Evaluation of the Safety of Uninterrupted Warfarin Anticoagulation With Tranexamic Acid in Total Joint Arthroplasty.

BACKGROUND: The continuation of long-term warfarin therapy is gaining acceptance in minor surgeries but maintaining therapeutic international normalized ratio (INR) values among patients during major orthopedic procedures raises concern. While bridging therapy with low-molecular-weight heparin is currently recommended for patients receiving anticoagulation, few studies have evaluated the safety of continuing warfarin during total joint arthroplasty. This study evaluated the safety and efficacy of continuous warfarin anticoagulation through total joint arthroplasty with and without prophylactic tranexamic acid (TXA). MATERIALS AND METHODS: We conducted a retrospective, matched-pair analysis of two experimental groups of patients who underwent primary total hip arthroplasty or total knee arthroplasty performed by a single surgeon. Our first experimental group, warfarin plus TXA (warfarin+TXA), consisted of 21 patients who underwent arthroplasty while receiving therapeutic anticoagulation with warfarin (INR, 2.0-3.0) and who received prophylactic TXA. Our second experimental group, warfarin without TXA (warfarin-TXA), consisted of 40 patients who underwent arthroplasty while receiving therapeutic anticoagulation with warfarin (INR, 2.0-3.0) without prophylactic TXA. RESULTS: The percent change in hemoglobin value after surgery, red blood cells transfused, surgical site infections, bleeding complications, and thrombotic complications were similar between both experimental and control groups. When comparing the historical group with the warfarin+TXA group, the addition of TXA resulted in a statistical decrease in mean red blood cells transfused and estimated blood loss, with no statistically significant increase in complications. CONCLUSION: Many factors must be considered when choosing perioperative thromboembolic prophylaxis for arthroplasty candidates with medical comorbidities requiring long-term anticoagulation. This study presents data indicating that it could be safe and effective to continue therapeutic warfarin while using prophylactic TXA. [Orthopedics. 202x;4x(x):xx-xx.].

The Joint Awareness Score: A Shortened, Simplified, Improved Alternative to the Forgotten Joint Score.

Background: The Forgotten Joint Score (FJS) is a 12-question patient-reported outcomes measure created to measure a patient's awareness of their artificial joint. The FJS has attained wide usage, though it is not without weaknesses. Our patients report that the semantics of the English translation are flawed and that the 5 answer options for each question are poorly differentiated. Additionally, the FJS will result in no score if 3 or more questions are unanswered. This prompted the development of an alternative patient-reported outcomes measure, the Joint Awareness Score (JAS), that builds upon the core concept of joint awareness underlying the FJS, but that is easier to understand and shorter to complete. We completed an exploratory, pilot study to evaluate this outcomes instrument. Our hypothesis is that the JAS will correlate strongly with the FJS and could be used as a substitute. Methods: Knee arthroplasty patients in a prospective registry were administered the FJS and the JAS. Internal consistency and correlation were calculated with Cronbach's alpha and Pearson's correlation coefficient, respectively. Results: This study included 174 patients. Cronbach's alpha for FJS was 0.97 for 6 months and 0.97 for 12 months, whereas JAS was 0.89 at 6 months and 0.85 at 12 months. Pearson correlation comparing FJS and JAS at 6 months was 0.88 (95% confidence interval: 0.83, 0.92) and 0.86 (95% confidence interval: 0.78, 0.92) at 12 months. Conclusions: The Joint Awareness Score is a new patient-reported outcomes measure that is a substitute for the FJS, with half the number of questions, improved semantics, and simplified answers.

Standardized Follow-Up Recommendations Improve Reporting of Incidental Renal Lesions in a Community Setting.

Introduction The objective of this quality improvement study was to assess radiology report follow-up recommendation trends upon detection of incidental renal lesions before and after instituting standardized follow-up macros.  Materials and methods A retrospective review was performed in 2019 of multiphase imaging workups on renal lesions (n = 396), including the following imaging modalities: ultrasound, CT with and without contrast, and spine MRI. Utilizing the same collection methods, a similar retrospective set of cases was collected in 2021, 12 months following the creation of the renal follow-up macros (n = 501). After exclusions, the second set was left with 98 cases of newly characterized incidental renal lesions. For both sets, we assessed the reports of the exams that initially detected the incidental renal lesion. We evaluated the incident reports for the presence of a follow-up recommendation, recommendation completeness, and alignment with the American College of Radiology (ACR) white paper suggestions for renal lesion follow-up. Results Before the implementation of the standardized renal follow-up macros, initial follow-up recommendations were in concordance with the ACR white paper recommendations in 33 of 98 cases (33.7%), incomplete or discordant in 49 of 98 (50.0%), and absent in 16 of 98 cases (16.3%). Following the institution of our macros, there was an improvement in concordant follow-up recommendations (51/98; 52.0%) (p = 0.009), a decrease in the number of incomplete or discordant recommendations (37/98; 37.8%), and a decrease in the number of reports lacking a follow-up recommendation (10/98; 10.2%).  Conclusion Utilization of standard language renal lesion follow-up macros improves the rate of appropriate follow-up recommendations in radiology reports when encountering a previously unknown incidental renal lesion.

Preparing Austere Maritime Surgical Teams for Deployment During the COVID-19 Global Pandemic: Is It Time to Change the Training Pipeline?

INTRODUCTION: Navy Medicine's Role 2 Light Maneuver (R2LM) Emergency Resuscitative Surgical Systems (ERSS) are austere surgical teams manned, trained, and equipped to provide life-saving damage control resuscitation and surgery in any environment on land or sea. Given the restrictions related to the COVID-19 pandemic, the previously established pre-deployment training pipeline for was modified to prepare a new R2LM team augmenting a Role 1 shipboard medical department. METHODS: The modified curriculum created in response to COVID-19 related restriction is compared and contrasted to the established pre-deployment R2LM ERSS curriculum. Subject Matter Experts and currently deployed R2LM members critically evaluate the two curricula. RESULTS: Both curricula included the team R2LM platform training and exposure to cadaver based team trauma skills training. The modified curriculum included didactics on shipboard resuscitation, anesthesia and surgery, shipboard COVID-19 management, and prolonged field care in austere maritime environments. CONCLUSIONS: We describe Navy Medicines R2LM ERSS capability and compare and contrast the standard R2LM pre-COVID-19 curriculum to the modified curriculum. Central to both curricula, the standard R2LM platform training is important for developing and honing team dynamics, communication skills and fluid leadership; important for the successful function austere surgical teams. Several opportunities for improvement in the pre-deployment training were identified for R2LM teams augmenting shipboard Role 1 medical departments.

Return on Investment Analysis of Health Experts onLine at Portsmouth: A 2-Year Review of the Navy's Newest Teleconsultation System.

BACKGROUND: Health Experts onLine at Portsmouth (HELP) is a web-based teleconsultation system launched in June 2014 to facilitate communication between specialists at Naval Medical Center Portsmouth and providers assigned to both the fleet forces and primary care clinics across the eastern United States, Europe, and the Middle East. Specialist consultations through the HELP system purport to improve access to care for patients who otherwise might be referred to the civilian network or medically evacuated (MEDEVACed) to Naval Medical Center Portsmouth for specialized care. If HELP-facilitated communications help avoid civilian referrals or MEDEVACs, the associated costs of that care should be reduced. METHODS: We evaluated cost savings associated with prevented MEDEVACs by analyzing both tangible savings (prevented costs of flights, per diems, and consults) and intangible savings (reduced lost productivity time). We compared these savings to the costs of maintaining and utilizing the HELP system: startup costs, administrative costs, and provider time costs. We used patient and provider data from the HELP database to evaluate clinical consult cases. Before this analysis, a panel of 3 physicians associated with HELP reviewed each consult to determine whether a case qualified as a prevented MEDEVAC. Data from the Military Health System (MHS) Management and Analysis Reporting Tool and the MHS Data Repository were used to estimate costs associated with provider time, patient time, and direct care medical encounters. FINDINGS: The HELP program delivered measurable, positive returns on investment (ROIs) between June 2014 and December 2015. In that time frame, 559 consult cases occurred in the HELP system. Of the 559 total consult cases, 50 consults prevented MEDEVACs. Incorporating only tangible savings, HELP produced an 80% ROI on the basis of prevented medical evacuations; the addition of intangible savings such as reduced lost productivity increased the ROI to 250%. The dollar values of these savings were $693,461 and $1,337,628, respectively. IMPACT: The HELP program produces considerable savings (both tangible and intangible) to the Military Healthcare System for small costs. It does this both by increasing access to care at previously inaccessibly remote medical treatment facilities and by consequently decreasing the forward provider's reliance on medical evacuation in questionable cases. This positive ROI was potentially underestimated as this analysis did not account for recapture of care that would otherwise have been sent to the civilian market. On the basis of this analysis, a low bandwidth, asynchronous, and internet accessible teleconsultation system is both a feasible and effective means of projecting quality care forward into the deployed setting. Future implementation of similar initiatives throughout the MHS can be expected, and will likely draw from the lessons learned during the successful implementation and execution of the HELP system.

Expanding the indications for laparoscopic retroperitoneal adrenalectomy: experience with 81 resections.

BACKGROUND: Laparoscopic retroperitoneal (RP) adrenalectomy has gained popularity as the preferred approach over transabdominal (TA) method; however, surgeons have been reluctant to offer this operation to obese patients because of the concerns over inadequate working space and overall perceived higher rate of complications. The aim of the present study was to evaluate the feasibility and safety of RP adrenalectomy compared with TA adrenalectomy, specifically in morbidly obese patients. METHODS: All laparoscopic adrenalectomies performed at our institution between 2004 and 2012 were reviewed retrospectively. Presenting features, operative characteristics, and postoperative outcomes were evaluated. Complications were graded using Clavien system. Continuous variables were compared using Student t-test. Categorical variables were compared using χ(2)-test. Prediction models were constructed using linear or logistic regression as appropriate. RESULTS: Eighty-one RP and 130 TA procedures were performed, 26 (12.3%) and 60 (28.4%), respectively in obese patients (BMI > 30). Among the obese patients, operative time and estimated blood loss were less for RP (90 versus 130 min; P < 0.001 and 0 versus 50 mL; P < 0.001). Differences in the length of stay, overall mortality, incidence and severity of postoperative complications, and rates of readmission were not statistically significant between RP and TA procedures for all comers and in the obese patients. Controlling the operative characteristics and patient-specific factors, neither operative approach nor obesity was found to independently predict the postoperative complications. CONCLUSIONS: Laparoscopic RP adrenalectomy is a safe and feasible technique for obese patients. In the obese patients and for all comers, it offers shorter operative time, decreased estimated blood loss, with comparable length of stay and morbidity and mortality rates. We therefore recommend that this technique should be considered for patients undergoing adrenal resection.

Myasthenia gravis--an unexpected cause of respiratory failure and reversible left ventricular dysfunction after cardiac surgery.

We report a case of postpericardiotomy myasthenia gravis. A 68-year-old male patient without prior history of neuromuscular or autoimmune disorders presented with respiratory failure and severe left ventricular dysfunction four weeks after mitral valve replacement. Markedly elevated acetylcholine receptor antibodies were noted, and the patient responded promptly to immunologic therapy. Awareness of this rare but potentially fatal consequence of cardiac surgery may allow the early institution of specific treatment.