surrounding disability-related recruitment and retention among medical students,¹⁰ health professionals may also develop a disability later in life.⁹ In order to reduce discrimination against and provide adequate resources for practitioners with disabilities, anesthesia providers should become familiar with definitions of disability, stigma associated with various conditions and disability in anesthesiology in particular.

According to the Centers for Disease Control and Prevention (CDC), a disability is any condition of the body or mind that makes it more difficult for a person to do certain activities and interact with the world.¹¹ A disability is marked by impairment, such as loss of a limb, blindness or memory loss; activity limitation, such as difficulty reading, hearing, walking or problem solving; and participation restrictions, such as working, engaging in social and recreational activities and obtaining health care services.¹² Specifically, work-related disabilities may result in employment problems because the individual is unable to perform a work role in a manner that is considered “normal.”¹³ A health care professional with a disability is one who is unable to practice medicine or nursing with reasonable skill and safety because of a physical or psychiatric condition.¹³ These vague, subjective definitions lead to a spectrum of interpretations and implementations, often causing stigma against workers with disabilities.⁸ Indeed, one study found that prejudice surrounding certain types of disabilities—such as AIDS, cerebral palsy and stroke—contributed to lower acceptance of the worker.⁶ The complexity of disability in client-facing roles, including the health professions, can have profound personal, professional and societal ramifications.¹³

Disability in anesthesia providers can manifest in a number of ways, and can arise from before medical school to later in life.⁹ For example, disability in anesthesiology includes a practitioner who has suffered an injury or illness and wants to return to practice; a provider with an established impairment who is seeking support or hoping to receive disability insurance benefits; and colleagues who are questioning whether an anesthesia provider with a particular limitation should be allowed to continue practicing.⁹ These issues almost always subjective and ethically challenging, and they are made more complex by the fact that a condition may be disabling in one context, but merely inconvenient in another.¹³ A case study by Fitzsimons et al. found that cognitive disabilities, such as attention deficit/hyperactivity disorder (ADHD), may go undiagnosed among anesthesiology trainees and contribute to the trainee’s struggles throughout residency.¹⁴ Meanwhile, a review by Katz shows that substance use disorder is one of the most common disabilities among resident and attending anesthesiologists.¹⁵ Other disabilities include physical issues, major psychiatric disorders like clinical depression, burnout and age-related dementia.¹⁵ Management of these disabilities among anesthesia providers can be complicated, given prejudices and potential impairment attached to the conditions.¹⁵

Though some degree of impairment will occur in one-third of anesthesiologists during their careers, there are few studies on the role of stigma and work difficulties for anesthesia providers with disabilities.¹⁵ Some general approaches to workplace disability can include diversity management services,⁴ improved definitions of disability in anesthesiology⁸ and individualized programs for anesthesiology trainees or attendings who may require special accommodations.¹⁴ Anesthesia professionals should embrace the diversity that providers with disabilities bring to the workforce⁴ while simultaneously preserving their mission to “do no harm” to patients.⁸

1.         Selden SC, Selden F. Rethinking Diversity in Public Organizations for the 21st Century: Moving toward a Multicultural Model. Administration & Society. 2001;33(3):303–329.

2.         Diversity includes Disability. Accessibility Information 2019; https://accessibility.cornell.edu/diversity-includes-disability/.

3.         Ball P, Monaco G, Schmeling J, Schartz H, Blanck P. Disability as diversity in Fortune 100 companies. Behavioral Sciences & the Law. 2005;23(1):97–121.

4.         Muyia Nafukho F, Roessler RT, Kacirek K. Disability as a Diversity Factor: Implications for Human Resource Practices. Advances in Developing Human Resources. 2010;12(4):395–406.

5.         The ADA: Your Employment Rights as an Individual With a Disability. Washington, D.C.: U.S. Equal Employment Opportunity Commission; 2008.

6.         McLaughlin ME, Bell MP, Stringer DY. Stigma and Acceptance of Persons With Disabilities: Understudied Aspects of Workforce Diversity. Group & Organization Management. 2004;29(3):302–333.

7.         Olkin R. Could you hold the door for me? Including disability in diversity. Cultural Diversity and Ethnic Minority Psychology. 2002;8(2):130–137.

8.         Sin CH, Fong J. ‘Do no harm’? Professional regulation of disabled nursing students and nurses in Great Britain. Journal of Advanced Nursing. 2008;62(6):642–652.

9.         Dangler LA, del Carmen Forrest M. A Diverse Perioperative Physician Workforce Includes Those With Disabilities. ASA Newsletter. 2019;83(6):20–22.

10.       Meeks LM, Jain NR, Moreland C, Taylor N, Brookman JC, Fitzsimons M. Realizing a Diverse and Inclusive Workforce: Equal Access for Residents With Disabilities. Journal of Graduate Medical Education. 2019;11(5):498–503.

11.       National Center on Birth Defects and Developmental Disabilities. Disability and Health Overview. September 4, 2019; https://www.cdc.gov/ncbddd/disabilityandhealth/disability.html.

12.       International Classification of Functioning, Disability and Health (ICF). Classifications March 2, 2018; https://www.who.int/classifications/icf/en/.

13.       Katz JD. The Disabled Anesthesiologist. ASA Newsletter. 2007;71(5):17-21.

14.       Fitzsimons MG, Brookman JC, Arnholz SH, Baker K. Attention-Deficit/Hyperactivity Disorder and Successful Completion of Anesthesia Residency: A Case Report. Academic Medicine. 2016;91(2):210–214.

15.       Katz JD. The impaired and/or disabled anesthesiologist. Current Opinion in Anaesthesiology. 2017;30(2):217–222.