Development of entrustable professional activities for regional anesthesia and pain medicine fellowship training.

INTRODUCTION: The Accreditation Council for Graduate Medical Education (ACGME) offers descriptions of competencies and milestones but does not provide standardized assessments to track trainee competency. Entrustable professional activities (EPAs) and special assessments (SAs) are emerging methods to assess the level of competency obtained by regional anesthesiology and acute pain medicine (RAAPM) fellows. METHODS: A panel of RAAPM physicians with experience in education and competency assessment and one medical student were recruited to participate in a modified Delphi method with iterative rounds to reach consensus on: a list of EPAs, SAs, and procedural skills; detailed definitions for each EPA and SA; a mapping of the EPAs and SAs to the ACGME milestones; and a target level of entrustment for graduating US RAAPM fellows for each EPA and procedural skill. A gap analysis was performed and a heat map was created to cross-check the EPAs and SAs to the ACGME milestones. RESULTS: Participants in EPA and SA development included 19 physicians and 1 medical student from 18 different programs. The Delphi rounds yielded a final list of 23 EPAs, a defined entrustment scale, mapping of the EPAs to ACGME milestones, and graduation targets. A list of 73 procedural skills and 7 SAs were similarly developed. DISCUSSION: A list of 23 RAAPM EPAs, 73 procedural skills, and 7 SAs were created using a rigorous methodology to reach consensus. This framework can be utilized to help assess RAAPM fellows in the USA for competency and allow for meaningful performance feedback.

Acute pain consult and management is associated with improved mortality in rib fracture patients.

INTRODUCTION: Traumatic rib fractures result in significant patient morbidity and mortality, which increases with patient age and number of rib fractures. A dedicated acute pain service (APS) providing expertize in multimodal pain management may reduce these risks and improve outcomes. We aimed to test the hypothesis that protocolized APS consultation decreases mortality and morbidity in traumatic rib fracture patients. METHODS: This is a retrospective observational, propensity-matched cohort study of adult patients with trauma with rib fractures from 2012 to 2015, at a single, large level 1 trauma center corresponding to introduction and incorporation of APS consultation into the institutional rib fracture pathway. Using electronic medical records and trauma registry data, we identified adult patients presenting with traumatic rib fractures. Patients with hospital length of stay (LOS) ≥2 days were split into two cohorts based on presence of APS consult using 1:1 propensity matching of age, gender, comorbidities and injury severity. The primary outcome was difference in hospital mortality. Secondary outcomes included LOS and pulmonary morbidity. RESULTS: 2486 patients were identified, with a final matched cohort of 621 patients receiving APS consult and 621 control patients. The mortality rate was 1.8% among consult patients and 6.6% among control patients (adjusted OR 0.25, 95% CI 0.13 to 0.50; p=0.001). The average treatment effect of consult on mortality was 4.8% (95% CI 1.2% to 8.5%;. p<0.001). APS consultation was associated with increased intensive care unit (ICU) LOS (1.19 day; 95% CI 0.48 to 1.90; p=0.001) and hospital LOS (1.61 days; 95% CI 0.81 to 2.41 days; p<0.001). No difference in pulmonary complications was observed. DISCUSSION: An APS consult in rib fracture patients is associated with decreased mortality and no difference in pulmonary complications yet increased ICU and hospital LOS.

Color Doppler ultrasonography of an agitated solution is predictive of accurate catheter placement for a continuous popliteal sciatic nerve block.

BACKGROUND: Continuous peripheral nerve catheters (PNCs) have been shown to provide superior postoperative analgesia, decrease opioid consumption, and improve patient satisfaction compared with single injection techniques. In order to achieve success and reliability, accurate catheter positioning is an essential element of PNC placement. An agitated solution of normal saline, D5W, or a local anesthetic solution can be produced by the introduction of air to the injectate, creating air bubbles that can enhance ultrasonographic visualization and possibly improve block success. METHODS: Eighty-three patients were enrolled. Ultrasound-guided continuous popliteal sciatic nerve blocks were performed by positioning the tip of a Tuohy needle between the tibial and common peroneal branches of the sciatic nerve and threading a catheter. An agitated local anesthetic solution was injected through the catheter, viewed with color Doppler ultrasound and video recorded. A peripheral block score (lower score = greater blockade, range 0-14) was calculated based upon the motor and sensory testing at 10, 20, and 30 min after block completion. The color Doppler agitation coverage pattern for the branches of the sciatic nerve was graded as follows: complete (> 50%), partial (> 0%, ≤ 50%), or none (0%). RESULTS: The degree of nerve blockade at 30 min as judged by median (10th, 90th percentile) peripheral block score was significant for partial or complete color Doppler coverage of the sciatic nerve injectate compared to no coverage [3 (0, 7) vs 8 (4, 14); p < 0.01] and block onset was faster (p = 0.03). The block success was higher in groups with partial or complete coverage of the branches of the sciatic nerve vs no coverage (96% vs 70%; p = 0.02). CONCLUSIONS: Injection of an agitated solution through a popliteal sciatic perineural catheter is predictive of accurate catheter placement when partial or complete coverage of the sciatic nerve branches is visualized with color Doppler ultrasound. TRIAL REGISTRATION: NCT01591603.

Repeated dose oral toxicological evaluation of concentrated barley beta-glucan in CD-1 mice including a recovery phase.

The cholesterol-lowering effect observed following consumption of oats and barley is attributable to the beta-glucan component of the soluble fiber fraction of these cereal grains. beta-Glucan has also been reported to modulate immune activity, however, few studies have evaluated the hematological effects of beta-glucan following oral exposure. In the current study, a concentrated beta-glucan (64%) preparation from barley (Barley Betafiber) was blended into mouse feed at concentrations of 1, 5, or 10% (corresponding to approximately 0.7, 3.5, and 7% beta-glucan) and evaluated in CD-1 mice. Plasma was collected for clinical chemistry and hematological measurements at the initiation of the study and again following 14 and 28 days of exposure. Plasma was also collected from animals that consumed the same diets for 28-days but were switched to control diet (containing no supplemental beta-glucan) for an additional 14-day period to evaluate reversibility or delayed occurrence of treatment-related changes. Half of the animals were sacrificed for histopathologic analysis following the 28-day exposure period and the other half were evaluated following the recovery period. Histopathologic analysis focused on primary lymphoid organs and lymph nodes proximal and distal to the route of exposure. An additional group of untreated animals (nai;ve) was bled and sacrificed at day 0, 14, 27 and 41 for comparison of the hematology parameters with those of the control group because it was not known if multiple blood draws would affect hematology parameters. Compared to animals consuming the control diet, no treatment-related adverse effects were observed in hematological or clinical chemistry measurements or in organ weights and immunopathology in either sex following consumption of concentrated barley beta-glucan for 28-days or following the recovery period. Likewise, no differences were observed between the nai;ve and control groups. Results from this study showed that consumption of concentrated barley beta-glucan did not cause treatment-related inflammatory or other adverse effects in CD-1 mice.

Simultaneous identification of soyasaponins and isoflavones and quantification of soyasaponin Bb in soy products, using liquid chromatography/electrospray ionization-mass spectrometry.

A method has been developed for simultaneous identification of soyasaponins and soy isoflavones in soy products, based on liquid chromatography/electrospray ionization-mass spectrometry (LC/ESI-MS). Soy-based nutraceutical products were analyzed by LC/ESI-MS with detection of protonated and sodiated molecular ions, as well as characteristic fragment ions for these compounds. Soy isoflavones were characterized by a strong protonated molecular ion in addition to corresponding [aglycone + H](+) ions. Monitoring the soyasaponin-specific protonated aglycone and dehydrated aglycone ions throughout the chromatogram provided a unique fingerprint for soyasaponin content in the samples. This mass spectrometric fingerprint also allowed immediate classification of the soyasaponin analytes as group A or B soyasaponins, based on the unique masses of aglycone ions observed for each class. Quantification of soyasaponin B(b) in soy-derived materials, based on the use of a purified soyasaponin B(b) standard and a glycyrrhizin internal standard, has been accomplished.

Beta-glucan fractions from barley and oats are similarly antiatherogenic in hypercholesterolemic Syrian golden hamsters.

The cholesterol-lowering activities of oats and barley are commonly attributed to the beta-glucan fractions. Although beta-glucan is present in both grains and appears to be chemically similar, the effect of source on cholesterol-lowering activity has not been evaluated. In the present study, the antiatherogenic properties of beta-glucan concentrates from oats and barley were evaluated in Syrian golden F(1)B hamsters consuming a semipurified hypercholesterolemic diet (HCD) containing cholesterol (0.15 g/100 g), hydrogenated coconut oil (20 g/100 g) and cellulose (15 g/100 g). After a 2-wk lead-in period, control hamsters were fed the HCD, whereas experimental hamsters consumed HCD formulated to include beta-glucan (2, 4, or 8 g/100 g) by addition of beta-glucan concentrate prepared from oats or barley at the expense of cellulose. Compared with control hamsters, dose-dependent decreases that were similar in magnitude in plasma total and LDL cholesterol concentrations were observed in hamsters fed beta-glucan from either source at wk 3, 6 and 9. Compared with controls, liver cholesterol concentrations were also reduced (P < 0.05) in hamsters consuming 8 g/100 g oat or barley beta-glucan. In agreement with previously proposed mechanisms, total fecal neutral sterol concentrations were significantly increased (P < 0.05) in hamsters consuming 8 g/100 g barley or oat beta-glucan. Aortic cholesterol ester concentrations were significantly reduced (P < 0.05) in hamsters fed 8 g/100 g beta-glucan from barley or oats. Although aortic total cholesterol and cholesterol ester concentrations were significantly correlated with LDL cholesterol (r = 0.565, P < 0.004 and r = 0.706, P < 0.0001, respectively), this association could explain only half of the variability. This study demonstrated that the cholesterol-lowering potency of beta-glucan is approximately identical whether its origin was oats or barley.