I Read, Therefore I Am: Examining Nonmedical Reading and Its Relationship to Empathy in Anesthesia Training.

Background: High levels of empathy among resident physicians are associated with improved patient outcomes. Empathy may be learned and practiced when reading nonmedical writing through narrative transportation, a process by which readers identify with characters and become emotionally involved in the plot. We hypothesized that residents and fellows who reported more nonmedical reading would have higher empathy levels and that empathy would decrease during training. Methods: An emailed survey was sent to program directors of Accreditation Council on Graduate Medical Education-accredited anesthesiology residency and fellowship programs, with a request to distribute the survey to trainees. The Toronto Empathy Questionnaire, reading volume, and demographics were included in the survey. Response data were analyzed using a multiple variable regression model. Results: Of 136 responses, 119 were included for data analysis. Seventeen partially completed surveys were excluded. Higher empathy scores were reported among women (P < .0001) and residents who worked 60 to 80 hours per week (P = .039). Age, postgraduate year of training, relationship status, time spent with family, and avid reading were not significantly associated with increased empathy. Conclusion: In this study, we examined whether nonmedical fiction reading would increase empathy in medical trainees. Our study was not able to find any significant association with time spent reading and increased empathy; however, we found that trainees who worked more hours, specifically 60 to 80 hours, had higher empathy scores. Limitations for this study included a smaller sample size. Further research should be done in this field to determine if there are other intangible factors that affect empathy in trainees.

The Golden Hour: Early Interventions for Medical Emergencies during Pregnancy.

Maternal mortality has increased in the last decades in the United States as a result of increased prevalence of coexisting medical diseases such as hypertension, diabetes, and both acquired and congenital heart diseases. Obstetricians and maternal-fetal medicine physicians should have the basic medical knowledge to initiate appropriate diagnostic and early therapeutic interventions since they may be the only provider available at the time of presentation. The goal of this article is not to extensively discuss the management of complex medical diseases during pregnancy, rather we provide a concise review of key early medical interventions that will likely result in improved clinical outcomes. KEY POINTS: · Obstetricians and maternal-fetal medicine physicians must be familiar with initial basic management of common medical emergencies.. · Management of these complex cases is ideally multidisciplinary.. · Residency/fellowship programs should include common disease management to improve maternal outcomes..

Context-dependent use of olfactory cues by foragers of Vespula germanica social wasps.

Food search is guided by cues from different sensory modalities, such as olfactory and visual. In social wasps, olfaction plays a key role in locating new resources. However, while several studies have focused on the importance of odours in predation, less is known about their role during scavenging, when spatial memories become a relevant guidance mechanism. Here, we investigated whether the use of odours during carrion exploitation by Vespula germanica wasps depends on whether they are locating or relocating the resource. By means of field choice experiments, we evaluated wasp response to odours: an odour eliciting a spontaneous aversive response, a learnt odour eliciting an appetitive response, and the conspecifics' odour eliciting an attractive response. Experiments were conducted in different contexts, i.e., during food localisation by naïve foragers, re-localisation of a resource at the learnt site and re-localisation of a resource that had been displaced from the learnt site. All olfactory stimuli evaluated markedly influenced foraging decisions in naïve wasps and in experienced wasps when the food was moved from the learnt location. However, odours were ignored during the wasp's return to the foraging site. These results suggest a cue hierarchy, in which local landmarks are more reliable to relocate carrion, while olfaction would be useful to locate novel resources or relocate a known source when spatial memories fail. Our findings demonstrate a context-dependent use of odours during carrion exploitation by V. germanica wasps and highlight the importance of spatial memories as an important factor modulating odour response.

Quantifying the incidence of clinically significant respiratory depression in women with and without obesity class III receiving neuraxial morphine for post-cesarean analgesia: a retrospective cohort study.

BACKGROUND: Obesity is a suspected risk factor for respiratory depression following neuraxial morphine for post-cesarean analgesia, however monitoring guidelines for obese obstetric patients are based on small, limited studies. We tested the hypothesis that clinically significant respiratory depression following neuraxial morphine occurs more commonly in women with body mass index (BMI) ≥40 kg/m2 compared with BMI <40 kg/m2. METHODS: We conducted a single-center, retrospective chart review (2006-2017) of obstetric patients with clinically significant respiratory depression following neuraxial morphine, defined as: (1) opioid antagonist administration; (2) rapid response team activation (initiated in April 2010); or (3) tracheal intubation due to a respiratory event. The incidence of respiratory depression was compared between women with BMI ≥40 kg/m2 and BMI <40 kg/m2. RESULTS: In total, 11 327 women received neuraxial morphine (n=1945 BMI ≥40 kg/m2; n=9382 BMI <40 kg/m2). Women with BMI ≥40 kg/m2 had higher rates of sleep apnea, hypertensive disorders, and magnesium administration. Sixteen cases of clinically significant respiratory depression occurred within seven days postpartum. The incidence did not significantly differ between groups (odds ratio 2.2, 95% CI 0.6 to 6.9, P=0.174). Neuraxial morphine was not deemed causative in any case, however women with BMI ≥40 kg/m2 had higher rates of tracheal intubation unrelated to neuraxial morphine (2/1945 vs. 0/9382, P=0.029). CONCLUSIONS: Respiratory depression in this population is rare. A larger sample (∼75 000) is required to determine whether the incidence is higher with BMI ≥40 kg/m2. Tracheal intubation was higher among the BMI ≥40 kg/m2 cohort, likely due to more comorbidities.

Risk Factors for Atonic Postpartum Hemorrhage: A Systematic Review and Meta-analysis.

OBJECTIVE: To identify and quantify risk factors for atonic postpartum hemorrhage. DATA SOURCES: PubMed, CINAHL, EMBASE, Web of Science, and and ClinicalTrials.gov databases were searched for English language studies with no restrictions on date or location. Studies included randomized trials, prospective or retrospective cohort studies, and case-control studies of pregnant patients who developed atonic postpartum hemorrhage and reported at least one risk factor. METHODS OF STUDY SELECTION: Title, abstract, and full-text screening were performed using the Raayan web application. Of 1,239 records screened, 27 studies were included in this review. Adjusted or unadjusted odds ratios (ORs), relative risks, or rate ratios were recorded or calculated. For each risk factor, a qualitative synthesis of low and moderate risk of bias studies classifies the risk factor as definite, likely, unclear, or not a risk factor. For risk factors with sufficiently homogeneous definitions and reference ranges, a quantitative meta-analysis of low and moderate risk of bias studies was implemented to estimate a combined OR. TABULATION, INTEGRATION, AND RESULTS: Forty-seven potential risk factors for atonic postpartum hemorrhage were identified in this review, of which 15 were judged definite or likely risk factors. The remaining 32 assessed risk factors showed no association with atonic postpartum hemorrhage or had conflicting or unclear evidence. CONCLUSION: A substantial proportion of postpartum hemorrhage occurs in the absence of recognized risk factors. Many risk factors for atonic hemorrhage included in current risk-assessment tools were confirmed, with the greatest risk conferred by prior postpartum hemorrhage of any etiology, placenta previa, placental abruption, uterine rupture, and multiple gestation. Novel risk factors not currently included in risk-assessment tools included hypertension, diabetes, and ethnicity. Obesity and magnesium were not associated with atonic postpartum hemorrhage in this review. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42020157521.

A School Intervention Helps Decrease Daily Stress While Enhancing Social Integration in Children.

Stress coping is highly relevant during childhood. This study analyses how the participation in a behavioral intervention involving mindfulness-based practices and empathic collaboration activities impact on diurnal cortisol rhythm and social integration in children. In both experimental and waitlist groups, we evaluated before and after the intervention: daily stress, by sampling salivary cortisol at three measurement time-points, and social integration, assessed by a social preference index. Daily average cortisol (DAC) and the area under the curve (AUC) differed when comparing pre-post intervention values in both groups: in the experimental group these measures decreased while in the waitlist group DAC and AUC increased. At the end of the intervention, the experimental group showed an enhancement in the social preference index whereas this parameter diminished in the waitlist group. This kind of behavioral intervention seems to be effective at reducing daily stress and improving social integration in Primary School children.

Opioid Prescribing by Primary Care Providers: a Cross-Sectional Analysis of Nurse Practitioner, Physician Assistant, and Physician Prescribing Patterns.

BACKGROUND: Prescription opioid overprescribing is a focal point for legislators, but little is known about opioid prescribing patterns of primary care nurse practitioners (NPs) and physician assistants (PAs). OBJECTIVE: To identify prescription opioid overprescribers by comparing prescribing patterns of primary care physicians (MDs), nurse practitioners (NPs), and physician assistants (PAs). DESIGN: Retrospective, cross-sectional analysis of Medicare Part D enrollee prescription data. PARTICIPANTS: Twenty percent national sample of 2015 Medicare Part D enrollees. MAIN MEASURES: We identified potential opioid overprescribing as providers who met at least one of the following: (1) prescribed any opioid to > 50% of patients, (2) prescribed ≥ 100 morphine milligram equivalents (MME)/day to > 10% of patients, or (3) prescribed an opioid > 90 days to > 20% of patients. KEY RESULTS: Among 222,689 primary care providers, 3.8% of MDs, 8.0% of NPs, and 9.8% of PAs met at least one definition of overprescribing. 1.3% of MDs, 6.3% of NPs, and 8.8% of PAs prescribed an opioid to at least 50% of patients. NPs/PAs practicing in states with independent prescription authority were > 20 times more likely to overprescribe opioids than NPs/PAs in prescription-restricted states. CONCLUSIONS: Most NPs/PAs prescribed opioids in a pattern similar to MDs, but NPs/PAs had more outliers who prescribed high-frequency, high-dose opioids than did MDs. Efforts to reduce opioid overprescribing should include targeted provider education, risk stratification, and state legislation.

Opioid Prescribing to Medicare Part D Enrollees, 2013-2017: Shifting Responsibility to Pain Management Providers.

OBJECTIVE: To examine opioid prescribing frequency and trends to Medicare Part D enrollees from 2013 to 2017 by medical specialty and provider type. METHODS: We conducted a retrospective, cross-sectional, specialty- and provider-level analysis of Medicare Part D prescriber data for opioid claims from 2013 to 2017. We analyzed opioid claims and prescribing trends for specialties accounting for ≥1% of all opioid claims. RESULTS: From 2013 to 2017, pain management providers increased Medicare Part D opioid claims by 27.3% to 1,140 mean claims per provider in 2017; physical medicine and rehabilitation providers increased opioid claims 16.9% to 511 mean claims per provider in 2017. Every other medical specialty decreased opioid claims over this period, with emergency medicine (-19.9%) and orthopedic surgery (-16.0%) dropping opioid claims more than any specialty. Physicians overall decreased opioid claims per provider by -5.2%. Meanwhile, opioid claims among both dentists (+5.6%) and nonphysician providers (+10.2%) increased during this period. CONCLUSIONS: From 2013 to 2017, pain management and PMR increased opioid claims to Medicare Part D enrollees, whereas physicians in every other specialty decreased opioid prescribing. Dentists and nonphysician providers also increased opioid prescribing. Overall, opioid claims to Medicare Part D enrollees decreased and continue to drop at faster rates.

Comparison of Twitter Use of the American Society of Anesthesiologists and the American Association of Nurse Anesthetists.

Twitter has become a powerful tool for dissemination of information. The objective of this study was to evaluate Twitter usage of the American Society of Anesthesiologists (ASA) and the American Association of Nurse Anesthetists (AANA). All tweets from ASA ("@ASALifeline") and AANA ("@aanawebupdates") were collected over a 1-year time period. The content of each tweet was categorized using a rubric. ASA generated more original tweets than AANA. Twitter use was highest in October for ASA and September for AANA. Both societies are actively using Twitter. Future work should evaluate the impact of societal Twitter use.

Management of peripartum intra-abdominal hypertension and abdominal compartment syndrome.

Normal pregnancy leads to a state of chronically increased intra-abdominal pressure. Obstetric and non-obstetric conditions may increase intra-abdominal pressure further, causing intra-abdominal hypertension and abdominal compartment syndrome, which leads to maternal organ dysfunction and a compromised fetal state. Limited medical literature exists to guide treatment of pregnant women with these conditions. In this state-of-the-art review, we propose a diagnostic and treatment algorithm for the management of peripartum intra-abdominal hypertension and abdominal compartment syndrome, informed by newly available studies.

The Las Vegas mass shooting: An analysis of blood component administration and blood bank donations.

BACKGROUND: The deadliest mass shooting in modern United States history occurred on October 1, 2017, in Las Vegas, killing 58 and overwhelming hospitals with more than 600 injured. The scope of the tragedy offers insight into medical demands, which may help guide preparedness for future mass shooting incidents. METHODS: Retrospective, deidentified, health care institution-provided data from all hospitals and blood banks providing care to Las Vegas shooting victims were gathered. Study authors independently reviewed all data and cross-referenced it for verification. Main outcomes and measures include the number of victims requiring hospital and intensive care admission, the amount and types of blood components transfused during the first 24 hours, and the amount of blood donated to local blood banks following the Las Vegas mass shooting. RESULTS: Two hundred twenty patients required hospital admission, 68 of them to critical care. Nearly 500 blood components were transfused during the first 24 hours in a red blood cell-to-plasma-to-platelet ratio of 1:0.54:0.81. Public citizens donated almost 800 units of blood immediately after the shooting; greater than 17% of this donated blood went unused. CONCLUSIONS: The amount of blood components transfused per patient admitted was similar in magnitude to other mass casualty events, and available blood supply met patient demand. The public call for blood donors was not necessary to meet immediate demand and led to resource waste. Preparation for future mass shooting incidents should include training the community in hemorrhage control, encouraging routine blood donation, and avoiding public calls for blood donation unless approved by local blood suppliers. LEVEL OF EVIDENCE: Therapeutic study, level V.

Massive Hemorrhage From Suspected Iatrogenic Uterine Rupture.

BACKGROUND: Intrauterine balloon tamponade is recommended for refractory postpartum hemorrhage resulting from atony, but few studies have assessed complications associated with placement. CASE: A 39-year-old woman, gravida 4 para 1, with posterior placenta previa and suspected placenta accreta had a postpartum hemorrhage after a scheduled cesarean delivery. An intrauterine balloon tamponade device was easily placed transcervically; however, the patient required additional analgesia for constant severe stabbing pain worsened on examination. Three hours after placement, the balloon was expelled from the cervix, resulting in 1,500 mL of fresh blood and clot. Emergent exploratory laparotomy identified a uterine rupture inferior and lateral to the hysterotomy site. CONCLUSION: Intrauterine balloon tamponade may contribute to iatrogenic uterine rupture and should be considered in patients with refractory hemorrhage, hemodynamic instability, or severe pain despite analgesia.

Damage-Control Surgery for Obstetric Hemorrhage.

Damage-control surgery (abdominopelvic packing followed by a period of medical stabilization in the intensive care unit) is a life-saving intervention usually reserved for critically injured patients who may not survive an attempt to achieve hemostasis and complete repair of the damage in the operating room. Most obstetricians have little or no experience in this area, although the use of damage-control surgery in selected cases may be life-saving. This approach should be considered when arterial bleeding has been controlled and persistent bleeding is deemed to be secondary to coagulopathy that is refractory to blood product replacement, particularly in the presence of hypothermia, acidosis, and vasopressor requirement. A prototypical (albeit hypothetical) case is described here in which damage-control surgery is indicated.