Schroeder, Darrell R.

Abstract Background: Medical education commonly utilizes the “see one, do one” two-step approach for teaching psychomotor skills; however, recent evidence suggests that Peyton’s four-step method leads to superior learning. The effect of Peyton’s four-step method on long term skill retention is less apparent and has never been assessed for Point-of-Care Ultrasound (POCUS). The purpose of this research project was to evaluate the effectiveness of Peyton’s four-step method on teaching the POCUS psychomotor skills of image acquisition to novice learners. Additionally, this research project assessed the influence of Peyton’s four-step method at three different points in time during the skill acquisition phase, in the setting of ongoing deliberate skill practice. Methods: A single-blinded, repeated measures interventional study based on experimental design was completed. PA students from one large academic medical center were randomized into a control group (using the two-step method) and intervention group (using Peyton’s four-step method). Students were taught POCUS of the aorta, bladder, heart, lungs, and kidneys. Students' POCUS skills were assessed during the immediate, intermediate, and delayed learning phases. At each assessment, an organ-specific score and a total score were obtained. Scores were compared using a Wilcoxon rank sum test. An ordinal logistic regression analysis was performed using a generalized linear mixed model with a multinomial distribution and cumulative logit link function to assess overall effect of Peyton's four-step method. Results: Students who were taught using Peyton’s method were found to have an increased likelihood of higher total scores compared to those taught using usual instruction (OR = 4.2, p = 0.003). Peyton’s method was found to have increased likelihood of higher scores for cardiac (OR = 2.3, p = 0.032), lung (OR = 2.5, p = 0.034), and kidney (OR = 3.0, p = 0.015). Student performance statistically improved with Peyton’s four-step method during the immediate (p = 0.031) and delayed (p = 0.011) skill acquisition phases, but not in the intermediate phase. Conclusion: Peyton’s four-step method improves overall psychomotor skill acquisition for POCUS. Peyton’s four-step method specifically improved psychomotor skills in the immediate skill acquisition phase and the delayed skill acquisition phase. The benefit of Peyton’s four-step method was more prominent in higher complexity POCUS applications.

Background: There is a lack of data regarding the current state of lactation accommodations at continuing medical education (CME) events to guide best practice recommendations. Objective: To evaluate CME attendee attitudes, experiences, and preferences as it pertains to lactation support accommodations at CME events. Design: A cross-sectional study utilizing an electronic-based survey. Methods: Surveys were administered electronically to attendees of seven CME courses from August 2022 to October 2023, and de-identified data were collected to a secure database. Attitudes regarding lactation accommodations, personal preferences for lactation accommodations, and experiences with lactation at CME events were analyzed. Results: Of the 337 survey respondents, 169 had personal experience with lactation and 47 had experience with lactation at a CME course within the past 10 years. The majority of respondents agreed that lactation accommodations should be a priority ( n = 264, 83%) and are a medical need ( n = 285, 89%). Of those with recent experience lactating at a CME course, only 19% ( n = 9) indicated adequate lactation accommodations were provided. Due to inadequate accommodations, 77% ( n = 36) of respondents experienced decreased participation in the CME course content, 70% ( n = 33) claimed fewer hours of CME credit, and 74% ( n = 35) experienced decreased satisfaction in the CME course. Preferences for lactation accommodations included proximity to the meeting, audio–visual streaming of content, privacy, security, and signage supporting lactation in addition to an adequate designated space with access to an electrical plug and water supply. Conclusions: The current state of lactation accommodations at CME courses is inadequate and contributes to inequitable experiences for lactating participants. Course participants are supportive of lactating healthcare professionals at CME courses and recognize lactation accommodations as a priority. Further work is needed to inform and institute changes to lactation accommodations for healthcare professionals.

Objectives: To investigate the association between hormone therapy use and severe outcomes due to COVID-19 in perimenopausal and postmenopausal women. Methods: Using the Rochester Epidemiology Project, we retrospectively searched for the records of women aged 40-65 years who had a documented case of COVID-19 between March 12 and September 29, 2020. We further identified those who were perimenopausal or postmenopausal. The rates of emergency department visits, hospitalizations, and deaths were compared by hormone therapy use. Logistic regression models were used to assess the odds of the combined outcome based on hormone therapy use. Results: Among the 689 patients included in this study, the median age was 56 years, and 77.5% were White. Compared with patients currently using hormone therapy, those with past/never use of hormone therapy were significantly older, had more risk factors for severe COVID-19, and had a higher incidence of diabetes. A total of 102 emergency department visits/hospitalizations/deaths occurred among both groups. Participants with current hormone therapy use had similar rates and risk of emergency department/hospitalization/death outcomes as those without hormone therapy, even after adjusting for age and severe COVID-19 risk factors. Conclusions: Severe COVID-19 outcomes were not significantly different between women with current versus past/never use of hormone therapy. Our study adds to the data suggesting no harm with hormone therapy use in women with severe symptoms of COVID-19.

Purpose: In this study, we compare the use of rescue antiemetics in transgender and gender-diverse (TGD) patients undergoing gender-affirming surgical procedures with cisgender patients undergoing matching procedures. Methods: TGD patients undergoing facial feminization, genitourinary, or chest procedures between 2018 and 2023 were matched to cisgender men and women controls (only women for chest/breast procedures) using age, smoking status, surgical duration, and year of surgery to compare the use of rescue antiemetics in the postanesthesia recovery room. Analyses were performed using generalized estimating equations with robust variance estimates to assess whether TGD patients’ risk for receiving rescue antiemetics differed from matched cisgender controls. Results: We identified 397 TGD patients assigned male at birth (AMAB) and 194 TGD patients assigned female at birth (AFAB) undergoing gender-affirming surgery. Regardless of gender identity, AFAB patients received more prophylactic antiemetics than AMAB patients. Both unadjusted and adjusted (for patient and procedural variables) analyses failed to find evidence that the need for rescue antiemetics differed between matched cisgender and TGD patients ( p > 0.41 for all unadjusted and p > 0.34 for all adjusted comparisons). Conclusion: When compared to matched cisgender controls, TGD patients undergoing gender-affirming procedures did not have a higher risk of needing postoperative rescue antiemetic therapy.

Objective Reference values of regional cerebral oxygen saturation (rScO 2 ) in preterm neonates across gestational age (GA) groups remain undefined. This study aimed to establish rScO 2 references for neonates born before 32 weeks of gestation. Design A prospective observational cohort study. Setting Large tertiary neonatal referral centre in Croatia. Patients Preterm neonates without major comorbidities born between 2018 and 2022 with normal cranial ultrasound findings. Interventions rScO 2 was assessed with near-infrared spectroscopy (NIRS) using neonatal sensors. Main outcome measures The primary analysis provided rScO 2 reference ranges for the entire preterm neonatal cohort, followed by stratified analyses based on GA: extremely preterm , <28.0 weeks; very preterm , 28.0–30.0 weeks; and very preterm , 30.1–32.0 weeks. Quantile regression was used to estimate the selected rScO 2 percentiles (5th, 10th, 50th, 90th and 95th) from 6 to 72 hours after birth. Results 114 neonates with median (IQR) GA of 29.9 (29.1–31.5) weeks were included: 22% were EP <28w , 29% were VP 28–30w and 49% were VP >30–32w . The median rScO 2 was 75.6% at 6 hours, 79.5% over the first 24 hours and exceeding 80% in the subsequent 48 hours. When analysed separately, notable differences emerged across prematurity categories, with the highest median rScO 2 observed in the VP >30–32w group. Supplementary analyses, comparing rScO 2 values across the three GA groups, revealed significant differences at 48 and 72 hours. The majority of the estimated rScO 2 fifth percentiles between 6 and 72 hours were in the range ≥60%, with a single lowest estimate of 56.3% at 6 hours in the EP <28w group. Thus, for all subgroups, the estimated fifth percentile of rScO 2 was above the brain hypoxic threshold. Conclusions The use of age-appropriate neonatal NIRS sensors provided the rScO 2 reference values for very and extremely preterm neonates without major comorbidities 6–72 hours after birth.

Objective: This study evaluated the feasibility and satisfaction of using a wearable brain activity sensing device for stress reduction among patients experiencing Long COVID (LC). Patients and Methods: Patients with LC (N = 45) were invited to participate in an open-label pilot study. Participants were asked to use a brain-sensing electroencephalogram (S-EEG) wearable device (Muse-S™) daily for 90 days and followed for an additional 90 days (180 days total participation). Study enrollment began June 28, 2022, and ended July 28, 2023. Results: Patients were predominantly female (82%), white (96%), and with an average age of 47.6 (±12.5) years. At the end of treatment (90 days), cognition, sleep, self-efficacy, and quality-of-life quality of life improved ( P < .001 to P = .04). In addition, stress and anxiety were significantly reduced ( P < .001). These significant changes persisted by end-of-study (180 days). For stress ( P = .023) and anxiety ( P = .033), a change from the baseline during follow-up was significantly associated with the amount of S-EEG usage. The end-of-study satisfaction survey indicated that patients were very satisfied with the S-EEG device, and 97% planned to continue using it. Conclusion: Results suggest that the S-EEG device improved cognition in LC, which is one of the main severe symptoms we see in our LC clinic. In addition, it helped reduce stress and anxiety. These findings have important clinical implications for LC patients using S-EEG as an adjunct to concurrent LC clinical care which includes pharmacotherapies.

Objective: Postoperative nausea and vomiting (PONV) is a frequent adverse event after bariatric surgery and is associated with patient dissatisfaction and increased health care burden. Aggressive multimodal antiemetic prophylaxis and the use of propofol infusion during anesthesia are associated with the reduction of PONV. In this study, we examined the use of rescue antiemetics following bariatric surgery performed with 3 different anesthetic strategies designed to reduce PONV: (1) primary volatile (VOL) anesthetic and propofol (PROP) infusion (VOL+PROP), (2) volatile anesthetic with propofol and dexmedetomidine (DEX) infusions (VOL+PROP+DEX), or (3) opioid-sparing total intravenous anesthesia (PROP+DEX). Methods: In this retrospective observational study, we included patients undergoing bariatric surgery from 2018-2022 who received 1 of 3 anesthetics: (1) VOL+PROP, (2) VOL+PROP+DEX, or (3) opioid-sparing PROP+DEX without a VOL. Inverse probability of treatment weighting analysis determined the association between the need for rescue-antiemetics in the postanesthesia care unit (PACU) and following PACU discharge. Results: Three hundred thirty-two patients received VOL+PROP, 354 VOL+PROP+DEX, and 166 PROP+DEX, and all received prophylactic antiemetics during surgery. After surgery, the PROP+DEX patients received fewer rescue antiemetics in the PACU compared with VOL+PROP (11% vs. 24%, P=0.002), and VOL+PROP+DEX fewer compared with VOL+PROP (16% vs. 24%, P=0.023). This differential antinausea effect was limited to PACU stay only. Rescue antiemetic use increased across all anesthetic management groups following PACU discharge until midnight on the day of surgery (ranging from 38% to 46% across groups, P=0.71) and through the first postoperative day (ranging from 47% to 57% across groups, P=0.20). Conclusions: The benefit associated with anesthetic strategies designed to reduce PONV was present but did not persist past PACU discharge. This finding suggests that aggressive perioperative multimodal antiemetic prophylaxis combined with anesthetic strategies designed to prevent PONV after bariatric surgery have only a short-lived effect, thus health care staff in hospital wards may expect to encounter high rates of PONV in these patients. There is a need for the development of novel antinausea treatments to reduce the rate of this frequent postoperative complication.

AbstractBackgroundPeople living with dementia have high rates of emergency department (ED) use and hospitalizations. Identifying factors that influence acute care utilization is important. We examined the influence of physical activity levels on risk of hospitalization and emergency department (ED) use in a population of older people living with mild cognitive impairment (MCI) or dementia.MethodsWe included people with a diagnosis of MCI or dementia followed in Community Internal Medicine at Mayo Clinic, age 55 years and older, who had a clinic visit between June 1, 2019 and June 30, 2021 and had completed a social determinants of health questionnaire about physical activity levels. Physical activity was classified based on responses to questions about time spent exercising per week and rated as sufficiently active (≥150 minutes per week), insufficiently active (10‐140 minutes) or physically inactive (0 minutes). The risk of hospitalization and ED visits across physical activity levels was examined using quasi‐Poisson regression and presented as rate ratios (95% confidence interval (CI)), with adjustment for demographics, Charlson Comorbidity Index, marital status, living arrangement and body mass index.ResultsA total of 3090 persons living with MCI (n = 1308) or dementia (n = 1782) were included. People who were physically inactive were more likely to be older, female, not married, obese, have higher comorbid burden and a dementia diagnosis (p<0.001). Hospitalization and ED visit rates in those who were physically inactive were approximately double the rates for the sufficiently active group (p<0.001). Compared with those who were sufficiently active, people who were physically inactive had a significantly higher risk of hospitalization (rate ratio 1.73, 95% CI 1.30‐2.31) and ED visits (rate ratio 1.59, 95% CI 1.26‐2.01).ConclusionsPhysical inactivity in older people living with MCI or dementia is associated with an increased risk of ED visits and hospitalization. Targeted physical activity interventions could potentially impact on acute care utilization in this population. Our findings emphasize an area for public health promotion in people living with MCI or dementia.

Objectives: To identify patient characteristics, health concerns, and barriers to care based on overweight or obesity. Methods: A 50-question anonymous survey was administered to patients. Data were compared by body mass index (BMI). Results: Among 3976 distributed surveys, 899 were returned and 682 were analyzed. Most respondents were women (60%), White (94%), and married/partnered (65%) and had some college education (80%). Younger and unmarried persons had higher BMI ( P < .001). Concern for quality of life ( P < .001) and importance of lifestyle changes ( P = .006) increased with BMI, but confidence in making changes decreased as BMI increased ( P < .001). Perceived good health decreased with increasing BMI ( P < .001), whereas depression and other comorbid conditions increased. Self-esteem decreased and stigma increased with higher BMI (both P < .001). Weight discussions with clinicians ( P < .001) and belief that clinicians should be involved in weight management ( P = .002) increased with BMI, yet self-perception of being judged by clinicians also increased ( P < .001). As BMI increased, delays in seeking health care increased ( P < .001). Conclusions: This survey study highlights perceived health concerns and barriers to care among persons with overweight and obesity. With higher BMI, self-esteem decreased, and stigma, self-perception of poor health, perception of being judged by clinicians, and delay in seeking medical care increased.