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Objective(s) The authors aimed to assess whether the introduction of a tailored Analgesia Prescription Guideline would decrease the amount of unused opioid following discharge from cardiac surgery. Design Prospective, observational, before and after study. Setting Quaternary care university hospital. Participants A total of 191 participants who underwent cardiac surgery requiring midline sternotomy and cardiopulmonary bypass. There were 99 participants in the before cohort (prior to introduction of the Analgesia Prescription Guideline), and 92 participants in the after cohort (after introduction of the Analgesia Prescription Guideline). Interventions Using prospectively collected observational data on participant opioid consumption in the before cohort, a tailored Analgesia Prescription Guideline was developed. This guideline then was introduced to all opioid-prescribing providers in the cardiothoracic surgery department. Prospective data then were collected in the after cohort of participants. Opioid prescription practices and opioid consumption between the two groups then were compared. Measurements and Main Results Opioid prescriptions were given to 62/99 participants (63%) in the before cohort, and 48/92 (52%) in the after cohort (rate difference 0.1, CI 95% -0.26, 0.046). In the before cohort, the mean (± standard deviation) number of opioid tablets prescribed, used, and leftover was 26 (±10), 11 (±10), and 15 (±12), respectively. In the after cohort, the mean number of opioid tablets prescribed, used, and leftover was 18 (mean difference -8, CI 95% -12, -5), 10 (mean difference -1, CI 95% -5, 3), and 8 (mean difference -7, CI 95% -11, -3), respectively. There were 110/191 (58%) participants using no opioids following discharge, and 10/191 (5%) still using opioids two weeks after discharge. There were no differences between groups with regard to demographics, opioid-related side effects, pain scores, satisfaction, opioid storage. and disposal practices. Conclusions The development and implementation of a tailored Analgesia Prescription Guideline decreased the amount of opioids prescribed after cardiac surgery and resulted in lower numbers of unused leftover opioid tablets in the community. Patient comfort and satisfaction scores remained high.

The rate of pregnant women with an opioid use disorder has risen drastically in the past 20 years, paralleling that in the general population. Pregnancies associated with opioid use, abuse, or dependence have significantly higher rates of complications, such as neonatal opioid withdrawal syndrome, intrauterine growth restriction, neural tube defects, stillbirth, increased maternal mortality, greater postpartum pain, and longer inpatient stays. Patient education about the risks and benefits of multimodal analgesia and empowering shared decision making may help curb the opioid epidemic. Tailoring pain management to individual needs might be the solution to the problem.

Study Objective The primary objective was to compare carbon dioxide (CO2) absorption rates in patients undergoing gynecologic laparoscopy with a standard versus valveless insufflation system (AirSeal; ConMed, Utica, NY) at intra-abdominal pressures (IAPs) of 10 and 15 mm Hg. Secondary objectives were assessment of surgeons’ visualization of the operative field, anesthesiologists’ ability to maintain adequate end-tidal CO2 (etCO2), and patients’ report of postoperative shoulder pain. Design A randomized controlled trial using an equal allocation ratio into 4 arms: standard insufflation/IAP 10 mm Hg, standard insufflation/IAP 15 mm Hg, valveless insufflation/IAP 10 mm Hg, and valveless insufflation/IAP 15 mm Hg. Setting Single tertiary care academic institution. Patients Women ≥ 18 years old undergoing nonemergent conventional or robotic gynecologic laparoscopic surgery. Interventions A standard or valveless insufflation system at IAPs of 10 or 15 mm Hg. Measurements and Main Results One hundred thirty-two patients were enrolled and randomized with 33 patients per group. There were 84 robotic cases and 47 conventional laparoscopic cases. CO2 absorption rates (mL/kg*min) did not differ across groups with mean rates of 4.00 ± 1.3 in the valveless insufflation groups and 4.00 ± 1.1 in the standard insufflation groups. The surgeons’ rating of overall visualization of the operative field on a 10-point Likert scale favored the valveless insufflation system (median visualization, 9.0 ± 2.0 cm and 9.5 ± 1.8 cm at 10 and 15 mm Hg, respectively) over standard insufflation (7.0 ± 3.0 cm and 7.0 ± 2.0 cm at 10 and 15 mm Hg, respectively; p .05). Conclusion CO2 absorption rates, anesthesiologists’ ability to maintain adequate etCO2, and postoperative shoulder pain did not differ based on insufflation system type or IAP. Surgeons’ rating of visualization of the operative field was significantly improved when using the valveless over the standard insufflation system.

Racial and ethnic diversification of the physician and nurse workforce is recommended as a leverage point to address the impact of structural racism in maternal care, but empirical evidence supporting this recommendation is currently lacking.This study aimed to assess the association between state-level registered nurse workforce racial and ethnic diversity and severe adverse maternal outcomes during childbirth.This population-based cross-sectional study analyzed 2017 US birth certificate data. Severe adverse maternal outcomes included eclampsia, blood transfusion, hysterectomy, or intensive care unit admission. Proportions of minoritized racial and ethnic registered nurses in each state were abstracted from the American Community Survey (5-year estimate, 2013-2017). This proportion was categorized into 3 terciles, with the first tercile corresponding to the lowest proportion and the third tercile corresponding to the highest proportion. Crude and adjusted odds ratios and 95% confidence intervals of severe adverse maternal outcomes associated with terciles of the state proportion of minoritized racial and ethnic nurses were estimated using logistic regression models.Of the 3,668,813 birth certificates studied, 29,174 recorded severe adverse maternal outcomes (79.5 per 10,000; 95% confidence interval, 78.6-80.4). The mean state proportion of minoritized racial and ethnic nurses was 22.1%, ranging from 3.3% in Maine to 68.2% in Hawaii. For White mothers, the incidence of severe adverse outcomes was 85.3 per 10,000 for those who gave births in states in the first tercile of the proportion of minoritized racial and ethnic nurses and 53.9 per 10,000 for those who gave birth in states in the third tercile (risk difference, -31.4 per 10,000; 95% confidence interval, -34.4 to -28.5). It corresponds to a 37% decreased risk of severe adverse maternal outcomes associated with giving birth in a state in the third tercile (crude odds ratio, 0.63; 95% confidence interval, 0.60-0.66). A decreased risk of severe adverse maternal outcomes was observed for Black mothers (crude odds ratio, 0.65; 95% confidence interval, 0.61-0.70), Hispanic mothers (crude odds ratio, 0.51; 95% confidence interval, 0.48-0.54), and Asian and Pacific Islander mothers (crude odds ratio, 0.65; 95% confidence interval, 0.58-0.72) but not for Native American mothers (crude odds ratio, 0.89; 95% confidence interval, 0.72-1.09) or mothers with1 race (crude odds ratio, 1.44; 95% confidence interval, 0.72-1.09). After adjustment for patients and hospital characteristics, giving birth in states in the third tercile was associated with a reduced risk of severe adverse outcomes as follows: 32% for White mothers (adjusted odds ratio, 0.68; 95% confidence interval, 0.59-0.77), 20% for Black mothers (adjusted odds ratio, 0.80; 95% confidence interval, 0.65-0.99), 31% for Hispanic mothers (adjusted odds ratio, 0.69; 95% confidence interval, 0.58-0.82), and 50% for Asian and Pacific Islander mothers (adjusted odds ratio, 0.50; 95% confidence interval, 0.38-0.65). The associations of the proportion of minoritized racial and ethnic nurses with the risk of severe adverse maternal outcomes were not statistically significant for Native American mothers and more than 1 race mothers. Results were similar when blood transfusion was excluded from the outcome measure.A diverse state registered nurse workforce was associated with a reduced risk of severe adverse maternal outcomes during childbirth.

As major stakeholders in the labor and delivery suite, obstetric anesthesiologists are frequently called upon to provide their unique skill sets and expertise to the management of postpartum hemorrhage, whether anticipated or not. Essential contributions of the anesthesia team ideally begin in the antenatal period with referral of women at high risk of postpartum hemorrhage to an outpatient obstetric anesthesia clinic where a tailored plan for both urgent or scheduled delivery for women with an anticipated complex delivery can be formulated. Maternal safety can be greatly improved if comorbidities are identified early and strategies to address these issues are proposed and known by the obstetric anesthesia team. Participation of the obstetric anesthesiology team is crucial in the development of systematic approaches that are customized to each institution and should comprise the creation and dissemination of algorithms and guidelines that are anesthesia specific, including detailed protocols for the labor and delivery unit and operating rooms, at large. Because management of postpartum hemorrhage requires a coordinated team effort, and may not always be planned, the anesthesia team should be prepared at all times to provide the appropriate anesthetic management and advanced cardiovascular support. The involvement of the anesthesia team should not only be limited to the immediate intrapartum period, but should also extend to the postpartum period where adequate anesthetic/analgesic plans will enhance maternal safety and recovery.

Novel coronavirus disease 2019 is rapidly spreading throughout the New York metropolitan area since its first reported case on March 1, 2020. The state is now the epicenter of coronavirus disease 2019 outbreak in the United States, with 84,735 cases reported as of April 2, 2020. We previously presented an early case series with 7 coronavirus disease 2019–positive pregnant patients, 2 of whom were diagnosed with coronavirus disease 2019 after an initial asymptomatic presentation. We now describe a series of 43 test-positive cases of coronavirus disease 2019 presenting to an affiliated pair of New York City hospitals for more than 2 weeks, from March 13, 2020, to March 27, 2020. A total of 14 patients (32.6%) presented without any coronavirus disease 2019–associated viral symptoms and were identified after they developed symptoms during admission or after the implementation of universal testing for all obstetric admissions on March 22. Among them, 10 patients (71.4%) developed symptoms of coronavirus disease 2019 over the course of their delivery admission or early after postpartum discharge. Of the other 29 patients (67.4%) who presented with symptomatic coronavirus disease 2019, 3 women ultimately required antenatal admission for viral symptoms, and another patient re-presented with worsening respiratory status requiring oxygen supplementation 6 days postpartum after a successful labor induction. There were no confirmed cases of coronavirus disease 2019 detected in neonates upon initial testing on the first day of life. Based on coronavirus disease 2019 disease severity characteristics by Wu and McGoogan, 37 women (86%) exhibited mild disease, 4 (9.3%) severe disease, and 2 (4.7%) critical disease; these percentages are similar to those described in nonpregnant adults with coronavirus disease 2019 (about 80% mild, 15% severe, and 5% critical disease).

During the novel Coronavirus Disease 2019 pandemic, New York City became an international epicenter for this highly infectious respiratory virus. In anticipation of the unfortunate reality of community spread and high disease burden, the Anesthesia and Obstetrics and Gynecology departments at NewYork-Presbyterian / Columbia University Irving Medical Center, an academic hospital system in Manhattan, created an Obstetric Intensive Care Unit on Labor and Delivery to defray volume from the hospital's preexisting intensive care units. Its purpose was threefold: (1) to accommodate the anticipated influx of critically ill pregnant and postpartum patients due to novel coronavirus, (2) to care for critically ill obstetric patients who would previously have been transferred to a non-obstetric intensive care unit, and (3) to continue caring for our usual census of pregnant and postpartum patients, who are novel Coronavirus negative and require a higher level of care. In this chapter, we share key operational details for the conversion of a non-intensive care space into an obstetric intensive care unit, with an emphasis on the infrastructure, personnel and workflow, as well as the goals for maternal and fetal monitoring.

Morquio syndrome, a congenital mucopolysaccharidosis, presents several challenges for the provision of effective labor analgesia. We report the case of a woman admitted for induction of labor who received an early epidural and subsequently required cesarean delivery. Optimal bilateral labor analgesia was not achieved despite multiple adjustments, and systemic analgesia was needed for cesarean delivery.

The influence of common disturbances seen in preeclampsia, such as changes in strong ions and weak acids (particularly albumin) on acid-base status, has not been fully elucidated. The aims of this study were to provide a comprehensive acid-base analysis in severe preeclampsia and to identify potential new biological predictors of disease severity.Fifty women with severe preeclampsia, 25 healthy non-pregnant- and 46 healthy pregnant controls (26-40 weeks' gestation), were enrolled in this prospective case-control study. Acid-base analysis was performed by applying the physicochemical approach of Stewart and Gilfix.Mean [sd] base excess was similar in preeclamptic- and healthy pregnant women (-3.3 [2.3], and -2.8 [1.5] mEq/L respectively). In preeclampsia, there were greater offsetting contributions to the base excess, in the form of hyperchloraemia (BE(Cl) -2 [2.3] vs -0.4 [2.3] mEq/L, P0.001) and hypoalbuminaemia (BE(Alb) 3.6 [1] vs 2.1 [0.8] mEq/L, P0.001). In preeclampsia, hypoalbuminaemic metabolic alkalosis was associated with a non-reassuring/abnormal fetal heart tracing (P0.001). Quantitative analysis in healthy pregnancy revealed respiratory and hypoalbuminaemic alkalosis that was metabolically offset by acidosis, secondary to unmeasured anions and dilution.While the overall base excess in severe preeclampsia is similar to that in healthy pregnancy, preeclampsia is associated with a greater imbalance offsetting hypoalbuminaemic alkalosis and hyperchloraemic acidosis. Rather than the absolute value of base excess, the magnitude of these opposing contributors may be a better indicator of the severity of this disease. Hypoalbuminaemic alkalosis may also be a predictor of fetal compromise.clinicaltrials.gov: NCT 02164370.

Studies on genetic contributions to labor analgesia have essentially evaluated the μ-opioid receptor gene (OPRM1), with some evidence that p.118A/G of OPRM1 influences the response to neuraxial opioids. As for labor progress, the β2-adrenergic receptor gene (ADRB2) is associated with preterm labor and delivery, and impacts the course of labor. Taken together though, there is no evidence that pharmacogenetic testing is needed or beneficial in the context of obstetric anesthesia; however, realizing the influence of genetic variants on specific phenotypes provides the rationale for a more cautious interpretation of clinical studies that attempt to find a dose-regimen that fits all.

We present five cases of women who received ultrasound-guided transversus abdominis plane catheters for post-cesarean delivery analgesia. Pain relief was maintained with repeated boluses of local anesthetic combined with oral acetaminophen and ibuprofen unless contraindicated. We conclude that repeated dosing through transversus abdominis plane catheters may be offered to women as an alternative or adjuvant to intrathecal morphine. Larger studies to evaluate the safety and further refinements of this novel procedure are warranted.

Until recently, the assessment of outdoor mobility of the elderly relied mainly on self-administered time-space diaries or on reports of family caregivers and institutional staff, using observational approaches, activity monitoring, or behavioral checklists. In recent years, however, the rapid development and availability of small, inexpensive, and reliable tracking devices has led to a growing volume of research that uses this technology as a tool for data collection in various disciplines. This paper presents new insights that are now available regarding the outdoor mobility of the elderly due to the analysis of GPS data with automatic scripts and GIS platforms. The data presented are based on the activity of 49 elderly people from the Tel-Aviv Metropolitan area (Israel), who took part in an interdisciplinary project, involving researchers in geography, social work, gerontology, psychology and medicine, that studies the outdoor activities of elderly people in time and space using advanced tracking technologies. Participants were tracked for an average of 28 consecutive days using a location kit that combined GPS with RFID technology. Differences were found in various walking and driving parameters, such as speed, length, timing, and frequency of participants with different levels of cognitive function. The trends present a general decline in out-of-home mobility of elderly people with cognitive impairment and illuminates as well the important role that additional factors as age, gender, and the accessibility to a private car play in determining levels of out-of-home mobility.

Points essentiels La variabilite interindividuelle dans la perception de la douleur et la reponse aux opiaces en termes d’efficacite et d’effets secondaires est bien connue. De tres nombreux genes ont ete proposes comme candidats ideaux pour l’etude de la composante genetique de la douleur et la pharmacogenetique des opiaces. Malgre la complexite inherente a l’etude de la douleur, il apparait clairement que plusieurs polymorphismes genetiques contribuent a moduler la nociception et la reponse antinociceptive aux morphiniques ; en particulier ceux intervenant dans la pharmacocinetique et metabolisme des opiaces (cytochrome P450) ou de neurotransmetteurs (catechol-O-methyltransferase), ainsi que ceux affectant la pharmacodynamique ou les cibles therapeutiques comme le recepteur μ aux opiaces ou le plus inattendu recepteur a la melanocortine 1.

Pharmacogenetics was born within the field of anesthesiology in the mid-1950s with the first observations that genetic factors might affect the response to various pharmacological agents. The first article published in this domain reported on cases of prolonged postoperative muscle relaxation following the administrationof succinylcholine due to an inherited variation of drug metabolism involving the enzyme butyrylcholinesterase. Over this last decade, there has been an explosion of scientific publications in the field of pharmacogenetics, the

Application of a unique social network inventory in a sample of persons age 75 and older in the Tel Aviv vicinity confirmed the presence of four distinct network types: kin, family-intensive, friend-focused, and diffuse-ties. The kin network was found to offer the greatest degree of support, and the family-intensive type, the least. The network type construct proved to be a significant predictor of social support even when taking into account respondents' living arrangements, physical disability level, and personal coping resources.

This article examines social workers' compliance with the law requiring reporting each case of sexual abuse of children or otherwise incompetent persons. In a random representative sample of 212 Israeli social workers, participants were asked to relate to an ethical dilemma concerning sexual abuse. The resolution of the ethical dilemma was measured by choice of one of the following: system oriented decision, client-oriented decision, combined client-system decision, and nonintervention. Participants in the study were also requested to provide reasons for their choice. The content of the arguments was analyzed by its relation to the ambiguity of the situation presented in the ethical dilemma, its relation to comply with the law, and the relationship between the reported choice and its argumentation. Moreover, social workers' compliance with the law was also analyzed by their field of practice. Findings showed that 52% of the social workers would report sexual abuse. The rate of social workers in the field of child welfare who would report sexual abuse is higher (70%). Among those respondents who gave reasons for their decision, only 24% related to the lack of adequate information in the presented vignette. Seventy one percent of those who explained their choice cited the legal requirement to report, and, of those, 73% evidenced a relationship between their reported choice and their reason. The article shows the ambiguity of the law regarding the obligation to report sexual abuse of children and discusses the implications of the findings for its implementation.

Introduction L’accouchement par cesarienne est associe a un taux de complications de l’anesthesie plus eleve que l’accouchement par voie basse [1] , [2] . En depit des efforts de la communaute anesthesique pour ameliorer la securite maternelle au cours des cesariennes, l’evolution du taux de complications de l’anesthesie au cours des cesariennes pendant la derniere decennie est inconnue. L’objectif de ce travail a ete de decrire l’evolution du taux de complications de l’anesthesie au cours des cesariennes entre 2003 et 2012 dans l’etat de New York. Materiel et methodes Les dossiers de cesariennes et les complications de l’anesthesie ont ete identifies par des codes ICD-9-CM specifiques dans la base de donnees administrative de l’etat de New York (State Inpatient Database) entre les annees 2003 et 2012. Le taux brut annuel de complications de l’anesthesie a ete analyse selon le type de cesarienne (programmee ou non programmee), le type d’anesthesie (anesthesie generale ou neuraxiale) et 3 caracteristiques hospitalieres : le nombre annuel de cesariennes realisees dans chaque hopital (faible, intermediaire ou eleve), la presence d’internes (oui ou non) et la localisation de l’hopital (urbain ou non urbain). L’evolution du taux de complications au cours du temps a ete analysee par des regressions logistiques ajustees sur les indices de comorbidite de Charlson et de Bateman. Resultats Parmi les 785 854 cesariennes etudiees, 362 192 (46 %) etaient programmees. Au moins une complication de l’anesthesie a ete identifiee pour 5715 d’entre elles (7,3/1000) dont 34 etaient associees a un arret cardiaque ou un deces. Le taux annuel de complications de l’anesthesie a diminue de 8,9/1000 en 2003 a 6,6/1000 en 2012 (−26 %, p Discussion La securite de l’anesthesie obstetricale au cours des cesariennes s’est globalement amelioree au cours de la derniere decennie dans l’etat de New York. Les facteurs responsables de l’absence de diminution pour l’anesthesie generale restent a determiner pour ameliorer les pratiques. Ces resultats sont a confirmer avec des donnees francaises.

The present study attempts to provide answers to the following questions: Does locus of control reflect real opportunities and resources such as higher income and education, or internal strengths and coping abilities? Is it locus of control, socioeconomic status or the interaction between these two variables that affects depression level and life satisfaction? Data was obtained from a stratified random sample of 150 Israeli widows, under the age of 54. Multiple regressional analysis was followed by analysis of variance in order to examine the interaction hypothesis. The results, providing no support for the interaction hypothesis, indicate that both locus of control and socioeconomic status are related to depression and life satisfaction independently, and that locus of control reflects more than socioeconomic resources.