Making it stick: use of active learning strategies in continuing medical education.

BACKGROUND: Despite the known benefits of active learning (AL), the predominate educational format in higher education is the lecture. The reasons for slow adaptation of AL in medical education are not well understood. The purpose of this survey was to determine knowledge, usage, attitudes, and barriers to AL use in academic Continuing Medical Education (CME). METHOD: A 20-item questionnaire was developed and sent with a link to an online questionnaire to the Society of Academic Continuing Medical Education (SACME) listserv of ~ 350 professionals representing academic medical centers, teaching hospitals, and medical specialty societies in the United States (U.S.) and Canada. Responses were collected with SurveyMonkey® from October-November, 2019. Data were analyzed using SPSS®. RESULTS: Responses from 146 SACME members in 91 CME units yielded a ~ 42% survey response rate. Many respondents reported their self-perceived knowledge of AL as high. Advanced training (e.g., certificate, Master of Education degree) was positively correlated with AL knowledge. AL methods were reportedly used in half of the CME activities in the majority (80%) of institutions. Higher levels of self-perceived knowledge were correlated with an increased percentage of AL-related CME activities. Commonly perceived barriers to use of AL were presenters' lack of familiarity and a need for more time-consuming preparation. CONCLUSIONS: More efforts are needed to increase innovation and incorporate evidence-based AL strategies in medical education, especially to foster learner engagement, critical thinking, and problem-solving ability.

Obstetric Anesthesia Workforce Survey: A 30-Year Update.

BACKGROUND: Obstetric Anesthesia Workforce Surveys were conducted in 1981, 1992, and 2001, and the 10-year update was conducted in 2012. Anesthesia providers from US hospitals were surveyed to identify the methods used to provide obstetric anesthesia. Our primary hypothesis was that the provision of obstetric anesthesia services has changed in the past 10 years. METHODS: A sample of hospitals was generated based on the number of births per year and US census region. Strata were defined as follows: I ≥ 1500 annual births (n = 341), II ≥ 500 to 1499 annual births (n = 438), and III < 500 annual births (n = 414). Contact email information for the anesthesia provider in charge of obstetric services was obtained by phone call. Electronic questionnaires were sent through email. RESULTS: Administration of neuraxial (referred to as "regional" in previous surveys) labor analgesia was available 24 hours per day in all stratum I hospitals responding to the survey. Respondents across all strata reported high rates of in-house coverage, with 86.3% (95% confidence interval [CI] = 82.7%-90%) of stratum I providers reporting that they provided in-house anesthesiology services for obstetrics. The use of patient-controlled epidural analgesia in stratum I hospitals was reported to be 35% in 2001 and 77.6% (95% CI = 73.2%-82.1%) in this survey. Independent Certified Registered Nurse Anesthetists were reported to provide obstetric anesthesia services in 68% (95% CI = 57.9%-77.0%) of stratum III hospitals. Although 76% (95% CI = 71.2%-80.3%) of responding stratum I hospitals allow postpartum tubal ligations, 14% report inadequate staffing to provide anesthesia either always or at off-hours. CONCLUSIONS: Since 2001, there have been significant changes in how responding hospitals provide obstetric anesthesia care and staff the labor and delivery ward. Obstetric anesthesia surveys, updated every 10 years, continue to provide information about changes in obstetric anesthesia practice.

Prevalence and descriptive analysis of congenital heart disease in parturients: obstetric, neonatal, and anesthetic outcomes.

STUDY OBJECTIVE: The study objectives are to (1) assess prevalence of congenital heart disease (CHD), (2) describe outcomes of pregnancies in women with CHD, (3) compare outcomes in women with and without CHD, and (4) characterize neonatal outcomes in pregnancies complicated by CHD. DESIGN: This was a retrospective cohort study of women who delivered at the University of Colorado Hospital. Diagnosis of CHD was identified based on history of cardiac disease, pulmonary disease, or subacute bacterial endocarditis prophylaxis during labor and confirmed with echocardiogram when available. Comprehensive retrospective review of anesthetic, obstetric, and neonatal outcomes was performed. SETTING: University of Colorado Hospital. PATIENTS: 18,226 women. INTERVENTIONS: Medical record review. MEASUREMENTS: Valvular abnormalities, New York Heart Failure Association classification scores, types of CHD, maternal age, race, gravidity, parity, maternal prepregnancy body mass index, cigarette use, type of delivery, type of analgesia used, early initiation of neuraxial analgesia, arrhythmias, need for peripartum diuretics, prolonged maternal hospital stay, preterm birth, small for gestational age, neonatal CHD, neonatal or maternal intensive care unit (ICU) admissions, and maternal or neonatal death. MAIN RESULTS: We identified 117 pregnancies in 110 women with CHD. Parturients with CHD were more likely to have operative vaginal delivery (P < .0001), neonatal ICU admissions (P = .003), and had prolonged hospital stays. Occurrence of CHD in neonates was 6%. Moderate-to-severe valvular disease was associated with increased rates of operative vaginal delivery, early initiation of neuraxial labor analgesia, cardiac complications (including arrhythmia and use of diuretics), prolonged hospital stay, and maternal ICU admission. However, most deliveries and births were uncomplicated; and there were one case each of maternal mortality and fetal death after birth. CONCLUSION: Operative abdominal deliveries and neonatal ICU admissions are more common in women with CHD, but these pregnancies are generally well tolerated with low mortality rates.

Predictors of early faculty attrition at one Academic Medical Center.

BACKGROUND: Faculty turnover threatens the research, teaching and clinical missions of medical schools. We measured early attrition among newly-hired medical school faculty and identified personal and institutional factors associated with early attrition. METHODS: This retrospective cohort study identified faculty hired during the 2005-2006 academic year at one school. Three-year attrition rates were measured. A 40-question electronic survey measured demographics, career satisfaction, faculty responsibilities, institutional/departmental support, and reasons for resignation. Odds ratios (ORs) and 95 percent confidence intervals (95% CI) identified variables associated with early attrition. RESULTS: Of 139 faculty, 34% (95% CI = 26-42%) resigned within three years of hire. Attrition was associated with: perceived failure of the Department Chair to foster a climate of teaching, research, and service (OR = 6.03; 95% CI: 1.84, 19.69), inclusiveness, respect, and open communication (OR = 3.21; 95% CI: 1.04, 9.98). Lack of professional development of the faculty member (OR = 3.84; 95% CI: 1.25, 11.81); institutional recognition and support for excellence in teaching (OR = 2.96; 95% CI: 0.78, 11.19) and clinical care (OR = 3.87; 95% CI: 1.04, 14.41); and >50% of professional time devoted to patient care (OR = 3.93; 95% CI: 1.29, 11.93) predicted attrition. Gender, race, ethnicity, academic degree, department type and tenure status did not predict early attrition. Of still-active faculty, an additional 27 (48.2%, 95% CI: 35.8, 61.0) reported considering resignation within the 5 years. CONCLUSIONS: In this pilot study, one-third of new faculty resigned within 3 years of hire. Greater awareness of predictors of early attrition may help schools identify threats to faculty career satisfaction and retention.

Impact of anesthesiologists on the incidence of vaginal birth after cesarean in the United States: role of anesthesia availability, productivity, guidelines, and patient safety.

The rate of vaginal birth after cesarean delivery (VBAC) has been steadily decreasing in the United States. What is not clear, however, is what part the availability of anesthesia personnel has played in this reduction. We review the role of anesthesia services in the trend of the decreasing rates of VBAC. Three areas of particular interest to anesthesiology services are addressed: (1) the current ability of anesthesiologists in the United States to provide "immediate" availability for VBAC at all delivery locations; (2) the workforce estimates for anesthesiology staffing in the future; and (3) the barriers to the immediate availability of anesthesiologists in all hospitals that provide obstetrical care. The concept of "immediate availability" is discussed, and examples of ways to reduce the risks to patients are provided. Finally, possible solutions that may improve patient safety without a dramatic increase in number of anesthesiologists available to work on labor and delivery units are highlighted.

Blood product replacement for postpartum hemorrhage.

Hemorrhage requiring blood transfusion is a common occurrence in obstetrics. This article reviews each step in the transfusion process, including laboratory preparation of blood, indications for various blood components, complications of blood transfusion, massive transfusion, and alternatives to homologous blood. Current thinking regarding transfusion-related acute lung injury, transfusion-related immunomodulation, early use of plasma for massive transfusion, and the use of adjuvant agents such as activated recombinant factor VII are also discussed.

Nitrous oxide concentrations in the posterior nasopharynx during administration by nasal mask.

PURPOSE: Nitrous oxide (N2O) administration with nasal mask produces variable outcomes in dental patients. This study describes a novel sampling method to measure actual inspired/expired N2O concentrations ([N2O]). METHODS: Fifteen adult volunteers (32.5 +/- 8.5 years) underwent placement of a nasopharyngeal probe. With a nasal mask, 100% oxygen (O2) was administered for 2 minutes. N2O was introduced incrementally every 2 minutes for a final flowmeter [N2O] of 50% and subsequently decreased in the same manner. Anesthesia gas monitors analyzed inspired/expired [N2O], [O2], and PETCO2 from the nasopharynx and end-inspired/expired [N2O] in the mask. Data were measured every 20 seconds and analyzed. Inspired/expired nasopharyngeal and nasal mask [N2O] and [O2] were expressed as the median value at each time point for all subjects and plotted against flowmeter settings. RESULTS: Average inspired nasal mask [N2O] was 31% lower than flowmeter settings and decreased by another 19% on the way to the nasopharyngeal sampling site. During the phase of increasing N2O, average expired nasopharyngeal [N2O] was 22% lower than inspired [N2O]. When N2O was decreased, the effect was reversed and average expired [N2O] was 18% higher than inspired. Expired [N2O] was on average 51% lower than flowmeter settings. Mean PETCO2 was 39.7 +/- 1.4 mm Hg. CONCLUSIONS: Nasopharyngeal end-expired [N2O] varied markedly from flowmeter settings. Correlation of PETCO2 with expected physiologic values validates sampling methodology. This method allows accurate, continuous, and actual measurements of inhaled/exhaled gases in awake patients as well as decision-making/analysis of effectiveness of mask type to determine average [N2O] during administration by nasal mask.

Intrathecal opioids versus epidural local anesthetics for labor analgesia: a meta-analysis.

BACKGROUND AND OBJECTIVES: Some anesthesiologists contend that intrathecal opioid administration has advantages over conventional epidural techniques during labor. Randomized clinical trials comparing analgesia and obstetric outcome using single-injection intrathecal opioids versus epidural local anesthetics suggest that intrathecal opioids provide comparable analgesia with few serious side effects. This meta-analysis compared the analgesic efficacy, side effects, and obstetric outcome of single-injection intrathecal opioid techniques versus epidural local anesthetics in laboring women. METHODS: Relevant clinical studies were identified using electronic and manual searches of the literature covering the period from 1989 to 2000. Searches used the following descriptors: intrathecal analgesia, spinal opioids, epidural analgesia, epidural local anesthetics, and analgesia for labor. Data were extracted from 7 randomized clinical trials comparing analgesic measures, incidence of motor block, pruritus, nausea, hypotension, mode of delivery, and/or Apgar scores. RESULTS: Combined test results indicated comparable analgesic efficacy 15 to 20 minutes after injection with single-injection intrathecal opioid administration. Intrathecal opioid injections were associated with a greater incidence of pruritus (odds ratio, 14.01; 99% confidence interval, 6.9 to 28.3), but there was no difference in the incidence of nausea or in the method of delivery. CONCLUSIONS: Published studies suggest that intrathecal opioids provide comparable early labor analgesia when compared with epidural local anesthetics. Intrathecal opioid administration results in a greater incidence of pruritus. The choice of technique does not appear to affect the method of delivery.