Purpose

Improved patient-provider relationships can positively influence patient outcomes. Sexual and gender minorities (SGM) represent a wide variety of marginalized populations. There is an absence of studies examining the inclusion of SGM-related health education within postgraduate training in anesthesia. This study's objective was to perform an environmental scan of the educational content of North American obstetric anesthesia fellowship programs.

Methods

An online survey was developed based on a review of the existing literature assessing the presence of SGM content within other healthcare-provider curricula. The survey instrument was distributed electronically to 50 program directors of North American obstetric anesthesia fellowship programs. Survey responses were summarized using descriptive statistics.

Results

Survey responses were received from 30 of the 50 program directors (60%). Of these, 54% (14/26) felt their curriculum adequately prepares fellows to care for SGM patients, yet only 19% (5/26) of participants stated that SGM content was part of their curriculum and 31% (8/26) would like to see more incorporated in the future. Perceived lack of need was chosen as the biggest barrier to curricular inclusion of SGM education (46%; 12/26), followed by lack of available/interested faculty (19%; 5/26) and time (19%; 5/26).

Conclusions

Our results suggest that, although curriculum leaders appreciate that SGM patients are encountered within the practice of obstetric anesthesia, most fellowship programs do not explicitly include SGM curricular content. Nevertheless, there appears to be interest in developing SGM curricular content for obstetric anesthesia fellowship training. Future steps should include perspectives of trainees and patients to inform curricular content.

Purpose

This scoping review aimed to summarize the current literature on postpartum psychiatric disorders (e.g., postpartum depression, postpartum anxiety, postpartum post-traumatic stress disorder) and the possible relationship of these disorders to the use of pharmacologic labour analgesia (e.g., epidural analgesia, nitrous oxide, parenteral opioids) to identify knowledge gaps that may aid in the planning of future research.

Sources

PubMed, PsycINFO, CINAHL, and EMBASE were searched from inception to November 9, 2018 for studies that included both labour analgesia and the postpartum psychiatric disorders specified above.

Principal findings

Two reviewers assessed the studies and extracted the data. Of the 990 identified citations, 17 studies were included for analysis. Existing studies have small sample sizes and are observational cohorts in design. Patient psychiatric risk factors, method of delivery, and type of labour analgesia received were inconsistent among studies. Most studies relied on screening tests for diagnosing postpartum psychiatric illness and did not assess the impact of labour analgesia on postpartum psychiatric illness as the primary study objective.

Conclusions

Future studies should correlate screen-positive findings with clinical diagnosis; consider adjusting the timing of screening to include the antepartum period, early postpartum, and late postpartum periods; and consider the degree of labour pain relief and the specific pharmacologic labour analgesia used when evaluating postpartum psychiatric disorders.

Background

Development of predictive models of preeclampsia has only yielded modest results. We hypothesized that impaired indices of microcirculatory function could be detected using sidestream dark field imaging. The objective of this study was to examine microvascular function in women at high risk for preeclampsia at mid-gestation.

Methods

Women between 16 and 22 weeks of gestation were screened for eligibility. Patients were recruited if they met eligibility criteria indicating high risk for preeclampsia. Investigators performed non-invasive sidestream dark field imaging of the sublingual microcirculation. Images were analyzed to determine microcirculatory parameters (microvascular flow index, perfused vessel density, total vessel density, and proportion of perfused vessels). After delivery, charts were reviewed to determine if they developed gestational hypertension, preeclampsia or severe preeclampsia.

Results

Twelve of 66 participants (18.2%) developed preeclampsia or severe preeclampsia during the course of their pregnancy. Microvascular flow index was not significantly different between participants with normal pregnancies and participants with preeclampsia or severe preeclampsia (2.75 ± 0.38 vs. 2.80 ± 0.34, respectively; P = 0.459). Similarly, there were no significant differences between groups in the remaining microcirculatory parameters.

Conclusions

Sidestream dark field imaging of the sublingual microcirculation may remain an appropriate tool to identify women at risk for preeclampsia, albeit later in pregnancy.

Background

Consistent formative feedback is cornerstone to competency-by-design programs and evidence-based approaches to teaching and learning processes. There has been no published research investigating feedback from residents' perspectives. We explored the value residents place on feedback in routine operating room settings, their experiences, and understanding of the role of feedback in their training and developing professional identity.

Methods

Interpretive phenomenological analysis of residents' experiences with feedback received in clinical settings involved two focus groups with 14 anesthesia residents at two time points. Analysis was completed in the context of a teaching hospital adapting to new practices to align with nationally mandated clinical competencies. Focus group conversations were transcribed and interpreted through the lens of a social constructivist approach to learning as a dynamic inter- and intra-personal process, and evidence-based assessment standards set by the International Test Commission (ITC).

Results

Residents described high quality feedback as consistent, effortful, understanding of residents' thought processes, and containing actionable advice for improvement. These qualities of effective evaluation were equally imperative for informal and formal evaluations. Residents commented that highest quality feedback was received informally, and formal evaluations often lacked what they needed for their professional development.

Conclusion

Residents have a deep sense of what promotes their learning. Structured feedback tools were seen positively, although the most important determinants of their impact were faculty feedback- and broader evaluation-skills and motivations for both formal and informal feedback loops.

Purpose

Labour epidural analgesia (LEA) is an evolving field. Various neuraxial techniques and dosing regimens are available to the modern obstetric anesthesia provider, allowing for significant practice variability. To begin a search for consensus on optimal care, we sought to query fellowship training practices for LEA.

Methods

We conducted an electronic survey of institutions with American Council for Graduate Medical Education-accredited obstetric anesthesiology fellowship programs. We studied the frequency of epidural initiation techniques, including combined spinal epidural (CSE), dural puncture epidural, and epidural bolus. For maintenance techniques, we appraised the use of continuous epidural infusion, programmed intermittent bolus (PIEB), and patient-controlled epidural analgesia (PCEA).

Results

Of 40 institutions surveyed, we received 32 responses (80% response rate). Twenty-eight of 40 (70%) were included in the analysis. A plurality of institutions (12/28; 43%) preferred CSE, and among those who used CSE, 23/27 (85%) included intrathecal opioids. A majority of institutions used protocols with PIEB (55%), while almost all (92%) used PCEA. Most participants (88%) reported using dilute concentration maintenance infusions of 0.1% bupivacaine/ropivacaine or less.

Conclusion

Despite significant variability in LEA practice, some clear patterns emerged in our survey, including preference for opioid-containing CSE and maintenance with PIEB, PCEA, and dilute epidural solutions.

Purpose

In this Continuing Professional Development module, we review the practical pharmacology of tranexamic acid and its clinical use in trauma, obstetrics, and major orthopedic surgery.

Principal findings

Tranexamic acid is a synthetic drug that inhibits fibrinolysis. Multiple clinical trials in various clinical settings have shown that it can reduce blood loss, transfusion rates, and bleeding-associated mortality. In trauma and obstetrical bleeding, early tranexamic acid administration (< three hours) may have greater clinical benefits. Overall, tranexamic acid use appears safe with no significant increase of thromboembolic or seizure events. Nevertheless, current evidence has limitations related to wide heterogeneity in dose, route, and timing of drug administration, as well as generalizability of the large-scale trial findings to higher income nations.

Conclusions

Tranexamic acid is an efficacious and safe pharmacological-based blood conservation technique in the management of clinically significant hemorrhage. All anesthesiologists should have a good understanding of the pharmacotherapeutic properties and perioperative role of tranexamic acid therapy both inside and outside of the operating room. The use of tranexamic acid is likely to continue to rise with endorsement by various clinical guidelines and healthcare organizations. Further quantitative research is needed to evaluate optimal dosing and drug efficacy in these clinical scenarios.

Purpose

Giving birth is the most common reason for hospital admission, with Cesarean delivery being the most frequently performed inpatient surgery. Through a needs assessment and iterative design process involving patients and obstetric anesthesiologists, we previously developed a mobile application, C-Care, for patients undergoing Cesarean delivery. The focus of C-Care is perioperative education and self-monitoring of potential anesthetic complications. This study aimed to obtain feedback on patient engagement with C-Care.

Method

We conducted a prospective cohort study of patients ≥ 18 yr (n = 36) undergoing elective Cesarean delivery. Anonymous usage data were recorded for 30 days. On postoperative days 1-5, participants received daily self-monitoring questionnaires within C-Care. Fourteen days after surgery, participants received an online survey regarding satisfaction and use of C-Care.

Results

Thirty-five out of 36 participants visited the application after orientation, with a median [interquartile range (IQR)] age of 32 [31-36] yr. Each participant visited the application a median of 15 [9-31] times over 30 days and completed a median of 3 [2-4] out of five self-monitoring questionnaires. Each participant viewed a median of 4 [2-7] out of eight education topics, with the most viewed patient education topics being "Controlling Pain" and "The First Few Days". Visits to the application were highest in the first week postpartum. Of the 18 respondents who completed the day 14 survey, 83% (n = 15) participants would recommend C-Care to other women, and the median participant satisfaction score was 7.5 out of 10 (range, 2-10).

Conclusion

Most participants used this mobile application for patient education and self-monitoring after elective Cesarean delivery. Insights into patient engagement with C-Care after Cesarean delivery could help design more effective perioperative mobile telehealth programs.

Trial registration

www.ClinicalTrials.gov (NCT03746678); registered 5 November 2018.

Purpose Patient preferences for labor epidural analgesia (LEA) have been incompletely evaluated. This study aimed to determine the importance of various LEA outcomes to both antenatal and postpartum patients. Methods This was a cross-sectional study approved by the institutional ethics board. Questionnaires were distributed to two separate and distinct cohorts screened for eligibility: pregnant patients at an antenatal visit and postpartum patients during childbirth admission. A list of common LEA outcomes was compiled using research published in leading anesthesia journals. Participants ranked the outcomes according to perceived importance. They assigned each a number from 1 to 10 (priority ranking; 1 indicated the highest priority outcome and 10 the least). They were also asked to 'spend' $100 towards the outcomes (relative value scale), allocating more money to outcomes more important to them. Results Two hundred twenty questionnaires were completed (105 antenatal, 115 postpartum). 'Achieving desired pain relief' was the most important outcome for both cohorts. It was valued more by the postpartum cohort (Median $50 (25 - 60) vs $30 (18 - 50)). 'Overall satisfaction with the pain management,' 'experiencing a short time to achieve pain relief,' and 'experiencing a short duration of labor' received more money than avoiding various LEA-related side effects. The postpartum cohort ranked 'experiencing a short time to achieve pain relief' as more important than the antenatal cohort (Median 5 (3 - 7) vs 3 (2 - 5)). Conclusions Achieving the desired pain relief was the highest LEA outcome preference for both antenatal and postpartum patients. Avoiding side effects was less important relative to pain-related outcomes.

Background

Health researchers are increasingly using social media in a professional capacity, and the applications of social media for health researchers are vast. However, there is currently no published evidence synthesis of the ways in which health researchers use social media professionally, and uncertainty remains as to how best to harness its potential.

Objective

This scoping review aimed to explore how social media is used by health researchers professionally, as reported in the literature.

Methods

The scoping review methodology guided by Arksey and O'Malley and Levac et al was used. Comprehensive searches based on the concepts of health research and social media were conducted in MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC, and Web of Science databases, with no limitations applied. Articles were screened at the title and abstract level and at full text by two reviewers. One reviewer extracted data that were analyzed descriptively to map the available evidence.

Results

A total of 8359 articles were screened at the title and abstract level, of which 719 were also assessed at full text for eligibility. The 414 articles identified for inclusion were published in 278 different journals. Studies originated from 31 different countries, with the most prevalent being the United States (52.7% [218/414]). The health discipline of the first authors varied, with medicine (33.3% [138/414]) being the most common. A third of the articles covered health generally, with 61 health-specific topics. Papers used a range of social media platforms (mean 1.33 [SD 0.7]). A quarter of the articles screened reported on social media use for participant recruitment (25.1% [104/414]), followed by practical ways to use social media (15.5% [64/414]), and use of social media for content analysis research (13.3% [55/414]). Articles were categorized as celebratory (ie, opportunities for engagement, 72.2% [299/414]), contingent (ie, opportunities and possible limitations, 22.7% [94/414]) and concerned (ie, potentially harmful, 5.1% [21/414]).

Conclusions

Health researchers are increasingly publishing on their use of social media for a range of professional purposes. Although most of the sentiment around the use of social media in health research was celebratory, the uses of social media varied widely. Future research is needed to support health researchers to optimize their social media use.