Challenges for Nurse Anesthetists Reentering Practice Following Substance Use Disorder Treatment.

Substance use disorder (SUD) is a persistent, relapsing condition that is present in approximately 10% of anesthesia providers, who, compared with other healthcare providers, face a greater risk of developing an SUD by virtue of constant access to medications. The ability of certified registered nurse anesthesiologists (CRNAs) to obtain or maintain employment after treatment for SUD treatment is not well documented. The purpose of this qualitative study was to explore challenges encountered by CRNAs in recovery as they attempt to reenter practice following SUD treatment. The phenomenon was explored through multiple-case study, using qualitative semistructured interviews with participants in four cases: CRNAs in recovery, CRNA colleagues, CRNA employers, and professional health program employees. Thirty-six participants conveyed their perspectives about challenges that CRNAs in recovery face upon reentry into practice following SUD treatment. The Worker Well-Being conceptual model was used to guide this study. The study revealed that more SUD education is a key facilitator for reentry, risk of relapse was a major concern, and stigma was the most significant barrier for CRNAs in recovery. Stigma persists as a considerable barrier in many facets of SUD, contributing to an increase in shame associated with having the disease.

Relapse Prevention and Prediction Strategies in Substance Use Disorder: A Scoping Review.

BACKGROUND: Relapse prevention for those with substance use disorder (SUD) is an evolving practice. Initiatives focused on relapse prevention from other populations may provide the foundation for future considerations and recommendations for recovering anesthesia providers in the workplace. The purpose of this scoping review was to examine what is known about return-to-use prediction and prevention strategies in various populations struggling with SUDs to inform future considerations and implications for recovering anesthesia providers with a history of SUD. METHODS: The Arksey and O'Malley framework was used to conduct a scoping review of the literature. A systematic search was conducted across three databases (PubMed, CINAHL, and PsycInfo) for relevant literature. Search terms used were "measures predicting relapse in substance use disorder" and "relapse prevention in substance use disorder AND anesthesia." Data from articles that met the eligibility criteria were extracted and summarized by the primary author. RESULTS: The search identified 46 articles highlighting various relapse prediction and prevention strategies related to craving and stress, underlying biological factors, neuroimaging, and mindfulness. Relapse prediction and prevention strategies ranged from cell phone applications, monitoring biological markers, and functional neuroimaging of the brain. CONCLUSIONS: Relapse is a concern for individuals with a history of SUD. For anesthesia providers, immediate access to powerful anesthesia medications requires return-to-use prediction and prevention strategies when anesthesia providers return to work after SUD treatment. Although some identified strategies are practical, more research is needed to predict and prevent return to use for recovering anesthesia providers.

Woody plant secondary chemicals increase in response to abundant deer and arrival of invasive plants in suburban forests.

Plants in suburban forests of eastern North America face the dual stressors of high white-tailed deer density and invasion by nonindigenous plants. Chronic deer herbivory combined with strong competition from invasive plants could alter a plant's stress- and defense-related secondary chemistry, especially for long-lived juvenile trees in the understory, but this has not been studied. We measured foliar total antioxidants, phenolics, and flavonoids in juveniles of two native trees, Fraxinus pennsylvanica (green ash) and Fagus grandifolia (American beech), growing in six forests in the suburban landscape of central New Jersey, USA. The trees grew in experimental plots subjected for 2.5 years to factorial treatments of deer access/exclosure × addition/no addition of the nonindigenous invasive grass Microstegium vimineum (Japanese stiltgrass). As other hypothesized drivers of plant secondary chemistry, we also measured nonstiltgrass herb layer cover, light levels, and water availability. Univariate mixed model analysis of the deer and stiltgrass effects and multivariate structural equation modeling (SEM) of all variables showed that both greater stiltgrass cover and greater deer pressure induced antioxidants, phenolics, and flavonoids, with some variation between species. Deer were generally the stronger factor, and stiltgrass effects were most apparent at high stiltgrass density. SEM also revealed that soil dryness directly increased the chemicals; deer had additional positive, but indirect, effects via influence on the soil; in beech photosynthetically active radiation (PAR) positively affected flavonoids; and herb layer cover had no effect. Juvenile trees' chemical defense/stress responses to deer and invasive plants can be protective, but also could have a physiological cost, with negative consequences for recruitment to the canopy. Ecological implications for species and their communities will depend on costs and benefits of stress/defense chemistry in the specific environmental context, particularly with respect to invasive plant competitiveness, extent of invasion, local deer density, and deer browse preferences.

Comprehensive Reentry Policy for Student Registered Nurse Anesthetists With Substance Use Disorder.

Substance use disorder (SUD) is a common problem in anesthesia. Although there are SUD policies in place for practicing anesthetists, there were no known studies before this inquiry discussing reentry policies specific to the student registered nurse anesthetist (SRNA). The purpose of this research was to describe key stakeholders' knowledge and perspectives surrounding policies for reentry into academic programs in Illinois for SRNAs with SUD and to create a comprehensive structured policy template for SRNAs with SUD. The theoretical framework for this research was based on the Biopsychosocial Theory. Between November 2017 and January 2018, qualitative interviews, using a semistructured interview guide, were conducted with anesthesiologists and Certified Registered Nurse Anesthetists (CRNAs) from throughout Illinois (n = 4). The interviews were audiorecorded, transcribed, and analyzed using thematic analysis. All participants stated that they did not have a policy in place to address SRNAs with SUD, yet 50% (2/4) reported knowing a student who had experienced SUD. Institutions that educate and use SRNA services should have a comprehensive reentry policy in place, which includes an option for SRNAs recovering from SUD to reenter their educational program. A policy template is provided for use by academic anesthesia programs.

Barriers and Facilitators to Intraoperative Alternatives to Opioids: Examining CRNA Perspectives and Practices.

Opioids are the mainstay of intraoperative pain control, but they have several deleterious effects. Alternative medications and strategies to opioids, while effective in producing intraoperative analgesia, are underutilized by anesthesia providers. The purpose of this study was to examine and describe Certified Registered Nurse Anesthetists' perspectives and practices on administering opioids vs nonopioid or opioid-sparing strategies ("opioid alternatives") to treat intraoperative pain. A qualitative study design using semistructured interviews was conducted (N = 12). Study participants described their perspectives and practices on treating intraoperative pain. Two key themes emerged: (1) barriers to intraoperative opioid-alternative administration and (2) facilitators to intraoperative opioid-alternative administration. Barriers expressed by study participants included opioid superiority, inconsistent analgesic effects of intraoperative opioid alternatives, limited experience with opioid alternatives, limited resources on opioid alternatives, negative experiences with intraoperative opioid-alternative administration, and patient comorbidities. Facilitators expressed by study participants included the adverse effects of opioids, institutional policy and procedures, positive experiences with opioid-alternative administration, and regional anesthesia superiority. This study highlights the importance of improving education, training, and institutional policies in support of opioid-alternative medications and strategies to treat intraoperative pain and better prevent opioid addiction and abuse.

Evidence for cross-tolerance to nutrient deficiency in three disjunct populations of Arabidopsis lyrata ssp. lyrata in response to substrate calcium to magnesium ratio.

Species with widespread distributions that grow in varied habitats may consist of ecotypes adapted to a particular habitat, or may exhibit cross-tolerance that enables them to exploit a variety of habitats. Populations of Arabidopsis lyrata ssp. lyrata (L.) O'Kane & Al-Shehbaz grow in a wide variety of edaphic settings including serpentine soil, limestone sand, and alluvial flood plains. While all three of these environments share some stressors, a crucial difference among these environments is soil calcium to magnesium ratio, which ranges from 25:1 in the limestone sand to 0.2:1 in serpentine soil. The three populations found on these substrates were subjected to three different Ca to Mg ratios under controlled environmental conditions during germination and rosette growth. Response to Ca to Mg ratio was evaluated through germination success and radicle growth rate, rosette growth rate, and the content of Ca and Mg in the rosette. All three populations were particularly efficient in fueling growth under nutrient deficiency, with the highest nutrient efficiency ratio for Ca under Ca deficiency and for Mg under Mg deficiency. Although the serpentine population had significantly higher leaf Ca to Mg ratio than the limestone or flood plain populations under all three Ca to Mg ratios, this increase did not result in any advantage in growth or appearance of the serpentine plants, during early life stages before the onset of flowering, even in the high Mg substrate. The three populations showed no population by substrate interaction for any of the parameters measured indicating that these populations may have cross-tolerance to substrate Ca to Mg ratio.

GENETICS OF RESISTANCE OF SALIX SERICEA TO A DIVERSE COMMUNITY OF HERBIVORES.

We measured resistance of Salix sericea, the silky willow, to a diverse assemblage of 12 herbivores. We investigated the potential for multispecies coevolution among these herbivores by measuring genetic correlations between pairs of herbivores interacting within the component community. After measuring herbivore attack on half-sib families of potted S. sericea during three years, we found significant narrow-sense heritabilities of resistance to Phyllonorycter salicifoliella and Phyllocnistis sp. in 1991. Thus, there is the potential for selection on resistance to these two herbivores. Despite the many significant phenotypic correlations between herbivore abundances within a year, most genetic correlations between herbivore abundances within a year were not significant. The genetic and phenotypic correlation structure varied from year to year in this three-year study. Thus, it appears that there is the potential for evolution of resistance to the two herbivores for which we found significant heritabilities, but multispecies coevolution seems unlikely.

Interspecific and temporal variation in herbivore responses to hybrid willows.

We studied herbivory of two species of willows (Salix sericea and S. eriocephala) and their interspecific hybrids to test alternative hypotheses concerning the effects of hybridization on plant resistance. Individually marked plants were identified using morphological traits in the field and random amplified polymorphic DNA (RAPD) band analysis was used to verify the genetic status of many parental and hybrid plants. The desities of 12 herbivore species on plants in the field were compared between two parents and their F2-type hybrids. We found about equal support for the additive, dominance, and hybrid susceptibility hypotheses over 4 years. In one year, one species supported the hybrid resistance hypothesis. Guild membership was not a good predictor of similar responses of species to hybrid versus parental plants. There were marked differences in support for particular hypotheses among years for four herbivore species. This study demonstrates the diversity of responses of phytophages in response to interspecific hybridization, and indicates that year-to-year variation in relative resistance of hybrid plants can be important.