Using Bibliometric Data to Define and Understand Publishing Network Equity in Anesthesiology.

BACKGROUND: Anesthesiology departments and professional organizations increasingly recognize the need to embrace diverse membership to effectively care for patients, to educate our trainees, and to contribute to innovative research. 1 Bibliometric analysis uses citation data to determine the patterns of interrelatedness within a scientific community. Social network analysis examines these patterns to elucidate the network's functional properties. Using these methodologies, an analysis of contemporary scholarly work was undertaken to outline network structure and function, with particular focus on the equity of node and graph-level connectivity patterns. METHODS: Using the Web of Science, this study examines bibliographic data from 6 anesthesiology-specific journals between January 1, 2017, and August 26, 2022. The final data represent 4453 articles, 19,916 independent authors, and 4436 institutions. Analysis of coauthorship was performed using R libraries software. Collaboration patterns were assessed at the node and graph level to analyze patterns of coauthorship. Influential authors and institutions were identified using centrality metrics; author influence was also cataloged by the number of publications and highly cited papers. Independent assessors reviewed influential author photographs to classify race and gender. The Gini coefficient was applied to examine dispersion of influence across nodes. Pearson correlations were used to investigate the relationship between centrality metrics, number of publications, and National Institutes of Health (NIH) funding. RESULTS: The modularity of the author network is significantly higher than would be predicted by chance (0.886 vs random network mean 0.340, P < .01), signifying strong community formation. The Gini coefficient indicates inequity across both author and institution centrality metrics, representing moderate to high disparity in node influence. Identifying the top 30 authors by centrality metrics, number of published and highly cited papers, 79.0% were categorized as male; 68.1% of authors were classified as White (non-Latino) and 24.6% Asian. CONCLUSIONS: The highly modular network structure indicates dense author communities. Extracommunity cooperation is limited, previously demonstrated to negatively impact novel scientific work. 2 , 3 Inequitable node influence is seen at both author and institution level, notably an imbalance of information transfer and disparity in connectivity patterns. There is an association between network influence, article publication (authors), and NIH funding (institutions). Female and minority authors are inequitably represented among the most influential authors. This baseline bibliometric analysis provides an opportunity to direct future network connections to more inclusively share information and integrate diverse perspectives, properties associated with increased academic productivity. 3 , 4.

Effects of Glucagon-Like Peptide-1 Receptor Agonists on Gastric Mucosal Visibility and Retained Gastric Contents During Esophagogastroduodenoscopy.

BACKGROUND AND AIMS: Glucagon-like peptide-1 receptor agonists (GLP-1RA) are increasingly utilized in diabetes and obesity management. GLP-1RAs delay gastric emptying; however, their impact on visibility during esophagogastroduodenoscopy (EGD) remains uncertain. METHODS: A 1:1 matched case-control study was conducted. Individuals undergoing EGD on GLP-1RAs were matched to non-users based on demographics and diabetes status. A validated scale (POLPREP) was used to determine gastric mucosal visibility scores. RESULTS: A total of 84 pairs (n=168) were included. GLP-1RA users showed significantly lower visibility scores, with a 2.54 times higher likelihood of lower scores compared to non-users. Additionally, GLP-1RA users had a higher incidence of retained gastric contents (13.1% vs. 4.8%, aOR:4.62, p=0.025) and aborted procedures due to this issue. No anesthesia-related adverse events were observed. CONCLUSIONS: GLP-1RA use at the time of endoscopy exhibited higher odds of lower gastric mucosal visibility scores, retained contents and aborted procedures. Further research is warranted.

Society for Ambulatory Anesthesia Updated Consensus Statement on Perioperative Blood Glucose Management in Adult Patients With Diabetes Mellitus Undergoing Ambulatory Surgery.

WHAT OTHER GUIDELINES ARE AVAILABLE ON THIS TOPIC: Since the publication of the SAMBA Consensus Statement for perioperative blood glucose management in the ambulatory setting in 2010, several recent guidelines have been issued by the American Diabetes Association (ADA), the American Association of Clinical Endocrinologists (AACE), the Endocrine Society, the Centre for Perioperative Care (CPOC), and the Association of Anaesthetists of Great Britain and Ireland (AAGBI) on DM care in hospitalized patients; however, none are specific to ambulatory surgery. HOW DOES THIS GUIDELINE DIFFER FROM THE PREVIOUS GUIDELINES: Previously posed clinical questions that were outdated were revised to reflect current clinical practice. Additional questions were developed relating to the perioperative management of patients with DM to include the newer therapeutic interventions.

A Call to Action: A Specialty-Specific Course to Support the Next Generation of Clinician Scientists in Anesthesiology.

Clinical production pressure is a significant problem for faculty of anesthesiology departments who seek to remain involved in research. Lack of protected time to dedicate to research and insufficient external funding add to this long-standing issue. Recent trends in funding to the departments of anesthesiology and their academic output validate these concerns. A 2022 study examining National Institutes of Health (NIH) grant recipients associated with anesthesiology departments across 10 years (2011-2020) outlines total awarded funds at $1,676,482,440, with most of the funds awarded to only 10 departments in the United States. Of note, the total 1-year NIH funding in 2021 for academic internal medicine departments was 3 times higher than the 10-year funding of anesthesiology departments. Additionally, American Board of Anesthesiology (ABA) diplomats represent a minority (37%) of the anesthesiology researchers obtaining grant funding, with a small number of faculty members receiving a prevalence of monies. Overall, the number of publications per academic anesthesiologist across the United States remains modest as does the impact of the scholarly work. Improving environments in which academic anesthesiologists thrive may be paramount to successful academic productivity. In fact, adding to the lack of academic time is the limited bandwidth of senior academic physicians to mentor and support aspiring physician scientists. Given then the challenges for individual departments and notable successes of specialty-specific collaborative efforts (eg Foundation for Anesthesia Education and Research [FAER]), additional pooled-resource approaches may be necessary to successfully support and develop clinician scientists. It is in this spirit that the leadership of Anesthesia and Analgesia and the Journal of Education in Perioperative Medicine, unified with the Association of University Anesthesiologists, aim to sponsor the Introduction to Clinical Research for Academic Anesthesiologists (ICRAA) Course. Directed toward early career academic anesthesiologists who wish to gain competency specifically in the fundamentals of clinical research and receive mentorship to develop an investigative project, the yearlong course will provide participants with the skills necessary to design research initiatives, ethically direct research teams, successfully communicate ideas with data analysts, and write and submit scientific articles. Additionally, the course, articulated in a series of interactive lectures, mentored activities, and workshops, will teach participants to review articles submitted for publication to medical journals and to critically appraise evidence in published research. It is our hope that this initiative will be of interest to junior faculty of academic anesthesiology departments nationally and internationally.

A Call to Action: A Specialty-Specific Course to Support the Next Generation of Clinician Scientists in Anesthesiology.

Clinical production pressure is a significant problem for faculty of anesthesiology departments who seek to remain involved in research. Lack of protected time to dedicate to research and insufficient external funding add to this long-standing issue. Recent trends in funding to the departments of anesthesiology and their academic output validate these concerns. A 2022 study examining National Institutes of Health (NIH) grant recipients associated with anesthesiology departments across 10 years (2011-2020) outlines total awarded funds at $1,676,482,440, with most of the funds awarded to only 10 departments in the United States. Of note, the total 1-year NIH funding in 2021 for academic internal medicine departments was 3 times higher than the 10-year funding of anesthesiology departments. Additionally, American Board of Anesthesiology (ABA) diplomats represent a minority (37%) of the anesthesiology researchers obtaining grant funding, with a small number of faculty members receiving a prevalence of monies. Overall, the number of publications per academic anesthesiologist across the United States remains modest as does the impact of the scholarly work. Improving environments in which academic anesthesiologists thrive may be paramount to successful academic productivity. In fact, adding to the lack of academic time is the limited bandwidth of senior academic physicians to mentor and support aspiring physician scientists. Given then the challenges for individual departments and notable successes of specialty-specific collaborative efforts (eg, Foundation for Anesthesia Education and Research [FAER]), additional pooled-resource approaches may be necessary to successfully support and develop clinician scientists. It is in this spirit that the leadership of Anesthesia & Analgesia and The Journal of Education in Perioperative Medicine, unified with the Association of University Anesthesiologists, aim to sponsor the Introduction to Clinical Research for Academic Anesthesiologists (ICRAA) Course. Directed toward early career academic anesthesiologists who wish to gain competency specifically in the fundamentals of clinical research and receive mentorship to develop an investigative project, the yearlong course will provide participants with the skills necessary to design research initiatives, ethically direct research teams, successfully communicate ideas with data analysts, and write and submit scientific articles. Additionally, the course, articulated in a series of interactive lectures, mentored activities, and workshops, will teach participants to review articles submitted for publication to medical journals and to critically appraise evidence in published research. It is our hope that this initiative will be of interest to junior faculty of academic anesthesiology departments nationally and internationally.

Moving Past Burnout, Looking Toward Engagement.

Physician engagement is often discussed in the medical literature; yet health care research examining this construct has been disjointed and plagued by conceptual ambiguities. Examining validated organizational evidence, we offer 3 key antecedents of work engagement that show promise as resources for medical professionals and health care organizations: psychological safety, organizational justice, and job crafting. In addition, we outline the nomological network of related, yet distinct, concepts, to demonstrate the relationship between engagement, burnout, and job satisfaction. As health care organizations facilitate engagement, they provide an additional avenue to decrease physician burnout, while also positively impacting provider and organizational outcomes.

Artificial Intelligence in Perioperative Medicine: A Proposed Common Language With Applications to FDA-Approved Devices.

As implementation of artificial intelligence grows more prevalent in perioperative medicine, a clinician's ability to distinguish differentiating aspects of these algorithms is critical. There are currently numerous marketing and technical terms to describe these algorithms with little standardization. Additionally, the need to communicate with algorithm developers is paramount to actualize effective and practical implementation. Of particular interest in these discussions is the extent to which the output or predictions of algorithms and tools are understandable by medical practitioners. This work proposes a simple nomenclature that is intelligible to both clinicians and developers for quickly describing the interpretability of model results. There are three high-level categories: transparent, translucent, and opaque. To demonstrate the applicability and utility of this terminology, these terms were applied to the artificial intelligence and machine-learning-based products that have gained Food and Drug Administration approval. During this review and categorization process, 22 algorithms were found with perioperative utility (in a database of 70 total algorithms), and 12 of these had publicly available citations. The primary aim of this work is to establish a common nomenclature that will expedite and simplify descriptions of algorithm requirements from clinicians to developers and explanations of appropriate model use and limitations from developers to clinicians.

Implementation of App-Based Diabetes Medication Management: Outpatient and Perioperative Clinical Decision Support.

PURPOSE OF REVIEW: Outpatient and perioperative therapeutic decision making for patients with diabetes involves increasingly complex medical-decision making due to rapid advances in knowledge and treatment modalities. We sought to review mobile decision support tools available to clinicians for this essential and increasingly difficult task, and to highlight the development and implementation of novel mobile applications for these purposes. RECENT FINDINGS: We found 211 mobile applications related to diabetes from the search, but only five were found to provide clinical decision support for outpatient diabetes management and none for perioperative decision support. We found a dearth of tools for clinicians to navigate these tasks. We highlight key aspects for effective development of future diabetes decision support. These include just-in-time availability, respect for the five rights of clinical decision support, and integration with clinical workflows including the electronic medical record.

Abdominal Surgery With Bilateral Rectus Sheath Block: A Case Report.

A 44-year-old man, American Society of Anesthesiologists physical status class IV, presented for fulguration of anal condyloma and diverting colostomy. The patient's medical history includes World Health Organization (WHO) class I pulmonary hypertension (PH), right heart failure, and bilateral lower extremity paralysis due to Pott's disease. The patient was not a candidate for neuraxial anesthesia due to sacral decubitus ulcers, and alternative options to general anesthesia (GA) were considered to avoid the high risk of right ventricular (RV) failure and ensuing complications. The case was successfully performed under sedation with dexmedetomidine infusion and bilateral rectus sheath blocks for surgical anesthesia.

Sitagliptin for prevention of stress hyperglycemia in patients without diabetes undergoing general surgery: A pilot randomized study.

AIM: We investigated if a dipeptidyl peptidase-4 inhibitor, sitagliptin, can prevent perioperative stress hyperglycemia in patients without prior history of diabetes mellitus undergoing general surgery. METHODS: This double-blind pilot trial randomized general surgery patients to receive sitagliptin (n = 44) or placebo (n = 36) once daily, starting one day prior to surgery and continued during the hospital stay. The primary outcome was occurrence of stress hyperglycemia, defined by blood glucose (BG) >140 mg/dL and >180 mg/dL after surgery. Secondary outcomes included: length-of-stay, ICU transfers, hypoglycemia, and hospital complications. RESULTS: BG >140 mg/dL was present in 44 (55%) of subjects following surgery. There were no differences in hyperglycemia between placebo and sitagliptin (56% vs. 55%, p = 0.93). BG >180 mg/dL was observed in 19% and 11% of patients treated with placebo and sitagliptin, respectively, p = 0.36. Both treatment groups had resulted in similar postoperative BG (148.9 ±â€¯29.4 mg/dL vs. 146.9 ±â€¯35.2 mg/dL, p = 0.73). There were no differences in length-of-stay (4 vs. 3 days, p = 0.84), ICU transfer (3% vs. 5%, p = 1.00), hypoglycemia <70 mg/dL (6% vs. 11%, p = 0.45), and complications (14% vs. 18%, p = 0.76). CONCLUSION: Preoperative treatment with sitagliptin did not prevent stress hyperglycemia or complications in individuals without diabetes undergoing surgery.

Effect of basal insulin dosage on blood glucose concentration in ambulatory surgery patients with type 2 diabetes.

STUDY OBJECTIVE: Among patients with type 2 diabetes treated with insulin, perioperative hyperglycemia and hypoglycemia may cause undesirable symptoms, surgery delay or cancellation, or unexpected hospitalization. Our objective was to compare preoperative glargine dosing regimens on perioperative glycemic control in patients undergoing ambulatory surgery. DESIGN: Observational study. SETTING: Pre- and postoperative holding areas. PATIENTS: One hundred fifty patients with type 2 diabetes using a once daily, evening insulin glargine regimen undergoing ambulatory surgery were included. INTERVENTIONS: None. MEASUREMENTS: To conduct the analysis, patients were divided into four groups based on the percentage of normal evening glargine dose taken. Group 1 took no glargine. Group 2 took 33%-57%. Group 3 took 60%-87% and Group 4 took 100% of their normal dose. The primary outcome was the proportion of patients in each group with blood glucose in the target range (100-180 mg/dL), and the incidence of hypoglycemia (defined as BG <70 mg/dL or symptomatic, requiring glucose). MAIN RESULTS: Group 3 had the highest proportion (78%) of patients within target range (P<.001) and Group 4 had the highest proportion of patients with hypoglycemia (P=.01). Patients in Group 3 were significantly more likely to achieve target blood glucose than patients in either Group 1 (P=.001) or Group 4 (P=.002). CONCLUSIONS: Our study shows that the percent of normal insulin dose given the evening before surgery directly impacts perioperative glucose levels in ambulatory surgery patients. Patients taking 60%-87% of their usual dose the evening before surgery were likely to arrive in target blood glucose range with decreased risk for hypoglycemia. The mean and mode dose taken in Group 3 were 73% and 75%, respectively, suggesting that the optimal dose may be 75% of normal dose.

The Emory University Perioperative Algorithm for the Management of Hyperglycemia and Diabetes in Non-cardiac Surgery Patients.

Hyperglycemia is a frequent manifestation of critical and surgical illness, resulting from the acute metabolic and hormonal changes associated with the response to injury and stress (Umpierrez and Kitabchi, Curr Opin Endocrinol. 11:75-81, 2004; McCowen et al., Crit Care Clin. 17(1):107-24, 2001). The exact prevalence of hospital hyperglycemia is not known, but observational studies have reported a prevalence of hyperglycemia ranging from 32 to 60 % in community hospitals (Umpierrez et al., J Clin Endocrinol Metab. 87(3):978-82, 2002; Cook et al., J Hosp Med. 4(9):E7-14, 2009; Farrokhi et al., Best Pract Res Clin Endocrinol Metab. 25(5):813-24, 2011), and 80 % of patients after cardiac surgery (Schmeltz et al., Diabetes Care 30(4):823-8, 2007; van den Berghe et al., N Engl J Med. 345(19):1359-67, 2001). Retrospective and randomized controlled trials in surgical populations have reported that hyperglycemia and diabetes are associated with increased length of stay, hospital complications, resource utilization, and mortality (Frisch et al., Diabetes Care 33(8):1783-8, 2010; Kwon et al., Ann Surg. 257(1):8-14, 2013; Bower et al., Surgery 147(5):670-5, 2010; Noordzij et al., Eur J Endocrinol. 156(1):137-42, 2007; Mraovic et al., J Arthroplasty 25(1):64-70, 2010). Substantial evidence indicates that correction of hyperglycemia reduces complications in critically ill, as well as in general surgery patients (Umpierrez et al., J Clin Endocrinol Metab. 87(3):978-82, 2002; Clement et al., Diabetes Care 27(2):553-97, 2004; Pomposelli et al., JPEN J Parented Enteral Nutr. 22(2):77-81, 1998). This manuscript reviews the pathophysiology of stress hyperglycemia during anesthesia and the perioperative period. We provide a practical outline for the diagnosis and management of preoperative, intraoperative, and postoperative care of patients with diabetes and hyperglycemia.

Postanesthesia Care for the Elderly Patient.

PURPOSE: As the general population lives longer, the perioperative physician is more likely to encounter disease states that increase in incidence in an aging population. This review focuses on anesthetic considerations for rational drug choices during the perioperative care of elderly patients. The primary aim of the review was to identify intraoperative and postanesthetic considerations for diseases associated with advancing age; it includes highlights of the commonly impaired major organs (eg, cardiovascular, pulmonary, neurologic, renal, hepatic systems). We also outline an approach to frequent issues that arise in the immediate postsurgical period while caring for these patients. METHODS: A systematic review was performed on aspects of the perioperative and postoperative periods that relate to the elderly. A list of pertinent key words was derived from the authors, and a PubMed database search was performed. FINDINGS: The anesthesiologist must account for changes in various organ systems that affect perioperative care, including the cardiovascular, pulmonary, renal, hepatic, and central nervous systems. The pharmacokinetic principles frequently differ and are often unpredictable because of anatomic changes and decreased renal and hepatic function. The most important pharmacodynamic consideration is that elderly patients tend to exhibit an exaggerated hypoactivity after anesthesia. IMPLICATIONS: Before surgery, it is essential to identify those patients at risk for delirium and other commonly encountered postanesthesia scenarios. Failure to manage these conditions appropriately can lead to an escalation of care and prolonged hospitalization.