Does Choice of Steroid Matter for Treatment of Chronic Low Back Pain with Sacroiliac Joint Injections: a Retrospective Study.

PURPOSE OF REVIEW: Prevalence of chronic low back pain (cLBP) is increasing. Sacroiliac joint (SIJ) is a common source of cLBP, but data behind its diagnosis and treatment is controversial. There is moderate quality evidence for effectiveness of therapeutic SIJ injections. However, there are no studies comparing the two most common steroid preparations, methylprednisolone (MTP) and triamcinolone (TAC) in SIJ injections. RECENT FINDINGS: After institutional IRB approval, a retrospective chart review was conducted to evaluate the effectiveness of SIJ injections in terms of pain relief at 1-month follow-up and compare MTP versus TAC. All injections were performed by a single pain physician with fluoroscopic guidance. RESULTS: Sixty-five percent of patients in the MTP group and 57% patients in the TAC group had >50% pain relief at 1-month follow-up, with no statistical difference between the two groups. Patients in the TAC group had significantly greater BMI and consisted of higher proportion of smokers (72% patients in TAC group versus 39% patients in the MTP group, p-value 0.004). Other sources of pain such as facet joints were unmasked post-procedurally after SIJ injections, with this unmasking being significant for the TAC group. Opiate use decreased in the MTP group from 35% pre-procedurally to 20% post-procedurally, and this difference did not reach statistical significance. Both MTP and TAC are effective in providing pain relief for SIJ pain at 1-month follow-up, with no statistical difference between the two types of steroids. Although not statistically significant, there is a modest reduction in opiate use in the MTP group.

Graduate medical education in anaesthesiology and COVID-19: lessons learned from a global pandemic.

PURPOSE OF REVIEW: The recent global pandemic has dramatically altered the anaesthesiology educational landscape in unexpected ways. It is important that we pause to learn from this crisis. RECENT FINDINGS: Most resident trainees actively caring for COVID-19 patients present with probable or subclinical finding of post-traumatic stress disorder. Anaesthesia resident training programmes evolved to continue the mission of anaesthesia education in the face of institutional restrictions and evolving clinical crises. SUMMARY: The recent global COVID-19 pandemic has illustrated how external stressors can cause significant disruption to traditional medical education pathways. Resilience to external disruptive forces in anaesthesia education include a willingness of leadership to understand the problem, flexibility in adapting to the needs of learners and instructors in the face of key challenges, deployment of technology and innovation-minded solution-finding where appropriate, and attention to Maslow's hierarchy of needs. VIDEO ABSTRACT: http://links.lww.com/COAN/A77.

The Feasibility of Incorporating a Flipped Classroom Model in an Anesthesia Residency Curriculum-Pilot Study.

Background: Medical education is evolving to incorporate learner-centered strategies which encourage student engagement. Educators need to ensure that meaningful education occurs within limited interaction time between teachers and trainees. The Flipped Classroom (FC) model combines the use of both online and face-to-face interaction. Studies describing the process and resource utilization in anesthesia residency programs are limited. Methods: After Institutional Review Board (IRB) exemption, a qualitative study to assess the feasibility of introducing an FC model in the anesthesia residency didactic curriculum was conducted. The Post Graduate Year 2 (PGY2) anesthesia resident didactic sessions were modified to include one session a month using the FC format with the other three sessions presented using traditional PowerPoint lecture format at a tertiary academic medical center. Post-session surveys were administered to both learners and teachers. Survey data were analyzed using Qualtrics® software. Survey data included perceptions of both learners and teachers regarding quality of learning and engagement in the new format. Results: Nineteen residents and 10 faculty participated in 10 sessions over the span of 10 months. A total of 153 resident responses and 8 faculty responses were submitted voluntarily. In our study, a majority of residents indicated they preferred the FC format. They also indicated they enjoyed working in groups. All the participating faculty felt that student interaction and student learning were higher in these sessions. Conclusions: Residency programs need to adopt evidence-based solutions to problems arising in medical education. We present our experiences in finding a solution to make didactic sessions more engaging. Our initial assessment shows that it is feasible to introduce the FC model into an existing curriculum in an anesthesia residency program and both residents and faculty felt that the format enhanced learning and interaction in class.

Resource Utilization in Implementation of a Point of Care Ultrasound Curriculum for Resident Training in Anesthesiology.

Purpose: Point of care ultrasound (POCUS) brings high-quality patient care to the bedside but continues to be an expensive training to implement in a residency program. There are multiple resources available to train providers in ultrasound, but they are all associated with significant cost. The Accreditation Council for Graduate Medical Education (ACGME) mandates anesthesiology residents to be competent in diagnostic and therapeutic uses of ultrasound. In this paper, we describe how an academic anesthesiology department implemented a POCUS curriculum for resident training. Methods: An anesthesiologist intensivist directed program was created to train residents in POCUS. We started by training a group of seven critical care trained anesthesiologists with the guidance of cardiologists. These anesthesiologists participated in the training of our anesthesiology residents. A hybrid curriculum consisting of a simulator as well as hands-on scanning of patients was created. We recorded the time that personnel spent in the training program as well as the money spent in acquiring equipment. Results: Seven faculty utilized a total of 270 hours of scanning and teaching time to train 48 residents who rotated through the ICU between July 2017 and June 2018. Simulation technicians used 48 hours to guide residents through simulation scenarios. The education administrator used 24 hours to coordinate sessions for residents. The technician and coordinator were both employees of the department with no additional cost for their responsibilities. The cost of equipment, including the ultrasound machine and simulator, was $45,000. An additional charge of $3500 was incurred for technician training time. Conclusion: Implementing a robust, sustainable POCUS curriculum requires a significant investment of time and money. Simulators and e-learning can allow efficiency in resource allocation and control cost in orienting new students to ultrasound. Having residents go through the simulator decreased the time that faculty would otherwise have spent going over basics with the students while allowing students to master these skills at their own pace. Advances in ultrasound technology have created newer, more affordable machines which can decrease cost considerably. It would serve departments well to consider alternatives and plan for resources when deciding to implement POCUS curriculum for resident training.

Role of in-situ simulation for training in healthcare: opportunities and challenges.

PURPOSE OF REVIEW: Simulation has now been acknowledged as an important part of training in healthcare, and most academic hospitals have a dedicated simulation center. In-situ simulation occurs in patient care units with scenarios involving healthcare professionals in their actual working environment. The purpose of this review is to describe the process of putting together the components of in-situ simulation for training programs and to review outcomes studied, and challenges with this approach. RECENT FINDINGS: In-situ simulation has been used to 'test-drive' new centers, train personnel in new procedures in existing centers, for recertification training and to uncover latent threats in clinical care areas. It has also emerged as an attractive alternative to traditional simulations for institutions that do not have their own simulation center. SUMMARY: In-situ simulation can be used to improve reliability and safety especially in areas of high risk, and in high-stress environments. It is also a reasonable and attractive alternative for programs that want to conduct interdisciplinary simulations for their trainees and faculty, and for those who do not have access to a fully functional simulation center. Further research needs to be done in assessing effectiveness of training using this method and the effect of such training on clinical outcomes.

Concern for pain in the pre-operative period- is the internet being used for information by patients?

OBJECTIVES: This study was conducted to provide information regarding prevalence of pain, type of provider managing pain, and use of Internet for information regarding pain, among patients coming for presurgical anesthesia consultation at a major academic institution. METHODS: With IRB approval, patients were invited to participate in a voluntary and anonymous 14 question survey given to them when they presented for anesthesia consultation prior to their surgical procedure. The qualitative/categorical data were summarized by number (percentage [%]) and analyzed by Chi-square test or Fisher's exact test as appropriate. All data analyses were performed using the statistical software SAS, v9.2. RESULTS: A total of 1039 patients were asked to complete the survey and 670 patients returned their responses (response rate = 64.5%). 83% of patients had a history of prior surgery. 57% were concerned about postoperative pain. 30% of patients had chronic pain for more than 3 months pre-operatively. 16% of patients had looked online for information regarding pain. Pain physicians were involved in pain management only in 3.8% of these patients. DISCUSSION: Patients are presenting for surgery with significant pre-operative pain issues. Knowing this information pre-operatively will help healthcare personnel manage postsurgical pain more effectively. Patients are also using the Internet to obtain information regarding pain. As providers, there may be value to directing patients to reliable information online during consultation. As all physicians will eventually be managing chronic pain in their patients, pain education should be given priority in medical school curriculum.

The changing landscape of anesthesia education: is Flipped Classroom the answer?

PURPOSE OF REVIEW: Educators in the specialty of anesthesiology are facing a number of challenges. A new generation of residents are entering the specialty and they have unique learning styles and expectations. The new duty hour regulations also encroach on the time available to the residents for education. In the last decade, a number of models for teaching and learning have been proposed to tackle these issues. RECENT FINDINGS: Recent research has looked at learning gains and acceptability of online material in medical education as well as specific models that can be implemented to address the challenges. SUMMARY: The 'Flipped Classroom' model seems to combine the best of both worlds. It allows the learner to assimilate basic information (lower order cognitive skills) from material that is placed online, allowing asynchronous learning. It frees up the teacher to use the face-to-face interaction time in the operating room and classroom for training the student in advanced concepts (higher order cognitive skills). This model allows efficient and effective use of time and technology, but involves the redesign of how in person time between faculty and residents are spent, along with the faculty development to effectively engage this new type of curriculum.

Threat and error management for anesthesiologists: a predictive risk taxonomy.

PURPOSE OF REVIEW: Patient care in the operating room is a dynamic interaction that requires cooperation among team members and reliance upon sophisticated technology. Most human factors research in medicine has been focused on analyzing errors and implementing system-wide changes to prevent them from recurring. We describe a set of techniques that has been used successfully by the aviation industry to analyze errors and adverse events and explain how these techniques can be applied to patient care. RECENT FINDINGS: Threat and error management (TEM) describes adverse events in terms of risks or challenges that are present in an operational environment (threats) and the actions of specific personnel that potentiate or exacerbate those threats (errors). TEM is a technique widely used in aviation, and can be adapted for the use in a medical setting to predict high-risk situations and prevent errors in the perioperative period. A threat taxonomy is a novel way of classifying and predicting the hazards that can occur in the operating room. TEM can be used to identify error-producing situations, analyze adverse events, and design training scenarios. SUMMARY: TEM offers a multifaceted strategy for identifying hazards, reducing errors, and training physicians. A threat taxonomy may improve analysis of critical events with subsequent development of specific interventions, and may also serve as a framework for training programs in risk mitigation.

Blended learning in anesthesia education: current state and future model.

PURPOSE OF REVIEW: Educators in anesthesia residency programs across the country are facing a number of challenges as they attempt to integrate blended learning techniques in their curriculum. Compared with the rest of higher education, which has made advances to varying degrees in the adoption of online learning anesthesiology education has been sporadic in the active integration of blended learning. The purpose of this review is to discuss the challenges in anesthesiology education and relevance of the Universal Design for Learning framework in addressing them. RECENT FINDINGS: There is a wide chasm between student demand for online education and the availability of trained faculty to teach. The design of the learning interface is important and will significantly affect the learning experience for the student. SUMMARY: This review examines recent literature pertaining to this field, both in the realm of higher education in general and medical education in particular, and proposes the application of a comprehensive learning model that is new to anesthesiology education and relevant to its goals of promoting self-directed learning.

Lessons from the COVID-19 Pandemic: The Case for Virtual Residency Interviews.

This perspective from a variety of stakeholders including aspiring surgeons, a current department chair for education, and a current chair of surgery advocates for making virtual residency interviews a permanent part of the match process. We delineate how a shift to virtual residency interviews can save applicants time and money, enhance equity in the match, and ultimately strengthen a program's ability to assess applicants.

Prolonged elevation of plasma argatroban in a cardiac transplant patient with a suspected history of heparin-induced thrombocytopenia with thrombosis.

BACKGROUND: Direct thrombin inhibitors (DTIs) provide an alternative method of anticoagulation for patients with a history of heparin-induced thrombocytopenia (HIT) or HIT with thrombosis (HITT) undergoing cardiopulmonary bypass (CPB). In the following report, a 65-year-old critically ill patient with a suspected history of HITT was administered argatroban for anticoagulation on bypass during heart transplantation. The patient required massive transfusion support (55 units of red blood cells, 42 units of fresh-frozen plasma, 40 units of cryoprecipitate, 40 units of platelets, and three doses of recombinant Factor VIIa) for severe intraoperative and postoperative bleeding. STUDY DESIGN AND METHODS: Plasma samples from before and after CPB were analyzed postoperatively for argatroban concentration using a modified ecarin clotting time (ECT) assay. RESULTS: Unexpectedly high concentrations of argatroban were measured in these samples (range, 0-32 microg/mL), and a prolonged plasma argatroban half life (t(1/2)) of 514 minutes was observed (published elimination t(1/2) is 39-51 minutes [< or = 181 minutes with hepatic impairment]). CONCLUSIONS: Correlation of plasma argatroban concentration versus the patient's coagulation variables and clinical course suggest that prolonged elevated levels of plasma argatroban may have contributed to the patient's extended coagulopathy. Because DTIs do not have reversal agents, surgical teams and transfusion services should remain aware of the possibility of massive transfusion events during anticoagulation with these agents. This is the first report to measure plasma argatroban concentration in the context of CPB and extended coagulopathy.

Anesthesia 2.0: internet-based information resources and Web 2.0 applications in anesthesia education.

PURPOSE OF REVIEW: Informatics is a broad field encompassing artificial intelligence, cognitive science, computer science, information science, and social science. The goal of this review is to illustrate how Web 2.0 information technologies could be used to improve anesthesia education. RECENT FINDINGS: Educators in all specialties of medicine are increasingly studying Web 2.0 technologies to maximize postgraduate medical education of housestaff. These technologies include microblogging, blogs, really simple syndication (RSS) feeds, podcasts, wikis, and social bookmarking and networking. 'Anesthesia 2.0' reflects our expectation that these technologies will foster innovation and interactivity in anesthesia-related web resources which embraces the principles of openness, sharing, and interconnectedness that represent the Web 2.0 movement. Although several recent studies have shown benefits of implementing these systems into medical education, much more investigation is needed. SUMMARY: Although direct practice and observation in the operating room are essential, Web 2.0 technologies hold great promise to innovate anesthesia education and clinical practice such that the resident learner need not be in a classroom for a didactic talk, or even in the operating room to see how an arterial line is properly placed. Thoughtful research to maximize implementation of these technologies should be a priority for development by academic anesthesiology departments. Web 2.0 and advanced informatics resources will be part of physician lifelong learning and clinical practice.