Explore the vast range of titles available.

Blood test results showed a white cell count of 23×109/L and an elevated C reactive protein level of 3.5 mg/L. Findings on physical examination of orthodeoxia (decrease in oxygen saturation by >2% when transitioning from supine to an upright position) or platypnea (dyspnoea induced by the upright position) in a patient with hypoxaemia and cyanosis suggests an intrapulmonary shunt.1 PAVMs may be complicated by paradoxical embolism with early development of cerebral abscesses and embolic strokes, and therefore, require prompt evaluation and management.2 3 PAVMs are most commonly caused by HHT, an autosomal dominant inherited disease with marked phenotypic heterogeneity and variable onset of disease manifestation.4 About 50% of HHT patients have PAVMs, while 70%–93% of patients with PAVM are diagnosed with HHT.5 The presentation in our patient highlights the physiology, clinical manifestation and consequence of PAVMs and the importance of considering intrapulmonary shunting as cause for hypoxemia. Contributors All authors met the criteria for authorship as recommended by the International Committee of Medical Journal Editors (ICMJE), were fully responsible for all content and editorial decisions, retained full control over all content contained in this report, and were involved with all stages of report development.

Adequate pain management is one of the biggest challenges of the modern healthcare system. Physician perception of patient subjective pain, which is crucial to pain management, is susceptible to a host of potential biases. Here we explore the timing of physicians’ work as a previously unrecognized source of systematic bias in pain management. We hypothesized that during night shifts, sleep deprivation, fatigue, and stress would reduce physicians’ empathy for others’ pain, leading to underprescription of analgesics for patient pain relief. In study 1, 67 resident physicians, either following a night shift or not, performed empathy for pain assessment tasks and simulated patient scenarios in laboratory conditions. As predicted, following a night shift, physicians showed reduced empathy for pain. In study 2, we explored this phenomenon in medical decisions in the field. We analyzed three emergency department datasets from Israel and the United States that included discharge notes of patients arriving with pain complaints during 2013 to 2020 (n = 13,482). Across all datasets, physicians were less likely to prescribe an analgesic during night shifts (compared to daytime shifts) and prescribed fewer analgesics than generally recommended by the World Health Organization. This effect remained significant after adjusting for patient, physician, type of complaint, and emergency department characteristics. Underprescription for pain during night shifts was particularly prominent for opioids. We conclude that night shift work is an important and previously unrecognized source of bias in pain management, likely stemming from impaired perception of pain. We consider the implications for hospitals and other organizations employing night shifts.