Purpose:Transgender individuals commonly undergo hormone therapy as part of their gender-affirming care. Given the lack of clinical data regarding the impact of these exogenous hormones on airway management as well as the limited knowledge of transgender health, we examined the prevalence of airway events in transgender women undergoing facial feminization procedures. Methods:Retrospective chart reviews were performed on 282 transgender women, ages 14-75, who underwent facial feminization surgeries between 2014 and 2020. Our control group consisted of 375 age-matched, cisgender patients undergoing rhinoplasty procedures during the same time period. Airway events, defined as desaturations (oxygen saturation ≤92%) within 45 minutes of induction and/or ≥ two attempts required for endotracheal intubation, were stratified based on severity. Statistical analysis was performed using multinomial logistic regression. Results:Compared to our cisgender men and cisgender women control cohorts, the total rate of airway events in transgender women was higher (14.2% vs. 7.5% and 3.6%). Within the transgender women cohort, 57.5% of airway events were considered mild, 35.0% moderate, and 7.5% severe. In a subgroup analysis, transgender women undergoing voice feminization or tracheal shaving experienced significantly more airway events. There were no statistically significant associations between airway events and the studied variables, including age, body mass index, and Mallampati scores. Conclusion:Transgender women may face a higher risk of airway events during facial feminization surgery influenced by various factors including previous surgeries, hormonal therapies, and comorbid conditions. Anesthesiologists should consider these variables along with the procedure type to preempt potential airway difficulties in their transgender patients.

Background: Rising cannabis use poses significant challenges in the administration of general anesthetics, particularly propofol, due to potential alterations in pharmacodynamics caused by tetrahydrocannabinol and its interactions with central nervous system receptors. This systematic review and meta-analysis aims to consolidate the existing literature to quantify propofol requirements in cannabis users, highlighting the complex relationship between cannabis use and anesthetic management. Methods: A systematic search of English-language literature was conducted to identify studies with data on propofol dosing in adult cannabis users. Propofol requirements were defined as the total intraoperative dose needed to achieve and maintain adequate sedation or anesthesia, assessed using parameters like monitoring and procedural tolerance. A random-effects model was used with DerSimonian–Laird estimations for pooled effect sizes and 95% confidence intervals. Heterogeneity was assessed using I2 and Cochran’s Q statistics, and sensitivity analysis was conducted by grouping publications by design, size, and quality. Results: Eight qualified studies were identified with 2268 patients included. Patients who used cannabis were typically younger and more likely to smoke tobacco than non-users. Propofol requirements were significantly higher in cannabis users, who required an average additional dose of 47.33 mg compared to non-users. Subgroup analyses revealed that cannabis users undergoing general anesthesia needed an additional 30.57 mg intraoperatively, while those undergoing sedation for endoscopic procedures required an additional 53.02 mg. Conclusions: These results underscore the need for personalized anesthetic plans to accommodate physiological variations in cannabis users. However, the lack of standardized definitions for propofol requirements and the heterogeneity across studies necessitate caution in interpretation. The observed increase in propofol requirements suggests altered central nervous system sensitivities and receptor changes in cannabis users, emphasizing the need for further research to establish clear definitions, elucidate underlying mechanisms, and refine clinical guidelines for anesthetic management in this population.

In the United States (U.S.), chronic pain poses substantial challenges in rural areas where access to effective pain management can be limited. Our literature review examines chronic pain management in rural U.S. settings, identifying key issues and disparities. A comprehensive search of PubMed, Web of Science, and Google Scholar identified high-quality studies published between 2000 and 2024 on chronic pain management in the rural U.S. Data were categorized into thematic areas, including epidemiology, management challenges, current strategies, research gaps, and future directions. Key findings reveal that rural populations have a significantly higher prevalence of chronic pain and are more likely to experience severe pain. Economic and systemic barriers include a shortage of pain specialists, limited access to nonpharmacologic treatments, and inadequate insurance coverage. Rural patients are also less likely to engage in beneficial modalities like physical therapy and psychological support due to geographic isolation. Additionally, rural healthcare providers more often fulfill multiple medical roles, leading to burnout and decreased quality of care. Innovative approaches such as telehealth and integrated care models show the potential to improve access and outcomes. Our review highlights the need for increased telehealth utilization, enhanced provider education, and targeted interventions to address the specific pain needs of rural populations.

Despite significant advances in medical imaging, thrombolytic therapy, and mechanical thrombectomy, acute ischemic strokes (AIS) remain a major cause of mortality and morbidity globally. Targeted temperature management (TTM) has emerged as a potential therapeutic intervention, aiming to mitigate neuronal damage and improve outcomes. This literature review examines the efficacy and challenges of TTM in the context of an AIS. A comprehensive literature search was conducted using databases such as PubMed, Cochrane, Web of Science, and Google Scholar. Studies were selected based on relevance and quality. We identified key factors influencing the effectiveness of TTM such as its timing, depth and duration, and method of application. The review also highlighted challenges associated with TTM, including increased pneumonia rates. The target temperature range was typically between 32 and 36 °C, with the duration of cooling from 24 to 72 h. Early initiation of TTM was associated with better outcomes, with optimal results observed when TTM was started within the first 6 h post-stroke. Emerging evidence indicates that TTM shows considerable potential as an adjunctive treatment for AIS when implemented promptly and with precision, thereby potentially mitigating neuronal damage and enhancing overall patient outcomes. However, its application is complex and requires the careful consideration of various factors.

PURPOSE:Medical educators have increasingly focused on the systemic effects of racism on health inequities in the United States (U.S.) and globally. There is a call for educators to teach students how to actively promote an anti-racist culture in healthcare. This scoping review assesses the existing undergraduate medical education (UME) literature of anti-racism curricula, implementation, and assessment. METHODS:The Ovid, Embase, ERIC, Web of Science, and MedEdPORTAL databases were queried on 7 April 2023. Keywords included anti-racism, medical education, and assessment. Inclusion criteria consisted of any UME anti-racism publication. Non-English articles with no UME anti-racism curriculum were excluded. Two independent reviewers screened the abstracts, followed by full-text appraisal. Data was extracted using a predetermined framework based on Kirkpatrick's educational outcomes model, Miller's pyramid for assessing clinical competence, and Sotto-Santiago's theoretical framework for anti-racism curricula. Study characteristics and anti-racism curriculum components (instructional design, assessment, outcomes) were collected and synthesized. RESULTS:In total, 1064 articles were screened. Of these, 20 met the inclusion criteria, with 90% (n = 18) published in the past five years. Learners ranged from first-year to fourth-year medical students. Study designs included pre- and post-test evaluations (n = 10; 50%), post-test evaluations only (n = 7; 35%), and qualitative assessments (n = 3; 15%). Educational interventions included lectures (n = 10, 50%), multimedia (n = 6, 30%), small-group case discussions (n = 15, 75%), large-group discussions (n = 5, 25%), and reflections (n = 5, 25%). Evaluation tools for these curricula included surveys (n = 18; 90%), focus groups (n = 4; 20%), and direct observations (n = 1; 5%). CONCLUSIONS:Our scoping review highlights the growing attention to anti-racism in UME curricula. We identified a gap in published assessments of behavior change in applying knowledge and skills to anti-racist action in UME training. We also provide considerations for developing UME anti-racism curricula. These include explicitly naming and defining anti-racism as well as incorporating longitudinal learning opportunities and assessments.

We describe a clinical case where a pregnant woman with twin gestation was given Tranexamic Acid (TXA) after delivery of her two neonates but was found to have a third fetus during placenta removal. Tranexamic acid is an antifibrinolytic agent that has been widely studied for its potential in reducing Postpartum Hemorrhage (PPH) [1]. Postpartum hemorrhage, defined as bleeding ≥500 mL in the first 24 hours after delivery, is responsible for 25% of all maternal deaths worldwide [1]. Despite advances in obstetric care, PPH remains a significant concern. Several studies, including the WOMAN Randomized Controlled Trial (RCT), have investigated the effects of TXA in women with PPH [2]. Results demonstrate that the use of TXA significantly reduces maternal death due to bleeding, without any increase in maternal adverse events. These benefits were particularly pronounced when TXA was administered within three hours of birth. Few studies, however, have thoroughly investigated the effects of TXA on neonates in utero.

There is a paucity of evidence regarding the utility of targeted temperature management (TTM) in COVID-19 patients who suffer cardiac arrest. This systematic review and meta-analysis aimed to use the available data of how temperature predicts outcomes in COVID-19 patients and the association between active cooling and outcomes in non-COVID-19 cardiac arrest patients to give recommendations for the utility of TTM in COVID-19 survivors of cardiac arrest. The PubMed, Embase, and Web of Science databases were queried in August 2022 for two separate searches: (1) temperature as a predictor of clinical outcomes in COVID-19 and (2) active cooling after return of spontaneous circulation (ROSC) in non-COVID-19. Forest plots were generated to summarize the results. Of the 4209 abstracts screened, none assessed the target population of TTM in COVID-19 victims of cardiac arrest. One retrospective cohort study evaluated hyperthermia in critically ill COVID-19 patients, two retrospective cohort studies evaluated hypothermia in septic COVID-19 patients, and 20 randomized controlled trials evaluated active cooling in non-COVID-19 patients after ROSC. Risk of death was higher in COVID-19 patients who presented with hyperthermia (risk ratio [RR] = 1.87) or hypothermia (RR = 1.77; p < 0.001). In non-COVID-19 victims of cardiac arrest, there was no significant difference in mortality (RR = 0.94; p = 0.098) or favorable neurological outcome (RR = 1.05; p = 0.41) with active cooling after ROSC. Further studies are needed to evaluate TTM in COVID-19 victims of cardiac arrest. However, given the available evidence that hyperthermia or hypothermia in COVID-19 patients is associated with increased mortality as well as our findings suggesting limited utility for active cooling in non-COVID-19 cardiac arrest patients, we posit that TTM to normothermia (core body temperature ∼37°C) would most likely be optimal for the best outcomes in COVID-19 survivors of cardiac arrest.

Ortega, Rafael MD; Binda, Dhanesh D. BS; Lavanier, Stephen A. BS; Uminski, Jake G. BA Author Information

Background While the Liaison Committee on Medical Education emphasizes the teaching of cultural competence in medical education, the concept of cultural humility, focusing on self-reflection and lifelong learning, has been proposed as a more effective approach. Although there have been numerous discussions on both topics, understanding how faculty in clinical settings help students develop cultural humility skills remains limited. Objective Our multimethod study utilized a survey and semi-structured interviews to identify strategies that faculty at one institution use to help students develop cultural humility skills. Methods We administered a 10-question survey to assess faculty demographics, teaching characteristics, and familiarity with cultural humility. Participants most familiar with cultural humility were invited for semi-structured interviews. Survey data were analyzed with descriptive statistics, and interview data were thematically analyzed to identify key teaching strategies. Results In our study of 49 medical faculty members, the majority of participants were female (61%) and predominantly White (67%), covering a wide range of specialties and years of teaching. Of the participants, 74% expressed being at least somewhat familiar with cultural humility, and 10 consented to interviews. Strategies for cultural humility education included one-on-one instruction, feedback, and reflections. Thematic analysis underscored fostering learner curiosity about cultures, early patient exposure, and incorporating diverse learning perspectives as essential in developing students’ cultural humility skills. Conclusion Cultural humility is an important attribute for healthcare professionals that can enhance patient-centered care. Through focused interviews with faculty in our study and subsequent thematic analysis, our results suggest the need for longitudinal and multimodal educational strategies to cultivate cultural humility among medical students. By understanding current teaching methods, educators can design and assess more effective curricula to prepare future doctors for a culturally diverse patient population.

High-voltage electrical injuries, especially from lightning strikes, can cause life-threatening complications due to extreme temperature and voltage exposure. While burns and cardiac complications have been widely described, the documentation of metabolic imbalances, particularly hypokalemia, has not been as prevalent. This report focuses on a patient with profound transient hypokalemia following a lightning strike, alongside a review of three similar cases of transient hypokalemia from the literature. Our patient, a previously healthy young man, was struck by lightning and subsequently suffered transient hypokalemia with lower extremity sensory changes, which resolved after the normalization of serum potassium levels. While the exact underlying mechanisms of transient hypokalemia following high-voltage electrical injuries are unknown, we propose a multifactorial mechanism, which includes massive intracellular shifts of potassium due to elevated epinephrine levels and the prevention of potassium efflux through the electrical disruption of voltage-gated potassium channels. Our report underscores the importance of recognizing hypokalemia in patients with high-voltage electrical injuries and contributes to the understanding of the complex mechanisms involved. Further research is necessary to understand the connection between cellular changes induced by high-voltage exposure and their effects on metabolism, particularly in relation to hypokalemia.

Introduction Literature demonstrates the detrimental impact of discrimination and microaggressions at personal and institutional levels in the health care workplace. Residents in our program requested curricula to help with addressing manifestations of bias. In response, we designed and implemented an adaptable and reproducible 4-hour virtual simulation session aimed at helping residents identify and constructively respond to microaggressions. Methods This curriculum, influenced by a preceding needs assessment, was delivered to 68 senior internal medicine residents. It began with a didactic overview to establish foundational knowledge of bias. This was followed by a workshop focused on strategies to address microaggressions. The session culminated with skills practice in a virtual simulation activity where learners addressed microaggressions as bystanders in realistic case scenarios employing simulated participants. We administered pre- and postevaluation individual key-linked surveys assessing learner confidence in responding to microaggressions. Results A total of 68 residents participated in the curriculum over two academic years, 27 of whom provided complete data for analysis. Overall, there was a statistically significant increase in learner confidence identifying microaggressions. As both a bystander and target/recipient of microaggressions, there were statistically significant increases in learner confidence addressing gender-based microaggressions, race-based microaggressions, and microaggressions reflecting other types of bias. Furthermore, there were statistically significant increases in learner confidence addressing microaggressions in low-acuity contexts, high-acuity contexts, across interprofessional disciplines, with a supervisor, and with a supervisee. Discussion Our virtual experiential curriculum on responding to microaggressions can help increase learner confidence in addressing microaggressions.

INTRODUCTION:The structure of medical residency in the United States has experienced significant changes, paralleling advances in medical science and education. While these changes have enhanced medical training, they have introduced challenges, particularly in resident wellness. The well-being of residents is critical for patient care and the healthcare system. This review aims to provide an overview of the historical trends in medical residency, focusing on the evolution of resident wellness and its associated challenges. METHODS:A narrative review was conducted, examining the evolution and challenges of medical residency with an emphasis on resident wellness. An exhaustive literature search on January 25, 2024 was conducted across PubMed, Web of Science, and Google Scholar. The search utilized keywords related to medical residency, wellness, and educational reforms. Articles were selected based on relevance and robust evidence, and information was organized into thematic categories for narrative synthesis. RESULTS:The search yielded 57 publications that met the inclusion criteria. Historical trends revealed a shift from an apprenticeship model to formalized training programs, with each phase bringing unique challenges to resident wellness. The Flexner Report's influence on standardizing medical education, the rise of modern residency programs, and the recognition of burnout as a significant issue were key developments. Policy changes, technological impacts, and the COVID-19 pandemic have further shaped residency training and wellness. Studies highlight the need for interventions addressing burnout and promoting wellness, with varied approaches across specialties and institutions. CONCLUSION:Residency burnout has been a growing concern since the 1970s, exacerbated by advancements in medicine, technology, and recent global events like the COVID-19 pandemic. Although awareness has increased, the need remains to address burnout and promote wellness during residency. Further research is warranted to develop effective interventions and adapt training to meet the evolving needs of residents.

Anesthesiology is one of the increasingly competitive surgical specialties with a growing emphasis on scholarly activity. A metric of productivity and citation influence, the Hirsch index (h-index), can help identify mentors capable of guiding postgraduate trainees toward successful academic achievements. This study sought to determine associations between h-indices or m-quotients and manuscript publication in anesthesiology. Using the American Society of Anesthesiologists (ASA) website, accepted abstracts from the ASA Annual Meetings from 2019 to 2021 were screened (n=2146). The first author (FAHi) and senior author (SAHi) h-indices, as well as the first author (FAMq) and senior author (SAMq) m-quotients, were collected for each abstract using the Scopus database. Whether an accepted abstract was subsequently published as a manuscript in a peer-reviewed journal was also noted, along with the number of days between ASA presentation and publication date. Linear and logistic regression models were used for statistical analyses. In total, 348 (34.4%) of the 1012 eligible abstracts were published as manuscripts. Mean FAHi, SAHi, FAMq, and SAMq, were significantly higher for accepted ASA abstracts that were later published in peer-reviewed journals compared to accepted abstracts that were not published (p<0.001). FAHi, SAHi, FAMq, and SAMq had significant positive associations with odds of publication (p=0.002; p<0.001; p=0.006; p<0.001, respectively). There was no statistical significance between FAHi, SAHi, FAMq, or SAMq and the number of days between ASA presentation and publication. Our study uniquely demonstrates the positive, direct association between h-indices and m-quotients with the probability of publication in anesthesiology. We propose that bibliometric indices are adapted to provide a refined perspective of a physician-scientist's capabilities. Postgraduate trainees can use these indices to discern research mentors primed to foster academic excellence.