Simulation-based training in obstetric anesthesia: an update.

In this update we explore the current applications of simulation in obstetric anesthesia, describe what is known regarding its impacts on care and consider the different settings in which simulation programs are required. We will introduce practical strategies, such as cognitive aids and communication tools, that can be applied in the obstetric setting and share ways in which a program might apply these tools. Finally, we provide a list of common obstetric emergencies essential for a program's curriculum and common teamwork pitfalls to address within a comprehensive obstetric anesthesia simulation program.

Practicality of using galvanic skin response to measure intraoperative physiologic autonomic activation in operating room team members.

BACKGROUND: Physiologic and psychological stress are commonly experienced by operating room (OR) personnel, yet there is little research about the stress levels in OR teams and their impact on performance. Previously published procedures to measure physiologic activation are invasive and impractical for the OR. The purpose of this study was to determine the practicality of a new watch-sized device to measure galvanic skin response (GSR) in OR team members during high-fidelity surgical simulations. METHODS: Interprofessional OR teams wore sensors on the wrist (all) and ankle (surgeons and scrub nurses/technicians) during the orientation, case, and debriefing phases for 17 simulations of a surgical airway case. Data were compared across all simulation phases, collectively and for each professional group. RESULTS: Forty anesthesiology residents, 35 surgery residents, 27 OR nurses, 12 surgical technicians, and 7 CRNAs participated. Collectively, mean wrist GSR levels significantly increased from orientation phase to the case (0.40-0.62 µS; P < .001) and remained elevated even after the simulation was over (0.40-0.67 µS; P < .001). Surgery residents were the only group that demonstrated continued increases in wrist GSR levels throughout the entire simulation (change in GSR = 0.21 to 0.32 to 0.11 µS; P < .01). Large intraindividual differences (≤ 200 times) were found in both wrist and ankle GSR. There was no correlation between wrist and ankle data. CONCLUSION: Continuous GSR monitoring of all professionals during OR simulations is feasible, but would be difficult to implement in an actual OR environment. Large variation in individual levels of physiologic activation suggests complementary qualitative research is needed to better understand how people respond to stressful OR situations.

Spontaneous coronary artery dissection in a parturient with Nail-Patella syndrome.

Spontaneous coronary artery dissection is an uncommon cause of acute coronary syndrome, occurring predominantly in women during and immediately after pregnancy; it carries a mortality rate of greater than 50%. While the exact etiology is unknown, possible contributing factors include pregnancy-related hormonal, connective tissue and hemodynamic changes. We present a case of a 35-year-old multigravid woman with Nail-Patella syndrome who developed an acute myocardial infarction secondary to spontaneous coronary artery dissection during labor which was not diagnosed until after delivery. We hypothesize that abnormal collagen fiber formation found in Nail-Patella syndrome may have put her at an increased risk of coronary dissection and myocardial infarction. Regardless of etiology, a delay in diagnosis of myocardial ischemia can lead to significant morbidity and mortality. In light of the increasing burden of cardiac disease in the obstetric population, clinicians should remain vigilant for signs of myocardial infarction and prepare for definitive diagnosis and treatment.

Experimental determination of the evolution of the Bjorken integral at low Q2.

We extract the Bjorken integral Gamma1(p-n) in the range 0.17 < Q2 < 1.10 GeV2 from inclusive scattering of polarized electrons by polarized protons, deuterons, and 3He, for the region in which the integral is dominated by nucleon resonances. These data bridge the domains of the hadronic and partonic descriptions of the nucleon. In combination with earlier measurements at higher Q2, we extract the nonsinglet twist-4 matrix element f2.

Precise measurement of the pi+-->pi0 e+nu branching ratio.

Using a large acceptance calorimeter and a stopped pion beam we have made a precise measurement of the rare pi(+)-->pi(0)e(+)nu (pi(beta)) decay branching ratio. We have evaluated the branching ratio by normalizing the number of observed pi(beta) decays to the number of observed pi(+)-->e(+)nu (pi(e2)) decays. We find the value of Gamma(pi(+)-->pi(0)e(+)nu)/Gamma(total)=[1.036+/-0.004(stat)+/-0.004(syst)+/-0.003(pi(e2))]x10(-8), where the first uncertainty is statistical, the second systematic, and the third is the pi(e2) branching ratio uncertainty. Our result agrees well with the standard model prediction.

Precise measurement of the pion axial form factor in the pi+-->e+nugamma decay.

We have studied radiative pion decays pi(+)-->e(+)nugamma in three broad kinematic regions using the PIBETA detector and a stopped pion beam. Based on Dalitz distributions of 41 601 events we have evaluated absolute pi-->enugamma branching ratios in the three regions. Minimum chi(2) fits to the integral and differential (E(e(+)),E(gamma)) distributions result in the axial-to-vector weak form factor ratio of gamma identical with F(A)/F(V)=0.443(15), or F(A)=0.0115(4) with F(V)=0.0259. However, deviations from standard model predictions in the high-E(gamma)-low-E(e(+)) kinematic region indicate the need for further theoretical and experimental work.

Measurement of the proton spin structure function g1(x,Q2) for Q2 from 0.15 to 1.6 GeV2 with CLAS.

Double-polarization asymmetries for inclusive ep scattering were measured at Jefferson Lab using 2.6 and 4.3 GeV longitudinally polarized electrons incident on a longitudinally polarized NH3 target in the CLAS detector. The polarized structure function g(1)(x,Q2) was extracted throughout the nucleon resonance region and into the deep inelastic regime, for Q(2)=0.15-1.64 GeV2. The contributions to the first moment Gamma(1)(Q2)= integral g(1)(x,Q2) dx were determined up to Q(2)=1.2 GeV2. Using a parametrization for g(1) in the unmeasured low x regions, the complete first moment was estimated over this Q2 region. A rapid change in Gamma(1) is observed for Q2<1 GeV2, with a sign change near Q(2)=0.3 GeV2, indicating dominant contributions from the resonance region. At Q(2)=1.2 GeV2 our data are below the perturbative QCD evolved scaling value.

Q2 Dependence of quadrupole strength in the gamma*p --> Delta(+)(1232) --> p pi(0) transition.

Models of baryon structure predict a small quadrupole deformation of the nucleon due to residual tensor forces between quarks or distortions from the pion cloud. Sensitivity to quark versus pion degrees of freedom occurs through the Q2 dependence of the magnetic (M1+), electric (E1+), and scalar (S1+) multipoles in the gamma*p-->Delta(+)-->p pi(0) transition. We report new experimental values for the ratios E(1+)/M(1+) and S(1+)/M(1+) over the range Q2 = 0.4-1.8 GeV2, extracted from precision p(e,e(')p)pi(0) data using a truncated multipole expansion. Results are best described by recent unitary models in which the pion cloud plays a dominant role.

First measurement of the double spin asymmetry in (-->)e(-->)p-->e(prime)pi(+)n in the resonance region.

The double spin asymmetry in the (-->)e(-->)p --> e(prime)pi(+)n reaction has been measured for the first time in the resonance region for four-momentum transfer Q2 = 0.35-1.5 GeV(2). Data were taken at Jefferson Lab with the CLAS detector using a 2.6 GeV polarized electron beam incident on a polarized solid NH3 target. Comparison with predictions of phenomenological models shows strong sensitivity to resonance contributions. Helicity-1/2 transitions are found to be dominant in the second and third resonance regions. The measured asymmetry is consistent with a faster rise with Q(2) of the helicity asymmetry A1 for the F(15)(1680) resonance than expected from the analysis of the unpolarized data.

The role of cognitive factors in cue reactivity: extinction on demand.

Cue reactivity measures have become common in addictions research for their apparent objectivity. We used an analog paradigm to examine whether such measures are subject to impression management. Students with conditioned reactions of salivation to the sight and smell of a lemon were assigned to a control group, an experimental group asked to reduce salivation, or an experimental group asked to reduce salivation and promised a reward if successful. Both experimental groups reduced salivation more than the control group; the group rewarded for reduction reduced salivation more than the group that was only asked to do so. This suggests that cue reactivity measures can be manipulated by research participants or clients in treatment. Suggestions for research and implications for treatment are addressed.