Responding to the Opioid Epidemic: Educational Competencies for Pain and Substance Use Disorder from the Medical Schools of the University of California.

OBJECTIVE: The University of California (UC) leadership sought to develop a robust educational response to the epidemic of opioid-related deaths. Because the contributors to this current crisis are multifactorial, a comprehensive response requires educating future physicians about safe and effective management of pain, safer opioid prescribing, and identification and treatment of substance use disorder (SUD). METHODS: The six UC medical schools appointed an opioid crisis workgroup to develop educational strategies and a coordinated response to the opioid epidemic. The workgroup had diverse specialty and disciplinary representation. This workgroup focused on developing a foundational set of educational competencies for adoption across all UC medical schools that address pain, SUD, and public health concerns related to the opioid crisis. RESULTS: The UC pain and SUD competencies were either newly created or adapted from existing competencies that addressed pain, SUD, and opioid and other prescription drug misuse. The final competencies covered three domains: pain, SUD, and public health issues related to the opioid crisis. CONCLUSIONS: The authors present a novel set of educational competencies as a response to the opioid crisis. These competencies emphasize the subject areas that are fundamental to the opioid crisis: pain management, the safe use of opioids, and understanding and treating SUD.

Evolving healthcare delivery paradigms and the optimization of 'value' in anesthesiology.

PURPOSE OF REVIEW: Healthcare worldwide is evolving to yield enhanced care provided at a lowered cost. Patient-centric paradigms that hasten surgical recovery and strengthen collaboration amongst medical professionals are gaining impetus. This review will discuss the changing healthcare landscape and outline its implications on anesthesiology practice. RECENT FINDINGS: Anesthesiologists must be nimble and versatile as they adapt to healthcare redesign. An increased responsibility for patient outcomes should be embraced by extending the breadth and depth of clinical practice throughout the surgical care continuum. The perioperative surgical home and enhanced recovery after surgery provide paradigms to further integrate expanding clinical opportunities and improved patient outcomes. Investment is needed in perioperative medical education and research efforts to best position anesthesiologists for success both now and in the future. SUMMARY: Exemplifying opportunities to demonstrate value-added care, the scope of anesthesiology education and clinical practice should diversify to further integrate perioperative care of surgical patients.

Evaluation of enzyme-linked immunosorbent assays for detecting circulating antibodies to Candida albicans.

Published studies indicate that Candida albicans antibody assays utilizing cytoplasmic antigens offer greater utility for identifying cases of systemic candidiasis when compared with assays utilizing cell wall components. We assessed the performance characteristics of a commercially available system that utilizes cytoplasmic antigens to measure C. albicans IgG, IgM, and IgA (Candida Detect ELISA reagents). Intra-assay variation was < or =5%, inter-assay variation was < or =10%, and good linearity was observed for all the three antibody isotypes. Results for specimens stored under various conditions were comparable to those obtained initially. Inter-laboratory reproducibility was excellent; qualitative concordance was > or =93% for all the three isotypes, with slopes and R(2) values approaching 1.0 in linear regression analyses. Seroprevalence in persons without apparent systemic candidiasis was evaluated using three different serum panels; seroprevalence rates ranged from 24 to 32% for IgG, 2-14% for IgM, and 15-36% for IgA. Seroprevalence rates in a panel of sera containing antibodies to other fungi were similar to rates observed in panels from individuals without systemic candidiasis. These findings demonstrate the acceptable performance of assay systems employing Candida Detect ELISA reagents.

Anesthesiology Residency Curriculum and Implementation of a Perioperative Surgical Home Curriculum: A Survey Study.

Background: The perioperative surgical home (PSH) is a physician-led, interdisciplinary, and patient-centered model of perioperative care that focuses on patient outcomes and comprehensive care management. Many studies to date have looked at the clinical implementation of varied PSH models with promising results discussed. There are no studies directly examining concrete plans for the various Accreditation Council for Graduate Medical Education (ACGME) anesthesiology residency programs to implement augmented PSH training into curricula. The aim of this survey study was to better assess current residency training in PSH. Methods: An 18-question survey developed by a team of research personnel familiar with the PSH was sent to all ACGME accredited anesthesiology training programs in the United States. Responses were quantified, and construct and external validity of the survey tool examined. Results: 41% of the programs responded. 89% (95% CI 78-96%) of programs reported moderate or better understanding of the PSH. 34% (21-47%) had incorporated additional PSH training in the previous three years, and 32% (with no significant correlation to the previous group) had plans to integrate more training in the next 3 years. Conclusions: Overall, the surveyed program directors voiced understanding of the value of the PSH model in patient care but remained hesitant to incorporate training specific to PSH into the anesthesiology residency curricula.

Transforming Perioperative Care: The Case for a Novel Curriculum for Anesthesiology Resident Training.

Currently, perioperative health care is undergoing transformative changes. One prospect for the specialty of anesthesiology is a reorientation of resident education to focus more on the entire spectrum of perioperative care as exemplified by the perioperative surgical home (PSH). To advance this novel paradigm for patients and anesthesiologists, one must also consider further incorporating the competencies fundamental to the PSH during residency training. As such, the purpose of this case report is to outline the successful implementation of a comprehensive PSH curriculum for anesthesiology residents.

A case management report: a collaborative perioperative surgical home paradigm and the reduction of total joint arthroplasty readmissions.

BACKGROUND: Efforts to mitigate costs while improving surgical care quality have received much scrutiny. This includes the challenging issue of readmission subsequent to hospital discharge. Initiatives attempting to preclude readmission after surgery require planned and unified efforts extending throughout the perioperative continuum. Patient optimization prior to discharge, enhanced disease monitoring, and seamless coordination of care between hospitals and community providers is integral to this process. The perioperative surgical home (PSH) has been proposed as a model to improve the delivery of perioperative healthcare via patient-centered risk stratification strategies that emphasize value and evidence-based processes. RESULTS: This case report seeks to specifically describe implementation of readmission reduction strategies via a PSH paradigm during total joint arthroplasty (TJA) procedures at the University of California Irvine (UCI) Health. An orthopedic surgeon open to collaborate within a PSH paradigm for TJA procedures was recruited to UCI Health in October of 2012. Institution specific data was then prospectively collected for 2 years post implementation of the novel program. A total of 328 unilateral, elective primary TJA (120 hip, 208 knee) procedures were collectively performed. Demographic analysis reveals the following: mean age of 64 ± 12; BMI of 28.5 ± 6.2; ASA Score distribution of 0.3 % class 1, 23 % class 2, 72 % class 3, and 4.3 % class 4; and 62.5 % female patients. In all, a 30-day unplanned readmission rate of 2.1 % (95 % CI 0.4-3.8) was observed during the study period. As a limitation of this case report, this reported rate does not reflect readmissions that may have occurred at facilities outside UCI Health. CONCLUSIONS: As healthcare evolves to emphasize value over volume, it is integral to invest efforts in longitudinal patient outcomes including patient disposition subsequent to hospital discharge. As outlined by this case management report, the PSH provides an institution-led means to implement a series of care initiatives that optimize the important metric of readmission following TJA, potentially adding further value to patients, surgical colleagues, and health systems.

IgM antibody response to antigens prepared from vegetative and coccoid forms of Helicobacter pylori.

This report describes the utility of antigens prepared from different coccoid and spiral forms of Helicobacter pylori in a serological method. The presence of IgM antibody to H. pylori was determined in 22 human sera on antigens prepared from 24 strains of H. pylori. Antigens prepared from spiral form of certain strains of H. pylori detected IgM in all confirmed positive sera. Antigens obtained from the coccoid cells of the same strains could not completely detect IgM in the same sera. Testing sera on boosted antigens of the coccoid cells showed reduction in the number of false negative, indicating that the coccoid cells do not have one or more antigenic fractions essential for accurate detection of antibody. Our data suggest that H. pylori may lose CagA during the coccoid conversion process and regain it in the spiral form. In conclusion, we suggest that the antigen used for the detection of antibodies to H. pylori in serological methods should contain a broad spectrum of antigenic fractions and should be prepared from certain strains and culturable cells of H. pylori.