Sustainability of the Subspecialty of Anesthesiology Critical Care: An Expert Consensus and Review of the Literature.

While considerable literature exists with respect to clinical aspects of critical care anesthesiology (CCA) practice, few publications have focused on how anesthesiology-based critical care practices are organized and the challenges associated with the administration and management of anesthesiology critical care units. Currently, numerous challenges are affecting the sustainability of CCA practice, including decreased applications to fellowship positions and decreased reimbursement for critical care work. This review describes what is known about the subspecialty of CCA and leverages the experience of administrative leaders in adult critical care anesthesiologists in the United States to describe potential solutions.

Discrimination during childbirth and postpartum care utilization among Black birthing people in California, United States.

BACKGROUND: The purpose of this study was to investigate the relationship between discrimination during childbirth hospitalization and postpartum care utilization among Black birthing people in California, United States. METHODS: This was a secondary analysis of data from the Listening to Mothers in California survey, a population-based survey of individuals with a singleton hospital-based birth in California in 2016. The primary outcome was number of postpartum care visits. The primary exposures were racial, language, and insurance discrimination. A multiple linear regression model was used to estimate associations between discrimination and postpartum care use, adjusting for sociodemographic covariates. RESULTS: Black birthing people in the sample had an average of two postpartum visits. Almost 15% of the sample reported one or more forms of discrimination during hospital-based childbirth. In adjusted models, racial discrimination (ß = 0.09, 95% CI = 0.04-0.14, p < 0.01) and language discrimination (ß = 1.03, 95% CI = 0.98-1.07, p < 0.01) were associated with increased postpartum visits, while insurance discrimination was linked to decreased postpartum visits (ß = -0.96, 95% CI = -1.04 to -0.89, p < 0.01). CONCLUSION: Among Black birthing people in California, the drivers of postpartum care utilization after childbirth are complex. There are multiple negative drivers (e.g., experiencing racial and language discrimination and unmet needs), barriers (e.g., insurance discrimination), and positive drivers (e.g., clinician type and education) that affect postpartum care utilization among Black birthing people.

Perfusion-Dependent Focal Neurologic Deficits in a Critically Ill Heart Transplant Recipient: A Case of Tacrolimus-Associated Reversible Cerebral Vasospasm Syndrome?

TACROLIMUS, a mainstay of immunosuppression after orthotopic heart transplantation (OHT), is associated with a broad range of side effects. Vasoconstriction caused by tacrolimus has been proposed as a mechanism underlying common side effects such as hypertension and renal injury. Neurologic side effects attributed to tacrolimus include headaches, posterior reversible encephalopathy syndrome (PRES), or reversible cerebral vasospasm syndrome (RCVS). Six case reports have been published describing RCVS in the setting of tacrolimus administration after OHT. The authors report a case of perfusion-dependent focal neurologic deficits attributed to tacrolimus-induced RCVS in an OHT recipient.

Teasing and alcohol drinking among African American adolescents in Chicago's Southside: Implications for nursing practice.

OBJECTIVE: Guided by the routine activity theory, the current study proposes and tests pathways by which an absence of a capable guardian can contribute to interactions with motivated offenders and suitable targets, increasing the likelihood of teasing others and using alcohol. SAMPLE: The study participants consisted of 612 African American adolescents in four low-income neighborhoods in Chicago's Southside. MEASURES: Measures include alcohol use, absence of a capable guardian, the presence of a motivated offender, target suitability, and teasing. Covariates include age, biological sex, and government assistance. Analyses included descriptive statistics, correlation analysis, and structural equation modeling. RESULTS: The absence of a capable guardian variable positively correlated with the presence of a motivated offender. The presence of a motivated offender variable was positively associated with target suitability, which was positively related to teasing and alcohol use. The presence of a motivated offender and target suitability variables were positively associated with teasing and alcohol use. CONCLUSION: Findings highlight the importance of capable guardians and potentially have implications for nursing practice.

Perceptions of Gender Disparities Among Women in Cardiothoracic Anesthesiology.

OBJECTIVE: In this study of women in cardiothoracic anesthesiology, the authors aimed to characterize demographics, roles in leadership, and perceived professional challenges. DESIGN: A prospective cross-sectional survey of female cardiothoracic anesthesiologists in the United States. SETTING: An internet-based survey of 43 questions was sent to women in cardiothoracic anesthesiology. The survey included questions on demographics, leadership, and perceptions of professional challenges including career advancement, compensation, promotion, harassment, and intimidation. PARTICIPANTS: A database of women in cardiothoracic anesthesiology was created via personal contacts and snowball sampling. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 153 responses were analyzed, for a response rate of 65.1%. Most respondents were at the Clinical Instructor or Assistant Professor rank. Many women perceived that compensation, promotion, authorship, and career advancement were affected by gender. Furthermore, 67% of respondents identified having children as having a negative impact on career advancement. Many women reported experiencing derogatory comments (55.6%), intimidation (57.8%), microaggression (69.6%), sexual harassment (25.2%), verbal harassment (45.2%), and unwanted physical or sexual advances (24.4%). These behaviors were most often from a surgical attending, anesthesia attending, or patient. CONCLUSION: This survey study of women in cardiothoracic anesthesiology found that many women perceived inequities in financial compensation, authorship opportunities, and promotion; in addition, many felt that their career advancement was impacted negatively by having children. A striking finding was that the majority of women have experienced intimidation, derogatory comments, and microaggressions in the workplace.

Does sexting predict sexual behaviors among adolescents? Gender and race effects.

INTRODUCTION: Sexting has emerged as a significant public health issue. Sexting is associated with substance use and other sexual behaviors, such as oral and vaginal sex (Houck et al., 2014; Temple & Choi, 2014). Current studies on sexting are often cross-sectional, limiting the ability to determine the temporal order of sexting and sexual behaviors. Additionally, studies focus on samples of young adults (Benotsch et al., 2013). The current study extends the literature by examining sexting and sexual behaviors longitudinally among adolescents and examines race and gender differences that play a role in sexting. METHODS: The current study utilizes a prospective, 4-year longitudinal study of 1240 adolescents (aged 11-17) living in the Midwestern United States. Overall, the sample was 10% Black males, 11% Black females, 34% White Males, 31% White females, and 15% identified as Other. Analysis includes an autoregressive model with cross-lagged effects in MPlus. RESULTS: Sexting (T1) predicted oral and sexual encounters (T4) for Black males, White males, and White females but not for Black females. Oral sex and sexual encounters (T4) did not predict any sexting (T1) for all groups. Therefore, analysis establishes sexting as an antecedent to sexual behaviors for Black males, White males, and White females. Sexting and sexual behaviors did not have a significant association for Black females. CONCLUSIONS: This study identifies sexting as a precursor to sexual behaviors among adolescents. Therefore, when tailoring programs for safe sex among these populations, focusing on sexting may reduce other sexual risky behaviors.

Attitudes about aggression and perpetration of Adolescent Dating Aggression: A cross-lagged panel model.

INTRODUCTION: Several cross-sectional and longitudinal studies have found associations between attitudes about aggression and aggressive behaviors. However, few studies examine all subtypes of Adolescent Dating Aggression (ADA)-physical, psychological/emotional, sexual, and stalking; occurring in person or electronically-and there is a paucity of longitudinal studies that follow adolescents over several years. METHODS: Middle school and high school students (N = 1240), in the Midwestern United States, participated in surveys one time per year for four years. Data from each year (Y1, Y2, Y3, & Y4) was used to conduct a cross-lagged panel analysis of attitudes about aggression and aggressive behaviors, among both cohorts. RESULTS: By Y4, approximately 46% of the middle school cohort and 60% of the high school cohort perpetrated some form of ADA. The cross-lagged panel analysis revealed significant cross-sectional associations in the middle school (Y1, Y2, & Y4) and high school (Y1 & Y2) cohorts. Aggressive behaviors were significantly associated with future aggressive behaviors for the middle and high school cohorts each year. Similarly, attitudes about aggression were significantly associated with attitudes in the following years for both cohorts. Among the middle school cohort, there were significant cross-lagged effects between aggressive behaviors in Y2 and attitudes about aggression in Y3, as well as aggressive behaviors in Y3 and attitudes about aggression in Y4. Among the high school cohort, a bidirectional association was found from Y2 to Y3. CONCLUSIONS: These findings suggest prevention programs should be implemented earlier, among middle school aged adolescents, and target factors beyond attitudes supporting aggression.

Stress, Coping, Resilience and Trust during the Flint Water Crisis.

In 2014, government officials in the City of Flint, Michigan switched the municipal water source from the Detroit Water System (water source: Lake Huron) to the Flint River. During this time, an estimated 102,000 Flint residents were potentially exposed to multiple chemical (e.g., lead) and biological threats (e.g., Legionella). After the switch to water sourced from the Flint River, Flint residents consistently reported concerns over water quality while also experiencing rashes, hair loss, and other health problems, including anxiety and depression. This study 1) reports on the Flint Water Crisis and its subsequent impact on residents' stress, coping, resilience and trust and 2) describes a process methodology that trained, hired and deployed Flint residents as members of a multidisciplinary research team. A random sample of 320 Flint residents underwent household-based interviews to assess their health and mental health needs. Concomitantly, household water samples were obtained and residents were connected to known resources based on interview responses relative to need. This study found that declines in health and mental health status were correlated with increased stressors (i.e., fatigue, financial concern, anxiety), coping and less resilience or the capacity to recover. Perceived trust in government officials was significantly lower after the water crisis. While the water crisis generated numerous stressors, the event also galvanized community competence to engage in solution-focused coping and other adaptive capacities. By assessing and building upon Flint residents' resilience, community resource specialists, identified and subsequently strengthened city residents' ability to survive devastating challenges.

The influence of racial discrimination on smoking among young black men: A prospective analysis.

Racial discrimination is a documented risk factor for smoking among Black men; mechanisms of effect and protective processes remain to be investigated. This study examined the mediating effect of anger/hostility on the association between racial discrimination and smoking and the influence of protective social ties in buffering the effects of racial discrimination. Hypotheses were tested using longitudinal data from a study of 505 Black men ages 19-22. Data collected for the study occurred at three timepoints, each 12 months apart. Racial discrimination is associated with increases in cigarette smoking between baseline and follow-up. Anger/hostility partially mediated this association. Moderational analyses indicated that discrimination had little or no impact on men's smoking in the presence of protective social ties. Study findings suggest that supportive networks make crucial contributions to the reduction of cigarette smoking and feelings of anger within this population. Intervention developers should consider targeting relationship dynamics with supportive networks to understand coping mechanisms and to reduce substance use among young black men.

Racial Discrimination, Protective Processes, and Sexual Risk Behaviors Among Black Young Males.

Racial discrimination is a documented risk factor for sexual risk behaviors among young Black men. Mechanisms of effect and protective processes remain to be investigated. This study examined the mediating effect of emotional distress, self-regulation, and substance use on the association between racial discrimination and sexual risk behaviors. Sexual risk behaviors included in this study were inconsistent condom use and sexual concurrency (sexual partnerships that overlap overtime). The protective effect of protective social ties was also investigated. A sample of 505 heterosexually active men aged 19-22 years were recruited and surveyed for 3 time points. Men answered questions on racial discrimination, sexual risk behaviors, emotional distress, self-regulation, and substance use. Mediation and moderation models were tested. Racial discrimination (T1) significantly and positively predicted emotional distress (T2). Emotional distress, substance use, and self-regulation partially mediated the association between racial discrimination and sexual risk behaviors. Protective social ties attenuated the effects of emotional distress on substance use and self-regulation. Racial discrimination is an important context for sexual risk behaviors. Minority stress may translate to sexual risk behavior through psychosocial mediators, such as emotional distress, self-regulation, and substance use. Protective social ties may buffer against emotional distress to reduce substance use and increase self-regulation. The findings of this study can provide new insights through the investigation of risk and protective processes that influence sexual risk behaviors among young Black men.

Deficiency of the Angiotensinase Aminopeptidase A Increases Susceptibility to Glomerular Injury.

Aminopeptidase A (APA) is expressed in glomerular podocytes and tubular epithelia and metabolizes angiotensin II (AngII), a peptide known to promote glomerulosclerosis. In this study, we tested whether APA expression changes in response to progressive nephron loss or whether APA exerts a protective role against glomerular damage and during AngII-mediated hypertensive kidney injury. At advanced stages of FSGS, fawn-hooded hypertensive rat kidneys exhibited distinctly increased APA staining in areas of intact glomerular capillary loops. Moreover, BALB/c APA-knockout (KO) mice injected with a nephrotoxic serum showed persistent glomerular hyalinosis and albuminuria 96 hours after injection, whereas wild-type controls achieved virtually full recovery. We then tested the effect of 4-week infusion of AngII (400 ng/kg per minute) in APA-KO and wild-type mice. Although we observed no significant difference in achieved systolic BP, AngII-treated APA-KO mice developed a significant rise in albuminuria not observed in AngII-treated wild-type mice along with increased segmental and global sclerosis and/or collapse of juxtamedullary glomeruli, microcystic tubular dilation, and tubulointerstitial fibrosis. In parallel, AngII treatment significantly increased the kidney AngII content and attenuated the expression of podocyte nephrin in APA-KO mice but not in wild-type controls. These data show that deficiency of APA increases susceptibility to glomerular injury in BALB/c mice. The augmented AngII-mediated kidney injury observed in association with increased intrarenal AngII accumulation in the absence of APA suggests a protective metabolizing role of APA in AngII-mediated glomerular diseases.

Pathways to HIV-Related Behavior Among Heterosexual, Rural Black Men: A Person-Centered Analysis.

We investigated the psychosocial mechanisms linking personal and contextual risk factors to HIV-related behavior among 498 rural Black men. We characterized HIV-related behavior in terms of profile groups and hypothesized that contextual and personal risk factors (childhood adversity, community disadvantage, incarceration, and racial discrimination) would predict HIV-related behavior indirectly via two psychosocial mechanisms: impulsivity and negative relational schemas. Study results documented three HIV-related behavior profile groups. The Safer group reported low levels of risky behavior. The Risk-Taking group reported inconsistent condom use and elevated substance use. The Multiple Partners group reported the highest numbers of partners and relatively consistent condom use. Risk factors predicted profile groups directly and indirectly through psychosocial mechanisms. Impulsivity mediated the association between community disadvantage and membership in the risk-taking group. Negative relational schemas mediated the associations of childhood experiences and community disadvantage with membership in the multiple partners group. Specificity in pathways suggests the need for targeted interventions based on multidimensional characterizations of risk behavior.

AFRICAN AMERICAN STEPFATHER-STEPCHILD RELATIONSHIPS, MARITAL QUALITY, AND MENTAL HEALTH.

This study examined associations between stepfather-stepchild relationship quality, stepfathers' depressive symptoms, and two aspects of marriage: marital quality and positive marital interactions. Marital quality was assessed in terms of commitment, trust, passionate and friendship-based love, and happiness. Marital interactions were assessed in terms of intimacy, shared activities, and verbal communication. Using data collected from 149 recently married African American stepfathers, structural equation modeling revealed that when stepfathers reported more positive relationships with their stepchildren, they also reported more positive marital quality and a higher frequency of positive marital interactions (relationship solidifying activities), and that, in turn, was associated with stepfathers experiencing fewer depressive symptoms.

A road less traveled in critical care: A call for improved acceptance and implementation of palliative and supportive care.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Suture Anchor Repair for Distal Patellar Tendon Avulsion in Tibial Tubercle Fractures: A Technical Description and Report of Two Cases.

Tibial tubercle avulsion fractures, though rare, pose a significant challenge in pediatric orthopedics, particularly in athletic adolescents. For nondisplaced fractures, conservative treatment involves the use of braces or casts, while displaced fractures necessitate operative intervention, often through screw fixation. Concomitant soft tissue injuries should also be identified and addressed operatively to ensure complete repair of the extensor mechanism. This paper introduces a method for open reduction and internal fixation (ORIF) of tibial tubercle fractures with suture anchor repair of the distal patellar tendon avulsion. Two case examples of 14-year-old males with displaced fractures undergoing this procedure are presented. After standard screw fixation of the displaced fragment was performed, a single suture anchor was placed into the tibia and an onlay tension slide technique was utilized to secure the distal patellar tendon avulsion. Both patients underwent immobilization and protected weightbearing for four weeks with physical therapy initiated at six weeks. At four months postoperatively, both patients had returned to competitive sports without issue. The described technique may represent a reliable and reproducible method for addressing the distal patellar tendon avulsion component of tibial tubercle fractures. Its biomechanical advantages contribute to the complete repair of the extensor mechanism, enabling a successful return to competitive athletics without hardware complications.

An exploratory two-part study of behavioral health service needs of women in jails.

Research shows that jailed women have disproportionately elevated rates of behavioral health conditions, including serious mental illness and substance use disorders; however, jails have not been able to effectively address these needs. There is a research gap in our understanding of mental health screening tools, linkages to care, and behavioral health service utilization for jailed women, specifically across multiple jails situated in urban and rural contexts. This two-part study compares the behavioral health needs and service utilization of women and men in eight Michigan jails. Results show significant differences in women's and men's behavioral health needs, including proportions of severe mental illness, alcohol and drug misuse, opioid preference, concerns for withdrawal, and length of jail stays. Mental health outcomes show significant gendered differences in advocacy for early release and jail- and post-jail treatment engagement. These findings highlight the need for jails to better assess behavioral health needs among women and may inform interventions aimed at improving women's (and men's) experiences while jailed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Blood Pressure Goals in Critically Ill Patients.

Blood pressure goals in the intensive care unit (ICU) have been extensively investigated in large datasets and have been associated with various harm thresholds at or greater than a mean pressure of 65 mm Hg. While it is difficult to perform interventional randomized trials of blood pressure in the ICU, important evidence does not support defense of a higher pressure, except in retrospective database analyses. Perfusion pressure may be a more important target than mean pressure, even more so in the vulnerable patient population. In the cardiac ICU, blood pressure targets are tailored to specific cardiac pathophysiology and patient characteristics. Generally, the goal is to maintain adequate blood pressure within a certain range to support cardiac function and to ensure end organ perfusion. Individualized targets demand the use of both invasive and noninvasive monitoring modalities and frequent titration of medications and/or mechanical circulatory support where necessary. In this review, we aim to identify appropriate blood pressure targets in the ICU, recognizing special patient populations and outlining the risk factors and predictors of end organ failure.

Management of Intraoperative Cardiac Arrest.

Perioperative arrests are both uncommon and heterogeneous and have not been described or studied to the same extent as cardiac arrest in the community. These crises are usually witnessed, frequently anticipated, and involve a rescuer physician with knowledge of the patient's comorbidities and coexisting anesthetic or surgically related pathophysiology ultimately leading to better outcomes. This article reviews the most probable causes of intraoperative arrest and their management.

Increases in doublecortin immunoreactivity in the dentate gyrus following extinction of heroin-seeking behavior.

Adult-generated neurons in the dentate gyrus (DG) of the hippocampus play a role in various forms of learning and memory. However, adult born neurons in the DG, while still at an immature stage, exhibit unique electrophysiological properties and are also functionally implicated in learning and memory processes. We investigated the effects of extinction of drug-seeking behavior on the formation of immature neurons in the DG as assessed by quantification of doublecortin (DCX) immunoreactivity. Rats were allowed to self-administer heroin (0.03 mg/kg/infusion) for 12 days and then subjected either to 10 days of extinction training or forced abstinence. We also examined extinction responding patterns following heroin self-administration in glial fibrillary acidic protein thymidine kinase (GFAP-tk) transgenic mice, which have been previously demonstrated to show reduced formation of immature and mature neurons in the DG following treatment with ganciclovir (GCV). We found that extinction training increased DCX immunoreactivity in the dorsal DG as compared with animals undergoing forced abstinence, and that GCV-treated GFAP-tk mice displayed impaired extinction learning as compared to saline-treated mice. Our results suggest that extinction of drug-seeking behavior increases the formation of immature neurons in the DG and that these neurons may play a functional role in extinction learning.

The Effects of Adverse Childhood Experiences on Internalizing and Externalizing Behaviors among Black Children and Youth.

There is limited research on the short-term effects of ACEs on Black children and youth. Black children and youth are disproportionately exposed to abuse, neglect, and other victimizations (Drake et al. 2009; Wade et al. Journal of Family Issues, 17(3), 283-316, 2014). Investigating ACEs will provide a broader understanding of childhood trauma on developmental processes. The current study investigates how ACES impacts psychological distress, substance use, and delinquency among Black children and youth. Hypotheses were tested using a subsample of longitudinal data from 265 participants who were recruited from six school districts in Southeast Michigan. ACEs at T1 significantly predicted depressive symptoms at T2 (ß = .19, p < .05), which in turn predicted substance use (ß = .20, p < .05), and delinquency (ß = .19, p < .05). Psychological distress also mediated the associations between ACEs and substance use, and delinquency. To engage youth in prevention/interventions and practice, it is important to understand the contexts in which they develop i.e. having knowledge on the specific type of victimization instances that Black youth may experience more than their peers as well as the social factors. Therefore, taking a trauma-informed approach that will acknowledge the adverse childhood experiences that youth went through and to understand how these experiences shape their development through adolescence may be efficacious.