Identifying a Window of Vulnerability during Fetal Development in a Maternal Iron Restriction Model

It is well acknowledged from observations in humans that iron deficiency during pregnancy can be associated with a number of developmental problems in the newborn and developing child. Due to the obvious limitations of human studies, the stage during gestation at which maternal iron deficiency causes an apparent impairment in the offspring remains elusive. In order to begin to understand the time window(s) during pregnancy that is/are especially susceptible to suboptimal iron levels, which may result in negative effects on the development of the fetus, we developed a rat model in which we were able to manipulate and monitor the dietary iron intake during specific stages of pregnancy and analyzed the developing fetuses. We established four different dietary-feeding protocols that were designed to render the fetuses iron deficient at different gestational stages. Based on a functional analysis that employed Auditory Brainstem Response measurements, we found that maternal iron restriction initiated prior to conception and during the first trimester were associated with profound changes in the developing fetus compared to iron restriction initiated later in pregnancy. We also showed that the presence of iron deficiency anemia, low body weight, and changes in core body temperature were not defining factors in the establishment of neural impairment in the rodent offspring

Predictive Validity of Anesthesiologists' Quality of Clinical Supervision and Nurse Anesthetists' Work Habits Assessed by Their Associations With Operating Room Times

At all Joint Commission-accredited hospitals, the anesthesia department chair must report quantitative assessments of anesthesiologists' and nurse anesthetists' (CRNAs') clinical performance at least annually. Most metrics lack evidence of usefulness, cost-effectiveness, reliability, or validity. Earlier studies showed that anesthesiologists' clinical supervision quality and CRNAs' work habits have content, convergent, discriminant, and construct validity. We evaluated predictive validity by testing for (expected) small but statistically significant associations between higher quality of supervision (work habits) and reduced probabilities of cases taking longer than estimated.BACKGROUNDAt all Joint Commission-accredited hospitals, the anesthesia department chair must report quantitative assessments of anesthesiologists' and nurse anesthetists' (CRNAs') clinical performance at least annually. Most metrics lack evidence of usefulness, cost-effectiveness, reliability, or validity. Earlier studies showed that anesthesiologists' clinical supervision quality and CRNAs' work habits have content, convergent, discriminant, and construct validity. We evaluated predictive validity by testing for (expected) small but statistically significant associations between higher quality of supervision (work habits) and reduced probabilities of cases taking longer than estimated.Supervision quality of each anesthesiologist was evaluated daily by assigned trainees using the 9-item de Oliveira Filho scale. The work habits of each CRNA were evaluated daily by assigned anesthesiologists using a 6-item scale. Both are scored binary, 1 if all items are rated the maximum, 0 otherwise. From 40,718 supervision evaluations and 53,722 work habit evaluations over 8 fiscal years, 16 mixed-effects logistic regression models were estimated, with raters as fixed effects and ratees (anesthesiologists or CRNAs) as random effects. Empirical Bayes means in the logit scale were obtained for 561 anesthesiologist-years and 605 CRNA-years. The binary-dependent variable was whether the case took longer than estimated from the historical mean time for combinations of scheduled procedures and surgeons. From 264,060 cases, 8 mixed-effects logistic regression models were fitted, 1 per fiscal year, using ratees as random effects. Predictive validity was tested by pairing the 8 one-year analyses of clinical supervision, and the 8 one-year analyses of work habits, by ratee, with the 8 one-year analyses of whether OR time was longer than estimated. Bivariate errors in variable linear least squares linear regressions minimized total variances.METHODSSupervision quality of each anesthesiologist was evaluated daily by assigned trainees using the 9-item de Oliveira Filho scale. The work habits of each CRNA were evaluated daily by assigned anesthesiologists using a 6-item scale. Both are scored binary, 1 if all items are rated the maximum, 0 otherwise. From 40,718 supervision evaluations and 53,722 work habit evaluations over 8 fiscal years, 16 mixed-effects logistic regression models were estimated, with raters as fixed effects and ratees (anesthesiologists or CRNAs) as random effects. Empirical Bayes means in the logit scale were obtained for 561 anesthesiologist-years and 605 CRNA-years. The binary-dependent variable was whether the case took longer than estimated from the historical mean time for combinations of scheduled procedures and surgeons. From 264,060 cases, 8 mixed-effects logistic regression models were fitted, 1 per fiscal year, using ratees as random effects. Predictive validity was tested by pairing the 8 one-year analyses of clinical supervision, and the 8 one-year analyses of work habits, by ratee, with the 8 one-year analyses of whether OR time was longer than estimated. Bivariate errors in variable linear least squares linear regressions minimized total variances.Among anesthesiologists, 8.2% (46/561) had below-average supervision quality, and 17.7% (99/561), above-average. Among CRNAs, 6.3% (38/605) had below-average work habits, and 10.9% (66/605) above-average. Increases in the logits of the quality of clinical supervision were associated with decreases in the logits of the probabilities of cases taking longer than estimated, unitless slope = -0.0361 (SE, 0.0053), P < .00001. Increases in the logits of CRNAs' work habits were associated with decreases in the logits of probabilities of cases taking longer than estimated, slope = -0.0238 (SE, 0.0054), P < .00001.RESULTSAmong anesthesiologists, 8.2% (46/561) had below-average supervision quality, and 17.7% (99/561), above-average. Among CRNAs, 6.3% (38/605) had below-average work habits, and 10.9% (66/605) above-average. Increases in the logits of the quality of clinical supervision were associated with decreases in the logits of the probabilities of cases taking longer than estimated, unitless slope = -0.0361 (SE, 0.0053), P < .00001. Increases in the logits of CRNAs' work habits were associated with decreases in the logits of probabilities of cases taking longer than estimated, slope = -0.0238 (SE, 0.0054), P < .00001.Predictive validity was confirmed, providing further evidence for using supervision and work habits scales for ongoing professional practice evaluations. Specifically, OR times were briefer when anesthesiologists supervised residents more closely, and when CRNAs had better work habits.CONCLUSIONSPredictive validity was confirmed, providing further evidence for using supervision and work habits scales for ongoing professional practice evaluations. Specifically, OR times were briefer when anesthesiologists supervised residents more closely, and when CRNAs had better work habits

Crisis Management Simulation: The Value of Interdisciplinary Debriefing

OBJECTIVE: Simulation offers an important avenue for surgical and anesthesia training. This is especially important for crisis management scenarios where individuals need to act quickly and efficiently for optimal patient care. Practice based performance can be measured and real time feedback provided during debriefing scenarios. METHODS: In this paper, we highlight a dual anesthesia and otolaryngology cavernous carotid injury scenario. The trials were run three different times with inter-trial debriefing. RESULTS: The focused debriefing improved resident performance in terms of blood loss on subsequent trials. Furthermore, the learners provided important feedback regarding the utility of training and how it improved their ability to handle crisis management scenarios in the future. CONCLUSION: Debriefing for crisis management in a simulation trial improves performance and trainee confidence. Follow up studies will evaluate real world effectiveness over a longer follow up period