Amy E. Vinson

Drug rash, eosinophilia, and systemic symptoms syndrome: Two pediatric cases demonstrating the range of severity in presentation--A case of vancomycin-induced drug hypersensitivity mimicking toxic shock syndrome and a milder case induced by minocycline.

Background: Drug rash, eosinophilia, and systemic symptoms syndrome is a type of drug hypersensitivity reaction characterized by the clinical triad of skin eruption, fever, and internal organ involvement. Drug rash, eosinophilia, and systemic symptoms syndrome has rarely been reported in association with vancomycin or in the pediatric population. There have only been four pediatric case reports of drug rash, eosinophilia, and systemic symptoms syndrome and three cases of drug rash, eosinophilia, and systemic symptoms syndrome involving vancomycin published in the English literature to date. Case Reports: We describe two pediatric cases of drug rash, eosinophilia, and systemic symptoms syndrome to illustrate the range in severity of presentation. The first case illustrates drug rash, eosinophilia, and systemic symptoms syndrome associated with vancomycin exposure in a 14-yr-old boy with Duchenne muscular dystrophy after posterior spinal fusion, whose clinical presentation was indistinguishable from toxic shock syndrome. The second case illustrates a milder and more typical presentation of drug rash, eosinophilia, and systemic symptoms syndrome in a 14-yr-old boy being treated with minocycline for acne. We also present a review of the literature relevant to this syndrome. Conclusions: Drug rash, eosinophilia, and systemic symptoms syndrome is relatively unknown among general pediatricians and pediatric intensivists and may potentially become more common with the increasing use of long-term medications in the pediatric population. Our cases demonstrate the importance of an awareness of drug rash, eosinophilia, and systemic symptoms syndrome among general pediatricians and pediatric intensivists because drug rash, eosinophilia, and systemic symptoms syndrome may present in any range of severity, from indolent illness to frank and refractory shock.

National Survey of US academic anesthesiology chairs on clinician wellness

STUDY OBJECTIVE The prevalence of anesthesiology department wellness programs is unknown. A database of wellness programs is needed as a resource for departments attempting to respond to the Accreditation Council for Graduate Medical Education Anesthesiology Milestones Project. The purpose of this study was to survey academic anesthesiology chairs on wellness issues, characterize initiatives, and establish wellness contacts for a Wellness Initiative Database (WID). DESIGN An Internet-based survey instrument was distributed to academic anesthesiology department chairs in the United States. SETTING On-line. PATIENTS None. INTERVENTIONS None. MEASUREMENTS Analysis for continuous variables used standard means, modes, and averages for individual responses; 95% confidence intervals for proportions were calculated by Wilsons method. MAIN RESULTS Seventy-five (56.4%) responses (of a potential 133 programs) were obtained. Forty-one (of 71 responders; 57.8%) expressed interest in participating in a WID, and 33 (44%) provided contact information. Most (74.7%) had recently referred staff for counseling or wellness resources, yet many (79.5% and 67.1%, respectively) had never surveyed their departments interest in wellness resources. Thirty-four percent had a wellness resources repository. Of 22 wellness topics, 8 garnered >60% strong interest from respondents: Addiction Counseling, Sleep Hygiene, Peer Support Program, Stress Management, Conflict Management, Burnout Counseling, Time Management, and Dealing with Adverse Events Training. There was a statistically significant difference in interest between those willing to participate or not in the WID across most topics but no significant difference based on need for recent staff referral. CONCLUSIONS The majority of chairs needed to recently refer a department member to wellness resources or counseling. Most were interested in participating in a WID, whereas a minority had gauged staff interest in wellness topics or had a wellness resource repository. Highest interest was in topics most related to function as an anesthesiologist. Those willing to participate in the database had statistically significant differences in interest across most wellness topics.

Anaesthetic considerations for surgery in newborns.

Almost 30 years ago, the American Academy of Pediatrics Committee on Fetus and Newborn coauthored a policy statement strongly advocating for the use of anaesthesia in all neonates stating ‘local or systemic pharmacologic agents now available permit relatively safe administration of anesthesia or analgesia to neonates undergoing surgical procedures and that such administration is indicated according to the usual guidelines for the administration of anesthesia to high-risk, potentially unstable patients’. With current techniques and advanced monitoring, preterm and full-term infants routinely undergo surgical procedures under general anaesthesia to repair congenital defects that were lethal in years past. Recent research in immature animal models, however, has shown evidence of enhanced neuroapoptosis and other signs of neurotoxicity with all of the currently used anaesthetic agents. There is also increasing concern about the potential adverse effects of perioperative hypotension and hypocapnia on neurocognitive development in infants. This review outlines the most recent animal and human evidence regarding the effects of general anaesthesia and anaesthetic-related haemodynamic changes on the developing brain of newborns.

Assessing levels of support for residents following adverse outcomes: A national survey of anesthesia residency programs in the United States

Abstract Aim: The impact of physician burnout is becoming apparent in the medical community, especially among anesthesiologists and young physicians. Anesthesia residents will experience emotionally charged adverse events during their training. The objective was to determine the prevalence, efficacy and utilization of support structures in place for residents following adverse events in order to develop a best-practices model of resident support. Methods: We sent an anonymous internet-based survey to program directors (PDs) at all American College of Graduate Medical Education (ACGME)-approved Anesthesia Residency programs, with an optional secondary survey of residents. Results: There was a 53% response rate among PDs with most reporting resource availability. The strongest support programs were the anesthesia support programs, morbidity and mortality (M&M) conference, and “individual meetings with department leadership.” These results were mirrored in the responses of residents at the 32 programs who opted to participate in the secondary survey. Both also cited M&M conference as being highly utilized, but not efficacious. The strongest support programs had a low prevalence. Conclusions: These data suggest that a best-practices model of resident support entails establishing a department-based support program, facilitating comfortable meetings with departmental leadership and optimizing M&M conference.

Is Mindful Practice Our Ethical Responsibility as Anesthesiologists

Every so often, and seemingly more often in today’s world of social media and 24-hour news networks, a word takes root and flourishes to the point of evolving from a provocative concept to the passé, or worse yet, the ludicrous. Such a metamorphosis has begun in recent years with the word “mindfulness”; although it is encouraging to see attention being given to this important concept, to many its impact has mirrored that of a new song that you love, but grow to hate upon hearing it for the hundredth time. “Mindfulness” is everywhere, from the gym to the doctor’s office, but has it lost its meaning in its ubiquity? We will argue that mindful practice is the ethical responsibility of anesthesiologists. With personal, subjective, and somewhat nebulous concepts such as mindfulness, mindful practice, ethical duties, and professionalism, anything but a rigorous and logical approach would fall short. We will present an argument for mindful practice, drawing from nonanesthesia-related sources where appropriate, and applying to anesthesiologists when indicated.

Individualized remediation during fellowship training

The Accreditation Council for Graduate Medical Education requires medical training programs to monitor, track, and formally document a fellows performance. If deficiencies are found, programs are expected to prepare and implement an effective plan of action for improvement and to ensure that graduates acquire the personal and professional attributes of an independent physician. We revised our evaluation policy and instituted a remediation protocol in 2008. Since that time, 130 pediatric anesthesia fellows have graduated. Seven fellows (5%) underwent departmental formal consultation for deficient behavior or poor performance. Of these 7 fellows, 4 underwent an individualized remediation program (IRP). A formal performance review and written contract, with specifically identified problems and general themes, recommendations for time-based successful behaviors, and clearly identified consequences for unsuccessful behaviors, was initiated for each fellow undergoing an IRP. All fellows who participated in this program completed their subspecialty training in pediatric anesthesia, and all eligible fellows have successfully achieved their subspecialty board certification. Our approach has the advantage of multimodality, time-based daily evaluations, and group discussions in the context of a Clinical Competency Committee. Utilization of an IRP as a metric for progress has features similar to effective cognitive behavioral therapy contracts and has ensured that our graduates are held to clearly delineated and specified skills and behaviors that allow them to work independently in the field of pediatric anesthesiology.

A Novel Approach to Rapid Determination of βS‐Globin Haplotypes: Sequencing of the Aγ‐IVS‐II Region

β‐Globin gene cluster haplotypes were originally determined by restriction endonuclease mapping with Southern blots of polymorphic sites around the gene cluster. Over the years, haplotyping has been found to be useful, not only in population genetics but also in predicting the severity of hemoglobinopathies such as sickle cell disease. The sickle mutation occurs on five distinct haplotypes. The hitherto used methods are cumbersome and time‐consuming, making haplotype determination a tedious procedure. We report our experience with a novel, rapid approach to haplotyping based on sequence polymorphisms in the Aγ‐IVS‐II region. We provide an algorithm that allows rapid assignment of the four African haplotypes carrying the sickle mutation.