The VeinViewer (Luminetx, Memphis, TN) helps identify veins by projecting an image of subcutaneous vasculature on the skin surface. We tested the primary hypothesis that VeinViewer use improves ...cannulation success by skilled nurses in pediatric patients with anticipated difficult IV access. A secondary goal was to evaluate the relationship between obesity and cannulation success.
Patients aged 0 to 18 years were included. Anticipated cannulation difficulty was evaluated with the difficult IV access score. All cannulations were performed by members of the Intravenous Access Team. Patients were randomized to: (1) routine IV catheter insertion; or (2) insertion facilitated by the VeinViewer. The primary outcome was first-attempt insertion success. The proportion of successful insertions was evaluated using Cochran-Mantel-Haenszel χ(2) analysis to adjust for any imbalanced baseline variables. The effect of obesity on cannulation success was evaluated with multivariable logistic regression.
Two hundred ninety-nine patients (49%) were randomly assigned to VeinViewer and 301 (51%) to routine cannulation. First-attempt cannulation success was 47% in patients assigned to VeinViewer vs 62% in patients assigned to routine cannulation, with an adjusted relative "risk" (95% confidence interval), of 0.76 (0.63-0.91). The Z-statistic of -3.6 crossed the "harm" boundary (Z < -2.41), with corresponding P value of 0.0003. The trial was stopped on statistical grounds since the harm boundary for the primary outcome was crossed. There was no association between first-attempt success and the 4-level categorization of obesity after adjusted for baseline variables (P = 0.94).
The VeinViewer worsened first-attempt IV insertion success by skilled nurses. Surprisingly, first-attempt success for IV cannulation was not worsened by obesity.
To determine the pattern of resilience and adjustment following pediatric cancer diagnosis and to evaluate hope as a mediator of adjustment.
61 participants with pediatric cancer completed measures ...of hope, depression, anxiety, and quality of life (QoL) within 4 weeks of cancer diagnosis and every 3 months for 1 year.
Participants showed high and increasing levels of hope and QoL, as well as low and decreasing levels of depression and anxiety. Linear mixed-effects regression analyses revealed changes in depression, anxiety, and hope to be significant predictors of changes in QoL. Changes in hope were found to partially mediate the effects of depression and anxiety on QoL.
While a variety of interventions are efficacious for treating anxiety and depression, hope theory provides a framework for choosing interventions that may more globally promote children's ability to maintain good functioning, adjustment, well-being, and QoL following cancer diagnosis.
The amount of education debt incurred by medical school graduates in the United States has grown considerably over the last 30 years; it has outpaced inflation to reach a mean of $158,000. With this ...dramatic increase in education debt, there has been limited information on how medical school debt loads of anesthesiology physicians impact their decisions concerning moonlighting and future career choices. Our aim was to survey current anesthesiology interns, residents, and fellows to assess the correlation between the amount of medical school debt they had collected and (1) their outlook toward moonlighting activities, (2) future career plans, and (3) choice of employer with a debt repayment program.
We developed a web-based survey instrument and contacted residency training programs to obtain access to their anesthesiology interns, residents, and fellows (residents). We assessed each relationship of interest using a multivariable proportional odds model, adjusting for all available baseline potential confounding factors. Second, we compared participants with >$150,000 medical school debt versus participants with no debt on the same questions of interest, each using a multivariable proportional odds model with the same covariable adjustment.
We had access to 2386 residents through their training programs and 537 completed the survey. Those respondents with a 1-category-larger amount of medical school debt (i.e., $30,000) were associated with 7%(99.3% confidence interval: 0%, 13%) increased odds of having the desire to moonlight during residency/fellowship, and were associated with 7% (1%, 13%) decreased odds of saying they would choose a career as an academic faculty, respectively. Also, those with a larger amount of medical school debt were more likely to be swayed to be interested in an anesthesiology group with an education debt repayment program (odds ratio: 1.3 1.22, 1.39 for 1-category increase in the debt amount); furthermore, the corresponding odds ratio was increased to 4.6 (2.8, 7.5) comparing those with >$150,000 debt with those without debt.
In an effort to compete with private practice anesthesiology groups and to reduce the impact of debt on future career choices of residents/fellows, academic anesthesiology groups would do well to (1) promote moonlighting activities that are within the Accreditation Council for Graduate Medical Education and institutional guidelines, (2) develop financial curriculum for residents/fellows, and (3) offer debt repayment programs as an incentive for new faculty to join academic medicine.
BACKGROUND:Intraoperative intraocular pressure (IOP) in the prone position and IOP changes over time have not been evaluated in pediatric surgical patients. We sought to determine time-dependent ...changes in IOP in children undergoing surgery in prone position.
METHODS:Thirty patients undergoing neurosurgical procedures in prone position were included. Using a pulse-mode pneumatonometer, IOP was measured in supine position after induction and before emergence of anesthesia and in prone position before the start and after the end of surgery. IOP changes over time in the prone position were assessed with a linear mixed model (i.e., random slope and intercept model) to adjust for the within-patient correlation.
RESULTS:IOP in prone position increased by an average of 2.2 mm Hg per hour (P < 0.001). Sixty-three percent of patients (95% confidence interval CI, 46%–81%) had at least 1 IOP value exceeding 30 mm Hg, and 13% (95% CI, 1%–25%) had at least 1 IOP value exceeding 40 mm Hg while prone. Mean IOP increased 7 mm Hg (95% CI, 6–9) during the position change from supine to prone (P < 0.001) and decreased 10 mm Hg (95% CI, 9–12) after changing the position from prone back to supine (P < 0.001).
CONCLUSIONS:Changing position from supine to prone significantly increases IOP in anesthetized pediatric patients. Moreover, the IOP continued to increase during surgery and reached potentially harmful values, especially when combined with low mean arterial blood pressures that are common during major surgery.
ABSTRACTThere has been a substantial increase in the education debt incurred by medical school graduates in the United States during the last 30 years. There is obvious concern by recent graduates ...over repayment of the loans that helped finance their medical school education. The mean debt for graduating medical students at present is $158,000. There is limited information on the impact of medical school debt loads among physicians in training programs on their decision to moonlight and future career choices.The aim of this survey was to determine whether the amount of medical school debt incurred by anesthesiology physicians currently in training programs would influence their decision to moonlight during residency and/or fellowship, their choice of practice (academic or private), and likelihood of choosing an employer who offered a debt repayment program. A Web-based survey instrument was developed. Survey participants were anesthesiology interns, residents, and fellows (residents) currently in allopathic and osteopathic anesthesiology residency programs within the United States. Several different categories of medical school debt load were used, ranging from no debt to a debt $150,000 or greater. In the primary analysis, each relationship of interest was assessed using a multivariable proportional odds model, with adjustment for baseline potentially confounding factors. The response to the same questions of interest was compared for participants with more than $150,000 medical school debt and those with no debt, using the same multivariable proportional odds model with adjustment for covariates. Because of multiple comparisons, a Bonferroni correction was applied, and 99.3% confidence intervals (CIs) were utilized instead of the usual 95% CIs.Of the 2386 residents contacted, 537 (22.5%) completed the survey. A 1-category-larger amount of medical school debt (ie, $30,000) was associated with a 7% (99.3% CI, 1%–13%) increased odds of desiring to moonlight during residency/fellowship and decreased odds of pursuing a career as an academic faculty (odds ratio OR of 0.93 with 99.3% CI of 0.87–0.99). Respondents with a larger amount of medical school debt were more likely to join an anesthesiology group with an education debt repayment program (OR,1.3; 99.3% CI, 1.22–1.39, for 1-category increase in the debt amount). Moreover, participants with $150,000 debt or greater were much more likely than those with no debt to be interested in joining an anesthesiology group with an education debt repayment program (OR, 4.6; 95% CI, 2.8–7.5).Based on these findings, in order for academic anesthesiology groups to successfully compete with private practice groups for new residents/fellows, they must reduce the impact of medical school debt on future career choices of residents by promoting moonlighting activities within the Accreditation Council for Graduate Medical Education and institutional guidelines and offering debt repayment programs as an incentive to enter academic medicine.
Gout is a common autoinflammatory joint diseases characterized by deposition of monosodium urate (MSU) crystals which trigger an innate immune response mediated by inflammatory cytokines. IGF1R is ...one of the loci associated with both urate levels and gout susceptibility in GWAS to date, and IGF-1-IGF-1R signaling is implicated in urate control. We investigate the role of IGF-1/IGF1R signaling in the context of gouty inflammation. Also, we test the gout and urate-associated IGF1R rs6598541 polymorphism for association with the inflammatory capacity of mononuclear cells. For this, freshly isolated human peripheral blood mononuclear cells (PBMCs) were exposed to recombinant IGF-1 or anti-IGF1R neutralizing antibody in the presence or absence of solubilized urate, stimulated with LPS/MSU crystals. Also, the association of rs6598541 with IGF1R and protein expression and with ex vivo cytokine production levels after stimulation with gout specific stimuli was tested. Urate exposure was not associated with IGF1R expression in vitro or in vivo. Modulation of IGF1R did not alter urate-induced inflammation. Developing urate-induced trained immunity in vitro was not influenced in cells challenged with IGF-1 recombinant protein. Moreover, the IGF1R rs6598541 SNP was not associated with cytokine production. Our results indicate that urate-induced inflammatory priming is not regulated by IGF-1/IGF1R signaling in vitro. IGF1R rs6598541 status was not asociated with IGF1R expression or cytokine production in primary human PBMCs. This study suggests that the role of IGF1R in gout is tissue-specific and may be more relevant in the control of urate levels rather than in inflammatory signaling in gout.
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