The opioid epidemic and the current prevalence of substance use disorder in anesthesiologists

Purpose of review There has been a substantial increase in prescription and illicit opioid abuse in the general population observed over the last two decades. Initially fueled by an influx of prescription opioid medications, the opioid epidemic now includes increasingly potent heroin and illicit fentanyl. Younger anesthesiologists, those currently in training or recent graduates, have come of age in a society where opioid abuse is much more prevalent. Recent findings The current prevalence of substance use disorder (SUD) in the physician population is slightly higher than in the general population and appears to be increasing. Although most anesthesiologists with SUD will abuse alcohol as their drug of choice, the incidence of opioid and nonopioid anesthetic agent abuse, especially propofol, is increasing. The incidence of SUD among the anesthesia resident population decreased somewhat during the 1990s but has been steadily increasing since the year 2000. Summary The increasing incidence of substance use disorder in anesthesia residents may reflect the significantly increased number of persons addicted to opioids and other drugs of abuse in the general population. Despite educational and surveillance programs put in place to prevent diversion, susceptible individuals with access are still abusing anesthetic agents. Correspondence to Ethan O. Bryson, MD, Department of Anesthesiology, Pain Management and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, Box 1010, One Gustave L Levy Place, New York, NY 10029, USA. Tel: +1 212 241 9240; fax: +1 212 876 3906; e-mail: ethan.bryson@mountsinai.org Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Occupational stress, burnout and personality in anesthesiologists

Purpose of review There is a growing awareness of the problem of occupational stress and burnout among anesthesiologists. Occupational stress was found to be related to burnout, a process that is supposed to be moderated by personality. This article will discuss the topic of stress and burnout in relationship to anesthesiologists' personality based on recent literature. Recent findings Studies among anesthesiologists are in concordance with the broader body of literature on this topic. Personality consistently influences stress appraisal and coping and consequently the development of burnout. Neuroticism, negative affectivity and cooperativeness all contribute to burnout. Summary Strategies to alleviate stress and hence the development of burnout should not only be directed at adapting occupational or organizational factors but also at equipping anesthesiologists with psychological tools to deal with occupational stress. Furthermore, personality traits that predispose for development of burnout could be taken into consideration in resident selection procedures. Correspondence to Raymond A.B. van der Wal, MD, Anesthesiologist, Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Center, Internal Postal Code 717, P.O. Box 9101, 6500 HB Nijmegen, the Netherlands. Tel: +31 24 361 4406; fax: +31 24 354 0462; e-mail: Raymond.vanderwal@radboudumc.nl Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Anesthesia and analgesia for gynecological surgery

Purpose of review High-quality analgesia has been linked to improved patient satisfaction as well as improved short-term and long-term postoperative outcomes. Acute surgical pain is a modifiable risk factor for development of chronic postoperative pain, which is reported by up to 26% of gynecologic surgical patients. In other surgical populations, multimodal analgesia has shown improved pain control and decreased reliance on opioids. This review examines recent evidence for various analgesic modalities applied specifically to the gynecologic surgical population. Recent findings Nonopioid agents like acetaminophen, nonsteroidal anti-inflammatories, and gamma-aminobutyric acid analogs resulted in reduction in postoperative pain and opioid consumption. Application of regional anesthetic techniques had a favorable effect that persisted beyond the immediate recovery period. Preemptive analgesia remains unproven. The best evidence for effective combinations comes from ERAS studies that incorporated multimodal analgesia into a systemic approach geared towards early discharge. Summary Multimodal analgesia had demonstrated advantages for all types of gynecological surgeries in terms of improving postoperative pain control and minimizing opioid-related adverse effects. Multimodal analgesia includes acetaminophen, NSAIDS, and gamma-aminobutyric acid analogs combined with intraoperative nonopioid analgesics such as ketamine, regional anesthesia or intrathecal morphine. Further research should focus on determining most effective combinations and doses of multimodal analgesia. Correspondence to Dr Ronald B. George, MD, FRCPC, Department of Women's and Obstetric Anesthesia, IWK Health Centre, 5850/5980 University Avenue, P.O. Box 9700, Halifax, NS B3K 6R8, Canada. Tel: +1 902 470 6627; fax: +1 902 470 6626; e-mail: rbgeorge@dal.ca,@Ron_George Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Technology as friend or foe? Do electronic health records increase burnout?

Purpose of review To summarize recent relevant studies regarding the use of electronic health records and physician burnout. Recent findings Recently acquired knowledge regarding the relationship between electronic health record use, professional satisfaction, burnout, and desire to leave clinical practice are discussed. Summary Adoption of electronic health records has increased across the United States and worldwide. Although electronic health records have many benefits, there is growing concern about the adverse consequences of their use on physician satisfaction and burnout. Poor usability, incongruent workflows, and the addition of clerical tasks to physician documentation requirements have been previously highlighted as ongoing concerns with electronic health record adoption. In multiple recent studies, electronic health records have been shown to decrease professional satisfaction, increase burnout, and the likelihood that a physician will reduce or leave clinical practice. One interventional study demonstrated a positive effect of a dedicated electronic health record entry clerk on physicians working in an outpatient practice. Correspondence to Jesse M. Ehrenfeld, MD, MPH, Professor of Anesthesiology, Surgery, Biomedical Informatics & Health Policy, Director, Education Research – Office of Health Sciences Education, Director, Program for LGBTI Health, Associate Director, Vanderbilt Anesthesiology & Perioperative Informatics Research Division, Vanderbilt University School of Medicine, 1301 Medical Center Drive, Suite TVC 4648, Nashville, TN 37232, USA. E-mail: jesse.ehrenfeld@vanderbilt.edu Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Cytotoxic T lymphocyte response to peptide vaccination predicts survival in stage III colorectal cancer

Abstract

We previously reported a phase I clinical trial of a peptide vaccine ring finger protein 43 (RNF43) and 34-kDa translocase of the outer mitochondrial membrane (TOMM34) combined with uracil–tegafur (UFT)/LV for patients with metastatic colorectal cancer (CRC), and demonstrated the safety and immunological responsiveness of this combination therapy. In this study, we evaluated vaccination-induced immune responses to clarify the survival benefit of the combination therapy as adjuvant treatment. We enrolled 44 patients initially in an HLA-masked fashion. After the disclosure of HLA, 28 patients were in the HLA-A*2402-matched and 16 were in the unmatched group. In the HLA-matched group, 14 patients had positive CTL responses specific for the RNF43 and/or TOMM34 peptides after two cycles of treatment and 9 had negative responses; in the HLA-unmatched group, CTL responses were 10 positive, 2 negative. In the HLA-matched group, 3-year relapse-free survival (RFS) was significantly better in the positive CTL subgroup than in the negative-response subgroup. Patients with negative vaccination-induced CTL responses showed a significant trend towards shorter RFS than those with positive responses. Moreover, in the HLA-unmatched group, the positive CTL response subgroup showed an equally good 3-year RFS as in the HLA-matched group. In conclusion, vaccination-induced CTL response to peptide vaccination could predict survival in the adjuvant setting for stage III CRC.

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Anti-human SIRPα antibody is a new tool for cancer immunotherapy

Summary

Interaction of signal regulatory protein α (SIRPα) expressed on the surface of macrophages with its ligand CD47 expressed on target cells negatively regulates phagocytosis of the latter cells by the former. We recently showed that blocking Abs to mouse SIRPα enhanced both the Ab-dependent cellular phagocytosis (ADCP) activity of mouse macrophages for Burkitt's lymphoma Raji cells opsonized with an Ab to CD20 (rituximab) in vitro as well as the inhibitory effect of rituximab on the growth of tumors formed by Raji cells in nonobese diabetic/severe combined immunodeficient (NOD/SCID) mice. However, the effects of blocking Abs to human SIRPα in preclinical cancer models have remained unclear given that such Abs have failed to interact with endogenous SIRPα expressed on macrophages of immunodeficient mice. With the use of Rag2^−/−γ_c^−/− mice harboring a transgene for human SIRPα under the control of human regulatory elements (hSIRPα-DKO mice), we here show that a blocking Ab to human SIRPα significantly enhanced the ADCP activity of macrophages derived from these mice for human cancer cells. The anti–human SIRPα Ab also markedly enhanced the inhibitory effect of rituximab on the growth of tumors formed by Raji cells in hSIRPα-DKO mice. Our results thus suggest that the combination of Abs to human SIRPα with therapeutic Abs specific for tumor antigens warrants further investigation for potential application to cancer immunotherapy. In addition, humanized mice, such as hSIRPα-DKO mice, should prove useful for validation of the antitumor effects of checkpoint inhibitors before testing in clinical trials.

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Cytotoxic T lymphocyte response to peptide vaccination predicts survival in stage III colorectal cancer

Abstract

We previously reported a phase I clinical trial of a peptide vaccine ring finger protein 43 (RNF43) and 34-kDa translocase of the outer mitochondrial membrane (TOMM34) combined with uracil–tegafur (UFT)/LV for patients with metastatic colorectal cancer (CRC), and demonstrated the safety and immunological responsiveness of this combination therapy. In this study, we evaluated vaccination-induced immune responses to clarify the survival benefit of the combination therapy as adjuvant treatment. We enrolled 44 patients initially in an HLA-masked fashion. After the disclosure of HLA, 28 patients were in the HLA-A*2402-matched and 16 were in the unmatched group. In the HLA-matched group, 14 patients had positive CTL responses specific for the RNF43 and/or TOMM34 peptides after two cycles of treatment and 9 had negative responses; in the HLA-unmatched group, CTL responses were 10 positive, 2 negative. In the HLA-matched group, 3-year relapse-free survival (RFS) was significantly better in the positive CTL subgroup than in the negative-response subgroup. Patients with negative vaccination-induced CTL responses showed a significant trend towards shorter RFS than those with positive responses. Moreover, in the HLA-unmatched group, the positive CTL response subgroup showed an equally good 3-year RFS as in the HLA-matched group. In conclusion, vaccination-induced CTL response to peptide vaccination could predict survival in the adjuvant setting for stage III CRC.

This article is protected by copyright. All rights reserved.

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