"The machine doesn't judge": Counternarratives on surveillance among people accessing a safer opioid supply via biometric machines.

People who use illegal drugs experience routine surveillance, including in healthcare and harm reduction settings. The MySafe Project - a safer supply pilot project that dispenses prescription opioids via a biometric vending machine - exists in the Canadian province of British Columbia. The machine scans a participant's palmprint and has a built-in camera that records every machine interaction. The aim of this paper is to understand participants' experiences of surveillance, privacy, and personal security when accessing this novel program. An integrative case study and grounded theory methodology was employed. Qualitative one-to-one interviews were conducted with 46 MySafe participants across three different program sites in Vancouver. We used a team-based approach to code interview transcripts and utilized directed and conventional content analyses for deductive and inductive analyses. While participants described negative experiences of surveillance in other public and harm reduction settings, they did not have concerns regarding cameras, collection of personal information, tracking, nor staff issues associated with MySafe. Similarly, while some participants had privacy concerns in other settings, very few privacy and confidentiality concerns were expressed regarding accessing the machine in front of others. Lastly, while some participants reported being targeted by others when accessing the machines, most participants described how cameras, staff, and machine locations helped ensure a sense of safety. Despite negative experiences of surveillance and privacy issues elsewhere, participants largely lacked concern regarding the MySafe program and machines. The machine-human interaction was characterized as different than some human-human interactions as the machine is completing tasks in a manner that is acceptable and comfortable to participants, leading to a social preference toward the machines in comparison to other surveilled means of accessing medications. These findings provide an opportunity to rethink how we conceptualize surveillance, medication access, and harm reduction programs targeting people who use drugs.

Use of symptom checkers for COVID-19-related symptoms among university students: a qualitative study.

OBJECTIVE: Symptom checkers are potentially beneficial tools during pandemics. To increase the use of the platform, perspectives of end users must be gathered. Our objectives were to understand the perspectives and experiences of young adults related to the use of symptom checkers for assessing COVID-19-related symptoms and to identify areas for improvement. METHODS: We conducted semistructured qualitative interviews with 22 young adults (18-34 years of age) at a university in Ontario, Canada. Interviews were audio-recorded, transcribed, and analysed using inductive thematic analysis. RESULTS: We identified six main themes related to the decision of using a symptom checker for COVID-19 symptoms: (1) presence of symptoms or a combination of symptoms, (2) knowledge about COVID-19 symptoms, (3) fear of seeking in-person healthcare services, (4) awareness about symptom checkers, (5) paranoia and (6) curiosity. Participants who used symptom checkers shared by governmental entities reported an overall positive experience. Individuals who used non-credible sources reported suboptimal experiences due to lack of perceived credibility. Five main areas for improvement were identified: (1) information about the creators of the platform, (2) explanation of symptoms, (3) personalised experience, (4) language options, and (5) option to get tested. CONCLUSIONS: This study suggests an increased acceptance of symptom checkers due to the perceived risks of infection associated with seeking in-person healthcare services. Symptom checkers have the potential to reduce the burden on healthcare systems and health professionals, especially during pandemics; however, these platforms could be improved to increase use.

Young Adults' Perspectives on the Use of Symptom Checkers for Self-Triage and Self-Diagnosis: Qualitative Study.

BACKGROUND: Young adults often browse the internet for self-triage and diagnosis. More sophisticated digital platforms such as symptom checkers have recently become pervasive; however, little is known about their use. OBJECTIVE: The aim of this study was to understand young adults' (18-34 years old) perspectives on the use of the Google search engine versus a symptom checker, as well as to identify the barriers and enablers for using a symptom checker for self-triage and self-diagnosis. METHODS: A qualitative descriptive case study research design was used. Semistructured interviews were conducted with 24 young adults enrolled in a university in Ontario, Canada. All participants were given a clinical vignette and were asked to use a symptom checker (WebMD Symptom Checker or Babylon Health) while thinking out loud, and were asked questions regarding their experience. Interviews were audio-recorded, transcribed, and imported into the NVivo software program. Inductive thematic analysis was conducted independently by two researchers. RESULTS: Using the Google search engine was perceived to be faster and more customizable (ie, ability to enter symptoms freely in the search engine) than a symptom checker; however, a symptom checker was perceived to be useful for a more personalized assessment. After having used a symptom checker, most of the participants believed that the platform needed improvement in the areas of accuracy, security and privacy, and medical jargon used. Given these limitations, most participants believed that symptom checkers could be more useful for self-triage than for self-diagnosis. Interestingly, more than half of the participants were not aware of symptom checkers prior to this study and most believed that this lack of awareness about the existence of symptom checkers hindered their use. CONCLUSIONS: Awareness related to the existence of symptom checkers and their integration into the health care system are required to maximize benefits related to these platforms. Addressing the barriers identified in this study is likely to increase the acceptance and use of symptom checkers by young adults.

A web-based data visualization tool for the MIMIC-II database.

BACKGROUND: Although MIMIC-II, a public intensive care database, has been recognized as an invaluable resource for many medical researchers worldwide, becoming a proficient MIMIC-II researcher requires knowledge of SQL programming and an understanding of the MIMIC-II database schema. These are challenging requirements especially for health researchers and clinicians who may have limited computer proficiency. In order to overcome this challenge, our objective was to create an interactive, web-based MIMIC-II data visualization tool that first-time MIMIC-II users can easily use to explore the database. RESULTS: The tool offers two main features: Explore and Compare. The Explore feature enables the user to select a patient cohort within MIMIC-II and visualize the distributions of various administrative, demographic, and clinical variables within the selected cohort. The Compare feature enables the user to select two patient cohorts and visually compare them with respect to a variety of variables. The tool is also helpful to experienced MIMIC-II researchers who can use it to substantially accelerate the cumbersome and time-consuming steps of writing SQL queries and manually visualizing extracted data. CONCLUSIONS: Any interested researcher can use the MIMIC-II data visualization tool for free to quickly and conveniently conduct a preliminary investigation on MIMIC-II with a few mouse clicks. Researchers can also use the tool to learn the characteristics of the MIMIC-II patients. Since it is still impossible to conduct multivariable regression inside the tool, future work includes adding analytics capabilities. Also, the next version of the tool will aim to utilize MIMIC-III which contains more data.

Gastrojejunostomy technique and anastomotic complications in laparoscopic gastric bypass.

BACKGROUND: Various surgical techniques exist to create the gastrojejunostomy during laparoscopic Roux-en-Y gastric bypasses (LRYGB). A hand-sewn anastomosis (HSA) and circular-stapled anastomosis (CSA) are both common techniques. We hypothesized that the CSA was associated with a greater incidence of anastomotic complications. As a secondary aim, we sought to determine if weight loss varied by technique. METHODS: This study is a retrospective review of patients who underwent primary LRYGB at the Medical College of Wisconsin from January 2010 to December 2011. Procedures were performed by one of 2 surgeons, each with a preferred gastrojejunostomy technique. Clinical information and patient outcomes were followed up to one year. RESULTS: A total of 190 patients underwent LRYGB during the study interval. The majority of patients underwent HSA. Forty-one of 190 (21.6%) patients experienced one or more complications. Most complications were Clavien Classification Grade III and were experienced within 30 days of surgery in 3 (2.2%) HSA patients and 6 (10.9%) CSA patients (P = .02). Anastomotic complications occurred more frequently with the CSA technique (marginal ulcer 5.5% CSA versus .7% HSA; P = .04 and stenosis 16.4% CSA versus 3% HSA; P = .01). There were no gastrojejunostomy leaks in this series. Operative time was significantly longer in HSA patients (204 minutes HSA versus 166 minutes CSA; P<.01), but length of hospital stay did not differ. Weight loss at 12 months was similar between techniques (69.4% percent excess BMI lost (EBMIL) HSA versus 76.6% EBMIL CSA; P = .11). No patients were lost to follow-up at 30 days. Thirty-five patients (19%) were lost to follow-up by one year. CONCLUSION: The CSA technique of gastrojejunostomy in gastric bypass is associated with a higher rate of nonlife threatening anastomotic complications than the HSA technique. Operative times are significantly longer for HSA, but length of hospital stay (LOS) and long-term weight loss are equivalent.

Surgery duration predicts urinary retention after inguinal herniorrhaphy: a single institution review.

BACKGROUND: Inguinal hernia repair, laparoscopic or open, is one of the most frequently performed operations in general surgery. Postoperative urinary retention (POUR) can occur in 0.2-35 % of patients after inguinal hernia repair. The primary objective of this study was to determine the incidence of POUR after inguinal hernia repair. As a secondary goal, we sought to determine whether perioperative and patient factors predicted urinary retention. METHODS: This study is a retrospective review of patients who underwent inguinal hernia repair with synthetic mesh at the Medical College of Wisconsin from January 2007 to June 2012. Procedures were performed by four surgeons. Clinical information and perioperative outcomes were collected up to hospital discharge. Urinary retention was defined as need for urinary catheterization postoperatively. RESULTS: A total of 192 patients were included in the study (88 bilateral, 46 %) and (104 unilateral, 54 %). The majority of subjects (76 %) underwent laparoscopic repair. The overall POUR rate was 13 %, with 25 of 192 patients requiring a Foley catheter prior to discharge. POUR was significantly associated with bilateral hernia repairs (p = 0.04), BMI ≥ 35 kg/m(2) (p = 0.05) and longer operative times (p = 0.03). Based on odds ratio (OR) estimates, for every 10-min increase in operative time, an 11 % increase in the odds of urinary retention is expected (OR 1.11, CI 1.004-1.223; p = 0.04). For every 10-min increase in operative time, an 11 % increase in POUR is expected. CONCLUSIONS: Bilateral hernia repairs, BMI ≥ 35 kg/m(2), and operative time are significant predictors of POUR. These factors are important to determine potential risk to patients and interventions such as strict fluid administration, use of catheters, and potential premedication.

Anemia after bariatric surgery cannot be explained by iron deficiency alone: results of a large cohort study.

BACKGROUND: We sought to identify the frequency and mechanisms of anemia after bariatric surgery in a bariatric surgery program at the Medical College of Wisconsin, (Milwaukee, WI). Anemia after bariatric surgery has often been attributed to iron deficiency, although an inflammatory component might be present, making the anemia after surgery mechanistically complex. METHODS: The body mass index and hemoglobin (Hb), vitamin B(12), folate, iron, and ferritin levels were extracted from the records of 1125 patients for ≤4 years after Roux-en-Y gastric bypass. Anemia was defined using the World Health Organization criteria. RESULTS: The mean body mass index, Hb, and ferritin decreased after surgery. The body mass index decreased from 50.1 kg/m(2) (95% confidence interval [CI] 49.6-50.6) at baseline to 33.0 kg/m(2) (95% CI 32.3-33.6) at 12 months and remained unchanged thereafter. The Hb level decreased from 13.4 g/dL (95% CI 13.3-13.5) to 12.8 (95% CI 12.6-13.1) and ferritin from 87.5 ng/mL (95% CI 75.2-99.7) to 55.4 (95% CI 42.9-68.0) at 24-48 months, and serum iron increased from 68.4 µg/dL (95% CI 66.8-70.0) to 82.8 (95% CI 76.4-88.7); all P values were <.01. Anemia was present in 12% (95% CI 10-14%) of patients at baseline and had increased to 23% (95% CI 16-30%) at 24-48 months. The changes in ferritin, Hb, and the percentage of patients with anemia were most pronounced in premenopausal women. Vitamin B(12) and folate levels were unaffected. CONCLUSION: The baseline incidence of anemia was greater than expected and increased significantly after surgery. The percentage of those with anemia and low ferritin was most significant in premenopausal women; however, the overall iron bioavailability improved significantly with pronounced weight loss, suggesting a reduction in inflammation. These findings indicate that anemia after bariatric surgery cannot be explained on the basis of iron availability and suggest that other mechanisms, currently undefined, contribute to the development of anemia in these patients.

Effects of interventions on intra- and interobserver agreement on interpretation of nonalcoholic fatty liver disease histology.

Accurate and reproducible interpretation of nonalcoholic fatty liver disease (NAFLD) histology has significant clinical and research-related implications. We evaluated the impact of 2 interventions ([1] review of illustrative histologic images of NAFLD with the study pathologists; [2] use of a scoring sheet with written diagnostic criteria for different NAFLD phenotypes) on intra- and interobserver agreement on interpretation of NAFLD histology. Before and after the interventions, 2 pathologists twice read 65 liver biopsies done for evaluation of suspected NAFLD. The intra- and interobserver agreement was highest on assessment of steatosis and fibrosis. The interventions significantly improved the intraobserver agreement only on assessment of hepatocellular ballooning. The interobserver agreement was only fair on assessment of lobular inflammation, ballooning, and diagnostic classification and did not improve after the interventions. Methods to improve interobserver agreement on assessment of lobular inflammation and ballooning are needed and would likely increase pathologists' agreement on NAFLD diagnostic classification.

Perioperative antibiotic prophylaxis in the gastric bypass patient: do we achieve therapeutic levels?

BACKGROUND: Perioperative surgical antibiotic prophylaxis requires that therapeutically effective drug concentrations be present in the tissues. METHODS: Patients undergoing Roux-en-Y gastric bypass for morbid obesity were given 2 g cefazolin preoperatively, followed by a second dose at 3 hours. Thirty-eight patients were each assigned to 1 of 3 body mass index (BMI) groups: (A) BMI=40-49 (N = 17); (B) BMI=50-59 (N=11); (C) BMI > or= 60 (N=10). Multiple timed serum (baseline; incision, 15, 30, 60 minutes; prior to second prophylactic dose; and closure) and tissue (skin, subcutaneous fat, and omentum) specimens were collected and cefazolin concentration analyzed by microbiological assay. RESULTS: No significant difference was observed in intraoperative fluid replacement or blood loss among BMI groups. Serum antimicrobial concentrations exceeded resistance breakpoint (32 microg/mL) in 73%, 68%, and 52% of BMI groups A, B, and C, respectively. No significant difference in cefazolin concentration was observed in mean incisional skin and closure tissue specimens in groups A, B, and C. A significant decrease in cefazolin concentration was noted in closure adipose (p=.04), initial (p=.03) and closure omentum (p=.05) tissues in groups B and C compared with A. Over 90% of serum samples exhibited therapeutic concentrations covering 53.8% of gram-positive and 78.6% of gram-negative surgical pathogens. However, therapeutic tissue levels were achieved in only 48.1%, 28.6%, and 10.2% of groups A, B, and C, respectively. CONCLUSIONS: Pharmacokinetic analysis suggests that present dosing strategies may fail to provide adequate perioperative prophylaxis in gastric bypass patients.

Retroperitoneal lateral lumbar interbody fusion with titanium threaded fusion cages.

OBJECT: Intertransverse arthrodesis in which instrumentation is placed is associated with an excellent fusion rate; however, treatment of patients with symptomatic nonunion presents a number of difficulties. Revision posterior and traditional anterior procedures are associated with methodological problems. For example, in the latter, manipulation of the major vessels from L-2 to L-4 may be undesirable. The authors describe a method for performing retroperitoneal lumbar interbody fusion (LIF) in which a threaded cage is placed from L-2 through L-5 via a lateral trajectory, and they also detail a novel technique for implanting a cage from L-5 to S-1 via an oblique trajectory. Although they present data obtained over a 2-year period in the study of 15 patients, the focus of this report is primarily on describing the surgical procedure. METHODS: The lateral lumbar spine was exposed via a standard retroperitoneal approach. Using the anterior longitudinal ligament as a landmark, the L2-3 through L4-5 levels were fitted with instrumentation via a true lateral trajectory; the L5-S1 level was fitted with instrumentation via an oblique trajectory. A single cage was placed at each instrumented level. Fifteen symptomatic patients in whom previous lumbar fusion had failed underwent retroperitoneal LIF. Thirty-eight levels were fitted with instrumentation. There have been no instrumentation-related failures, and fusion has occurred at 37 levels during the 2-year postoperative period. CONCLUSIONS: The use of retroperitoneal LIF in which threaded fusion cages are used avoids the technical difficulties associated with repeated posterior procedures. In addition, it allows L2-S1 instrumentation to be placed anteriorly via a single surgical approach. This construct has been shown to be biomechanically sound in animal models, and it appears to be a useful alternative for the management of failed multilevel intertransverse arthrodesis.