Leading progress: the role of the chief diversity officer in anesthesiology departments

Canadian Journal of Anesthesia/Journal canadien d'anesthésie -     

Discordance in HIV-1 viral loads and antiretroviral drug concentrations comparing semen and blood plasma

Objectives

For individuals not on antiretroviral therapy, the risk of heterosexual transmission of HIV appears negligible when blood plasma (BP) viral loads are <1500 HIV‐1 RNA copies/mL. It is not clear whether this observation can be extrapolated to individuals on highly active antiretroviral therapy (HAART). Because of differential tissue penetration, antiretroviral drug concentrations may be sufficient to maintain an undetectable viral load in the BP yet not achieve adequate levels to suppress HIV in the genital tract. Therefore, we wanted to correlate HIV viral loads and drug concentrations in semen plasma (SP) and BP.

Methods

Thirty‐three men were included. All were on combination antiretroviral therapy with an undetectable BP viral load for at least 1 year. Blood and semen samples were collected within 2 h of each other and tested for HIV RNA by the NucliSens QT (bioMerieux, St Laurent, QC, Canada) method; drug concentrations were determined by liquid chromatography tandem mass spectrometry.

Results

Two of the 33 patients (6.1%) with BP viral loads below detection had time‐matched HIV viral loads in SP ≥700 copies/mL. Both patients were on efavirenz, the SP concentrations of which were ≤10% of the levels in BP and well below the minimal therapeutic drug monitoring target concentration required to suppress HIV.

Conclusions

Because, at least in part, of poor drug penetration into the genital tract, an undetectable HIV viral load in the BP does not guarantee an undetectable viral load in semen. In view of this, caution should be taken in concluding that patients on HAART with suppressed viraemia are sexually non‐infectious.     

Current status and solutions for gender equity in anaesthesia research

Despite increasing numbers of women entering anaesthesia, they remain persistently under-represented within academic anaesthesia and research. Gender discordance is seen across multiple aspects of research, including authorship, editorship, peer review, grant receipt, speaking and leading. Women are also under-represented at higher faculty ranks and in department chair positions. These inequities are further magnified for women with intersectional identities, such as those who identify as Black, indigenous and women of colour. Several barriers to participation in research have been identified to date, including a disproportionate amount of family responsibilities, a disproportionate burden of clinical service, gender bias, sexual harassment and the gender pay gap. Several strategies to improve gender equity have been proposed. Increasing access to formal mentorship of women in academic medicine is frequently cited and has been used by healthcare institutions and medical societies. Senior faculty and leaders must also be conscious of including women in sponsorship and networking opportunities. Institutions should provide support for parents of all genders, including supportive parental leave policies and flexible work models. Women should also be materially supported to attend formal educational conferences targeted for women, aimed at improving networking, peer support and professional development. Finally, leaders must display a clear intolerance for sexual harassment and discrimination to drive culture change. Peers and leaders alike, of all genders, can act as upstanders and speak up on behalf of targets of discrimination, both in the moment or after the fact. Gender inequities have persisted for far too long and can no longer be ignored. Diversifying the anaesthesia research community is essential to the future of the field.     

Severe infantile colic and food intolerance: a long-term prospective study

To determine the relationship between infantile colic and cow's milk protein intolerance (CMPI) in formula-fed infants, 70 infants (38 male, 32 female) were selected, with mean age 30.2 +/- 21.4 days, with severe colic (duration of crying greater than 4 h per day for 5 days per week). In 50 of the infants in the study group (71.4%) there was a remission of symptoms when cow's milk protein (CMP) was eliminated from the diet. Two successive challenges caused the return of symptoms in all these 50 infants. There was a positive anamnesis for atopy in 9 of 50 of the patients with CMP-related colic and in 1 of 20 of those with non-CMP-related colic (p greater than 0.05). A follow-up period of 18 months' mean duration showed that 22 of 50 (44%) of the infants with CMP-related colic and 1 of 20 (5%) of those with non-CMP-related colic developed an overt alimentary intolerance (p less than 0.02). We conclude that a considerable percentage of the infants with severe colic also have CMPI and that in these cases, dietetic treatment should be the first therapeutic approach.     

Quantifying axonal loss after optic neuritis with optical coherence tomography

OBJECTIVE: To determine to what degree changes in retinal nerve fiber layer (RNFL) thickness after optic neuritis (ON) correlate with either visual recovery or impairment. METHODS: ON can cause visible defects within the RNFL, which can be quantified using optical coherence tomography (OCT). It may be possible to predict visual recovery by measuring RNFL loss after ON. Fifty-four patients underwent repeated evaluations with optical coherence tomography and standardized ophthalmic testing after ON. Regression analyses were used to determine the relationship between RNFL thickness and visual function. RESULTS: Thinning of the RNFL was seen in the majority of patients (74%), and it tended to occur within 3 to 6 months of ON. The average RNFL value was thinner (p<0.0001) in the affected (78 microm) compared with the unaffected eye (100 microm). Patients with incomplete visual recovery demonstrated greater RNFL loss after ON. Regression analyses demonstrated a threshold of RNFL thickness (75 microm), below which RNFL measurements predicted persistent visual dysfunction. INTERPRETATION: Determination of RNFL thickness may predict visual recovery after ON, and lower RNFL values correlate with impaired visual function. Optical coherence tomography may have a potential role as a surrogate marker for axonal integrity within the optic nerve among patients with ON.     

Serum Trypsin in Chronic Renal Failure and Transplant Patients

The frequency and degree of elevated serum levels of trypsin (T) and correlation with other pancreatic enzymes were determined in several groups of patients with renal disease, i.e., patients with chronic renal failure (CRF), hemodialysis patients (HD), renal transplant recipients (RT), and in a control (C) group. Mean values of T were significantly higher in all other groups than in the C group (p less than 0.0001). A statistically significant correlation between T and creatininemia levels was found only for the RT group (p less than 0.0001). Correlations between T versus pancreatic amylase and T versus lipase activity were found to be statistically significant in the CRF and RT groups (p less than 0.01), but not in the HD group. Most patients in all groups had T values higher than the maximum value observed in the controls and, of them, most had very elevated values. The results suggest that in chronic renal pathology there are frequent and significant increases in serum T levels, circulating in parallel with the other pancreatic enzymes. It is possible that, together with the renal excretion impairment, there could also be subclinical pancreatic damage or a dysfunction of the other means of elimination of T that can be responsible for, or contribute to, the serum increase in the enzyme.     

Gastric emptying in infants with gastroesophageal reflux. Ultrasound evaluation before and after cisapride administration.

The present study aimed to evaluate gastric emptying in children with gastroesophageal reflux (GER) by means of real-time ultrasonography, on the basis of measurements of the cross-sectional area of the gastric antrum. Twelve children with GER were studied (seven males, five females; age range, 3-13 months) and compared with 12 normal control children (six males, six females; age range, 3-13 months). The diagnosis of GER was confirmed by 24-h esophageal pH-monitoring. The GER patients had a significantly greater antral area than the controls at 90, 105, and 120 min after eating a standard meal (cow's milk formula, 300 ml/m2 body surface area); in addition, final gastric emptying time was significantly greater in the patients than in the controls (145 +/- 36.9 versus 78.7 +/- 19.3 min; p less than 0.0025). After 8 weeks of treatment with cisapride (0.3 ml/kg, three times a day) 24-h esophageal pH-monitoring and ultrasonography studies were repeated in the patients. The total percentage reflux time was significantly lower (p less than 0.038), and ultrasonography showed a decreased antral area at all the various study times, with no significant difference between patients and controls; final gastric emptying time was also significantly lower than before treatment (p less than 0.009). Furthermore, in the GER patients there was a significant correlation between gastric emptying time and the sum of the various reflux times recorded in the 2 h after all meals over the 24 h.(ABSTRACT TRUNCATED AT 250 WORDS)     

Pancreatic insufficiency in celiac disease is not dependent on nutritional status

To determine the relationship between pancreatic secretory capacity and nutritional status in celiac patients, we studied 52 patients with celiac disease (24 males, 28 females; age range 6–36 months) and 30 healthy control subjects (14 males, 16 females; age range 6–42 months). A secretin-cerulein test was performed on all patients, and levels of serum albumin and plasma fibronectin were assayed. In addition, weight/height ratios were calculated in the celiacs, who were then divided into three groups on this basis, as follows: celiacs with weight/height ratio3rd percentile; those with weight/height ratio between the 4th and 10th percentiles; and those with weight/height ratio>10th percentile. There was no significant difference in the duodenal output of chymotrypsin, phospholipase and lipase between these groups. When the total celiac group was compared to control subjects, only lipase levels were significantly lower (P<0.009). However, subnormal values in one or more pancreatic enzymes were observed in 15/52 celiacs (29%). A residual enzyme activity<10% of normal secretory capacity, was also found in 4/52 patients. There was no correlation between the output of the various pancreatic enzymes and levels of albumin, fibronectin, and weight/height ratios in the patients. Furthermore, there was no difference in weight/height ratio and levels of albumin and fibronectin between the celiac subjects with pancreatic deficiency and those with normal pancreatic function. We conclude that a mild/moderate pancreatic insufficiency is quite frequent in celiacs, but that it may be completely independent of nutritional status; further studies are therefore required to shed light on its pathogenesis.     

Impact of the intersection of anaesthesia and gender on burnout and mental health,illustrated by the COVID-19 pandemic

Physician burnout and poor mental health are prevalent and often stigmatised. Anaesthetists may be at particular risk and this is further increased for women anaesthetists due to biases and inequities within the specialty. However, gender-related risk factors for and experiences of burnout and poor mental health remain under-researched and under-reported. This negatively impacts individual practitioners, the anaesthesia workforce and patients and carries significant financial implications. We discuss the impact of anaesthesia and gender on burnout and mental health using the COVID-19 pandemic as an example illustrating how women and men differentially experience stressors and burnout. COVID-19 has further accentuated the gendered effects of burnout and poor mental health on anaesthetists and brought further urgency to the need to address these issues. While both personal and organisational factors contribute to burnout and poor mental health, organisational changes that recognise and acknowledge inequities are pivotal to bolster physician mental health.