Anesthesiology Residency Recruitment: A Prospective Study Comparing In-Person and Virtual Interviews.

Background: Residency recruitment requires significant resources for both applicants and residency programs. Virtual interviews offer a way to reduce the time and costs required during the residency interview process. This prospective study investigated how virtual interviews affected scoring of anesthesiology residency applicants and whether this effect differed from in-person interview historical controls. Methods: Between November 2020 and January 2021, recruitment members at the University of Chicago scored applicants before their interview based upon written application materials alone (preinterview score). Applicants received a second score after their virtual interview (postinterview score). Recruitment members were queried regarding the most important factor affecting the preinterview score as well as the effect of certain specified applicant interview characteristics on the postinterview score. Previously published historical controls were used for comparison to in-person recruitment the year prior from the same institution. Results: Eight hundred and sixteen virtual interviews involving 272 applicants and 19 faculty members were conducted. The postinterview score was higher than the preinterview score (4.06 versus 3.98, P value of <.0001). The change in scores after virtual interviews did not differ from that after in-person interviews conducted the previous year (P = .378). The effect of each characteristic on score change due to the interview did not differ between in-person and virtual interviews (all P values >.05). The factor identified by faculty as the most important in the preinterview score was academic achievements (64%), and faculty identified the most important interview characteristic to be personality (72%). Conclusions: Virtual interviews led to a significant change in scoring of residency applicants, and the magnitude of this change was similar compared with in-person interviews. Further studies should elaborate on the effect of virtual recruitment on residency programs and applicants.

The Influence of the In-person Residency Interview: A Prospective Study.

BACKGROUND: This prospective study investigated whether in-person interviews affected interviewer assessments of anesthesiology residency applicants at an academic medical center, and which applicant characteristics influenced interview performance. METHODS: Eighteen faculty members involved in residency recruitment between November 2019 and January 2020 documented preinterview (after full application review) and postinterview scores of the applicants on a scale of 1 to 5. Faculty also reported the relative contributions of specific interview characteristics (personality, physical appearance, professional demeanor, discussion regarding academic/scholarly activity, and level of interest in the specialty) to their postinterview assessments. Mixed-effects models were used to assess whether interviews changed faculty assessment of applicants, and what the relative contributions of applicant characteristics were to faculty assessments. RESULTS: A total of 696 interviews were conducted with 232 applicants. The postinterview scores differed significantly from the preinterview scores (estimated mean difference, 0.09 ± 0.02; P < 0.0001). The characteristics most affecting postinterview scores were positive impressions of applicants' personalities (marginal mean change in postinterview score, 0.259; 95% confidence interval, 0.221-0.297) and negative impressions of applicants' professional demeanor (marginal mean change, -0.257; 95% confidence interval, -0.350 to -0.164). CONCLUSIONS: In-person interviews significantly affected residency applicants' scores. Personality and professional demeanor influenced scores more than did other characteristics examined. Further studies are needed to clarify the relevance of in-person interviews to the assessment of residency applicants.

A Predictive Model for Pediatric Postoperative Respiratory Failure: A National Inpatient Sample Study.

STUDY OBJECTIVE: To identify risk factors for pediatric postoperative respiratory failure and develop a predictive model. DESIGN: This retrospective case-control study utilized the US National Inpatient Sample (NIS) from 2012 to 2014. Significant predictors were selected, and the predicted probability of pediatric postoperative respiratory failure was calculated. Sensitivity, specificity, and accuracy were then calculated, and receiver-operator curves were drawn. SETTING: National Inpatient Sample data sets from years 2012, 2013, and 2014 were used. PATIENTS: Patients aged 17 and younger in the 2012, 2013, and 2014 NIS data sets. INTERVENTIONS: Candidate predictors included demographic variables, type of surgical procedure, a modified pediatric comorbidity score, presence of substance abuse diagnosis, and presence/absence of kyphoscoliosis. MEASUREMENTS: The primary outcome measure was the pediatric quality indicator (PDI 09), which is defined by the Agency for Healthcare Research Quality, and identifies pediatric patients with postoperative respiratory failure. MAIN RESULTS: The incidence of pediatric postoperative respiratory failure in each year's data set varied from 1.31% in 2012 to 1.41% in 2014. Significant risk factors for the development of postoperative respiratory failure included abdominal surgery ([OR] = 1.92 in 2012 data set, 1.79 in 2013 data set), spine surgery (OR = 7.10 in 2012 data set, 6.41 in 2013 data set), and an elevated pediatric comorbidity score (score of 3 or greater: OR = 32.58 in 2012 data set, 22.74 in 2013 data set). A predictive model utilizing these risk factors achieved a C statistic of 0.82. CONCLUSIONS: Risk factors associated with postoperative respiratory failure in pediatric patients undergoing noncardiac surgery include type of surgery (abdominal and spine) and higher pediatric comorbidity scores. A prediction model based on the identified factors had good predictive ability.

Be Active and Be Well? A Cross-sectional Survey of US Anesthesia Residents.

BACKGROUND: Wellness among resident physicians is important to their well-being and ability to provide clinical care. The relationship between physical activity and wellness among anesthesia residents has not yet been evaluated. We surveyed anesthesia residents to evaluate their levels of physical activity and self-perceived wellness scores. We hypothesized that residents with high self-reported physical activity levels would be more likely to have higher wellness scores. METHODS: Three hundred and twenty-three anesthesia residents were invited to participate in this cross-sectional survey study. The survey included questions regarding demographics (age, gender, clinical anesthesia year, work hours), physical activity (based off the US Department of Health and Human Services [USDHHS] guidelines), and wellness (using the Satisfaction With Life Scale). The relationship between wellness and physical activity levels was evaluated. RESULTS: One hundred forty-one residents responded (43.6% response rate). Thirty-eight (27.1%) residents met our activity threshold for physically active. Eighty-six respondents (61.4%) were classified as having high wellness based on their survey answers. No significant associations were found between demographic data and wellness, including age or clinical anesthesia training year. Among those residents who described physical activity consistent with USDHHS guidelines, 29 (76.3%) had high wellness scores. After logistic regression analysis, residents who achieved the physical activity guidelines were more likely to have high wellness scores (odds ratio 2.54, 95% confidence interval 1.13-6.20, P value .03). CONCLUSIONS: Anesthesia resident physicians with high physical activity levels had higher self-perceived wellness scores.

Intensivist staffing and outcome in the ICU: daytime, nighttime, 24/7?

PURPOSE OF REVIEW: Many hospitals, particularly large academic centers, have begun to provide 24-h in-house intensive care attending coverage. Proposed advantages for this model include improved patient care, greater provider, nursing and patient satisfaction, better communication, and greater cost-effectiveness. This review will evaluate current evidence with respect to 24/7 coverage, including patient outcomes, cost-effectiveness, and impact on training/education. RECENT FINDINGS: Evidence surrounding 24-h intensivist staffing has been mixed. Although a subset of studies suggest a possible benefit to 24-h intensivist coverage, recent prospective studies have shown no difference in major patient outcomes, including mortality and ICU length of stay between patients in ICUs with and those without 24-h intensivist coverage. SUMMARY: Although some studies cite increased caregiver and patient satisfaction, outcome studies find no consistent effect on patient-centered outcomes such as mortality or length of stay. Downsides to in-house nighttime attending staffing include physician burnout, adverse effects on physician health, decreased trainee autonomy, and effects on trainee specialty choices because of undesirable lifestyle considerations. Tele-ICU and other novel approaches may allow for attending supervision without physical presence.

Hypertensive Diseases of Pregnancy Increase Risk of Readmission With Heart Failure: A National Readmissions Database Study.

OBJECTIVE: To study the association between hypertensive diseases of pregnancy and immediate postpartum development of heart failure in a large national database. PATIENTS AND METHODS: Using the 2013 to 2014 National Readmissions Database, which covered admissions from January 1 through September 30 in years 2013 and 2014, we examined 90-day readmission rates in parturients with a diagnosis of hypertensive disease of pregnancy who were discharged after delivery. The primary outcome was the association between the presence of hypertensive disease of pregnancy and readmission with heart failure within 90 days of delivery discharge. Secondary outcomes included readmission mortality, time between delivery discharge and readmission, length of stay, and costs of readmission. RESULTS: Women with hypertensive disease of pregnancy were more likely to be readmitted with heart failure (1809 of 25,908 readmissions (7.0%) vs 2622 of 89,660 readmissions (2.9%); P<.001). This difference persisted after adjustment for potential cofounders (6.3% vs 3.1%; odds ratio, 2.15; 95% CI, 1.92-2.40; P<.001). Women with a diagnosis of heart failure at readmission were readmitted sooner (11 days vs 23 days; P<.001) and had a longer length of stay (4 days vs 3 days; P<.001) and higher costs of readmission ($10,361 vs $6977; P<.001) than did women without a diagnosis of heart failure. CONCLUSION: Parturients with hypertensive disease of pregnancy were more likely to be readmitted with heart failure within 90 days of delivery. Most patients readmitted with heart failure were readmitted within 2 weeks of discharge after delivery. Patients readmitted with heart failure had substantial health care expenditures.

Activin A and Late Postpartum Cardiac Dysfunction Among Women With Hypertensive Disorders of Pregnancy.

Women with hypertensive disorders of pregnancy have an increased risk of subsequent heart failure and cardiovascular disease when compared with women with normotensive pregnancies. Although the mechanisms underlying these findings are unclear, elevated levels of the biomarker activin A are associated with myocardial dysfunction and may have predictive value. We hypothesized that elevated levels of antepartum activin A levels would correlate with postpartum cardiac dysfunction in women with hypertensive disorders of pregnancy. We prospectively studied 85 women to determine whether increased antepartum activin A levels were associated with cardiac dysfunction at 1 year postpartum as measured by global longitudinal strain. Thirty-two patients were diagnosed with preeclampsia, 28 were diagnosed with gestational or chronic hypertension, and the remainder were nonhypertensive controls. Activin A levels were measured with ELISA both in the third antepartum trimester and at 1 year postpartum. Comprehensive echocardiograms including measurement of global longitudinal strain were also performed at enrollment and at 1 year postpartum. Antepartum activin A levels correlated with worsening antepartum global longitudinal strain (r=0.70; P=0.0001). Across the entire cohort, elevated antepartum activin A levels were associated with the development of abnormal global longitudinal strain at 1 year (C statistic 0.74; P=0.004). This association remained significant after multivariable adjustment for clinically relevant confounders (C statistic 0.93; P=0.01). Postpartum activin A levels also correlated with increasing left ventricular mass index (P=0.02), increasing mean arterial pressures (P=0.02), and decreasing E' values (P=0.01). Activin A may be a useful tool for identifying and monitoring patients at risk for postpartum development of cardiovascular disease.

Opioid Abuse or Dependence Increases 30-day Readmission Rates after Major Operating Room Procedures: A National Readmissions Database Study.

BACKGROUND: Although opioids remain the standard therapy for the treatment of postoperative pain, the prevalence of opioid misuse is rising. The extent to which opioid abuse or dependence affects readmission rates and healthcare utilization is not fully understood. It was hypothesized that surgical patients with a history of opioid abuse or dependence would have higher readmission rates and healthcare utilization. METHODS: A retrospective cohort analysis was performed of patients undergoing major operating room procedures in 2013 and 2014 using the National Readmission Database. Patients with opioid abuse or dependence were identified using International Classification of Diseases codes. The primary outcome was 30-day hospital readmission rate. Secondary outcomes included hospital length of stay and estimated hospital costs. RESULTS: Among the 16,016,842 patients who had a major operating room procedure whose death status was known, 94,903 (0.6%) had diagnoses of opioid abuse or dependence. After adjustment for potential confounders, patients with opioid abuse or dependence had higher 30-day readmission rates (11.1% vs. 9.1%; odds ratio 1.26; 95% CI, 1.22 to 1.30), longer mean hospital length of stay at initial admission (6 vs. 4 days; P < 0.0001), and higher estimated hospital costs during initial admission ($18,528 vs. $16,617; P < 0.0001). Length of stay was also higher at readmission (6 days vs. 5 days; P < 0.0001). Readmissions for infection (27.0% vs. 18.9%; P < 0.0001), opioid overdose (1.0% vs. 0.1%; P < 0.0001), and acute pain (1.0% vs. 0.5%; P < 0.0001) were more common in patients with opioid abuse or dependence. CONCLUSIONS: Opioid abuse and dependence are associated with increased readmission rates and healthcare utilization after surgery. VISUAL ABSTRACT: An online visual overview is available for this article at http://links.lww.com/ALN/B704.

Abnormal mid-trimester cardiac strain in women with chronic hypertension predates superimposed preeclampsia.

BACKGROUND: Chronic hypertension (cHTN) affects 7% of all pregnancies. We hypothesized that cHTN during pregnancy would be associated with abnormal myocardial strain patterns and adverse perinatal outcomes. METHODS: This was a retrospective cohort study of patients seen in a high-risk obstetrics clinic with cHTN. Parturients with a singleton pregnancy who had undergone an echocardiogram as part of routine clinical care were eligible. Clinical and demographic information was collected from medical records. Global peak longitudinal strain (GLS) was measured using automated software from stored echocardiographic images. RESULTS: 60 patients were included in this analysis, of which 48 (80.0%) were African American. The median BMI was 40.6, age was 34 years, and the gestational age was 20.4 weeks at the time of the echo and 37.9 weeks at delivery. Thirty-four patients (56.7%) demonstrated abnormal strain, defined as a GLS <= -19%. Patients with abnormal strain were similar in age and BMI to patients with normal cardiac function. When compared to women with normal strain, those with abnormal strain had lower stroke volume (69.0 ml vs 81.5 ml; p = .001) and ejection fraction (49.6% vs 57.5%; p < .0001). Rates of superimposed preeclampsia were higher (38.2% vs 11.5%, p-value = .02) and a higher proportion of patients in the abnormal strain group delivered before 37 weeks (44.1% vs 19.2%; p = .04). CONCLUSION: In a population of parturients with cHTN, we found that more than one-half demonstrated subclinical abnormal cardiac function. The presence of abnormal cardiac strain predates superimposed preeclampsia and preterm delivery. Further studies are needed to validate these findings.

Interval Changes in Myocardial Performance Index Predict Outcome in Severe Sepsis.

OBJECTIVES: Septic cardiomyopathy is a well-described consequence of septic shock and is associated with increased sepsis-related mortality. The myocardial performance index (MPI), a parameter derived from echocardiographic tissue Doppler measurements, allows for a more sensitive assessment of global cardiac function than do traditional metrics for cardiac function. The authors hypothesized that changes in left ventricular MPI in patients with severe sepsis would be associated with a higher 90-day mortality. DESIGN: Prospective, observational study. SETTING: Intensive care units of a tertiary medical center. PARTICIPANTS: The study comprised 47 patients admitted with new diagnoses of severe sepsis or septic shock. INTERVENTIONS: All patients underwent transthoracic echocardiograms with assessment of MPI at enrollment and 24 hours later. Hemodynamic data and information on sepsis-related mortality were collected. In the primary analysis, the association between change in MPI from enrollment to 24 hours and sepsis-related 90-day mortality was assessed. MEASUREMENTS AND MAIN RESULTS: Of the 47 patients enrolled, 30 demonstrated an improvement in MPI from 0 to 24 hours ("improved" group), and MPI worsened in the remaining 17 patients ("worsened" group). Despite no significant differences in ejection fraction or severity of illness, the median MPI at enrollment in the "improved" group was higher than baseline values in the "worsened" group (p = 0.005). A worsening MPI over the 24-hour study interval was associated with increased mortality at 90 days (p = 0.04), which remained significant (hazard ratio 3.72; 95% confidence interval 1.12-12.41; p = 0.03) after adjusting for severity of illness (Acute Physiology and Chronic Health Evaluation II score), intravenous fluids, and vasopressor use. CONCLUSIONS: In patients admitted to the intensive care unit with a diagnosis of severe sepsis or septic shock, a worsening MPI during the first 24 hours after intensive care unit admission was associated with higher 90-day mortality.

Cardiogenic shock in pregnancy: Analysis from the National Inpatient Sample.

OBJECTIVE: Cardiogenic shock (CS) may occur during pregnancy and dramatically worsen peripartum outcomes. METHODS: We analyzed the National Inpatient Sample from 2002 to 2013 to describe the incidence of, risk factors for and outcomes of CS during pregnancy. RESULTS: Of the 53,794,192 hospitalizations analyzed, 2044 were complicated by CS. The mortality rate in peripartum women with CS was 18.81% versus 0.02% without. It occurs more often during postpartum (58.83%) as compared with delivery (23.47%) or antepartum (17.70%) hospitalizations. Factors associated with CS -related death included cardiac arrest, renal failure, and sepsis. CONCLUSIONS: CS during pregnancy occurs more commonly in the postpartum period and is associated with a high mortality.

Circulating Antiangiogenic Factors and Myocardial Dysfunction in Hypertensive Disorders of Pregnancy.

Hypertensive disorders of pregnancy (HDP) are associated with subclinical changes in cardiac function. Although the mechanism underlying this finding is unknown, elevated levels of soluble antiangiogenic proteins such as soluble fms-like tyrosine kinase-1 (sFlt1) and soluble endoglin (sEng) are associated with myocardial dysfunction and may play a role. We hypothesized that these antiangiogenic proteins may contribute to the development of cardiac dysfunction in HDP. We prospectively studied 207 pregnant women with HDP and nonhypertensive controls and evaluated whether changes in global longitudinal strain (GLS) observed on echocardiography is specific for HDP and whether these changes correlate with HDP biomarkers, sFlt1 and sEng. A total of 62 (30%) patients were diagnosed with preeclampsia (group A), 105 (51%) did not have an HDP (group B), and 40 (19%) were diagnosed with chronic or gestational hypertension (group C). Blood was drawn and sFlt1 and sEng levels measured using enzyme-linked immunosorbent assay. Comprehensive echocardiograms, including measurement of GLS, were performed on all patients. Overall, GLS was worse in women in group A (preeclampsia) than those in group B or C. Increasing sFlt1 and sEng levels correlated with worsening GLS (r=0.44 for sFlt1 and r=0.46 for sEng, both P<0.001), which remained significant after multivariable analysis (r=0.18 and r=0.22, both P≤0.01). Increasing levels also correlated with increasing left ventricular mass index, which also remained significant after multivariable analysis (r=0.20 for sFlt1 and 0.19 for sEng, both P=0.01). Elevated circulating levels of antiangiogenic proteins in HDP correlate with and may contribute to myocardial dysfunction as measured by GLS.

Racial Disparities in Comorbidities, Complications, and Maternal and Fetal Outcomes in Women With Preeclampsia/eclampsia.

OBJECTIVE: The mechanisms leading to worse outcomes in African-American (AA) women with preeclampsia/eclampsia remain unclear. Our objective was to identify racial differences in maternal comorbidities, peripartum characteristics, and maternal and fetal outcomes. METHODS/RESULTS: When compared to white women with preeclampsia/eclampsia, AA women had an increased unadjusted risk of inpatient maternal mortality (OR 3.70, 95% CI: 2.19-6.24). After adjustment for covariates, in-hospital mortality for AA women remained higher than that for white women (OR 2.85, 95% CI: 1.38-5.53), while the adjusted risk of death among Hispanic women did not differ from that for white women. We also found an increased risk of intrauterine fetal death (IUFD) among AA women. When compared to white women with preeclampsia, AA women had an increased unadjusted odds of IUFD (OR 2.78, 95% CI: 2.49-3.11), which remained significant after adjustment for covariates (adjusted OR 2.45, 95% CI: 2.14-2.82). In contrast, IUFD among Hispanic women did not differ from that for white women after adjusting for covariates. CONCLUSIONS AND RELEVANCE: Our data suggest that African-American women are more likely to have risk factors for preeclampsia and more likely to suffer an adverse outcome during peripartum care. Future research should examine whether controlling co-morbidities and other risk factors will help to alleviate racial disparities in outcomes in this cohort of women.

Detection of Myocardial Dysfunction in Septic Shock: A Speckle-Tracking Echocardiography Study.

BACKGROUND: Patients with septic shock are at increased risk of myocardial dysfunction. However, the left ventricular ejection fraction (EF) typically remains preserved in septic shock. Strain measurement using speckle-tracking echocardiography may quantify abnormalities in myocardial function not detected by conventional echocardiography. To investigate whether septic shock results in greater strain changes than sepsis alone, we evaluated strain in patients with sepsis and septic shock. METHODS: We prospectively identified 35 patients with septic shock and 15 with sepsis. These patients underwent serial transthoracic echocardiograms at enrollment and 24 hours later. Measurements included longitudinal, radial, and circumferential strain in addition to standard echocardiographic assessments of left ventricular function. RESULTS: Longitudinal strain worsened significantly over 24 hours in patients with septic shock (P < 0.0001) but did not change in patients with sepsis alone (P = 0.43). No significant changes in radial or circumferential strain or EF were observed in either group over the 24-hour measurement period. In patients with septic shock, the significant worsening in longitudinal strain persisted after adjustment for left ventricular end-diastolic volume and vasopressor use (P < 0.0001). In patients with sepsis, adjustment for left ventricular end-diastolic volume and vasopressor use did not alter the finding of no significant differences in longitudinal strain (P = 0.48) or EF (P = 0.96). CONCLUSIONS: In patients with septic shock, but not sepsis, myocardial strain imaging using speckle-tracking echocardiography identified myocardial dysfunction in the absence of changes in EF. These data suggest that strain imaging may play a role in cardiovascular assessment during septic shock.

Effect of cardiogenic shock hospital volume on mortality in patients with cardiogenic shock.

BACKGROUND: Cardiogenic shock (CS) is associated with significant morbidity, and mortality rates approach 40% to 60%. Treatment for CS requires an aggressive, sophisticated, complex, goal-oriented, therapeutic regimen focused on early revascularization and adjunctive supportive therapies, suggesting that hospitals with greater CS volume may provide better care. The association between CS hospital volume and inpatient mortality for CS is unclear. METHODS AND RESULTS: We used the Nationwide Inpatient Sample to examine 533 179 weighted patient discharges from 2675 hospitals with CS from 2004 to 2011 and divided them into quartiles of mean annual hospital CS case volume. The primary outcome was in-hospital mortality. Multivariate adjustments were performed to account for severity of illness, relevant comorbidities, hospital characteristics, and differences in treatment. Compared with the highest volume quartile, the adjusted odds ratio for inpatient mortality for persons admitted to hospitals in the lowest-volume quartile (≤27 weighted cases per year) was 1.27 (95% CI 1.15 to 1.40), whereas for admission to hospitals in the low-volume and medium-volume quartiles, the odds ratios were 1.20 (95% CI 1.08 to 1.32) and 1.12 (95% CI 1.01 to 1.24), respectively. Similarly, improved survival was observed across quartiles, with an adjusted inpatient mortality incidence of 41.97% (95% CI 40.87 to 43.08) for hospitals with the lowest volume of CS cases and a drop to 37.01% (95% CI 35.11 to 38.96) for hospitals with the highest volume of CS cases. Analysis of treatments offered between hospital quartiles revealed that the centers with volumes in the highest quartile demonstrated significantly higher numbers of patients undergoing coronary artery bypass grafting, percutaneous coronary intervention, or intra-aortic balloon pump counterpulsation. A similar relationship was demonstrated with the use of mechanical circulatory support (ventricular assist devices and extracorporeal membrane oxygenation), for which there was significantly higher use in the higher volume quartiles. CONCLUSIONS: We demonstrated an association between lower CS case volume and higher mortality. There is more frequent use of both standard supportive and revascularization techniques at the higher volume centers. Future directions may include examining whether early stabilization and transfer improve outcomes of patients with CS who are admitted to lower volume centers.