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Tricyclic antidepressants prevent presynaptic reuptake of norepinephrine and serotonin. This class of antidepressant has risks of more severe drug interactions. First, a reaction between TCAs and tramadol could result in seizures and a serotonergic crisis. Next, an anesthesiologist should be aware of the possibility of a hypertensive crisis from an interaction between indirectly acting sympathomimetic contained in local anesthetic solutions and TCAs.5 Finally, and most importantly, the contractile force of the heart has been found to be decreased by increasing levels of TCAs.7,11 This can result in hypotension, slowing of sodium channel electrical conduction and result in dysrhythmias.7 Monoamine oxidase inhibitors are an older class of antidepressant drug. They can be either reversible or irreversible and function by inhibiting the breakdown of norepinephrine and serotonin. Like other antidepressants, MAOIs carry risks of precipitating a serotonergic crisis of hypertension, agitation, rigidity, convulsions, and hyperthermia when given with meperidine.5,12 The combination of MAOIs with sympathomimetics has also been shown to cause hypertensive crises.7 Antipsychotics: There are two classes of drugs used to treat psychotic disorders: typical and atypical. Typical antipsychotics block dopamine, histamine, alpha1-adrenergic, and cholinergic receptors. Atypical antipsychotics may block subtypes of the dopaminergic receptor family and affect the serotonin-2A receptor with reduced extrapyramidal side effects.5 Both classes of drugs are significant to a patient’s clinical team because of the high rate of patient relapse if the drug is discontinued. Anesthesiologists should be aware of the complication of sudden death related to a prolongation of the QTc interval and torsades des pointes, a malignant ventricular arrhythmia that is associated with syncope and sudden death.6 Thioridazine, pimozide, sertindole, droperidol, and haloperidol all have been documented to cause torsade de pointes and sudden death, but even those antipsychotics without specific documented evidence of these complications have the potential for these serious adverse events.13 Therefore, these medications that prolong the QT interval should be avoided and there should be careful cardiac monitoring in patients using these drugs.14 Other notable reactions include the concurrent use of an antipsychotic with desflurane, which has been reported to cause seizures, and the use of antipsychotics with drugs producing an antidopaminergic effect like other antiemetics, choline, the TCA antidepressants, and a drug as innocuous as melatonin, which could exacerbate the potential for side effects of the drug.5,15 Anxiolytics Benzodiazepines are the common drugs used to treat short-term anxiety symptoms and come with little surgical risk to the patient. Medco data show that the rate of usage in middle-aged women (11%) is nearly double the usage in the similar age range for men (5.7%).1 Antianxiety medications, although sedatives, come with the potential of withdrawal symptoms in patients who have fasted for a prolonged period, like when waiting to undergo surgery, so physicians should be cognizant of possible signs of withdrawal in those patients.5 percent, an increase of 0.4 percent over last year. § In 2021, Family Medicine offered 4,823 positions (the highest number since 1992) and 4,472 filled (92.7%). U.S. MD seniors filled 33.3 percent of the positions; however, a record number of U.S. DO seniors (1,440) matched, accounting for 29.9 percent of total applicants who matched to the specialty. § Pediatrics (categorical) has gained positions every year since 2005 and offered a record-high 2,901 positions in 2021. The overall fill rate was 98.6 percent, with 60.3 percent filled by U.S. MD seniors and 17.9 percent filled by U.S. DO seniors. ·The number of Psychiatry positions has grown every year since 2008. There were 1,907 positions offered in 2021, an increase of 838 positions (78.4%) in 14 years. ·In 2021, 14,115 applicants were eligible to participate in SOAP, 2,299 more than in 2020. A fourth SOAP offer round was added in 2021. Of the 1,892 positions placed in SOAP, 1,773 positions filled, 86 more than 2020. We hope you find the data contained in the following pages useful as you reflect on the 2021 Match and prepare for future Matches. Donna L. Lamb, D.HSc., M.B.A., B.S.N., President and Chief Executive Officer National Resident Matching Program 2121 K Street NW, Suite 1000 Washington, DC 20037 admin@nrmp.org Results and Data 2021 Main Residency Match® vi Table 1 Table 1 summarizes the 2021 Main Residency Match and shows the numbers of participating programs, offered positions, and unfilled programs. It also provides ranking and matching data for U.S. MD seniors (Table 1A) and U.S. DO seniors (Table 1B). Using Anesthesiology PGY-1 as an example on Table 1A: · The first three columns (“No. of Programs,” “Positions Offered,” and “Unfilled Programs”) show that 159 programs offered 1,460 Anesthesiology PGY-1 positions and that 2 of those programs were unfilled after the matching algorithm had been processed. · The numbers of U.S. MD senior applicants and total applicants are provided in the next two columns under “No. of Applicants.” In 2021, 1,460 U.S. MD seniors ranked at least one Anesthesiology program, and 2,706 applicants in total ranked Anesthesiology. Note that the figures do not mean that Anesthesiology was the preferred choice of those applicants. · The next two columns (under “No. of Matches”) show that 1,024 of the 1,460 PGY-1 positions offered in Anesthesiology were filled by U.S. MD seniors, with 1,457 filled by all applicants. · The fill rates (calculated as positions filled divided by positions offered) can be found in the two columns under “% Filled.” Of the 1,460 PGY-1 positions offered in Anesthesiology, 70.1 percent were filled by U.S. MD seniors and 99.8 percent were filled overall. · The “Ranked Positions” columns show that, collectively, U.S. MD seniors ranked the positions offered by those Anesthesiology programs 15,977 times and the total number of ranks by all applicants was 23,046. The 2021 Match offered 38,106 positions, 850 more than 2020; of those, 35,194 were PGY-1 positions, 928 more than last year. An ethics analysis of the rationale for publicly funded plastic surgery Lars Sandman1,2,3* and Emma Hansson4,5 Abstract Background: Healthcare systems are increasingly struggling with resource constraints, given demographic changes, technological development, and citizen expectations. The aim of this article is to normatively analyze different suggestions regarding how publicly financed plastic surgery should be delineated in order to identify a wellconsidered, normative rationale. The scope of the article is to discuss general principles and not define specific conditions or domains of plastic surgery that should be treated within the publicly financed system. Methods: This analysis uses a reflective equilibrium approach, according to which considered normative judgements in one area should be logically and argumentatively coherent with considered normative judgements and background theories at large within a system. Results and conclusions: In exploring functional versus non-function conditions, we argue that it is difficult to find a principled reason for an absolute priority of functional conditions over non-functional conditions. Nevertheless, functional conditions are relatively easier to establish objectively, and surgical intervention has a clear causal effect on treating a functional condition. Considering non-functional conditions that require plastic surgery [i.e., those related to appearance or symptomatic conditions (not affecting function)], we argue that the patient needs to experience some degree of suffering (and not only a preference for plastic surgery), which must be ‘validated’ in some form by the healthcare system. This validation is required for both functional and non-functional conditions. Functional conditions are validated by distinguishing between statistically normal and abnormal functioning. Similarly, for non-functional conditions, statistical normality represents a potential method for distinguishing between what should and should not be publicly funded. However, we acknowledge that such a concept requires further development. Keywords: Plastic surgery, Esthetic surgery, Rationing, Prioritizing, Normality, Functional condition, Psychosocial condition, Etiology, Healthcare need, Patient experience Background Healthcare systems are increasingly struggling with resource
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