Racial and Ethnic Concordance Between the Patient and Anesthesia Team and Patients' Satisfaction With Pain Management During Cesarean Delivery.

BACKGROUND: Racial and ethnic concordance between patients and health care providers increases patient satisfaction but has not been examined in obstetric anesthesia care. This study evaluated the association between racial and ethnic concordance and satisfaction with management of pain during cesarean delivery (PDCD). METHODS: This was a secondary analysis on a cohort of patients undergoing cesarean deliveries under neuraxial anesthesia that examined PDCD. The outcome was satisfaction, recorded within 48 hours after delivery using the survey question, "Overall, how satisfied are you with the anesthesia care during the C-section as it relates to pain management?" Using a 5-point Likert scale, satisfaction was defined with the answer "very satisfied." Participants were also asked, "If you have another C-section, would you want the same anesthesia team?" The exposure was racial and ethnic concordance between the patient and anesthesia team members (attending with a resident, nurse anesthetist, or fellow) categorized into full concordance, partial concordance, discordance, and missing. Risk factors for satisfaction were identified using a multivariable analysis. RESULTS: Among 403 participants, 305 (78.2%; 95% confidence interval [CI], 73.8-82.1) were "very satisfied," and 358 of 399 (89.7%; 95% CI, 86.3-92.5) "would want the same anesthesia team." Full concordance occurred in 18 (4.5%) cases, partial concordance in 117 (29.0%), discordance in 175 (43.4%), and missing in 93 (23.1%). Satisfaction rate was 88.9% for full concordance, 71.8% for partial concordance, 81.1% for discordance, and 78.5% for missing (P value = .202). In the multivariable analysis, there was insufficient evidence for an association of concordance with satisfaction. Compared to full concordance, partial concordance was associated with a nonsignificant 57% (95% CI, -113 to 91) decrease in the odds of being satisfied, discordance with a 29% (95% CI, -251 to 85) decrease, and missing with a 39% (95% CI, -210 to 88) decrease. Risk factors for not being "very satisfied" were PDCD, anxiety disorders, pregnancy resulting from in vitro fertilization, intravenous medication administration, intrapartum cesarean with extension of labor epidural, having 3 anesthesia team members (instead of 2), and a higher intraoperative blood loss. CONCLUSIONS: Our inability to identify an association between concordance and satisfaction is likely due to the high satisfaction rate in our cohort (78.2%), combined with low proportion of full concordance (4.5%). Addressing elements such as PDCD, anxiety, intravenous medication administration, and use of epidural anesthesia for cesarean delivery, and a better understanding of the interplay between concordance and satisfaction are warranted.

Mismatch between pollen and pistil size causes asymmetric mechanical reproductive isolation across Phlox species.

In flowering plants, pollen-pistil interactions can serve as an important barrier to reproduction between species. As the last barrier to reproduction before fertilization, interactions between these reproductive organs are both complex and important for determining a suitable mate. Here, we test whether differences in style length generate a post-mating prezygotic mechanical barrier between five species of perennial Phlox wildflowers with geographically overlapping distributions. We perform controlled pairwise reciprocal crosses between three species with long styles and two species with short styles to assess crossing success (seed set). We find that heterospecific seed set is broadly reduced compared to conspecific cross success and reveal a striking asymmetry in heterospecific crosses between species with different style lengths. To determine the mechanism underlying this asymmetric reproductive isolating barrier we assess pollen tube growth in vitro and in vivo. We demonstrate that pollen tubes of short-styled species do not grow long enough to reach the ovaries of long-styled species. We find that short-styled species also have smaller pollen and that both within and between species pollen diameter is highly correlated with pollen tube length. Our results support the hypothesis that the small pollen of short-styled species lacks resources to grow pollen tubes long enough to access the ovaries of the long-styled species, resulting in an asymmetrical, mechanical barrier to reproduction. Such mechanisms, combined with additional pollen-pistil incompatibilities, may be particularly important for closely related species in geographic proximity that share pollinators.

Pain during cesarean delivery: A patient-related prospective observational study assessing the incidence and risk factors for intraoperative pain and intravenous medication administration.

INTRODUCTION: The incidence of pain during cesarean delivery (PDCD) remains unclear. Most studies evaluated PDCD using interventions suggesting inadequate analgesia: neuraxial replacement, unplanned intravenous medication (IVM), or conversion to general anesthesia. Few assess self-reported pain. This study evaluates the incidence of and risk factors for self-reported PDCD and IVM administration. METHODS: Between May and September 2022, English-speaking women undergoing cesarean delivery under neuraxial anesthesia were approached within the first 48 h. Participants answered a 16-question survey about intraoperative anesthesia care. Clinical characteristics were extracted from electronic medical records. The primary outcome was PDCD. Secondary outcomes were analgesic IVM (opioids alone or in combination with ketamine, midazolam, or dexmedetomidine) and conversion to general anesthesia. Risk factors for PDCD and analgesic IVM were identified using multivariable logistic regression models. RESULTS: Pain was reported by 46/399 (11.5%; 95% CI: 8.6, 15.1) participants. Analgesic IVM was administered to 16 (34.8%) women with PDCD and 45 (12.6%) without. Conversion to general anesthesia occurred in 3 (6.5%) women with and 4 (1.1%) without PDCD. Risk factors associated with PDCD were substance use disorder and intrapartum epidural extension. Risk factors associated with analgesic IVM were PDCD, intrapartum epidural extension when ≥2 epidural top-ups were given for labor analgesia, and longer surgical duration. DISCUSSION: In our cohort of scheduled and unplanned cesarean deliveries, the incidence of PDCD was 11.5%. A significant proportion of women (15.1%) received analgesic IVM, of which some but not all reported pain, which requires further evaluation to identify triggers for IVM administration and strategies optimizing shared decision-making.

Teaching Designing for Additive Manufacturing: Formulating Educational Interventions That Encourage Design Creativity.

As additive manufacturing (AM) processes become more ubiquitous in engineering, design, and manufacturing, the need for a workforce skilled in designing for additive manufacturing (DfAM) has grown. Despite this need for an AM-skilled workforce, little research has systematically investigated the formulation of educational interventions for training engineers in DfAM. In this article, we synthesize findings from our experiments with 596 engineering design students to inform the development of educational interventions-comprising content presentations and design tasks-that encourage student learning and creativity. Specifically, we investigated the effects of four variations of DfAM educational interventions by manipulating the following: (1) the content of DfAM information presented, (2) the order of presenting the DfAM content, (3) the definition of the AM design task, and (4) the competitive structure of the AM design task. The effects of these variations were experimentally tested by comparing changes in students' DfAM self-efficacy and the creativity of students' design outcomes. Validated measures were also developed as part of our studies to help mature the nascent field of DfAM education. Based on the findings of our experiments, we discuss how task-based educational interventions can be formulated to (1) increase students' DfAM self-efficacy, (2) encourage students to generate ideas of high AM technical goodness, and (3) encourage students to generate more creative ideas when using AM. The novel synthesis of our findings in this article will help educators formulate effective DfAM educational interventions and tasks to foster a workforce skilled in DfAM.

Design and manufacturability data on additively manufactured solutions for COVID-19.

Designers around the world have leveraged the rapid prototyping and manufacturing capabilities of additive manufacturing (AM), commonly known as 3D printing, to develop numerous engineering design solutions for the COVID-19 pandemic. This dataset consists of the design and manufacturability data for twenty-six such engineering design solutions spanning three categories: (1) face masks (N = 12), (2) face shields (N = 6), and (3) hands-free door openers (N = 8). The designs were collected from open-source websites such as Thingiverse, GrabCAD, and the NIH 3D Print Exchange. The manufacturability of these designs was simulated using Ultimaker Cura software and three measures were obtained: (1) build time, (2) build cost, and (3) build material. Furthermore, these simulations were performed for multiple materials and infill densities for comparison. Additionally, the manufacturing cost using injection molding was simulated using the Cost Estimation Tool in Solidworks. This dataset comprises (1) the STL files for the designs, (2) the simulated manufacturability data (for additive manufacturing and injection molding), and (3) images that depict the build orientation used in these manufacturability simulations. This dataset can facilitate the development of future innovations that leverage the capabilities of AM processes. Furthermore, this dataset can be used by designers and manufacturers to compare solutions and choose appropriate ones for manufacturing.

Looks can be deceiving: Gaze pattern differences between novices and experts during placement of central lines.

BACKGROUND: The objective of this study was to determine whether gaze patterns could differentiate expertise during simulated ultrasound-guided Internal Jugular Central Venous Catheterization (US-IJCVC) and if expert gazes were different between simulators of varying functional and structural fidelity. METHODS: A 2017 study compared eye gaze patterns of expert surgeons (n = 11), senior residents (n = 4), and novices (n = 7) during CVC needle insertions using the dynamic haptic robotic trainer (DHRT), a system which simulates US-IJCVC. Expert gaze patterns were also compared between a manikin and the DHRT. RESULTS: Expert gaze patterns were consistent between the manikin and DHRT environments (p = 0.401). On the DHRT system, CVC experience significantly impacted the percent of time participants spent gazing at the ultrasound screen (p < 0.0005) and the needle and ultrasound probe (p < 0.0005). CONCLUSION: Gaze patterns differentiate expertise during ultrasound-guided IJCVC placement and the fidelity of the simulator does not impact gaze patterns.

Evaluating Surgical Resident Needle Insertion Skill Gains in Central Venous Catheterization Training.

BACKGROUND: Training for ultrasound-guided central venous catheterization (CVC) is typically conducted on static manikin simulators with real-time feedback from a skilled observer. Dynamic haptic robotic trainers (DHRTs) are an alternative method that simulates various patient anatomies and provides consistent feedback for each insertion. This study evaluates CVC needle insertion efficiency and skill gains of both methods. MATERIALS AND METHODS: Fifty-two first-year surgical residents were trained by placing internal jugular (IJ) CVC needles in manikins (n = 26) or robots (n = 26). Manikin-trained participants received verbal feedback from an experienced observer, whereas robotically trained participants received quantitative feedback from the personalized DHRT learning interface. All participants were pretested on a Blue Phantom manikin; participants completed posttesting on a Blue Phantom manikin (n = 26) or a novel manikin (n = 26) with different vessel depth and position. During pretests and posttests residents were timed, motion-tracked, and scored on an IJ CVC checklist. RESULTS: (1) All skills on the IJ CVC checklist showed significant (P < 0.014) improvements from pretests to posttest; (2) Average angle of insertion, path length, and jerk improved significantly (P < 0.005); (3) Average procedural completion time, with standard error (SE) reported, decreased significantly from pretest (M = 3.516 min, SE = 0.277) to posttest (M = 1.997, SE = 0.409). CONCLUSIONS: No significant group differences were observed in overall skill gains, but residents' average procedural completion time decreased significantly from pretests to posttest. Overall results support DHRT as an effective method for training IJ CVC skills.

Building Ultrasound Phantoms With Modified Polyvinyl Chloride: A Comparison of Needle Insertion Forces and Sonographic Appearance With Commercial and Traditional Simulation Materials.

INTRODUCTION: Training using ultrasound phantoms allows for safe introduction to clinical skills and is associated with improved in-hospital performance. Many materials have been used to simulate human tissue in phantoms including commercial manikins, agar, gelatin, and Ballistics Gel; however, phantom tissues could be improved to provide higher-fidelity ultrasound images or tactile sensation. This article describes a novel phantom tissue mixture of a modified polyvinyl chloride (PVC) polymer, mineral oil, and chalk powder and evaluates needle cutting and ultrasonic properties of the modified PVC polymer mixture compared with a variety of phantom tissues. METHODS: The first experiment measured axial needle forces of a needle insertion into nine phantom materials, including three formulations of modified PVC. The second experiment used a pairwise comparison survey of ultrasound images to determine the perceived realism of phantom ultrasound images. RESULTS: It was found that the materials of Ballistics Gel and one of the PVC mixtures provide stiff force feedback similar to cadaver tissue. Other phantom materials including agar and gelatin provide very weak unrealistic force feedback. The survey results showed the PVC mixtures being viewed as the most realistic by the survey participants, whereas agar and Ballistics Gel were seen as the least realistic. CONCLUSIONS: The realism in cutting force and ultrasound visualization was determined for a variety of phantom materials. Novel modified PVC polymer has great potential for use in ultrasound phantoms because of its realistic ultrasound imaging and modifiable stiffness. This customizability allows for easy creation of multilayer tissue phantoms.

Role of apoptosis and autophagy in tuberculosis.

Tuberculosis (TB) is one of the oldest known human diseases and is transmitted by the bacteria Mycobacterium tuberculosis (Mtb). TB has a rich history with evidence of TB infections dating back to 5,800 bc TB is unique in its ability to remain latent in an individual for decades, with the possibility of later reactivation, causing widespread systemic symptoms. Currently, it is estimated that more than one-third of the world's population (~2 billion people) are infected with Mtb. Prolonged periods of therapy and complexity of treatment regimens, especially in active infection, have led to poor compliance in patients being treated for TB. Therefore, it is vitally important to have a thorough knowledge of the pathophysiology of Mtb to understand the disease progression, as well as to develop novel diagnostic tests and treatments. Alveolar macrophages represent both the primary host cell and the first line of defense against the Mtb infection. Apoptosis and autophagy of macrophages play a vital role in the pathogenesis and also in the host defense against Mtb. This review will outline the role of these two cellular processes in defense against Mtb with particular emphasis on innate immunity and explore developing therapies aimed at altering host responses to the disease.

Simultaneous Bilateral Hypertrophies of the Parotid Gland and Masseter Muscle: Case Report.

Increased salivary demand can lead to enlarged parotid salivary glands, and increased activity of the masseter muscles can cause masseter hypertrophy. This report describes a most unusual case of simultaneous bilateral hypertrophies of the parotid gland and masseter muscle originating from the very extensive habit of chewing gum. An extensive literature review uncovered many cases of the independent existence of masseteric or parotid hypertrophy, but no example of the simultaneous occurrence of these 2 conditions.