Ethics education in medical training remains difficult to standardize and sustain. Many curricula still rely heavily on didactic teaching rather than immersive ethical reasoning. Although large language models (LLMs) can generate structured analyses of ethical dilemmas, they are not designed to facilitate embodied, conversational engagement that mirrors real-world ethics discussions. We developed CALEB (Conversational Agent Learning Ethics Bot), a domain-specific, extended reality (XR)-enabled conversational agent designed to simulate pragmatic, case-based moral deliberation. CALEB integrates a curated medical ethics knowledge base, structured persona design, and bounded generative architecture to promote focused, dialogical interaction. We conducted a two-phase feasibility evaluation. In phase 1, CALEB and GPT-4o accessed through the ChatGPT interface were compared using standardized transcript outputs generated from matched medical ethics prompts. In phase 2, medical ethicists interacted with CALEB in a live XR setting and provided formative post-session feedback. GPT-4o generated substantially longer and comprehensive responses. In contrast, CALEB produced significantly shorter but more principle-dense responses and was the only system to consistently demonstrate first-person and emotionally interpretive language. Computational analysis revealed higher empathy scores for CALEB in interpretive dimensions ( p < 0.001). In the live XR phase, post-session feedback suggested that CALEB was perceived more favorably in an interactive, embodied setting than in transcript-only review. This study provides evidence that domain-specific agents like CALEB are feasible and pedagogically distinct from general-purpose LLMs. Foundational and specialized systems may serve complementary roles in advancing scalable, interactive medical ethics education.

Background:The primary aim of our study was to identify patient and clinical characteristics associated with longer cesarean delivery operative time at our hospital. Methods:Our institutional review board approved this study and waived the requirement for informed consent. Patients who had cesarean deliveries from July 1, 2023, to June 30, 2024, at Baylor Scott & White Medical Center - Temple were eligible for inclusion. Patients who were Black, Hispanic, or Caucasian were divided into shortest and longest quartiles of operative time. A bivariate analysis and multivariate logistic regression were performed between the short and long operative time cohorts to determine which characteristics were independently associated with a longer operative time. Results:There were 231 and 220 patients in the short and long cohorts, respectively. Medicaid vs commercial insurance (adjusted odds ratio [aOR] 1.57; 95% confidence interval [CI] 1.00-2.45; P = 0.049), a five-unit increase in body mass index (aOR 1.64; 95% CI 1.38-1.95; P < 0.001), and performing a sterilization procedure (aOR 3.20; 95% CI 1.80-5.70; P < 0.001) were independently associated with the long cohort. Discussion:Medicaid insurance, body mass index, and performing a sterilization procedure were associated with a 57%, 64%, and 220% increase, respectively, of being in the longer operative cohort.

Enhanced recovery after surgery programs for cesarean deliveries (ERAC) aim to optimize the quality of care for all patients. Race is not routinely monitored in ERAC programs. Given the extensive reports of racial disparities in obstetrical care, the goal of this study was to investigate racial differences in adherence rates to individual ERAC protocol elements.A cohort study was performed among cesarean delivery patients enrolled in an ERAC program at two hospitals from October 2016 to September 2020. Compliance with anesthesia-specific ERAC metrics, including ketorolac, ondansetron, and active warming methods, were compared by race. Race was self-reported by all patients. Logistic regression models stratified by pre- and post-ERAC status were used to assess relationships.The sample consisted of 7,812 cesarean delivery patients, of which 4,640 were pre-ERAC (59.4%) and 3,172 were post-ERAC (40.6%). There were no racial differences found in overall ERAC protocol adherence, active warming methods, or ondansetron administration in the pre- and post-ERAC groups. The odds of ketorolac administration in Black patients (adjusted odds ratio [aOR]: 0.72; 95% confidence interval [CI]: 0.55-0.95; p = 0.020) and Asian patients (aOR: 0.81; 95% CI: 0.68-0.98; p = 0.027) pre-ERAC were significantly lower compared with white patients. In the post-ERAC group, this disparity persisted in Black (aOR: 0.80; 95% CI: 0.65-0.99; p = 0.042) and Asian patients (aOR: 0.85; 95% CI: 0.73-0.98; p = 0.023).Appropriate implementation and adherence to all elements of the ERAC program may provide a practical approach to reducing disparities in outcomes and ensuring equitable treatment for all patients. · No racial differences were found in ondansetron administration pre- and post-ERAC.. · No racial differences were found in active warming methods pre- and post-ERAC.. · Black patients had significantly lower odds of ketorolac administration pre- and post-ERAC.. · Asian patients had significantly lower odds of ketorolac administration pre- and post-ERAC.. · ERAC metrics must be routinely monitored by race to resolve any observed inequities..

Background/Objectives: Artificial intelligence (AI) is increasingly applied across the perioperative continuum, with potential benefits in efficiency, personalization, and patient safety. Unfortunately, most such tools are developed in isolation, limiting their clinical utility. Multi-Agent Systems for Healthcare (MASH), in which autonomous AI agents coordinate tasks across multiple domains, may provide the necessary framework for integrated perioperative care. This critical review synthesizes current AI applications in anesthesiology and considers their integration within a MASH architecture. This is the first review to advance MASH as a conceptual and practical framework for anesthesiology, uniquely contributing to the AI discourse by proposing its potential to unify isolated innovations into adaptive and collaborative systems. Methods: A critical review was conducted using PubMed and Google Search to identify peer-reviewed studies published between 2015 and 2025. The search strategy combined controlled vocabulary and free-text terms for AI, anesthesiology, perioperative care, critical care, and pain management. Results were filtered for randomized controlled trials and clinical trials. Data were extracted and organized by perioperative phase. Results: The 16 studies (6 from database search, 10 from prior work) included in this review demonstrated AI applications across the perioperative timeline. Preoperatively, predictive models such as POTTER improved surgical risk stratification. Intraoperative trials evaluated systems like SmartPilot and Navigator, enhancing anesthetic dosing and physiologic stability. In critical care, algorithms including NAVOY Sepsis and VentAI supported early detection of sepsis and optimized ventilatory management. In pain medicine, AI assisted with opioid risk assessment and individualized pain-control regimens. While these trials demonstrated clinical utility, most applications remain domain-specific and unconnected from one another. Conclusions: AI has broad potential to improve perioperative care, but its impact depends on coordinated deployment. MASH offers a unifying framework to integrate diverse agents into adaptive networks, enabling more personalized anesthetic care that is safer and more efficient.

Background/Objectives: Virtual reality (VR), a component of extended reality (XR), has shown promise in pre-procedural planning by providing immersive, patient-specific simulations. In pain management, where precise anatomical understanding is critical for interventions such as peripheral nerve stimulation (PNS), nerve blocks, and intrathecal pump placement, the application of VR remains underexplored. This case series examines the role of VR in enhancing pre-procedural planning for complex chronic pain interventions. Methods: From August 2022 to December 2024, six patients with anatomically challenging conditions underwent VR-assisted pre-procedural planning at Weill Cornell Medical Center. Patient-specific 3D models were created using the manual or automatic segmentation of imaging data and reviewed in VR to optimize procedural strategies by the surgeons performing the case. Procedures were then performed using conventional fluoroscopic or ultrasound guidance. Results: In all cases, VR facilitated the improved visualization of complex anatomies and informed optimal procedural trajectories. In patients with a complex cancer anatomy, previous surgical changes, or hardware, VR enabled precise PNS lead or needle placement, resulting in significant pain reductions postoperatively. In certain cases where previous interventional pain procedures had failed, VR allowed for a “second opinion” to develop an alternative approach with improved outcomes. Finally, in one case, VR served to potentially prevent patient harm by providing insight to the proceduralists regarding an alternative approach. Across the series, VR enhanced the spatial awareness, procedural accuracy, and confidence in navigating challenging anatomical scenarios. Conclusions: This case series demonstrates the utility of VR in pre-procedural planning for chronic pain interventions. By enabling detailed anatomical visualization and trajectory optimization, VR has the potential to improve outcomes in complex cases. Further studies are needed to evaluate its broader clinical applications and cost-effectiveness in pain management.

Microplastics have been detected in human placental and neural tissues, raising urgent concerns about their potential effects on maternal and fetal health. Emerging evidence links microplastics to systemic inflammation, neurotoxicity, and endocrine disruption, yet their impact on pregnancy outcomes and fetal development remains poorly understood. Given the placenta's central role in early-life health, perinatal researchers are uniquely positioned to lead investigations into this environmental threat. We call for collaborative, multidisciplinary research to better understand and mitigate the effects of microplastic exposure during pregnancy.

Total hip arthroplasty (THA) is a widely performed surgical procedure in the United States, but disparities in THA outcomes related to hospital-level factors, such as safety-net burden, are underexplored. This study expands on previous research by analyzing multicenter, multistate data from 2015 to 2020 to investigate the impact of hospital safety-net burden-defined as the proportion of services billed to Medicaid and uninsured patients-on THA outcomes. This study is a retrospective analysis using data from the State Inpatient Databases for Florida, Kentucky, Maryland, New York, Washington, New Jersey, and North Carolina. The study cohort included 543,814 inpatient primary THA admissions, with patient demographics, comorbidities, and hospital characteristics analyzed across 3 categories of hospital safety-net burden (low, medium, and high). Generalized linear mixed models assessed the association between safety-net burden and in-hospital mortality and postoperative complications, whereas multilevel negative binomial regression evaluated the impact on hospital length of stay. The study findings indicate that patients undergoing THA at hospitals with high safety-net burden had significantly higher odds of in-hospital mortality (adjusted odds ratio [aOR]: 1.20, 95% confidence interval [CI]: 1.02-1.42), postoperative complications (aOR 1.33, 95% CI 1.20-1.48), and longer hospital stays (adjusted incidence rate ratio 1.15, 95% CI 1.10-1.21) compared with those at low-burden hospitals. These results suggest that hospitals with higher safety-net burden, often serving more vulnerable populations, may have suboptimal perioperative processes and protocols, leading to poorer outcomes. The study underscores the need for targeted interventions to improve THA outcomes in these hospitals.

BackgroundThere is a lack of consensus in the literature as to whether anesthetic modality influences perioperative complications in hip fracture surgery. The aim of the present study was to assess the effect of spinal anesthesia compared with general anesthesia on postoperative morbidity and mortality in patients who underwent hip fracture surgery using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). MethodsWe used the ACS NSQIP to identify patients aged 50 and older who received either spinal or general anesthesia for hip fracture surgery from 2016 to 2019. Propensity-score matching was performed to control for clinically relevant covariates. The primary outcome of interest was the combined incidence of stroke, myocardial infarction (MI) or death within 30 days. Secondary outcomes included 30-day mortality, hospital length of stay and operative time. ResultsAmong the 40 527 patients aged 50 and over who received either spinal or general anesthesia for hip fracture surgery from 2016 to 2019, 7358 spinal anesthesia cases were matched to general anesthesia cases. General anesthesia was associated with a higher incidence of combined 30-day stroke, MI or death compared with spinal anesthesia (OR 1.219 (95% CI 1.076 to 1.381); p=0.002). General anesthesia was also associated with a higher frequency of 30-day mortality (OR 1.276 (95% CI 1.099 to 1.481); p=0.001) and longer operative time (64.73 vs 60.28 min; p<0.001). Spinal anesthesia had a longer average hospital length of stay (6.29 vs 5.73 days; p=0.001). ConclusionOur propensity-matched analysis suggests that spinal anesthesia as compared with general anesthesia is associated with lower postoperative morbidity and mortality in patients undergoing hip fracture surgery.

Background: Neighborhood disadvantage, a social driver of health (SDOH), has been associated with adverse perinatal outcomes; yet little is known about its association with anesthetic choice. Objective: The purpose of this study is to assess the association of neighborhood disadvantage and anesthetic choice for cesarean deliveries. We hypothesize that people from the most disadvantaged neighborhoods are more likely to receive general anesthesia for cesarean deliveries compared to those from the most advantaged neighborhoods. Study design: This single-center retrospective cohort study identified index cesarean deliveries performed between 2008 and 2017. People were categorized into no, low, moderate, and high disadvantage neighborhood using the area deprivation index. The odds of receiving general anesthesia versus neuraxial anesthesia (epidural, spinal, or combined spinal-epidural) were compared using logistic regression models. Results: Of the 16,351 people with cesarean deliveries, 96.0% received neuraxial versus 4.0% general anesthesia. The rates of general anesthesia were 6.3%, 4.2%, 3.1%, and 2.4% for the high, moderate, low, and no disadvantage groups (P<.001), respectively. Indications for general anesthesia by obstetric indication were different by neighborhood disadvantage (P<.001), but no differences were observed by contraindications of neuraxial anesthesia (P=.091). Compared to the no disadvantage group, the high disadvantage group had higher odds of general anesthesia (aOR 2.0, 95% CI (1.5 to 2.7), P<.001). Results were unchanged after evaluating people in labor only. Conclusions: People from disadvantaged neighborhoods are more likely to receive general anesthesia for cesarean deliveries, even after considering clinical features. The general anesthesia rate is a meaningful benchmark in obstetric anesthesia that may contribute to disparities.

•General anesthesia should be avoided for cesarean delivery when possible but initiated when indicated•Prevention and management of inadequate analgesia for cesarean delivery should be emphasized in obstetric anesthesia care•Call to action: we should investigate the experience of pain during cesarean delivery with high quality studies

Background Studies have identified widespread variation in neuraxial labor analgesia use by race, ethnicity, and geographic location. However, limited research has investigated patient-level factors in the decision not to use neuraxial analgesia for labor. Methods We conducted semi-structured interviews at a New York City medical center from October 1, 2022, to May 30, 2023. Participants had delivered vaginally and selected not to receive neuraxial analgesia. Structured demographic questions were asked after interview completion. Interviews were recorded and transcribed verbatim. We analyzed data and grouped responses into themes according to grounded theory. Results We identified five themes encompassing the main factors participants had considered when deciding not to receive neuraxial analgesia for birth: preferences for a natural birth experience, an empowering and supportive labor environment, preparation or preparedness for birth without medication, positive outlook on labor pain, and information, misinformation, knowledge gaps and fears about the epidural. All study participants mentioned these overarching themes in their interviews. Conclusions Participants described various factors important in their decision to give birth without an epidural, which we mapped onto five primary themes. Our results can be used to guide effective patient-provider interactions centered on mutual understanding, evidence-based medicine, and honoring patients’ wishes. The information gathered may provide insight into how providers can incorporate shared decision-making into their practice.

The exacerbation of health disparities in maternal mortality and severe maternal morbidity during the coronavirus disease 2019 (COVID-19) pandemic have been well documented.[1] Studies have shown that among pregnant individuals, COVID-19 infection was associated with elevated risk for overall mortality and serious morbidity.[2] Few studies have considered the potential impact of state-level responses and policies to the COVID-19 pandemic on maternal outcomes. Previous studies have already shown the impact that state-level policies can have on maternal health, with one study showing the association between Medicaid expansion and lower maternal mortality.[3] There have also been data highlighting the maternal health outcome disparities between restrictive versus protective states regarding abortion policies, and how the recent Supreme Court Dobbs versus Jackson ruling could further exacerbate outcomes.[4] Due to the immense variation in state COVID-19 policies and implementation dates, we examined state policy-based performance during the pandemic and its association with severe maternal morbidity and mortality, stratified by race, ethnicity, and rurality.