A Comparative Analysis of Local Anesthetics: Injection Associated Pain and Duration of Anesthesia.

BACKGROUND: Local anesthesia administration is frequently the most painful step of dermatologic surgery. Identification of an anesthetic that minimizes infiltration pain and toxicity while maximizing duration of action would improve both patient satisfaction and procedural safety. This study compared eight local anesthetic solutions to identify the composition that minimizes infiltration pain, maximizes duration of effect, and minimizes amount of local anesthetic needed. METHODS: In a double-blinded study, thirty subjects were injected with eight local anesthetic solutions of varied concentrations of lidocaine, epinephrine, benzyl alcohol, and sodium bicarbonate. Infiltration pain was rated by subjects using a visual analog scale and duration of anesthesia was assessed by needle prick sensation every 15 minutes. RESULTS: Solutions 2, 7, and 8, were significantly less painful (P<0.001), though not statistically different from each other. Two of the three solutions were buffered 10:1 with sodium bicarbonate. Additionally, two of the three contained notably decreased concentrations of lidocaine, 0.091% and 0.083%, than traditionally used in practice. The use of benzyl alcohol did not result in a reduction of reported pain. The duration of action was equal among the solutions regardless of anesthetic concentration. CONCLUSIONS: A solution of 0.091% lidocaine with epinephrine 1:1,100,000 and 0.82% benzyl alcohol reduces medication dose while ensuring maximum patient comfort and, theoretically, increases shelf life. While considered off-label, clinically effective dermal anesthesia may be obtained at a lower concentration of lidocaine and epinephrine than is commonly used, aiding conservative use of local anesthetic, particularly during times of national shortage. J Drugs Dermatol. 2023;22(4): doi:10.36849/JDD.5183 Citation: Moses A, Klager S, Weinstein A, et al. A comparative analysis of local anesthetics: Injection associated pain and duration of anesthesia. J Drugs Dermatol. 2023;22(4):364-368. doi:10.36849/JDD.5183.

Needs assessment for enhancing pediatric clerkship readiness.

BACKGROUND: Many students report feeling inadequately prepared for their clinical experiences in pediatrics. There is striking variability on how pediatric clinical skills are taught in pre-clerkship curricula. METHODS: We asked students who completed their clerkships in pediatrics, family medicine, surgery, obstetrics-gynecology and internal medicine to rate their pre-clinical training in preparing them for each clerkship, specifically asking about medical knowledge, communication, and physical exam skills. Based on these results, we surveyed pediatric clerkship and clinical skills course directors at North American medical schools to describe the competence students should have in the pediatric physical exam prior to their pediatric clerkship. RESULTS: Close to 1/3 of students reported not feeling adequately prepared for their pediatrics, obstetrics-gynecology, or surgery clerkship. Students felt less prepared to perform pediatric physical exam skills compared to physical exam skills in all other clerkships. Pediatric clerkship directors and clinical skills course directors felt students should have knowledge of and some ability to perform a wide spectrum of physical exam skills on children. There were no differences between the two groups except that clinical skills educators identified a slightly higher expected competence for development assessment skills compared to pediatric clerkship directors. CONCLUSIONS: As medical schools undergo cycles of curricular reform, it may be beneficial to integrate more pre-clerkship exposure to pediatric topics and skills. Further exploration and collaboration establishing how and when to incorporate this learning could serve as a starting point for curricular improvements, with evaluation of effects on student experience and performance. A challenge is identifying infants and children for physical exam skills practice.

A novel box for aerosol and droplet guarding and evacuation in respiratory infection (BADGER) for COVID-19 and future outbreaks.

The coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has infected millions and killed more than 1.7 million people worldwide as of December 2020. Healthcare providers are at increased risk of infection when caring for patients with COVID-19. The mechanism of transmission of SARS-CoV-2 is beginning to emerge as airborne spread in addition to direct droplet and indirect contact as main routes of transmission. Here, we report on the design, construction, and testing of the BADGER (Box for Aerosol and Droplet Guarding and Evacuation in Respiratory Infection), an affordable, scalable device that contains droplets and aerosol particles, thus minimizing the risk of infection to healthcare providers. A semi-sealed environment is created inside the BADGER, which is placed over the head of the patient and maintains at least 12-air changes per hour using in-wall vacuum suction. Multiple hand-ports enable healthcare providers to perform essential tasks on a patient's airway and head. Overall, the BADGER has the potential to contain large droplets and small airborne particles as demonstrated by simulated qualitative and quantitative assessments to provide an additional layer of protection for healthcare providers treating COVID-19 and future respiratory contagions.

Prenatal and postnatal mercury exposure and blood pressure in childhood.

Elevated blood pressure in childhood is an important risk factor for hypertension in adulthood. Environmental exposures have been associated with elevated blood pressure over the life course and exposure to mercury (Hg) has been linked to cardiovascular effects in adults. As subclinical vascular changes begin early in life, Hg may play a role in altered blood pressure in children. However, the evidence linking early life Hg exposure to altered blood pressure in childhood has been largely inconsistent. In the ongoing New Hampshire Birth Cohort Study, we investigated prenatal and childhood Hg exposure at multiple time points and associations with blood pressure measurements in 395 young children (mean age 5.5 years, SD 0.4). Hg exposure was measured in children's toenail clippings at age 3 and in urine at age 5-6 years, as well as in maternal toenail samples collected at ∼28 weeks gestation and 6 weeks postpartum, the latter two samples reflecting early prenatal and mid-gestation exposures, respectively. Five measurements of systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) were averaged for each child using a standardized technique. In covariate-adjusted linear regression analyses, we observed that a 0.1 µg/g increase in child toenail Hg at age 3 or a 0.1 µg/L urine Hg at age 5-6 were individually associated with greater DBP (toenail ß: 0.53 mmHg; 95% CI: -0.02, 1.07; urine ß: 0.48 mmHg; 95% CI: 0.10, 0.86) and MAP (toenail ß: 0.67 mmHg; 95% CI: 0.002, 1.33; urine ß: 0.55 mmHg; 95% CI: 0.10, 1.01). Neither early prenatal nor mid-gestation Hg exposure, as measured by maternal toenails, were related to any changes to child BP. Simultaneous inclusion of both child urine Hg and child toenail Hg in models suggested a potentially stronger relationship of urine Hg at age 5-6 with DBP and MAP, as compared to toenail Hg at age 3. Our findings suggest that Hg exposure during childhood is associated with alterations in BP. Childhood may be an important window of opportunity to reduce the impacts of Hg exposure on children's blood pressure, and in turn, long-term health.

Enhancing Empathy in Medical Students: Family-Faculty Members Facilitate Patient-Centered Reflection.

Parents of children with medical complexity can serve as family-faculty in undergraduate medical education. Medical students can learn about family-centered care through structured interviews, reflective writing, and classroom discussions with family-faculty.

Epinephrine-induced electrical storm after aortic surgery.

Electrical storm (ES) is a potentially lethal syndrome defined as three or more sustained episodes of ventricular tachycardia or ventricular fibrillation within 24 h. There are multiple inciting factors for ES, one of which involves excess catecholamine (endogenous and exogenous) effects. Exogenous catecholamines used for hemodynamic support can paradoxically engender or exacerbate an underling arrhythmia leading to ES. We report on an 63-year-old man who presented for repair of an ascending aortic dissection. After cardiopulmonary bypass separation assisted with high-dose epinephrine, ES developed requiring over 40 defibrillatory shocks. The epinephrine infusion was held and within 5 min, the ES self-terminated. ES in the context of cardiovascular surgery with the use of epinephrine for hemodynamic support has not be previously reported. Clinicians need to be cognizant of the seemingly paradoxical effect of epinephrine to induce ES. Initial ES treatment involves acute stabilization (treating or removing exacerbating factors (i.e., excess catecholamines)).

Preoperative Cardiac Stress Tests Ordered in the Preoperative Evaluation Clinic: A Retrospective Review of Ordering Patterns.

BACKGROUND: The role of anesthesiologists has expanded from operating rooms to preoperative evaluation clinics. This role involves performing preoperative cardiovascular evaluation and optimization of patients before elective surgery, which can include ordering cardiac stress tests. We aimed to study the ordering patterns by anesthesiologists for preoperative cardiac stress tests, focusing on whether societal and institutional guidelines and recommendations were used. Choice of type of cardiac stress test was also examined. METHODS: A single center retrospective chart review from December 1, 2005 to May 31, 2015 was performed on 492 patients who had a cardiac stress test ordered by an anesthesiologist. Patients were categorized by indication for ordering the cardiac stress test based on societal practice guidelines, institutional guidelines or other relevant reasons at the time of patient encounter. Those "other" category cardiac stress tests were assessed for indication and evaluated by physician peer review to see if there was peer agreement for being appropriately ordered. Exercise electrocardiography (ECG) cardiac stress tests ordered were evaluated for appropriateness based on baseline resting ECG findings. Patients with left bundle branch block (LBBB) or right ventricular (RV) pacing were evaluated for appropriateness of proper cardiac stress test modality based on whether a pharmacological vasodilator cardiac stress test was ordered. RESULTS: Analysis of the cardiac stress tests ordered showed that 43% were ordered according to American College of Cardiology/American Heart Association guidelines, 29% were ordered according to institutional guidelines, and 28% were categorized as "other". Of the 28% "other" cardiac stress tests, 53% were in agreement for ordering by peer review. Sixty-four exercise ECG cardiac stress tests were ordered, of which 58% were appropriate based on having no baseline resting ECG abnormalities. Fifty-one patients were identified as having a resting ECG of LBBB or RV pacing of which 41% had an appropriate pharmacological vasodilator cardiac stress tests ordered. CONCLUSIONS: Anesthesiologists order most preoperative cardiac stress tests according to professional societal or institutional guidelines (72%), yet they are not always choosing the best modality of cardiac stress test. A significant portion of cardiac stress tests are ordered (28%) based on clinical judgment, likely due to the lack of guidelines and recommendations being all-encompassing on many commonly encountered preoperative patient situations.

Seizure as the Presenting Symptom for Atypical Hemolytic Uremic Syndrome.

BACKGROUND: Atypical hemolytic uremic syndrome (aHUS) is a complement-mediated disease manifesting in thrombocytopenia, microangiopathic hemolytic anemia, and acute kidney injury. It has a higher incidence of extrarenal manifestations, including central nervous system findings like seizure or stroke, pancreatitis, and cardiac manifestations. CASE REPORT: We present a case of an unimmunized 14-month-old girl presenting with generalized seizure and ultimately diagnosed with aHUS. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: These atypical neurological symptoms can cause the diagnosis to be commonly missed in the emergency department. The etiology of approximately 60% of patients with aHUS can be attributed to genetic mutations in complement regulators including factor H, membrane cofactor protein, factor I, activator factor B, or C3. Although previously treated with plasma transfusion and immunosuppressants, eculizumab is a newer treatment that has been changing prognosis and management of aHUS, but it should be administered within 48 h of symptom onset for best efficacy.

The effect of CT-based attenuation correction on the automatic perfusion score of myocardial perfusion imaging using a dedicated cardiac solid-state CZT SPECT/CT.

BACKGROUND: Data regarding cardiac cadmium-zinc-telluride (CZT)-specific augmented databases and their impact on CT-based attenuation correction (AC) perfusion scores in myocardial perfusion imaging (MPI) were obtained on a multiple-pinhole CZT SPECT/CT. METHODS AND RESULTS: Summed stress (SSS) and rest scores (SRS) were measured using automated software in three independent patient groups: group 1 (n = 80) underwent MPI on both CZT and conventional sodium iodide (NaI) devices, group 2 (n = 80) with low coronary artery disease likelihood and normal MPI provided reference CZT databases; and group 3 (n = 152) served to compare AC and non-AC (NAC) scores on CZT. Group 1 CZT and NaI scores gave a significant 1:1 linear correlation for CZT scores referenced to the custom database vs NaI scores referenced to the default database, but these were not concordant when CZT scores were referenced to the default database. AC significantly decreased average SSS and SRS in men vs NAC, 4.29 ± 6.30 vs 5.37 ± 7.26 (P < 0.001) and 2.37 ± 4.72 vs 3.13 ± 5.85 (P < 0.001), but not in women, 2.28 ± 3.42 vs 2.28 ± 3.08 (p NS) and 0.46 ± 1.51 vs 0.61 ± 1.86, (p NS), respectively. CONCLUSIONS: Specifically designed databases for solid-state CZT cardiac SPECT provide accurate quantitation of perfusion scores concordant with those previously validated for conventional SPECT. AC and NAC CZT scores differed significantly, especially in men.

Prenatal lead exposure and elevated blood pressure in children.

Growing evidence suggests that environmental exposures can influence blood pressure over the course of a lifetime. Exposure to toxic metals, such as lead (Pb) and arsenic (As), has been associated with increased blood pressure in adults, but few studies have examined the impacts of in utero and early life toxic metals exposure on blood pressure in childhood. As subclinical vascular changes are thought to begin early in life, it is possible that in utero toxic metals exposure may play a role in blood pressure homeostasis. In the ongoing New Hampshire Birth Cohort Study, we investigated whether in utero exposure to Pb and As was associated with measures of blood pressure in a total of 323 young children (mean age 5.5 years, SD 0.4). Pb and As were measured in maternal toenail samples collected at ~28 weeks gestation (n = 257) and/or 6 weeks postpartum (n = 285), which represent exposures ~6 to 12 months prior to collection and therefore reflect the early prenatal and late prenatal exposures, respectively. Five measurements of systolic blood pressure (SBP) and diastolic blood pressure (DBP) were averaged for each child using a standardized technique. In linear regression analyses, where log2-transformed prenatal toenail Pb and As were modeled jointly and adjusted for child age, sex, height, weight and maternal smoking during pregnancy, we observed that a doubling of maternal prenatal toenail Pb was associated with statistically significant increases in child SBP (ß: 0.58 mm Hg, 95% CI: 0.05, 1.11). We did not observe any association of prenatal or postpartum As, or postpartum Pb, with SBP or DBP. Exploratory sex-stratified analyses suggest that associations of prenatal Pb with BP may be stronger among boys (SBP ß: 0.72 mm Hg: 95% CI: -0.01, 1.44; DBP ß: 0.37; 95% CI: -0.09, 0.84), compared to girls (SBP ß: 0.48 mm Hg: 95% CI: -0.31, 1.26; DBP ß: -0.05; 95% CI: -0.52, 0.41), though tests for interaction did not reach statistical significance (p-interaction SBP = 0.059; DBP = 0.057). Our preliminary results suggest that in utero toxic metals exposures may be associated with early life increases in blood pressure in children, which could have consequences for long-term health.

Comparison of Preoperative Assessment of Patient's Metabolic Equivalents (METs) Estimated from History versus Measured by Exercise Cardiac Stress Testing.

BACKGROUND: Preoperative anesthetic evaluations of patients before surgery traditionally involves assessment of a patient's functional capacity to estimate perioperative risk of cardiovascular complications and need for further workup. This is typically done by inquiring about the patient's physical activity, with the goal of providing an estimate of the metabolic equivalents (METs) that the patient can perform without signs of myocardial ischemia or cardiac failure. We sought to compare estimates of patients' METs between preoperative assessment by medical history with quantified assessment of METs via the exercise cardiac stress test. METHODS: A single-center retrospective chart review from 12/1/2005 to 5/31/2015 was performed on 492 patients who had preoperative evaluations with a cardiac stress test ordered by a perioperative anesthesiologist. Of those, a total of 170 charts were identified as having a preoperative evaluation note and an exercise cardiac stress test. The METs of the patient estimated by history and the METs quantified by the exercise cardiac stress test were compared using a Bland-Altman plot and Cohen's kappa. RESULTS: Exercise cardiac stress test quantified METs were on average 3.3 METS higher than the METs estimated by the preoperative evaluation history. Only 9% of patients had lower METs quantified by the cardiac stress test than by history. CONCLUSIONS: The METs of a patient estimated by preoperative history often underestimates the METs measured by exercise stress testing. This demonstrates that the preoperative assessments of patients' METs are often conservative which errs on the side of patient safety as it lowers the threshold for deciding to order further cardiac stress testing for screening for ischemia or cardiac failure.

Ligand-Promoted Palladium-Catalyzed Aerobic Oxidation Reactions.

Palladium-catalyzed aerobic oxidation reactions have been the focus of industrial application and extensive research efforts for nearly 60 years. A significant transition occurred in this field approximately 20 years ago, with the introduction of catalysts supported by ancillary ligands. The ligands play crucial roles in the reactions, including promotion of direct oxidation of palladium(0) by O2, bypassing the typical requirement for Cu salts or related redox cocatalysts to facilitate oxidation of the reduced Pd catalyst; facilitation of key bond-breaking and bond-forming steps during substrate oxidation; and modulation of chemo-, regio-, or stereoselectivity of a reaction. The use of ligands has contributed to significant expansion of the scope of accessible aerobic oxidation reactions. Increased understanding of the role of ancillary ligands should promote the development of new synthetic transformations, enable improved control over the reaction selectivity, and improve catalyst activity and stability. This review surveys the different ligands that have been used to support palladium-catalyzed aerobic oxidation reactions and, where possible, describes mechanistic insights into the role played by the ancillary ligand.

Diagnosing and Remediating Clinical Reasoning Difficulties: A Faculty Development Workshop.

Introduction: Clinical reasoning is a complex cognitive process that involves multiple steps. Diagnosing and remediating clinical reasoning difficulties requires faculty to have an understanding of the cognitive theory behind clinical reasoning, familiarity with terminology, and a framework to identify different domains of struggle in their learners. Published resources on faculty development to diagnose and remediate clinical reasoning difficulties are limited. We created and implemented a workshop to assist faculty in developing these skills based on the five-domain framework described by Audétat, Laurin, and Sanche. This workshop provides all the materials needed to replicate this training with faculty at other institutions. Methods: The workshop consists of a didactic component and case-based active learning in small groups. Each case focuses on different domains of clinical reasoning difficulties and targets different learner levels (preclinical medical students through residents). The workshop was given in multiple venues in 2016 and 2017. Results: Participants reported the session was valuable (4.71/5.0), the facilitators were effective (4.5/5.0), and the objectives were met (4.28/5.0). They highlighted the strengths of the interactive format, the framework to diagnose and remediate clinical reasoning difficulties, and the excellent take-home resources. They suggested more time for the workshop, revision of cases to better highlight difficulties, and refinement of instructions to approach the cases. These suggestions were incorporated into the current iteration of the workshop. Discussion: We successfully implemented a workshop for diagnosing and remediating clinical reasoning difficulties in multiple venues. The sessions were diverse in terms of faculty participants and learner groups addressed.

Synthesis of Indole-2-carboxylate Derivatives via Palladium-Catalyzed Aerobic Amination of Aryl C-H Bonds.

A direct oxidative C-H amination affording 1-acetyl indolecarboxylates starting from 2-acetamido-3-arylacrylates has been achieved. Indole-2-carboxylates can be targeted with a straightforward deacetylation of the initial reaction products. The C-H amination reaction is carried out using a catalytic Pd(II) source with oxygen as the terminal oxidant. The scope and application of this chemistry is demonstrated with good to high yields for numerous electron-rich and electron-poor substrates. Further reaction of selected products via Suzuki arylation and deacetylation provides access to highly functionalized indole structures.

The global pediatric nephrology workforce: a survey of the International Pediatric Nephrology Association.

BACKGROUND: The global pediatric nephrology workforce is poorly characterized. The objectives of our study were to assess pediatric nephrologists' perceptions of the adequacy of the pediatric nephrology workforce, and understand regional challenges to fellow recruitment and job acquisition. Perceptions regarding optimal length of training and research requirements were also queried. METHODS: A 17-question web-based survey comprised of 14 close-ended and 3 open-ended questions was e-mailed to members of the International Pediatric Nephrology Association. Quantitative and qualitative analyses were performed. RESULTS: We received 341 responses from members of the International Pediatric Nephrology Association from 71 countries. There was a high degree of overall perceived workforce inadequacy with 67 % of all respondents reporting some degree of shortage. Perceived workforce shortage ranged from 20 % in Australia/New Zealand to 100 % in Africa. Respondents from Africa (25 %) and North America (22.4 %) reported the greatest difficulty recruiting fellows. Respondents from Australia/New Zealand (53.3 %) and Latin America (31.3 %) reported the greatest perceived difficulty finding jobs as pediatric nephrologists after training. Low trainee interest, low salary, lack of government or institutional support, and few available jobs in pediatric nephrology were the most frequently reported obstacles to fellow recruitment and job availability. CONCLUSIONS: Globally, there is a high level of perceived inadequacy in the pediatric nephrology workforce. Regional variability exists in perceived workforce adequacy, ease of recruitment, and job acquisition. Interventions to improve recruitment targeted to specific regional barriers are suggested.