Examination of publications from academic anesthesiology faculty in the United States.

BACKGROUND: Leaders in academic anesthesiology in the United States have called for an examination of the state of scholarship within anesthesiology departments. National Institutes of Health funding and publication quality of subsets of U.S anesthesiologists have been examined; however, the publication output of and the demographic characteristics that are associated with academic anesthesiologists, defined as faculty associated with a medical college, are unknown. A database from the American Association of Medical Colleges containing demographic information of all academic anesthesiologists in the United States was used to examine the publication output and demographic characteristics of anesthesiology faculty during a 2-year period from 2006 to 2008. METHOD: All the publications found in the PubMed database for each faculty member were retrieved and included in a database containing their demographics including institution, gender, academic degree, academic rank, nature of appointment (part versus full-time), status of appointment (joint versus primary), departmental division, subspecialty certification status, and additional graduate medical education training. RESULTS: Six thousand one hundred forty-three faculty who held positions at the 108 U.S. academic anesthesiology programs published 8521 manuscripts between 2006 and 2008. Thirty-seven percent of faculty published a manuscript, and the overall median publication rate was 0. The proportion of faculty with at least 1 publication was larger among faculty with higher rank (Odds Ratio [OR] for professors versus instructors = 6.4; confidence interval [CI], 4.57-8.49; P < 0.0001), male gender (OR 1.3; CI, 0.14-1.47; P < 0.0001), possessing a courtesy appointment status (OR 2.1; CI, 1.25-3.52; P = 0.0048) and lacking postgraduate training and subspecialty certification (OR for MD versus MD w/training + certification 1.3; CI, 1.11-1.60; P = 0.0020). Those faculty with an MD had lower probablility of publishing when compared with MD/PhD or PhD faculty (OR 0.45; CI, 0.32-0.65; P < 0.0001; OR 0.27; CI, 0.20-0.37; P < 0.0001, respectively). Within the group of faculty who published at least 1 paper, full professor faculty had 3.8 times more publications than instructors (CI, 2.99-4.88; P < 0.0001), and those who lacked postgraduate training had 1.4 times more publications than those who were trained and certified (CI, 1.16-1.78; P = 0.0009). PhD degree (P = 0.006), male gender (P = 0.013), and courtesy anesthesia appointment (P = 0.037) also were associated with higher publication rates. CONCLUSIONS: The overall publication rate of anesthesiologists associated with medical schools was low in this time period. These data establish the pre-"call to action" baseline of scholarly activity by U.S. academic anesthesiologists for future comparisons. Increased use of structured resident and fellow research education programs as well as recruiting more MD/PhD and PhD scientists to the field may help to improve the publication productivity of academic anesthesiology departments.

Analgesic efficacy of ultrasound-guided regional anesthesia: a meta-analysis.

STUDY OBJECTIVE: To determine if the use of ultrasound guidance (vs non-ultrasound techniques) improves the success rate of nerve blocks. DESIGN: Meta-analysis of randomized controlled trials (RCTs) in the published literature. SETTING: University medical center. MEASUREMENTS: 16 RCTs of patients undergoing elective surgical procedures were studied. Patients underwent ultrasound-guided or non-ultrasound techniques (nerve stimulation, surface landmark) for peripheral nerve blocks. Success rates were measured. MAIN RESULTS: Ultrasound guidance (vs all non-ultrasound techniques) was associated with a significant increase in the success rate of nerve blocks [relative risk (RR) = 1.11 (95% confidence interval [CI]: 1.06 to 1.17, P < 0.0001]). When compared with nerve stimulator techniques only, ultrasound guidance was still associated with an increase in the success rate (RR = 1.11 [95% CI: 1.05 to 1.17, P = 0.0001]). For specific blocks, ultrasound guidance (vs all non-ultrasound) was associated with a significant increase in successful brachial plexus (all) nerve blocks (RR = 1.11 [95% CI: 1.05 to 1.20, P = 0.0001]), sciatic popliteal nerve block (RR = 1.22 [95% CI: 1.08 to 1.39, P = 0.002]) and brachial plexus axillary nerve block (RR = 1.13 [95% CI: 1.00 to 1.26, P = 0.05]) but not brachial plexus infraclavicular nerve block (RR = 1.25 [95% CI: 0.88 to 1.76, P = 0.22]). CONCLUSIONS: Ultrasound-guided peripheral nerve block is associated with an increased overall success rate when compared with nerve stimulation or other methods. Ultrasound-guided techniques also increase the success rate of some specific blocks.

Transverse-plane pelvic asymmetry in patients with cerebral palsy and scoliosis.

BACKGROUND: Pelvic obliquity and loss of sitting balance develop from progressive scoliosis in cerebral palsy (CP) and are indications for surgery. Our goal was to quantify pelvic asymmetry to help understand skeletal deformity in CP and its surgical correction. METHODS: We assessed pelvic angles and transverse plane symmetry in 27 consecutive patients with scoliosis and severe CP who had undergone computed tomography for spinal surgery (subjects). The program used allowed measurement of angles in the true transverse plane, compensating for any obliquity present. Measurements included angles of the upper and lower ilium with respect to the sacrum, acetabular anteversion, and sacroiliac joint angles. We compared subject measurements with those of 20 age-matched controls and used Student t test to determine whether subjects had greater asymmetry and if the asymmetry direction was correlated with the adducted hip and/or the scoliosis in subjects with windswept hips. RESULTS: Subjects had significantly more iliac angle asymmetry (P=0.01) and asymmetry of at least 10 degrees in these categories: upper ilium, 15 (mean difference, 18); above sciatic notch, 14 (mean difference, 17); just below sciatic notch, 15 (mean difference, 19); sacroiliac joint, 5; and acetabular anteversion, 6. No control had asymmetry greater than 10 degrees. Comparing subjects with and without windswept hips, the former had more asymmetrical upper iliac angles. In 16 subjects with windswept hips, the scoliosis curve convexity was ipsilateral to the more internally rotated ilium. In 4 of the 5 subjects with severely windswept hips, the side of the adducted hip had more inward iliac rotation than did the contralateral (abducted) hip. CONCLUSIONS: Transverse pelvic asymmetry, a little-recognized deformity in patients with severe CP, is most pronounced above the acetabulum and is more common in patients with windswept hips. Spine surgeons should be aware of such asymmetry because it may make iliac fixation challenging and account for some persistent postoperative deformity. LEVEL OF EVIDENCE: Case-control study, Level III.

Low profile pelvic fixation with the sacral alar iliac technique in the pediatric population improves results at two-year minimum follow-up.

STUDY DESIGN: Retrospective review. OBJECTIVE: Anchor stability and prominence are problems with pelvic fixation in pediatric spinal deformity surgery. We compared the new sacral alar iliac (SAI) fixation technique (with a starting point in the sacral ala and in-line anchors deep under the midline muscle flap) with other methods of screw fixation. SUMMARY OF BACKGROUND DATA: Iliac anchors have been shown to provide the best form of pelvic fixation. A trajectory from the posterior sacral surface to the iliac wings has recently been described. To our knowledge, no clinical series has compared this method of pelvic fixation in children to others. METHODS: Of 32 consecutive pediatric patients who underwent SAI fixation, 2 died and 26 returned for follow-up (>2 years). Mean age at surgery was 14 years. Average screw size was 67 mm long and 7 to 9 mm in diameter. Clinical examinations, radiographs, and computed tomography scans were analyzed. Outcomes included pain over the implants, screw placement, implant prominence, radiographic lucency, need for revision, and infection. SAI patients were compared with 27 previous patients who had pelvic fixation via other screw techniques. RESULTS: For SAI fixation, correction of pelvic obliquity and Cobb angles were 20° ± 11° (70%) and 42° ± 25° (67%), respectively. For other pelvic fixation methods, those values were 10° ± 9° (50%), and 46° ± 16° (60%), respectively. Compared with other screws, SAI screws provided significantly better pelvic obliquity correction (P = 0.002) but no difference in Cobb correction. There were 2 lucencies adjacent to screws in both groups. Computed tomography scans of 18 SAI patients showed no intrapelvic protrusion, but 1 screw extended laterally (<5 mm). One early SAI patient required revision with larger screws, which relieved pain; there was 1 revision in the comparison group. SAI patients had no deep infections, implant prominence, late skin breakdown, or anchor migration; traditional patients had 3 deep infections (P = 0.09) and 3 instances of implant prominence, skin breakdown, or anchor migration. CONCLUSION: SAI pelvic fixation produces better correction of pelvic obliquity than do previous techniques. Radiographic and clinical anchor stability is satisfactory at 2-year follow-up.

The effect of intravenous opioid patient-controlled analgesia with and without background infusion on respiratory depression: a meta-analysis.

BACKGROUND: Although the addition of a background infusion for intravenous patient-controlled analgesia (IV-PCA) has been identified as a risk factor for the development of respiratory depression, this has not clearly been examined in a systematic fashion. The authors undertook a systematic review and meta-analysis of available randomized controlled trials (RCTs) to examine whether the addition of a background or continuous infusion to an IV-PCA regimen would be associated with an increased risk of respiratory depression. METHODS: Studies were identified by searching the National Library of Medicine's PubMed database (1966 to November 30, 2008). Inclusion criteria were a clearly defined analgesic technique of demand-only IV-PCA versus IV-PCA utilizing both a demand dose and background infusion, opioid medication used, and randomized trials. Data were abstracted and analyzed with the RevMan 4.2.7 (The Cochrane Collaboration, 2004). RESULTS: The search yielded 687 abstracts from which the original articles were obtained and data abstracted with a total of 14 articles analyzed. There were 402 subjects in the continuous IV-PCA with demand group versus the 394 subjects in the demand-only IV-PCA group. Addition of a background infusion to the demand dose for IV-PCA with opioids was associated with a significant increased risk for respiratory depression (odds ratio [OR] = 4.68, 95% confidence interval [CI]: 1.20-18.21). Subgroup analysis revealed that this increased risk was seen in adult but not in pediatric patients. CONCLUSIONS: Our meta-analysis indicates that the addition of a continuous or background infusion to the demand dose for IV-PCA is associated with a higher incidence of respiratory events than demand IV-PCA alone in adult but not in pediatric patients; however, our overall results should be interpreted with caution due to the relatively small sample size and the wide range of definitions for respiratory depression in studies examined.