Predictors of combat training attrition in Israel Defense Forces soldiers.

BACKGROUND: Attrition from combat service carries significant organizational and personal ramifications, but predicting factors associated with attrition remains challenging. AIMS: To evaluate medical and psychosocial factors associated with attrition from basic combat training (BCT) in the Israel Defense Forces (IDF). In addition, we identify subsets of the recruit population which exhibit certain trends in terms of medical corresponding with a high risk of attrition. METHODS: A cross-sectional study of IDF combat trainees undergoing infantry BCT between 2012 and 2017. Data were collected from the soldiers' electronic medical and administrative records. We used multivariable logistic regression and the SAS® decision-tree tool to analyse key predictive factors for attrition. RESULTS: A total of 46 472 soldiers enlisted to BCT during the research period. The mean body mass index (BMI) was 21.8 (SD 3.54). The overall attrition rate was 10%. The following factors were associated with attrition from BCT: ethnicity (P < 0.01), BMI (P < 0.01), pre-enlisting motivation score (P < 0.01) and the number of mental health officer visits (P < 0.01). Using a decision-tree model, we found a high attrition rate among soldiers who had >5.2 to primary care physician visits (11% attrition rate versus 3%) or more than 11 sick leave days (59% versus 19%). CONCLUSIONS: This study sheds light on unique measures relating to attrition. Attrition is associated with several demographic and psychosocial factors. Early prediction of motivation and monitoring of healthcare utilization may enable early identification and focused interventions targeting soldiers at high risk for attrition. These findings need to be further translated into actionable directives and further investigations.

Neuraxial anaesthesia and peripheral nerve blocks during the COVID-19 pandemic: a literature review and practice recommendations.

Coronavirus disease 2019 (COVID-19) has had a significant impact on global healthcare services. In an attempt to limit the spread of infection and to preserve healthcare resources, one commonly used strategy has been to postpone elective surgery, whilst maintaining the provision of anaesthetic care for urgent and emergency surgery. General anaesthesia with airway intervention leads to aerosol generation, which increases the risk of COVID-19 contamination in operating rooms and significantly exposes the healthcare teams to COVID-19 infection during both tracheal intubation and extubation. Therefore, the provision of regional anaesthesia may be key during this pandemic, as it may reduce the need for general anaesthesia and the associated risk from aerosol-generating procedures. However, guidelines on the safe performance of regional anaesthesia in light of the COVID-19 pandemic are limited. The goal of this review is to provide up-to-date, evidence-based recommendations or expert opinion when evidence is limited, for performing regional anaesthesia procedures in patients with suspected or confirmed COVID-19 infection. These recommendations focus on seven specific domains including: planning of resources and staffing; modifying the clinical environment; preparing equipment, supplies and drugs; selecting appropriate personal protective equipment; providing adequate oxygen therapy; assessing for and safely performing regional anaesthesia procedures; and monitoring during the conduct of anaesthesia and post-anaesthetic care. Implicit in these recommendations is preserving patient safety whilst protecting healthcare providers from possible exposure.

Strong ion and weak acid analysis in severe preeclampsia: potential clinical significance.

BACKGROUND: The influence of common disturbances seen in preeclampsia, such as changes in strong ions and weak acids (particularly albumin) on acid-base status, has not been fully elucidated. The aims of this study were to provide a comprehensive acid-base analysis in severe preeclampsia and to identify potential new biological predictors of disease severity. METHODS: Fifty women with severe preeclampsia, 25 healthy non-pregnant- and 46 healthy pregnant controls (26-40 weeks' gestation), were enrolled in this prospective case-control study. Acid-base analysis was performed by applying the physicochemical approach of Stewart and Gilfix. RESULTS: Mean [sd] base excess was similar in preeclamptic- and healthy pregnant women (-3.3 [2.3], and -2.8 [1.5] mEq/L respectively). In preeclampsia, there were greater offsetting contributions to the base excess, in the form of hyperchloraemia (BE(Cl) -2 [2.3] vs -0.4 [2.3] mEq/L, P<0.001) and hypoalbuminaemia (BE(Alb) 3.6 [1] vs 2.1 [0.8] mEq/L, P<0.001). In preeclampsia, hypoalbuminaemic metabolic alkalosis was associated with a non-reassuring/abnormal fetal heart tracing (P<0.001). Quantitative analysis in healthy pregnancy revealed respiratory and hypoalbuminaemic alkalosis that was metabolically offset by acidosis, secondary to unmeasured anions and dilution. CONCLUSIONS: While the overall base excess in severe preeclampsia is similar to that in healthy pregnancy, preeclampsia is associated with a greater imbalance offsetting hypoalbuminaemic alkalosis and hyperchloraemic acidosis. Rather than the absolute value of base excess, the magnitude of these opposing contributors may be a better indicator of the severity of this disease. Hypoalbuminaemic alkalosis may also be a predictor of fetal compromise. CLINICAL TRIAL REGISTRATION: clinicaltrials.gov: NCT 02164370.

Persistent opioid use after cesarean delivery in the United States of America: a systematic review.

BACKGROUND: This systematic review assessed the incidence of persistent opioid use after cesarean delivery in opioid-naïve individuals in the United States of America (USA). METHODS: A literature search identified articles that reported persistent opioid use after cesarean delivery between January 2000 and February 2022. Studies were manually reviewed, and data pertaining to rates of persistent postpartum opioid use and methodologic information were qualitatively analyzed. Sixty studies were identified, and four met inclusion criteria. All four studies were retrospective reviews of insurance claims data among individuals naïve to opioids. Data from 486 263 individuals delivering between 2001 and 2016 were included. The criteria to define persistent opioid use in opioid-naïve individuals generally involved two or more opioid prescriptions filled within the first year after cesarean delivery, with each definition including additional varying criteria. RESULTS: Rates of persistent opioid use after cesarean delivery ranged from 0.12% to 2.2%, with the highest rate reported in private insurance claims between 2008 and 2016. Findings suggest a substantial number of individuals are at risk (from 1:1000 to 1:50) for persistent opioid use up to 12 months postpartum. With 1.2 million individuals undergoing cesarean delivery annually in the USA, as few as 1440 and as many as 26 400 may continue using opioids past the fourth trimester. CONCLUSIONS: Findings emphasize the importance of developing a standardized definition of persistent opioid use to accurately assess the risk, rate, and trends for persistent opioid use among opioid-naïve individuals undergoing cesarean delivery.

Analysis of Twitter conversations in obstetric anesthesiology using the hashtag #OBAnes during the onset of the COVID-19 pandemic.

BACKGROUND: #OBAnes is the most used hashtag in obstetric anesthesiology. The primary objective of the study was to characterize #OBAnes tweets at the onset of the COVID-19 pandemic. METHODS: Observational study of all tweets using #OBAnes between June 30, 2019 and October 19, 2020. A list of 19 topics was compiled to categorize each tweet. All Twitter users were manually assigned into one of 19 Symplur Healthcare Stakeholder categories. RESULTS: There were 12 431 tweets with #OBAnes during the study period, posted by 1704 unique users. The top user category was Doctor (n = 1211, 71%) with 9665 (78%) tweets. The top three topics identified within Twitter conversations were neuraxial anesthesia, COVID-19, and general anesthesia. CONCLUSIONS: Twitter facilitated thousands of obstetric anesthesia-related discussions during the onset of the COVID-19 pandemic, with most conversations centering on anesthesia type (neuraxial or general anesthesia).

Pharmacogenetics and anaesthesia: the value of genetic profiling.

Approximately 50 years ago, pharmacogenetics was described as a new field of medicine that may explain human drug action. Anaesthesia played a key role in the early investigations. An understanding of how a person's DNA influences drug metabolism and effectiveness may allow individually tailored prescriptions, improving outcomes and safety. The ultimate goal of pharmacogenetic research is to offer tailored personalised medicine to improve both the efficacy of medication and patient safety by helping to predict risk of adverse outcomes. In this review, we present a selection of historical landmarks where anaesthesia has been a catalyst for pharmacogenetic development. We examine the level of evidence and cite examples of candidate genes and common polymorphisms known to alter the response to peri-operative medication. Finally, we set forth current views and potential exciting perspectives that may arise from the application of pharmacogenetics to the daily practice of anaesthesia and pain medicine.

Diagnosis of Stress fractures in military trainees: a large-scale cohort.

INTRODUCTION: The Israel Defense Forces (IDF) has strict protocols for the diagnosis and treatment of stress fractures wherein diagnosis is clinical with imaging used for persistent symptoms only. The purpose of this study was to examine the incidence of clinical and radiological stress fractures during IDF combat training. METHODS: Medical records of all soldiers enlisted to combat training between 2014 and 2017 were scanned for the diagnosis of stress fractures. We examined the imaging tests ordered (plain radiographs and bone scans) and their results and the time between the clinical diagnosis to imaging tests. RESULTS: During 4 years, 62 371 soldiers (10.1% women) had started combat training, and 3672 of them (5.9%) were diagnosed with clinical stress fractures. Radiographs were ordered for 53.5% of those diagnosed, of whom 29.7% also had a bone scan. Some 42% of radiographs were taken within 21 days. Radiographs were positive for stress fractures in 11.1% of tests. Bone scans showed evidence of stress fractures in 49.7%, of which 49.2% diagnosed stress fractures in multiple bones. CONCLUSION: The high percentage of negative radiographs may indicate towards alternative causes for symptoms. Performing the radiograph before or after 21 days did not affect workup results diverting from current belief that later radiographs will be more sensitive. Multiple stress fractures are a common finding, indicating that the increased training load puts the whole musculoskeletal system at increased risk for injury. Research results may necessitate a revision of clinical guidelines for the diagnosis of stress fractures in military trainees.

The time is now: addressing the need for training in maternal critical care medicine.

Amongst many high-income countries, indirect medical conditions (e.g. cardiovascular disease, sepsis) now account for the majority of maternal deaths. In response to this concerning rise in indirect causes of maternal deaths, professional societies have developed guidelines that regionalize high-risk obstetric care and prioritize critical care expertise as a requirement for designated 'top' maternity hospitals. Critical care proficiency is mandated by the Accreditation Council for Graduate Medical Education for graduating obstetric anesthesiology fellows. Despite these requirements, no formal obstetric critical care educational curricula or fellowship pathways, combining critical care medicine and obstetric anesthesiology, currently exist. Dual subspecialty training in both obstetric anesthesiology and critical care medicine represents one strategy to improve the care of critically-ill obstetric patients and reduce maternal mortality and morbidity, which is one of the pressing healthcare issues of our time.

Temporal trends in the incidence of post-dural puncture headache following labor neuraxial analgesia in the United States, 2006 to 2015.

BACKGROUND: Labor neuraxial analgesia utilization has increased in the United States (U.S.) but its impact on maternal safety is unknown. This study analyzed the temporal trends in the incidence of post-dural puncture headache (PDPH) in obstetrics. METHODS: Data for vaginal or intrapartum cesarean deliveries came from the National Inpatient Sample 2006-2015, a U.S. 20% representative sample of hospital discharge records. The outcome was PDPH (ICD-9-CM codes 349.0 and 03.95) categorized into (1) PDPH coded without epidural blood patch (EBP), and (2) PDPH coded with EBP. Temporal trends in incidence were described using the percent change between 2006 and 2015 and its 95% confidence interval (CI). RESULTS: Of the 29 011 472 deliveries studied, 86 558 (29.8 per 10 000; 95% CI: 29.3 to 30.2) recorded a diagnosis of PDPH, including 34 019 without EBP (11.7 per 10 000; 95% CI 11.4 to 12.0) and 52 539 with EBP (18.1 per 10 000; 95% CI 17.8 to 18.4). A significant decrease in the incidence of PDPH was observed from 31.5 per 10 000 in 2006 to 29.2 per 10 000 in 2015 (-7.5%; 95% CI -2.2 to -0.5; P=0.001). The decrease in the incidence of PDPH was significant irrespective of the presence of EBP. The decrease was observed in the three categories of hospitals examined (rural, urban non-teaching, and urban teaching). CONCLUSIONS: During the study period, the reported incidence of PDPH in the U.S. has decreased modestly. Intervention programs are needed to address this persistent and preventable cause of maternal morbidity.

Comparative efficacy of epidural clonidine versus epidural fentanyl for treating breakthrough pain during labor: a randomized double-blind clinical trial.

BACKGROUND: Breakthrough pain during neuraxial labor analgesia is typically alleviated with additional administration of epidural local anesthetics, with or without adjuvants. Sometimes avoiding neuraxial opioids may be warranted and clonidine is an alternative. In a randomized double-blind trial we compared the efficacy of clonidine versus fentanyl, added to bupivacaine, for the management of breakthrough pain. METHODS: Term parturients (n=98) receiving bupivacaine 0.0625% with fentanyl 2 µg/mL at 12 mL/h, a patient-administered bolus of 5 mL at lockout 6-10 min and a maximum of four boluses per hour, and experiencing breakthrough pain ≥5/10, were randomized to receive a 10 mL bolus containing 12.5 mg bupivacaine and either clonidine 100 µg or fentanyl 100 µg. The primary outcome was 'success' of study drug treatment, defined as a pain score reduction ≥4/10 within 15 min of administration. Maternal hemodynamics and fetal heart rate were documented for two hours after treatment. RESULTS: There was no significant difference between groups in success rates (66.0% after clonidine (n=47) vs 74.5% after fentanyl (n=51), P=0.48) or in the incidence of hypotension (systolic blood pressure ≤80% of baseline or <90 mmHg) or sedation at 15 min, with 2/51 and 1/47 subjects in the fentanyl and clonidine groups, respectively, receiving phenylephrine. CONCLUSION: Epidural clonidine 100 µg was not superior to fentanyl 100 µg for decreasing pain scores within 15 min of co-administration with bupivacaine 0.125% for intrapartum breakthrough pain. The analgesic efficacy and hemodynamic side effects did not significantly differ.

GRP78 as a marker of pre-eclampsia: an exploratory study.

Although the exact mechanisms that lead to shallow invasion or defective trophoblastic differentiation in pre-eclampsia are still unknown, it is widely admitted that the etiology of pre-eclampsia is a defect in trophoblast invasion of the uterine spiral arteries. We have previously observed that the status of a chaperone protein, glucose regulated protein 78 (GRP78) is associated with the invasive properties of cytotrophoblastic cells; we therefore hypothesized that circulating GRP78 could serve as a diagnostic tool in pre-eclampsia. In a prospective case-control study, we quantified GRP78 autoantibodies, complexes of GRP78 with autoantibodies and GRP78 (C-term fragment, N-term fragment and full-length GRP78) by ELISA. Plasma from women diagnosed with pre-eclampsia (n = 16), from women during the first trimester of pregnancy who subsequently developed pre-eclampsia (n = 10) and from healthy pregnant women (controls, n = 58 at term, n = 26 at first trimester) were analysed and compared. We observed no significant difference between pre-eclamptic and healthy pregnant women for autoantibodies-GRP78 complexes or total GRP78 at both first trimester and at delivery. In contrast, the ratio of C-terminal GRP78 over full length GRP78 was significantly different in plasma of pre-eclamptic patients as compared with controls both during first trimester (P < 0.004) and at term (P < 0.0001). Our findings suggest that circulating C-terminal GRP78 reflect the invasive properties of cells, and could be used as a predictive marker for pre-eclampsia early in pregnancy.

[Is preeclampsia a new cardiovascular and end-stage renal diseases risk marker?]. / La prééclampsie: un nouvea facteur de risque de maladies cardiovasculaire et rénale?

Is preeclampsia a new cardiovascular and end-stage renal diseases risk marker? Preeclampsia is a major obstetrical problem leading to high maternal and perinatal morbidity and mortality worldwide. It is characterized by hypertension and proteinuria occurring after 20 weeks of gestation. Increasing evidence indicates that preeclampsia is not just a pregnancy disease that resolves at the time of delivery, but represent a risk marker of cardiovascular and end-stage renal diseases later in life. The underlying link between preeclampsia and cardiovascular disease is unclear. Women with early onset/severe preeclampsia, recurrent preeclampsia, or preeclampsia with onset as a multipara appear to be at highest risk of cardiovascular disease later in life, including during the premenopausal period.

Post-cesarean delivery pain. Management of the opioid-dependent patient before, during and after cesarean delivery.

The opioid crisis has reached an unprecedented magnitude in the United States and worldwide, and data on opioid use and misuse in the obstetric population are extremely concerning. Despite an abundant number of studies evaluating strategies to prevent neonatal opioid withdrawal syndrome in babies born to mothers who are chronic opioid users, in babies born to mothers using chronic opioids, numerous questions remain unanswered, including (1) how to optimally manage postpartum pain in opioid-dependent patients (2) how to reconcile buprenorphine and methadone use with intrapartum and post-partum analgesia, so as to avoid opioid withdrawal during and after delivery (3) how to safely and effectively provide a stepwise multimodal approach that incorporates systemic opioid-sparing approaches, such as neuraxial opioids, clonidine, ketamine, gabapentin, and regional anesthetic blocks, to ensure adequate pain relief while avoiding opioid withdrawal (4) how to optimally manage post-partum recovery and (5) how to avoid excessive opioid prescription and possibly leftover opioids that may promote persistent use, misuse and diversion. With the recognition that an increasing number of pregnant women are taking chronic opioids, the goals of this review article are to summarize the existing literature on post-cesarean pain management in the obstetric patient with an opioid-use disorder; and to provide clinicians with a stepwise approach for management before, as well as during and after, cesarean delivery of women who have been chronically using opioids during their pregnancy.

How low did we go? A case report of unexpected thrombocytopenia.

We report the case of a normotensive 31-year-old parturient who received combined spinal-epidural analgesia for early labor, and who was then found to have an unexpectedly low platelet count (25 000/µL) with elevated liver enzymes, but without alterations in blood pressure.

Observational study evaluating obstetric anesthesiologist residents' well-being, anxiety and stress in a North American academic program.

BACKGROUND: The obstetric work environment has a unique set of stressors that may be associated with burnout. We investigated how well-being during the obstetric anesthesia (ObA) rotation compared to other rotations; which workplace environment characteristics precipitated the greatest stress; and whether anxiety and stress levels changed in trainees before and after an ObA rotation. METHODS: Using a survey, anesthesia residents (n=36) ranked their well-being on each anesthesia rotation and answered questions about their work environment. A separate survey measured anxiety and stress before and after an ObA rotation. Friedman's test was used to compare ranking data and Likert responses. T-tests were used to compare stress and anxiety scores. RESULTS: Residents' ranking of well-being on ObA was higher than that on another high demand rotation (cardiothoracic anesthesia, P=0.007). Work environment stress scores were significantly higher among community and fairness domains than for workload (P=0.002 and P=0.0001, respectively). While stress and anxiety scores did not significantly differ before and after the ObA rotation, they were higher than the reference population scores. CONCLUSIONS: We provide the first example of tools for assessing work environment stressors in ObA. Our study illustrates that beyond excessive workload, lack of fairness and community values are areas that impact physician well-being. Use of these tools can guide initiatives to address work environment concerns, and presents a need for a validated well-being instrument to gauge physician well-being, in order to create a cultural shift from burnout to one of well-being.

Sex selection for social purposes in Israel: quest for the "perfect child" of a particular gender or centuries old prejudice against women?

On 9 May 2005, the Israeli Ministry of Health issued guidelines spelling out the conditions under which sex selection by preimplantation genetic diagnosis (PGD) for social purposes is to be permitted in Israel. This article first reviews the available medical methods for sex selection, the preference for children of a specific gender in various societies and the ethical controversies surrounding PGD for medical and social purposes in different countries. It focuses then on the question of whether procreative liberty or parental responsibility should be the centre of attention in this context. Finally, the article critically examines the new Israeli guidelines and their implications for the women undergoing the necessary medical treatments, for the children born as a result, for other members of the family and for society in general.

Unusual Sequence of Events in a Case of Takotsubo Syndrome.

A 73-year-old female with multiple comorbidities including coronary artery disease was admitted for an elective PCI of a lesion detected in the RCA. On the day of the planned PCI, shortly after right femoral artery cannulation, the patient developed a sudden complete heart block requiring the administration atropine and insertion of a temporary pacemaker. Concomitantly, the patient developed acute pulmonary edema, hypotension, and hypoxia requiring intubation for mechanical ventilation. Vasopressors were administered. A coronary angiogram showed patent left and right coronary arteries, unchanged when compared to the previous angiogram. An echocardiogram performed in the cardiac catheterization lab revealed global hypokinesis of the left and right ventricles, with severe LV systolic dysfunction (EF < 20%). Following an insertion of an intra-aortic balloon pump, the patient was transferred to the CICU. A repeat echocardiogram in the CICU two hours later revealed a classical echocardiographic presentation of Takotsubo syndrome, apical hypokinesis. By the next morning the patient's hemodynamic status significantly improved, the balloon pump was removed, and vasopressors were discontinued. Another echocardiogram was performed 24 hours after the event occurred and revealed a marked improvement in LV systolic function (EF 60%), with complete resolution of apical and septal wall motion abnormalities. Three days after the event, the patient was successfully discharged and asymptomatic at two-month follow-up. This case illustrates an atypical presentation of Takotsubo syndrome that was witnessed from onset to its complete resolution during the patient's hospital stay.