Comparison of Preoperative Alpha-blockade for Resection of Paraganglioma and Pheochromocytoma.

OBJECTIVE: Phenoxybenzamine (nonselective, noncompetitive alpha-blocker) is the preferred drug for preoperative treatment of pheochromocytoma, but doxazosin (selective, competitive alpha-blocker) may be equally effective. We compared the efficacy of doxazosin vs phenoxybenzamine. METHODS: We conducted a prospective study of patients undergoing pheochromocytoma or paraganglioma resection by randomizing pretreatment with phenoxybenzamine or doxazosin at a single tertiary referral center. The high cost of phenoxybenzamine led to high crossover to doxazosin. Randomization was halted, and a consecutive historical cohort of phenoxybenzamine patients was included for a case-control study design. The efficacy of alpha-blockade was assessed with preinduction infusion of incremental doses of phenylephrine. The primary outcomes were mortality, cardiovascular complications, and intensive care unit admission. The secondary outcomes were hemodynamic instability index (proportion of operation outside of hemodynamic goals), adequacy of blockade by the phenylephrine titration test, and drug costs. RESULTS: Twenty-four patients were prospectively enrolled (doxazosin, n = 20; phenoxybenzamine, n = 4), and 15 historical patients treated with phenoxybenzamine were added (total phenoxybenzamine, n = 19). No major cardiovascular complications occurred in either group. The phenylephrine dose-response curves showed less blood pressure rise in the phenoxybenzamine than in the doxazosin group (linear regression coefficient = 0.008 vs 0.018, P = .01), suggesting better alpha-blockade in the phenoxybenzamine group. The median hemodynamic instability index was 14% vs 13% in the phenoxybenzamine and doxazosin groups, respectively (P = .56). The median highest daily cost of phenoxybenzamine was $442.20 compared to $5.06 for doxazosin. CONCLUSION: Phenoxybenzamine may blunt intraoperative hypertension better than doxazosin, but this difference did not translate to fewer cardiovascular complications and is offset by a considerably increased cost.

Implementation and Evaluation of a Neurology Telemedicine Initiative at a Major Academic Medical Center.

Introduction: The COVID-19 pandemic forced rapid adoption of telemedicine for care of neurology patients. This study contributes to this literature by describing the structure and implementation of telemedicine-based outpatient neurology clinics at the UCLA Medical Center and estimates patient cost savings, before and after the California COVID-19 "Safer at Home" directive, and patient satisfaction. Methods: This was a retrospective, nonrandomized, case series study of telemedicine-based neurological management in an urban academic medical center from October 2018 to June 2020. We estimated roundtrip travel time, roundtrip travel distance, total savings, and surveyed patient and provider satisfaction with telemedicine care. We supported these findings through evaluation of 7,194 patients by telemedicine and conducted 9,189 video visits for neurological care. Results: The median telemedicine patient avoided a roundtrip driving distance of 33 miles and roundtrip travel time of 75 min. Within sample, median hourly earnings were $27/h. The median patient saved $18 on fuel and parking and $36 of time-based opportunity savings, for total savings of $54 per video visit. Eighty-six percent of patients surveyed were satisfied with their video visit experience. Conclusions: Telemedicine reduced travel time and also reduced costs for neurology patients. Patients and providers both reported high levels of satisfaction with telemedicine.

Development, Implementation, and Evaluation of a Telemedicine Preoperative Evaluation Initiative at a Major Academic Medical Center.

BACKGROUND: With health care practice consolidation, the increasing geographic scope of health care systems, and the advancement of mobile telecommunications, there is increasing interest in telemedicine-based health care consultations. Anesthesiology has had experience with telemedicine consultation for preoperative evaluation since 2004, but the majority of studies have been conducted in rural settings. There is a paucity of literature of use in metropolitan areas. In this article, we describe the implementation of a telemedicine-based anesthesia preoperative evaluation and report the program's patient satisfaction, clinical case cancellation rate outcomes, and cost savings in a large metropolitan area (Los Angeles, CA). METHODS: This is a descriptive study of a telemedicine-based preoperative anesthesia evaluation process in an academic medical center within a large metropolitan area. In a 2-year period, we evaluated 419 patients scheduled for surgery by telemedicine and 1785 patients who were evaluated in-person. RESULTS: Day-of-surgery case cancellations were 2.95% and 3.23% in the telemedicine and the in-person cohort, respectively. Telemedicine patients avoided a median round trip driving distance of 63 miles (Q1 24; Q3 119) and a median time saved of 137 (Q1 95; Q3 195) and 130 (Q1 91; Q3 237) minutes during morning and afternoon traffic conditions, respectively. Patients experienced time-based savings, particularly from traveling across a metropolitan area, which amounted to $67 of direct and opportunity cost savings. From patient satisfaction surveys, 98% (129 patients out of 131 completed surveys) of patients who were consulted via telemedicine were satisfied with their experience. CONCLUSIONS: This study demonstrates the implementation of a telemedicine-based preoperative anesthesia evaluation from an academic medical center in a metropolitan area with high patient satisfaction, cost savings, and without increase in day-of-procedure case cancellations.

Improvement in Adherance to Anesthesia Preoperative Appointment With Telemedicine: A Retrospective Analysis.

BACKGROUND: Amidst the coronavirus disease 2019 (COVID-19) pandemic, the sudden demand for virtual medical visits drove the expansion of telemedicine across all medical specialties. Current literature demonstrates limited knowledge of the impact of telehealth on appointment adherence, particularly in preoperative anesthesia evaluations. This study aims to describe the impact of telemedicine-based anesthesia evaluation and its effects on appointment completion.  Methods: This was a retrospective, non-randomized, cohort study of adult patients at the University of California, Los Angeles, United States, who received preoperative anesthesia evaluations by telemedicine or in-person in an academic medical center. From January to September 2021, we evaluated telemedicine and in-person appointment completion in patients scheduled for surgery. The primary outcome was the incidence of appointment completion. The secondary outcomes included appointment no-shows and cancellations.  Results: Of 1332 patients included in this study, 956 patients received telehealth visits while 376 patients received in-person preoperative anesthesia evaluations. Compared to the in-person group, the telemedicine group had more appointment completions (81.38% vs 76.60%), fewer cancellations (12.55% vs 19.41%), and no statistical difference in appointment no-shows (6.07% vs 3.99%). Compared to the in-person group, patients who received telemedicine evaluations were younger (55.81 ± 18.38 vs 65.97 ± 15.19), less likely Native American and Alaska Native (0.31% vs 1.60%), more likely of Hispanic or Latino ethnicity (16.63% vs 12.23%), required less interpreter services (4.18% vs 9.31%), had more private insurance coverage (53.45% vs 37.50%) and less Medicare coverage (37.03% vs 50.53%). CONCLUSIONS: This study demonstrates that telemedicine can improve preoperative anesthesia appointment completion and decrease appointment cancellations. We also demonstrate potential shortcomings of telemedicine in serving patients who are older, require interpreter services, or are non-privately insured. These inequities highlight potential avenues to increase equity and access to telemedicine.

Evaluation of Telemedicine Use for Anesthesiology Pain Division: Retrospective, Observational Case Series Study.

BACKGROUND: An increasing number of patients require outpatient and interventional pain management. To help meet the rising demand for anesthesia pain subspecialty care in rural and metropolitan areas, health care providers have used telemedicine for pain management of both interventional patients and those with chronic pain. OBJECTIVE: In this study, we aimed to describe the implementation of a telemedicine program for pain management in an academic pain division in a large metropolitan area. We also aimed to estimate patient cost savings from telemedicine, before and after the California COVID-19 "Safer at Home" directive, and to estimate patient satisfaction with telemedicine for pain management care. METHODS: This was a retrospective, observational case series study of telemedicine use in a pain division at an urban academic medical center. From August 2019 to June 2020, we evaluated 1398 patients and conducted 2948 video visits for remote pain management care. We used the publicly available Internal Revenue Service's Statistics of Income data to estimate hourly earnings by zip code in order to estimate patient cost savings. We estimated median travel time and travel distance with Google Maps' Distance Matrix application programming interface, direct cost of travel with median value for regular fuel cost in California, and time-based opportunity savings from estimated hourly earnings and round-trip time. We reported patient satisfaction scores derived from a postvisit satisfaction survey containing questions with responses on a 5-point Likert scale. RESULTS: Patients who attended telemedicine visits avoided an estimated median round-trip driving distance of 26 miles and a median travel time of 69 minutes during afternoon traffic conditions. Within the sample, their median hourly earnings were US $28 (IQR US $21-$39) per hour. Patients saved a median of US $22 on gas and parking and a median total of US $52 (IQR US $36-$75) per telemedicine visit based on estimated hourly earnings and travel time. Patients who were evaluated serially with telemedicine for medication management saved a median of US $156 over a median of 3 visits. A total of 91.4% (286/313) of patients surveyed were satisfied with their telemedicine experience. CONCLUSIONS: Telemedicine use for pain management reduced travel distance, travel time, and travel and time-based opportunity costs for patients with pain. We achieved the successful implementation of telemedicine across a pain division in an urban academic medical center with high patient satisfaction and patient cost savings.

Cerebrovascular Accident Manifesting as Altered Mental Status During a Telehealth Visit: Preoperative Evaluation in the COVID-19 Era.

We present the case of a 91-year-old patient scheduled for a preoperative telehealth evaluation who was found to have altered mental status from an acute stroke. Her care, if delayed, could have caused permanent morbidity during the coronavirus disease 2019 (COVID-19) pandemic. This case highlights the digital leap the pandemic spurred: 1. telehealth in the elderly, 2. meaningful history and physical during telehealth visit, 3. family engagement and education, and 4. meaningful impact on patient outcomes.

Telemedicine-Based Perioperative Management of Pheochromocytoma in a Patient With Von Hippel Lindau Disease: A Case Report.

We present the case of a young woman with Von Hippel Lindau (VHL) disease who underwent a combined pheochromocytoma resection along with pancreaticoduodenectomy. Her preoperative management, including effective alpha-blockade, was conducted remotely via telemedicine video visits, patient-entered vital sign data, and secure messaging between provider and patient. Similar remote management was undertaken before a subsequent pheochromocytoma resection while the patient was pregnant, and both surgeries had positive outcomes. This represents the first time that telemedicine and mobile health monitoring have been successfully used for preoperative alpha-blockade in a high-acuity patient before a complex multivisceral surgery.

Distinct cerebellar contributions to intrinsic connectivity networks.

Convergent data from various scientific approaches strongly implicate cerebellar systems in nonmotor functions. The functional anatomy of these systems has been pieced together from disparate sources, such as animal studies, lesion studies in humans, and structural and functional imaging studies in humans. To better define this distinct functional anatomy, in the current study we delineate the role of the cerebellum in several nonmotor systems simultaneously and in the same subjects using resting state functional connectivity MRI. Independent component analysis was applied to resting state data from two independent datasets to identify common cerebellar contributions to several previously identified intrinsic connectivity networks (ICNs) involved in executive control, episodic memory/self-reflection, salience detection, and sensorimotor function. We found distinct cerebellar contributions to each of these ICNs. The neocerebellum participates in (1) the right and left executive control networks (especially crus I and II), (2) the salience network (lobule VI), and (3) the default-mode network (lobule IX). Little to no overlap was detected between these cerebellar regions and the sensorimotor cerebellum (lobules V-VI). Clusters were also located in pontine and dentate nuclei, prominent points of convergence for cerebellar input and output, respectively. The results suggest that the most phylogenetically recent part of the cerebellum, particularly crus I and II, make contributions to parallel cortico-cerebellar loops involved in executive control, salience detection, and episodic memory/self-reflection. The largest portions of the neocerebellum take part in the executive control network implicated in higher cognitive functions such as working memory.

Methylnaltrexone-Associated Bowel Perforation in Postoperative Opioid-Induced Constipation and Ogilvie Syndrome: A Case Report.

Pain management with opioids is often limited by medication side effects. One of the most common and distressing side effects is opioid-induced constipation (OIC), a syndrome that is now getting significant national attention. We report the case of an opioid-dependent 56-year-old man who underwent lumbar decompression for spinal stenosis. Postoperatively, he developed OIC and Ogilvie syndrome, then following treatment with methylnaltrexone experienced an acute bowel perforation. We briefly review the recommended management of OIC as well as indications and contraindications of methylnaltrexone and similar new medications.