Scoping Review: Anesthesiologist Involvement in Alternative Payment Models, Value Measurement, and Nonclinical Capabilities for Success in the United States of America.

The US healthcare sector is undergoing significant payment reforms, leading to the emergence of Alternative Payment Models (APMs) aimed at improving clinical outcomes and patient experiences while reducing costs. This scoping review provides an overview of the involvement of anesthesiologists in APMs as found in published literature. It specifically aims to categorize and understand the breadth and depth of their participation, revolving around 3 main axes or "Aims": (1) shaping APMs through design and implementation, (2) gauging the value and quality of care provided by anesthesiologists within these models, and (3) enhancing nonclinical abilities of anesthesiologists for promoting more value in care. To map out the existing literature, a comprehensive search of relevant electronic databases was conducted, yielding a total of 2173 articles, of which 24 met the inclusion criteria, comprising 21 prospective or retrospective cohort studies, 2 surveys, and 1 case-control cohort study. Eleven publications (45%) discussed value-based, bundled, or episode-based payments, whereas the rest discussed non-payment-based models, such as Enhanced Recovery After Surgery (7 articles, 29%), Perioperative Surgical Home (4 articles, 17%), or other models (3 articles, 13%).The review identified key themes related to each aim. The most prominent themes for aim 1 included protocol standardization (16 articles, 67%), design and implementation leadership (8 articles, 33%), multidisciplinary collaboration (7 articles, 29%), and role expansion (5 articles, 21%). For aim 2, the common themes were Process-Based & Patient-Centric Metrics (1 article, 4%), Shared Accountability (3 articles, 13%), and Time-Driven Activity-Based Costing (TDABC) (3 articles, 13%). Furthermore, we identified a wide range of quality metrics, spanning 8 domains that were used in these studies to evaluate anesthesiologists' performance. For aim 3, the main extracted themes included Education on Healthcare Transformation and Policies (3 articles, 13%), Exploring Collaborative Leadership Skills (5 articles, 21%), and Embracing Advanced Analytics and Data Transparency (4 articles, 17%).Findings revealed the pivotal role of anesthesiologists in the design, implementation, and refinement of these emerging delivery and payment models. Our results highlight that while payment models are shifting toward value, patient-centered metrics have yet to be widely accepted for use in measuring quality and affecting payment for anesthesiologists. Gaps remain in understanding how anesthesiologists assess their direct impact and strategies for enhancing the sustainability of anesthesia practices. This review underscores the need for future research contributing to the successful adaptation of clinical practices in this new era of healthcare delivery.

Relationship between demographic and social variables and performance in virtual reality among healthcare personnel: an observational study.

BACKGROUND: Virtual reality is emerging as an important component of medical education. Although the benefits of virtual reality are apparent, the optimal strategy to orient to or differentiate learners in the virtual space have not been delineated. The purpose of this study was to investigate the relationships between demographic variables, social variables, and self-perceived comfort with technology to performance on a standardized non-medical virtual reality experience. METHODS: This observational study was performed at the International Meeting on Simulation in Healthcare in 2022. This conference includes medical and non-medical attendees. Participants provided demographic information and participated in a scored non-medical VR experience due to the heterogeneity of the sample. Participants then completed a System Usability Index and NASA Task Load Index form. Participants were dividedintolow scoring, medium scoring, and high scoring groups according to their final game score for further analysis. RESULTS: 95 participants were included in final analysis. 55 (57.9%) of participants had prior virtual reality experience. Higher scores were associated with younger age (11.09, p < 0.001), identifying as male (11.09, p < 0.001), and a higher frequency of playing video games in the past (18.96, p < 0.001). The high score group was more likely to report comfort with virtual reality (6.29, p = 0.003) as well as comfort with new technology (4.61, p = 0.012). NASA Task Load Index scores trended down and System Usability Index scores trended up with increasing score. Being a nurse was a positive predictor of a higher score when compared to physicians in the multivariate analysis. CONCLUSION: Performance during an immersive virtual reality experience was most closely related to age, gender, and frequency of playing video games. Self-perceived comfort with virtual reality was more predictive of score than prior virtual reality experience.

The use of simulation in liver transplantation anesthesiology fellowship training: A survey of fellowship program directors in the United States.

INTRODUCTION: Liver transplantation surgeries are challenging cases for anesthesiologists. While intra-operative teaching is paramount, simulation has emerged as an educational tool to augment clinical training. A variety of simulation modalities have been described in the literature, but no study has aimed to assess the use of simulation in liver transplantation fellowship training. METHODS: A 20-question survey detailing the use of simulation, including simulation modalities used and barriers to simulation use, was developed and distributed to 22 program directors for liver transplantation anesthesiology fellowships. An exploratory analysis was performed on multiple-choice and free-text responses. RESULTS: Thirteen program directors completed the survey and were included in our analysis. Most programs (61.5%) did not report the use of simulation for liver transplantation fellow training. Of the programs that did use simulation, four required it as a mandatory component of their curriculum. Task trainers and screen-based simulators were more commonly used by these programs. Faculty availability and interest, as well as a lack of an established curriculum, were cited as major limitations to simulation use. CONCLUSIONS: Simulation is an important component of anesthesiology trainee education, as evidenced by the requirement for simulation during residency by the American Council for Graduate Medical Education. Our findings suggest that simulation is an underutilized educational tool that we believe could greatly augment the training of liver transplantation anesthesiology fellows by providing exposure to a wide range of clinical challenges.

Propofol misuse in medical professions: a scoping review.

PURPOSE: We aimed to describe the current literature concerning propofol misuse in medical professionals, specifically relating to the individual demographics of those misusing propofol and the outcomes of propofol misuse. METHODS: We conducted a retrospective scoping review of the literature using a modified PRISMA approach. We used MEDLINE, EMBASE, and PsycINFO databases to identify relevant studies based on search terms. Studies describing individual medical professionals misusing propofol were included. RESULTS: Twenty-four articles describing 88 individual cases of propofol misuse were included for data charting and analysis. Anesthesiologists and certified registered nurse anesthetists were most commonly identified. Death was a common method of identification of misuse, while rehabilitation and death were common final outcomes associated with propofol misuse. CONCLUSIONS: Despite knowledge of the pharmacokinetic and pharmacodynamic properties of propofol by those misusing this medication, death was a common outcome reported in the literature. Data related to long-term outcomes including re-entry to clinical practice or success of rehabilitation were limited.

RéSUMé: OBJECTIF: Nous avons cherché à décrire la littérature actuelle concernant l'abus de propofol chez les professionnels de la santé, en particulier en ce qui concerne les données démographiques individuelles de ceux qui abusent du propofol et les issues d'un tel abus. MéTHODE: Nous avons réalisé une étude de portée rétrospective de la littérature à l'aide d'une approche PRISMA modifiée. Nous avons utilisé les bases de données MEDLINE, EMBASE et PsycINFO pour identifier les études pertinentes en fonction des termes de recherche. Les études décrivant des professionnels de la santé abusant du propofol ont été incluses. RéSULTATS: Vingt-quatre articles décrivant 88 cas individuels d'abus de propofol ont été inclus pour la cartographie et l'analyse des données. Les anesthésiologistes et les infirmières anesthésistes autorisées certifiées ont été le plus souvent identifiés. La mort était une méthode courante d'identification de l'abus, tandis que la réhabilitation et la mort étaient des issues finales fréquemment associées à l'abus de propofol. CONCLUSION: Malgré la connaissance des propriétés pharmacocinétiques et pharmacodynamiques du propofol par ceux qui abusent de ce médicament, le décès était une issue fréquente rapportée dans la littérature. Les données relatives aux issues à long terme, y compris le retour à la pratique clinique ou le succès de la réhabilitation, étaient limitées.

Self-reported Race/Ethnicity and Intraoperative Occult Hypoxemia: A Retrospective Cohort Study.

BACKGROUND: Pulse oximetry is ubiquitous in anesthesia and is generally a reliable noninvasive measure of arterial oxygen saturation. Concerns regarding the impact of skin pigmentation and race/ethnicity on the accuracy of pulse oximeter accuracy exist. The authors hypothesized a greater prevalence of occult hypoxemia (arterial oxygen saturation [Sao2] less than 88% despite oxygen saturation measured by pulse oximetry [Spo2] greater than 92%) in patients undergoing anesthesia who self-reported a race/ethnicity other than White. METHODS: Demographic and physiologic data, including self-reported race/ethnicity, were extracted from a departmental data warehouse for patients receiving an anesthetic that included at least one arterial blood gas between January 2008 and December 2019. Calculated Sao2 values were paired with concurrent Spo2 values for each patient. Analysis to determine whether Black, Hispanic, Asian, or Other race/ethnicities were associated with occult hypoxemia relative to White race/ethnicity within the Spo2 range of 92 to 100% was completed. RESULTS: In total, 151,070 paired Sao2-Spo2 readings (70,722 White; 16,011 Black; 21,223 Hispanic; 8,121 Asian; 34,993 Other) from 46,253 unique patients were analyzed. The prevalence of occult hypoxemia was significantly higher in Black (339 of 16,011 [2.1%]) and Hispanic (383 of 21,223 [1.8%]) versus White (791 of 70,722 [1.1%]) paired Sao2-Spo2 readings (P < 0.001 for both). In the multivariable analysis, Black (odds ratio, 1.44 [95% CI, 1.11 to 1.87]; P = 0.006) and Hispanic (odds ratio, 1.31 [95% CI, 1.03 to 1.68]; P = 0.031) race/ethnicity were associated with occult hypoxemia. Asian and Other race/ethnicity were not associated with occult hypoxemia. CONCLUSIONS: Self-reported Black and Hispanic race/ethnicity are associated with a greater prevalence of intraoperative occult hypoxemia in the Spo2 range of 92 to 100% when compared with self-reported White race/ethnicity.

Barrier Devices, Intubation, and Aerosol Mitigation Strategies: Personal Protective Equipment in the Time of Coronavirus Disease 2019.

BACKGROUND: Numerous barrier devices have recently been developed and rapidly deployed worldwide in an effort to protect health care workers (HCWs) from exposure to coronavirus disease 2019 (COVID-19) during high-risk procedures. However, only a few studies have examined their impact on the dispersion of droplets and aerosols, which are both thought to be significant contributors to the spread of COVID-19. METHODS: Two commonly used barrier devices, an intubation box and a clear plastic intubation sheet, were evaluated using a physiologically accurate cough simulator. Aerosols were modeled using a commercially available fog machine, and droplets were modeled with fluorescein dye. Both particles were propelled by the cough simulator in a simulated intubation environment. Data were captured by high-speed flash photography, and aerosol and droplet dispersion were assessed qualitatively with and without a barrier in place. RESULTS: Droplet contamination after a simulated cough was seemingly contained by both barrier devices. Simulated aerosol escaped the barriers and flowed toward the head of the bed. During barrier removal, simulated aerosol trapped underneath was released and propelled toward the HCW at the head of the bed. Usage of the intubation sheet concentrated droplets onto a smaller area. If no barrier was used, positioning the patient in slight reverse Trendelenburg directed aerosols away from the HCW located at the head of the bed. CONCLUSIONS: Our observations imply that intubation boxes and sheets may reduce HCW exposure to droplets, but they both may merely redirect aerosolized particles, potentially resulting in increased exposure to aerosols in certain circumstances. Aerosols may remain within the barrier device after a cough, and manipulation of the box may release them. Patients should be positioned to facilitate intubation, but slight reverse Trendelenburg may direct infectious aerosols away from the HCW. Novel barrier devices should be used with caution, and further validation studies are necessary.

Managing COVID-19 from the epicenter: adaptations and suggestions based on experience.

In March 2020, the New York City metropolitan area became the epicenter of the United States' SARS-CoV-2 pandemic and the surge of new cases threatened to overwhelm the area's hospital systems. This article describes how an anesthesiology department at a large urban academic hospital rapidly adapted and deployed to meet the threat head-on. Topics included are preparatory efforts, development of a team-based staffing model, and a new strategy for resource management. While still maintaining a fully functioning operating theater, discrete teams were deployed to both COVID-19 and non-COVID-19 intensive care units, rapid response/airway management team, the difficult airway response team, and labor and delivery. Additional topics include the creation of a temporary 'pop-up' anesthesiology-run COVID-19 intensive care unit utilizing anesthesia machines for monitoring and ventilatory support as well as the development of a simulation and innovation team that was instrumental in the rapid prototyping of a controlled split-ventilation system and conversion of readily available BIPAP units into emergency ventilators. As the course of the disease is uncertain, the goal of this article is to assist others in preparation for what may come next with COVID-19 as well as potential future pandemics.

Utilization of a Voice-Based Virtual Reality Advanced Cardiac Life Support Team Leader Refresher: Prospective Observational Study.

BACKGROUND: The incidence of cardiac arrests per year in the United States continues to increase, yet in-hospital cardiac arrest survival rates significantly vary between hospitals. Current methods of training are expensive, time consuming, and difficult to scale, which necessitates improvements in advanced cardiac life support (ACLS) training. Virtual reality (VR) has been proposed as an alternative or adjunct to high-fidelity simulation (HFS) in several environments. No evaluations to date have explored the ability of a VR program to examine both technical and behavioral skills and demonstrate a cost comparison. OBJECTIVE: This study aimed to explore the utility of a voice-based VR ACLS team leader refresher as compared with HFS. METHODS: This prospective observational study performed at an academic institution consisted of 25 postgraduate year 2 residents. Participants were randomized to HFS or VR training and then crossed groups after a 2-week washout. Participants were graded on technical and nontechnical skills. Participants also completed self-assessments about the modules. Proctors were assessed for fatigue and task saturation, and cost analysis based on local economic data was performed. RESULTS: A total of 23 of 25 participants were included in the scoring analysis. Fewer participants were familiar with VR compared with HFS (9/25, 36% vs 25/25, 100%; P<.001). Self-reported satisfaction and utilization scores were similar; however, significantly more participants felt HFS provided better feedback: 99 (IQR 89-100) vs 79 (IQR 71-88); P<.001. Technical scores were higher in the HFS group; however, nontechnical scores for decision making and communication were not significantly different between modalities. VR sessions were 21 (IQR 19-24) min shorter than HFS sessions, the National Aeronautics and Space Administration task load index scores for proctors were lower in each category, and VR sessions were estimated to be US $103.68 less expensive in a single-learner, single-session model. CONCLUSIONS: Utilization of a VR-based team leader refresher for ACLS skills is comparable with HFS in several areas, including learner satisfaction. The VR module was more cost-effective and was easier to proctor; however, HFS was better at delivering feedback to participants. Optimal education strategies likely contain elements of both modalities. Further studies are needed to examine the utility of VR-based environments at scale.

Knowledge retention after simulated crisis: importance of independent practice and simulated mortality.

BACKGROUND: Simulation is an important component of postgraduate medical education, but optimal parameters for simulation are not known. Managing simulations independently and allowing simulated morbidity and mortality have been shown to improve follow-up performance in simulation. We hypothesised that allowing simulated mortality improves performance in follow-up simulations more than independent practice. METHODS: Using a randomised, controlled, observer-blinded design, 48 first-year residents in anaesthesia were exposed to a hyperkalaemia scenario. Subjects were divided into two groups (n=24) that allowed for independent practice or support from an attending physician. Each of these groups was then subdivided into two groups (n=12) that allowed for simulated mortality or did not. All groups received a standardised debriefing. Six months later, the subjects returned to manage a different hyperkalaemia scenario independently with potential simulated mortality. The primary outcome was total treatment score; secondary outcomes included subjects' time to request diagnostic information, time to treatment, and simulator mortality rate. RESULTS: Subject characteristics were not statistically different. The independent practice-mortality possible group had the highest total treatment score (P=0.004), fastest time to treatment (P=0.009), and lowest mortality rate (P=0.002) compared with all groups. Two-way analysis of variance and least-squares means were calculated for each combination of variables. The overall practice effect was contrasted to the potential for mortality and was insignificant; however, their interaction effect (P=0.003) was significant and produced the best results. CONCLUSIONS: Independence and the potential for simulated mortality have a greater impact on performance in follow-up simulations when combined than either factor alone.

Human dissection for anesthesiology resident training augments anatomical knowledge and clinical skills.

Anatomy is an essential component of clinical anesthesiology. The use of simulated patients and alternative materials, including embalmed human bodies, have become increasingly common during resident physician training due to the deemphasis on anatomical education during undergraduate medical training. In this report, the need for a more extensive review of relevant anatomy for the practice of anesthesiology was addressed by the design, evaluation, and dissemination of a human dissection course for procedural training of anesthesiology residents. The course utilized "freedom art" embalmed human bodies that allowed trainees to perform ultrasound-based regional and neuraxial techniques followed by detailed dissections of critical anatomy. One hundred and four residents participated in workshops and small group discussions and were evaluated using pre- and post-course assessments. A variety of clinical techniques were performed on the bodies, including regional blocks and neuraxial catheter placement. Insertion of peripheral/neuraxial catheters was successful, with dissections demonstrating the expected placement. Assessment scores improved following the course (pre-course mean 52.7%, standard deviation (σ) 13.1%; post-course mean 72.2%, σ 11.6%; t-test p < 0.0001) and feedback highlighted the usefulness and clinical relevance of course content. The ability to correlate ultrasound imaging with subsequent dissections of the "blocked" area and visualization of dye staining was extremely relevant for spatial understanding of the anatomy relevant for the clinical practice of these techniques. This manuscript demonstrates successful implementation of a comprehensive course for anesthesiology resident physicians to address gaps in undergraduate anatomical education and suggests that broader adoption of dissection courses may be beneficial for training anesthesiologists.

Analgesic options for anterior approach to scoliosis repair: a scoping review.

PURPOSE: The ideal analgesic regimen for the anterior approach to scoliosis repair is not clearly defined. The purpose of the study was to summarize and identify gaps in the current literature specific to the anterior approach to scoliosis repair. METHODS: A scoping review was conducted in July 2022 utilizing PubMed, Cochrane, and Scopus databases guided by the PRISMA-ScR framework. RESULTS: The database search generated 641 possible articles, 13 of which met all inclusion criteria. All articles focused on the effectiveness and safety of regional anesthetic techniques, while a minority also provided both opioid and non-opioid medication frameworks. CONCLUSION: Continuous Epidural Analgesia (CEA) is the most well-studied intervention for pain control in anterior scoliosis repair, but other, more novel regional anesthetic techniques offer safe and effective potential alternatives. More research is indicated to compare the effectiveness of different regional techniques and perioperative medication regimens specific to anterior scoliosis repair.

Single-use versus reusable metallic laryngoscopes for non-emergent intubation: A retrospective review of 72,672 intubations.

STUDY OBJECTIVE: Increased regulatory requirements for sterilization in recent years have prompted a widespread transition from reusable to single-use laryngoscopes. The purpose of this study was to determine if the transition from metallic reusable to metallic single-use laryngoscopes impacted the performance of direct laryngoscopy at an academic medical center. DESIGN: Single-site retrospective cohort study. SETTING: General anesthetic cases requiring tracheal intubation. PATIENTS: Adult patients undergoing non-emergent procedures. INTERVENTIONS: Data were collected two years before and two years after a transition from metallic reusable to metallic single-use laryngoscopes. MEASUREMENTS: The primary outcome was need for intubation rescue with an alternate device. Secondary outcomes were difficult laryngeal view (modified Cormack-Lehane grade ≥ 2b) and hypoxemia (SpO2 < 90% for >30 s) during direct laryngoscopy intubations. Subgroup analyses for rapid sequence induction, Macintosh blades, Miller blades, and patients with difficult airway risk factors (Obstructive Sleep Apnea, Mallampati ≥3, Body Mass Index >30 kg/m2) were performed. MAIN RESULTS: In total, 72,672 patients were included: 35,549 (48.9%) in the reusable laryngoscope cohort and 37,123 (51.1%) in the single-use laryngoscope cohort. Compared with reusable laryngoscopes, single-use laryngoscopes were associated with fewer rescue intubations with an alternate device (covariates-adjusted odds ratio [OR] 0.81 95% CI 0.66-0.99). Single-use laryngoscopes were also associated with lower odds of difficult laryngeal view (OR 0.86; 95% CI 0.80-0.93). Single use laryngoscopes were not associated with hypoxemia during the intubation attempt (OR 1.03; 95% CI 0.88-1.20). Similar results were observed for subgroup analyses including rapid sequence induction, Macintosh blades, Miller blades, and patients with difficult airway risk factors. CONCLUSIONS: Metallic single-use laryngoscopes were associated with less need for rescue intubation with alternate devices and lower incidence of poor laryngeal view compared to reusable metallic laryngoscopes.

In vivo imaging of photoreceptor disruption associated with age-related macular degeneration: A pilot study.

BACKGROUND AND OBJECTIVE: Age-related macular degeneration is one of the leading causes of vision loss in the developed world. As the disease progresses, the central part of the retina, called the macula, is compromised leading to a disruption of both structure and visual function. In this study, we investigate the disruption of macular photoreceptor cells in vivo as a function of disease stage in patients with the dry form of age-related macular degeneration AMD. MATERIALS AND METHODS: An investigational confocal Adaptive Optics Scanning Laser Ophthalmoscope (AO-SLO) was used to obtain high resolution images of the macular photoreceptor mosaic in patients previously diagnosed with AMD. Four patients were selected as representative cases, comprising each of the four clinical stages of AMD progression. RESULTS: AO-SLO imaging revealed slight disruption in the photoreceptor mosaic in early stage AMD due to focal drusen formation and identified several small drusen deposits that were not observed with standard clinical imaging techniques. An increase in photoreceptor disruption was visualized within the macula in direct correlation with the stage of AMD progression leading to a decrease in visual acuity. Large coalescent drusen and areas of geographic atrophy in advanced stage dry AMD exhibited a significant decrease in visible photoreceptor density. Significant decrease in photoreceptor counts (∼35-50%) were observed when comparing earlier stages of AMD progression (Categories I and II) to later stages of the disease (Categories III and IV). CONCLUSIONS: This study demonstrates the capabilities of adaptive optics retinal imaging to monitor disruption of individual photoreceptor cells as a function of disease progression yielding valuable diagnostic findings in early stage AMD beyond what can be learned about the health of photoreceptors using conventional retinal imaging techniques. Lasers Surg. Med. 44: 603-610, 2012. © 2012 Wiley Periodicals, Inc.

Development of an Easily Reproducible Cough Simulator With Droplets and Aerosols for Rapidly Testing Novel Personal Protective Equipment.

INTRODUCTION: The current COVID-19 pandemic has produced numerous innovations in personal protective equipment, barrier devices, and infection mitigation strategies, which have not been validated. During high-risk procedures such as airway manipulation, coughs are common and discrete events that may expose healthcare workers to large amounts of viral particles. A simulated cough under controlled circumstances can rapidly test novel devices and protocols and thus aid in their evaluation and the development of implementation guidelines. Physiologic cough simulators exist but require significant expertise and specialized equipment not available to most clinicians. METHODS: Using components commonly found in healthcare settings, a cough simulator was designed for clinicians to easily assemble and use. Both droplet and aerosol particle generators were incorporated into a bimodal experimental system. High-speed flash photography was used for data collection. RESULTS: Using a gas flow analyzer, video recordings, and high-speed digital photography, the cough and particle simulators were quantitatively and qualitatively compared with known physiologic cough parameters and in vivo Schlieren imaging of human coughs. CONCLUSIONS: Based on our validation studies, this cough and particle simulator model approximates a physiologic, human cough in the context of testing personal protective equipment, barrier devices, and infection prevention measures.

Alpha-tocotrienol enhances arborization of primary hippocampal neurons via upregulation of Bcl-xL.

Alpha-tocotrienol (α-TCT) is a member of the vitamin E family. It has been reported to protect the brain against various pathologies including cerebral ischemia and neurodegeneration. However, it is still unclear if α-TCT exhibits beneficial effects during brain development. We hypothesized that treatment with α-TCT improves intracellular redox homeostasis supporting normal development of neurons. We found that primary hippocampal neurons isolated from rat feti grown in α-TCT-containing media achieved greater levels of neurite complexity compared to ethanol-treated control neurons. Neurons were treated with 1 µM α-TCT for 3 weeks, and media were replaced with fresh α-TCT every week. Treatment with α-TCT increased α-TCT levels (26 pmol/mg protein) in the cells, whereas the control neurons did not contain α-TCT. α-TCT-treated neurons produced adenosine triphosphate (ATP) at a higher rate and increased ATP retention at neurites, supporting formation of neurite branches. Although treatment with α-TCT alone did not change neuronal viability, neurons grown in α-TCT were more resistant to death at maturity. We further found that messenger RNA and protein levels of B-cell lymphoma-extra large (Bcl-xL) are increased by α-TCT treatment without inducing posttranslational cleavage of Bcl-xL. Bcl-xL is known to enhance mitochondrial energy production, which improves neuronal function including neurite outgrowth and neurotransmission. Therefore α-TCT-mediated Bcl-xL upregulation may be the central mechanism of neuroprotection seen in the α-TCT-treated group. In summary, treatment with α-TCT upregulates Bcl-xL and increases ATP levels at neurites. This correlates with increased neurite branching during development and with protection of mature neurons against oxidative stress.

Development of entrustable professional activities for regional anesthesia and pain medicine fellowship training.

INTRODUCTION: The Accreditation Council for Graduate Medical Education (ACGME) offers descriptions of competencies and milestones but does not provide standardized assessments to track trainee competency. Entrustable professional activities (EPAs) and special assessments (SAs) are emerging methods to assess the level of competency obtained by regional anesthesiology and acute pain medicine (RAAPM) fellows. METHODS: A panel of RAAPM physicians with experience in education and competency assessment and one medical student were recruited to participate in a modified Delphi method with iterative rounds to reach consensus on: a list of EPAs, SAs, and procedural skills; detailed definitions for each EPA and SA; a mapping of the EPAs and SAs to the ACGME milestones; and a target level of entrustment for graduating US RAAPM fellows for each EPA and procedural skill. A gap analysis was performed and a heat map was created to cross-check the EPAs and SAs to the ACGME milestones. RESULTS: Participants in EPA and SA development included 19 physicians and 1 medical student from 18 different programs. The Delphi rounds yielded a final list of 23 EPAs, a defined entrustment scale, mapping of the EPAs to ACGME milestones, and graduation targets. A list of 73 procedural skills and 7 SAs were similarly developed. DISCUSSION: A list of 23 RAAPM EPAs, 73 procedural skills, and 7 SAs were created using a rigorous methodology to reach consensus. This framework can be utilized to help assess RAAPM fellows in the USA for competency and allow for meaningful performance feedback.