Enhancing Our Workforce: Recruitment and Retention in Anesthesiology.

Increasingly, both healthcare leaders and studies of healthcare outcomes recommend a medical workforce that is representative of the patient population as a method to reduce health disparities and medical costs. Anesthesiology remains a specialty with lower proportions of women and underrepresented in medicine (URiM) physicians as compared to the overall physician workforce, with 26.1% of anesthesiologists identifying as women and 31.3% of anesthesiologists as URiM. Two areas of focus are commonly identified when discussing inadequate representation in the workforce: recruitment into the specialty and retention in the profession. As medical educators, we provide a critical role in the recruitment and retention of women and URiM anesthesiologists, through implementation of processes, programs, and cultural change. Here, we will discuss the current problems of recruitment and retention of women and URiM anesthesiologists and suggest action plans for now and the future to enhance our specialty's diversity.

Graded chronic pain scale revised: validation in a Veteran sample.

OBJECTIVE: The Graded Chronic Pain Scale (GCPS) is frequently used in pain research and treatment to classify mild, bothersome, and high impact chronic pain. This study's objective was to validate the revised version of the GCPS (GCPS-R) in a US Veterans Affairs (VA) healthcare sample to support its use in this high-risk population. METHODS: Data were collected from Veterans (n = 794) via self-report (GCPS-R and relevant health questionnaires) and electronic health record extraction (demographics and opioid prescriptions). Logistic regression, adjusting for age and gender, was used to test for differences in health indicators by pain grade. Adjusted odds ratio (AOR) with 95% confidence intervals (CIs) were reported with CIs not including an AOR of 1 indicating that the difference exceeded chance. RESULTS: In this population, the prevalence of chronic pain (pain present most or every day, prior 3 months) was 49.3%: 7.1% with mild chronic pain (mild pain intensity and lower interference with activities); 23.3% bothersome chronic pain (moderate to severe pain intensity with lower interference); and 21.1% high impact chronic pain (higher interference). Results of this study mirrored findings in the non-VA validation study; differences between bothersome and high impact were consistent for activity limitations and present but not fully consistent for psychological variables. Those with bothersome chronic pain or high impact chronic pain were more likely to receive long-term opioid therapy compared to those with no/mild chronic pain. CONCLUSIONS: Findings highlight categorical differences captured with the GCPS-R, and convergent validity supports use of the GCPS-R in US Veterans.

Misconceptions about women in leadership in academic medicine.

Despite progress made over the past decade, women are under-represented in positions of leadership in academic medicine. Women physicians face numerous challenges throughout their careers. Despite achieving leadership positions, women in leadership continue to experience the impact of those challenges. In this review, we describe four misconceptions about women in leadership, along with their impact and recommendations. First, we describe differences between mentorship and sponsorship, as well as their impact on attaining leadership positions. Second, the gender pay gap persists throughout women's careers, regardless of leadership positions. Third, we explore the role of self-efficacy in leadership in the context of stereotype threats. Fourth, gendered expectations of leadership characteristics place an undue burden on women, detracting from their leadership effectiveness. Organizations can address the challenges women face by creating robust mentorship and sponsorship networks, establishing transparent and equitable pay policies, promoting and normalizing a broader range of leadership styles, and improving work flexibility and support structure. Ultimately, such changes serve all members of the organization through increased retention and engagement.

RéSUMé: Malgré les progrès réalisés au cours de la dernière décennie, les femmes demeurent sous-représentées dans les postes de direction en médecine universitaire. Les femmes médecins font face à de nombreux défis tout au long de leur carrière. Malgré leur accession à des postes de direction, les femmes occupant ces postes continuent de subir l'impact de ces défis. Dans ce compte-rendu, nous décrivons quatre idées fausses sur les femmes en position de leadership, ainsi que leur impact et quelques recommandations. Tout d'abord, nous décrivons les différences entre le mentorat et le parrainage, ainsi que leur impact sur l'accession à des postes de leadership. Deuxièmement, l'écart de rémunération entre les sexes persiste tout au long de la carrière des femmes, quels que soient les postes de leadership. Troisièmement, nous explorons le rôle de l'auto-efficacité dans le leadership dans le contexte des menaces stéréotypées. Quatrièmement, les attentes genrées à l'égard des caractéristiques recherchées dans le leadership imposent un fardeau indu aux femmes, ce qui nuit à l'efficacité de leur leadership. Les organisations peuvent relever les défis auxquels les femmes sont confrontées en créant de solides réseaux de mentorat et de parrainage, en établissant des politiques salariales transparentes et équitables, en promouvant et en normalisant un éventail plus varié de styles de leadership et en améliorant la flexibilité du travail et les structures de soutien. En fin de compte, de tels changements servent tous les membres de l'organisation grâce à une rétention et une implication accrues.

Use of Capsaicin Cream in Cannabinoid Hyperemesis Syndrome in Patients Presenting to the Emergency Department.

BACKGROUND: Cannabinoid hyperemesis syndrome (CHS) is characterized by cyclical nausea, vomiting, and abdominal pain often relieved with hot showers. Patients with CHS are usually long-term cannabis smokers whose symptoms are not relieved by antiemetics. The use of topical capsaicin has been recently reported as an adjunctive therapy in the emergency department (ED). OBJECTIVE: To describe the use of capsaicin cream in patients presenting to the ED with suspected CHS. METHODS: We performed a retrospective review of patients with suspected CHS receiving capsaicin in an ED from July 2014 to October 2018. We report data on demographics, cannabis consumption, hot showers use, length of stay, concurrent treatments, pain scores, and adverse events. RESULTS: There were 57 patients who received capsaicin cream for suspected CHS. Nearly all patients received antiemetics (98%), whereas 47% of patients received an opioid. Antiemetics were typically administered first (median, 1.6 hours; interquartile range [IQR], 0.9-2.4]), followed by an opioid (median, 1.8 hours [IQR, 1-3.75]), followed by capsaicin cream (median 4 hours [IQR, 2.7-5.2]). The overall precapsaicin pain score was 8 (IQR, 2-9), decreasing to 5.5 (IQR, 0-8). Around 42% of patients received no further symptomatic therapy after capsaicin. No adverse drug events to capsaicin were reported. CONCLUSION AND RELEVANCE: This is the largest retrospective study describing capsaicin cream use in suspected CHS patients with a focus on abdominal pain relief. Capsaicin treatment was associated with a modest pain score reduction. Application of these findings may help providers in identifying more effective therapies to provide symptomatic relief for CHS patients.

Intrathecal 2-Chloroprocaine 3% Versus Hyperbaric Bupivacaine 0.75% for Cervical Cerclage: A Double-Blind Randomized Controlled Trial.

BACKGROUND: Cervical cerclage is a short ambulatory procedure. For spinal anesthesia, local anesthetic agents with rapid postoperative resolution are desired. We hypothesized that in combination with fentanyl, intrathecal 2-chloroprocaine would produce earlier resolution of motor block, resulting in shorter time to meet recovery room discharge criteria than hyperbaric bupivacaine. METHODS: Women undergoing cervical cerclage with spinal anesthesia were randomized to receive intrathecal 2-chloroprocaine 3% 50 mg or hyperbaric bupivacaine 0.75% 9 mg, both with fentanyl 15 µg. Doses were empirically selected. The onset and resolution of sensory and motor blockade and time to achieve recovery room discharge criteria were monitored. On postoperative day 1, patients rated their satisfaction with the anesthetic and reported on transient neurologic symptoms (TNS), back pain, or headache. The primary outcome was time from spinal injection to motor block resolution. The main secondary outcomes included times from spinal injection to (i) T12 dermatomal level, (ii) sensory block resolution, and (iii) ability to ambulate and void. RESULTS: Forty-three women were enrolled and randomized to either the chloroprocaine (N = 23) or bupivacaine group (N = 20). The mean (standard deviation [SD]) duration of surgery was 35.3 (11.4) minutes. There was no difference between groups for time to motor block resolution-the median [interquartile range] time for the bupivacaine group (N = 17) was 112 [97-143] minutes versus 109 [88-148] minutes in the chloroprocaine group (N = 22), P = .66, but there was a significant difference in median time to sensory block resolution: 143 [116-162] minutes in the chloroprocaine group versus 198 [152-263] minutes in the bupivacaine group, P = .002. The recovery room discharge criteria, which at our institution include the ability to ambulate unassisted and void urine, were met 76 (95% CI, 33-145) minutes earlier in the chloroprocaine group, P < .0005. One complete block failure occurred with hyperbaric bupivacaine and 2 subjects in each group received treatment for intraoperative discomfort. No patients reported TNS. CONCLUSIONS: Intrathecal 2-chloropocaine 3% provided similarly effective surgical anesthesia for cerclage placement. Although no difference in time to motor block resolution between groups was observed, the time to sensory block resolution and time to meet recovery room discharge criteria were both significantly shorter among patients who received chloroprocaine than patients who received bupivacaine. Future studies are needed to identify and compare equipotent doses of chloroprocaine and bupivacaine to confirm the superiority of chloroprocaine for this ambulatory obstetric procedure.

Missed abortion with negative biomarkers.

BACKGROUND: First-trimester bleeding and pregnancy loss are common reasons for presentation to emergency departments. Women of childbearing age frequently receive urine and serum pregnancy tests, which are thought to be reliable markers of pregnancy. CASE PRESENTATION: We report a case of a 34-year-old woman who presented to an emergency department with vaginal bleeding and abdominal pain and was found to have negative urine and serum markers of pregnancy. A transvaginal ultrasound detected non-viable fetal tissue and the patient underwent an uncomplicated spontaneous abortion. CONCLUSIONS: Physicians should consider the use of ultrasonography to assess for pregnancy or retained fetal products in the appropriate patient, even with negative serum or urine markers of pregnancy.

Causes of health inequities.

PURPOSE OF REVIEW: A renewed focus on U.S. racial and ethnic maternal health disparities has arisen following high-profile incidents of police violence and antiracism protests which coincided with the coronavirus disease 2019 pandemic, which has exerted a disproportionate effect on minority communities. Understanding the causes of disparities is pivotal for developing solutions. RECENT FINDINGS: Social determinants of health must be addressed during clinical care; however, race must be used with caution in clinical decision-making. Medicaid expansion has been associated with a decrease in severe maternal morbidity and mortality, especially for racial and ethnic minority women. Indirect obstetric causes are the leading cause of maternal death. SUMMARY: Policy-level changes and investment in marginalized communities are required to improve access to quality maternity care at all stages, including preconception, interconception, prenatal, intrapartum and postpartum for 12 months after delivery. Improvements in hospital quality and implementation of evidence-based bundles of care are crucial. Clinicians should receive training regarding susceptibility to implicit bias. To support the research agenda, better collection of race and ethnicity data and anesthesia care indicators is a priority (see Video, Supplemental Digital Content 1 {Video abstract that provides an overview of the causes racial and ethnic disparities in maternal health outcomes.} http://links.lww.com/COAN/A85).

Prevalence of and characteristics associated with in-hospital mortality in a Ugandan neurology ward.

BACKGROUND: While the burden of neurologic illness in developing countries is increasing, less is known about mortality among patients admitted to sub-Saharan African hospitals with neurologic disease. We sought to characterize the rate and patient-level predictors of in-hospital mortality in a Ugandan Neurology ward.cc. METHODS: Data was prospectively collected on 335 patients admitted to the Neurology ward of Mulago Hospital, Kampala, Uganda. Kaplan-Meier survival curves and multivariate COX proportional hazard modeling were used to assess survival. RESULTS: Within our sample (n = 307), 35.8% received no diagnosis at time of hospital admission. Stroke (27.3%), head trauma (19.6%), and malaria (16.0%) were the most common diagnoses. Among the 56 (18.5%) patients who died during the index hospitalization, the most common diagnosis at admission and at death was stroke. Adjusted regression analysis showed that patients without a diagnosis at time of death (HR = 7.01 [2.42-20.35], p < .001) and those with diagnoses of infections (HR = 5.21 [2.16-12.58], p = <.001), stroke (HR = 2.69 [1.20-6.04], p = .017), or head trauma (HR = 3.39, [1.27-9.07], p = 0.15) had worse survival. CONCLUSIONS: In-hospital mortality affected nearly 20% of the cohort, with worse survival among those without a diagnosis and with infections, stroke, head trauma. Future work should identify reasons for increased mortality among these high-risk groups and implement targeted interventions.

Patient Experiences Navigating Chronic Pain Management in an Integrated Health Care System: A Qualitative Investigation of Women and Men.

Background: Rates of pain among veterans are as high as 60%; rates approach 80% in women seeking Department of Veterans Affairs (VA) care. Prior studies examined experiences managing pain in community samples, with gender disparities observed. As the largest national integrated health care system in the country, the VA offers a unique environment to a) study perceptions of pain care among men and women and b) contrast experiences using an integrated health care setting with prior observations in the private sector. Methods: A purposive sample of chronic pain patients was recruited to qualitatively describe perceptions of managing pain in an integrated health care system (VA) and to explore gender differences. A constant comparative approach with sequential analysis was used to reach thematic consensus. Results: Ten focus groups (N = 48; six groups of women [N = 22]; four groups of men [N = 26]) revealed an overarching theme, "just keep plugging," which reflected pain as a constant struggle. Three subthemes emerged: "always a reacquaintance process" described frustration with the use of trainees in the medical center. The need to navigate "so many hoops" referred to frustrations with logistical barriers. "To medicate or not" reflected tensions around medication use. A distinct theme, "the challenges of being female," reflected women's perceptions of stigma and bias. Conclusions: Most of the identified challenges were not unique to the integrated setting. Findings revealed advantages to receiving pain care in this setting. Tensions between patient expectations and guidelines governing provider behavior emerged. Improved patient education, provider communication and sensitivity to the unique needs of women may optimize care.

Predictors of Participation in a Nonpharmacological Intervention for Chronic Back Pain.

Objective: Cognitive behavioral therapy for chronic pain (CBT-CP) has been identified as an evidence-based adjunct or alternative to opioid pain care. However, little is known about which patients participate in CBT-CP. This study examined predictors of enrollment in a noninferiority trial of in-person vs technology-based CBT-CP for patients with chronic back pain. Setting: A single Veterans Health Affairs (VHA) medical center. Subjects: Veterans with chronic back pain. Design and Methods: For eligible participants (N = 290), individual factors (demographics, distance from a VHA medical center, pain intensity, receipt of opioid prescription, and recruitment method) collected at trial screening were examined to identify predictors of enrollment (i.e., signed consent form). Of those who enrolled, duration of participation in the treatment portion of the study was examined. Results: Among eligible patients, 54% declined enrollment due to lack of interest. Regression analyses revealed that patients not in receipt of an opioid were more likely to enroll. The probability of being in the trial long enough to receive a "dose" of treatment (3 visits or more) was 0.76 (0.04). Conclusions: Overall, enrollment rates were low. However, most patients who enrolled in the study (102 of 134 signed consent) were retained and received a treatment dose. Patients not receiving opioids were more likely to enroll, suggesting that patients who are prescribed opioids, an important group for treatment outreach, are likely underengaged. Identifying predictors of enrollment in CBT-CP may help increase recruitment efficiency and assist in targeting patients who may benefit but are not currently interested in treatment.

Project STEP: Implementing the Veterans Health Administration's Stepped Care Model of Pain Management.

Objective: The "stepped care model of pain management" (SCM-PM) prioritizes the role of primary care providers in optimizing pharmacological management and timely and equitable access to patient-centered, evidence-based nonpharmacological approaches, when indicated. Over the past several years, the Veterans Health Administration (VHA) has supported implementation of SCM-PM, but few data exist regarding changes in pain care resulting from implementation. We examined trends in prescribing and referral practices of primary care providers with hypotheses of decreased opioid prescribing, increased nonopioid prescribing, and increased referrals to specialty care for nonpharmacological services. Design: An initiative was designed to foster implementation and systematic evaluation of the SCM-PM over a five-year period at the VA Connecticut Healthcare System (VACHS) while fostering collaborative, partnered initiatives to promote organizational improvements in the delivery of pain care. Subjects: Participants were veterans receiving care at VACHS with at least one pain intensity rating ≥4/10 over the course of the study period (7/2008-6/2013). Methods: We used electronic health record data to examine changes in indicators of pain care including pharmacy and health care utilization data. Results: We observed hypothesized changes in long-term opioid and nonopioid analgesic prescribing and increased utilization of nonpharmacological treatments such as physical therapy, occupational therapy, and clinical health psychology. Conclusions: Through a multifaceted comprehensive implementation approach, primary care providers demonstrated increases in guideline-concordant pain care practices. Findings suggest that engagement of interdisciplinary teams and partnerships to promote organizational improvements is a useful strategy to increase the use of integrated, multimodal pain care for veterans, consistent with VHA's SCM-PM.

Left Lateral Table Tilt for Elective Cesarean Delivery under Spinal Anesthesia Has No Effect on Neonatal Acid-Base Status: A Randomized Controlled Trial.

BACKGROUND: Current recommendations for women undergoing cesarean delivery include 15° left tilt for uterine displacement to prevent aortocaval compression, although this degree of tilt is practically never achieved. We hypothesized that under contemporary clinical practice, including a crystalloid coload and phenylephrine infusion targeted at maintaining baseline systolic blood pressure, there would be no effect of maternal position on neonatal acid base status in women undergoing elective cesarean delivery with spinal anesthesia. METHODS: Healthy women undergoing elective cesarean delivery were randomized (nonblinded) to supine horizontal (supine, n = 50) or 15° left tilt of the surgical table (tilt, n = 50) after spinal anesthesia (hyperbaric bupivacaine 12 mg, fentanyl 15 µg, preservative-free morphine 150 µg). Lactated Ringer's 10 ml/kg and a phenylephrine infusion titrated to 100% baseline systolic blood pressure were initiated with intrathecal injection. The primary outcome was umbilical artery base excess. RESULTS: There were no differences in umbilical artery base excess or pH between groups. The mean umbilical artery base excess (± SD) was -0.5 mM (± 1.6) in the supine group (n = 50) versus -0.6 mM (± 1.5) in the tilt group (n = 47) (P = 0.64). During 15 min after spinal anesthesia, mean phenylephrine requirement was greater (P = 0.002), and mean cardiac output was lower (P = 0.014) in the supine group. CONCLUSIONS: Maternal supine position during elective cesarean delivery with spinal anesthesia in healthy term women does not impair neonatal acid-base status compared to 15° left tilt, when maternal systolic blood pressure is maintained with a coload and phenylephrine infusion. These findings may not be generalized to emergency situations or nonreassuring fetal status.

Aortocaval Compression Syndrome: Time to Revisit Certain Dogmas.

More than 70 years ago, the phenomenon of "postural shock" in the supine position was described in healthy women in late pregnancy. Since then, avoidance of the supine position has become a key component of clinical practice. Indeed, performing pelvic tilt in mothers at term to avoid aortocaval compression is a universally adopted measure, particularly during cesarean delivery. The studies on which this practice is based are largely nonrandomized, utilized a mix of anesthetic techniques, and were conducted decades ago in the setting of avoidance of vasopressors. Recent evidence is beginning to refine our understanding of the physiologic consequences of aortocaval compression in the context of contemporary clinical practice. For example, magnetic resonance imaging of women at term in the supine and tilted positions has challenged the dogma that 15° of left tilt is sufficient to relieve inferior vena cava compression. A clinical investigation of healthy term women undergoing elective cesarean delivery with spinal anesthesia found no difference in neonatal acid-base status between women randomized to be either tilted to the left by 15° or to be in the supine position, if maternal systolic blood pressure is maintained at baseline with a crystalloid coload and prophylactic phenylephrine infusion. This review presents a fresh look at the decades of evidence surrounding this topic and proposes a reevaluation and appraisal of current guidelines regarding entrenched practices.

Estimating prevalence of chronic obstructive pulmonary disease in the Southern Cone of Latin America: how different spirometric criteria may affect disease burden and health policies.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death worldwide. The study aimed to determine and compare the prevalence of COPD in the general population aged 45-74 years old according to fixed ratio and lower limit of normal (LLN) thresholds in four cities in the Southern Cone of Latin America. METHODS: The Pulmonary Risk in South America (PRISA) study used a 4-stage stratified sampling method to select 5814 participants from 4 cities in the Southern Cone of Latin America (Bariloche and Marcos Paz, Argentina; Temuco, Chile; and Pando-Barros Blancos, Uruguay). Data on demographic information, medical history, risk factors, pre-bronchodilator and post-bronchodilator spirometry were obtained using a standard protocol. According to GOLD, COPD was defined as a post-bronchodilator ratio of forced expiratory volume in one second (FEV1) over forced vital capacity (FVC) less than 70%. The LLN threshold was defined as the lower fifth percentile for predicted FEV1/FVC, and was evaluated as an alternative COPD definition. RESULTS: Overall COPD prevalence was 9.3% (95% CI 8.4, 10.2%), and men had a higher prevalence [11.8% (95% CI 10.3, 13.3%)] than women [7.3% (95% CI 6.2, 8.3%)] with the fixed ratio. Overall COPD prevalence using LLN was 4.7% (95% CI 4.1, 5.3%), higher in men: 5.8% (95% CI 4.7, 6.8%) than women: 3.9% (95% CI 3.1, 4.7%). COPD prevalence was significantly higher among those who were older, had

Genome-wide diel growth state transitions in the diatom Thalassiosira pseudonana.

Marine diatoms are important primary producers that thrive in diverse and dynamic environments. They do so, in theory, by sensing changing conditions and adapting their physiology accordingly. Using the model species Thalassiosira pseudonana, we conducted a detailed physiological and transcriptomic survey to measure the recurrent transcriptional changes that characterize typical diatom growth in batch culture. Roughly 40% of the transcriptome varied significantly and recurrently, reflecting large, reproducible cell-state transitions between four principal states: (i) "dawn," following 12 h of darkness; (ii) "dusk," following 12 h of light; (iii) exponential growth and nutrient repletion; and (iv) stationary phase and nutrient depletion. Increases in expression of thousands of genes at the end of the reoccurring dark periods (dawn), including those involved in photosynthesis (e.g., ribulose-1,5-bisphosphate carboxylase oxygenase genes rbcS and rbcL), imply large-scale anticipatory circadian mechanisms at the level of gene regulation. Repeated shifts in the transcript levels of hundreds of genes encoding sensory, signaling, and regulatory functions accompanied the four cell-state transitions, providing a preliminary map of the highly coordinated gene regulatory program under varying conditions. Several putative light sensing and signaling proteins were associated with recurrent diel transitions, suggesting that these genes may be involved in light-sensitive and circadian regulation of cell state. These results begin to explain, in comprehensive detail, how the diatom gene regulatory program operates under varying environmental conditions. Detailed knowledge of this dynamic molecular process will be invaluable for new hypothesis generation and the interpretation of genetic, environmental, and metatranscriptomic data from field studies.