Association Between Antifibrinolytic Therapy and Perioperative Outcomes in Patients With Coronary Artery Stents Undergoing Noncardiac Surgery.

BACKGROUND: Patients with existing coronary artery stents are at an increased risk for major adverse cardiac events (MACEs) when undergoing noncardiac surgery (NCS). Although the use of antifibrinolytic (AF) therapy in NCS has significantly increased in the past decade, the relationship between perioperative AF use and its association with MACEs among patients with existing coronary artery stents has yet to be assessed. In this study, we aim to evaluate the association of MACEs in patients with existing coronary artery stents who receive perioperative AF therapy during orthopedic surgery. METHODS: A single-center retrospective cohort study was conducted in adult patients with existing coronary artery stents who underwent orthopedic surgery from 2008 to 2018. Two cohorts were established: patients with existing coronary artery stents who did not receive perioperative AF and patients with coronary artery stents who received perioperative AF. Associations between AF use and the primary outcome of MACEs within 30 days postoperatively and the secondary outcomes of thrombotic complications, excessive surgical bleeding, and intensive care unit (ICU) admissions were analyzed using logistic regression models. Inverse probability of treatment weighting was used to control for confounding. Secondary analyses examining the association between coronary stent type/timing and the outcomes of interest were performed using unadjusted logistic regression models. RESULTS: A total of 473 patients met study criteria, including 294 who did not receive AF and 179 patients who received AF. MACEs occurred in 15 (5.1%) patients who did not receive AF and 1 (0.6%) who received AF (P = .007). In weighted analyses, no significant difference was found in patients who received AF with regard to MACEs (odds ratio [OR] = 0.13, 95% confidence interval [CI], 0.01-1.74, P = .12), thrombotic complications (OR = 1.19, 95% CI, 0.53-2.68, P = .68), or excessive surgical bleeding (OR = 0.13, 95% CI, 0.01-2.23, P = .16) compared to patients who did not receive AF. CONCLUSIONS: The results of this study are inconclusive whether an association exists between perioperative AF use in patients with coronary artery stents and the outcome of MACEs compared to patients who did not receive perioperative AF therapy. The authors acknowledge that the imprecise CI hinders the ability to definitively determine whether an association exists in the study population. Further large prospective studies, powered to detect differences in MACEs, are needed to assess the safety of perioperative AF in patients with existing coronary artery stents and to clarify the mechanism of perioperative MACEs in this high-risk population.

Pulmonary Complications in Esophagectomy Based on Intraoperative Fluid Rate: A Single-Center Study.

OBJECTIVES: Esophagectomy is associated with significant morbidity and mortality. The authors assessed the relationship between intraoperative fluid (IOF) administration and postoperative pulmonary outcomes in patients undergoing a transthoracic, transhiatal, or tri-incisional esophagectomy. DESIGN: Retrospective cohort study (level 3 evidence). SETTING: Tertiary care referral center. PARTICIPANTS: Patients who underwent esophagectomy from 2007 to 2017. INTERVENTIONS: The IOF rate (mL/kg/h) was the predictor variable analyzed both as a continuous and binary categorical variable based on median IOF rate for this cohort (11.90 mL/kg/h). MEASUREMENTS: Primary outcomes included rates of acute respiratory distress syndrome (ARDS) within ten days after esophagectomy. Secondary outcomes included rates of reintubation, pneumonia, cardiac or renal morbidity, intensive care unit admission, length of stay, procedure-related complications, and mortality. Multivariate regression analysis determined associations between IOF rate and postoperative outcomes. Analysis was adjusted for age, sex, body mass index, procedure type, year, and thoracic epidural use. MAIN RESULTS: A total of 1,040 patients comprised this cohort. Tri-incisional esophagectomy was associated with a higher hospital mortality rate (7.8%) compared with transthoracic esophagectomy (2.6%, p = 0.03) or transhiatal esophagectomy (0.7%, p = 0.01). Regression analysis revealed a higher IOF rate was associated with greater ARDS within ten days (adjusted odds ratio [OR] = 1.03, p = 0.01). For secondary outcomes, a higher IOF rate was associated with greater hospital mortality (adjusted OR = 1.05, p = 0.002), although no significant association with 30-day hospital mortality was identified. CONCLUSIONS: Increased IOF administration during esophagectomy may be associated with worse postoperative pulmonary complications, specifically ARDS. Future well-powered studies are warranted, including randomized, controlled trials comparing liberal versus restrictive fluid administration in this surgical population.

Homeless experiences and support needs of transgender people: A systematic review of the international evidence.

AIM: To examine the experiences and support needs of homeless transgender people by synthesizing the existing evidence. BACKGROUND: Transgender people face many challenges in society in terms of people's knowledge, understanding and acceptance of a person's gender identity. Evidence regarding the homelessness experiences and available supports to transgender people remains sparse. METHODS: A systematic review was undertaken and included qualitative and quantitative studies. A total of twelve papers were included in the review, utilizing the PRISMA method. Methodological quality was evaluated using the Mixed Methods Assessment Tool (MMAT). RESULTS: Following analysis, the themes that emerged were (a) pathways into homelessness, (b) experiences whilst homeless and (c) routes out of homelessness. CONCLUSION: It has become increasingly clear that the distinct needs of this group are complex and multifaceted. In order to adequately address the issues and concerns comprehensively, coordinated and effective collaborations need to be in place. IMPLICATIONS FOR NURSING MANAGEMENT: Clinical nurses need to recognize and respond to the distinct needs of trans homeless people. Nurse managers need to provide leadership to promote the needs of homeless trans people and ensure that policies and procedures are in place that are responsive to issues and concerns.

Peripheral Nerve Blockade with Combined Standard and Liposomal Bupivacaine in Major Lower-Extremity Amputation.

BACKGROUND AND OBJECTIVES: Optimizing perioperative analgesia for patients undergoing major lower-extremity amputation remains a considerable challenge. The utility of liposomal bupivacaine as a component of peripheral nerve blockade for lower-extremity amputation is unknown. METHODS: We conducted an observational study comparing three different perioperative analgesic techniques for adults undergoing major lower-extremity amputation under general anesthesia between 2012 and 2017 at an academic medical center: (1) no regional anesthesia, (2) peripheral nerve blockade with standard bupivacaine, and (3) peripheral nerve blockade with a mixture of standard and liposomal bupivacaine. The primary outcome of cumulative opioid oral morphine milligram equivalent utilization in the first 72 hours postoperatively was compared across groups utilizing multivariable linear regression. RESULTS: A total of 631 unique anesthetics were included for 578 unique patients, including 416 (66%) without regional anesthesia, 131 (21%) with peripheral nerve blockade with a mixture of standard and liposomal bupivacaine, and 84 (13%) with peripheral nerve blockade with standard bupivacaine alone. Cumulative morphine equivalents were lower in those receiving peripheral nerve blockade with combined standard and liposomal bupivacaine compared with those not receiving regional anesthesia (multiplicative increase 0.67; 95% CI 0.50 to 0.90; P = 0.007). There were no significant differences in opioid utilization between peripheral nerve blockade groups (P = 0.59). CONCLUSIONS: Peripheral nerve blockade is associated with reduced opioid requirements after lower-extremity amputation compared with general anesthesia alone. However, the incorporation of liposomal bupivacaine is not significantly different to blockade employing only standard bupivacaine.

Antinausea Protocol Reduces Hospital Length of Stay for Laparoscopic Nissen Fundoplication.

OBJECTIVE: The perioperative course of patients undergoing laparoscopic Nissen fundoplication (LNF) was reviewed to determine whether the use of a new treatment protocol consisting of total intravenous anesthesia (TIVA) plus triple antiemetic therapy was associated with shorter hospital length of stay (HLOS). DESIGN: Retrospective cohort. SETTING: Single academic center. PARTICIPANTS: The study comprised 448 patients. Fifty-four patients undergoing LNF who received TIVA were compared with 394 who received standard inhalational anesthesia (non-TIVA) between January 2010 and June 2017. INTERVENTIONS: Patients who received TIVA were compared with those who received non-TIVA. MEASUREMENTS AND MAIN RESULTS: In multivariate analysis, TIVA was significantly associated with reduced HLOS (odds ratio 2.91, 95% confidence interval 1.47-5.78) and a 7.8% reduction in cost of care (p < 0.01). Female sex, length of surgery, and older age all were negatively associated with length of stay. The association between the use of TIVA and reduced HLOS and institutional cost was compared using univariate and multivariate analyses. CONCLUSIONS: The use of TIVA in patients undergoing uncomplicated LNF shortens HLOS and is associated with reduced cost of care. This study illustrates that communication among surgeons and anesthesiologists results in improved patient care.

Lower limb alignment becomes more varus and hyperextended from supine to bipedal stance in asymptomatic, osteoarthritic and prosthetic neutral or varus knees.

PURPOSE: Knee alignment is a fundamental measurement in the assessment, monitoring and surgical management of patients with osteoarthritis. There is a lack of data regarding how static tibiofemoral alignment varies between supine and standing conditions. This study aimed to quantify the relationship between supine and standing lower limb alignment in asymptomatic, osteoarthritic (OA) and prosthetic (TKA) knees. METHODS: A non-invasive position capture system was used to assess knee alignment for 30 asymptomatic controls and 31 patients with OA both before and after TKA. Coronal and sagittal mechanical femorotibial angles were measured supine with the lower limb in extension and in bipedal stance. Changes between conditions were analysed using paired ttests. Vector plots of ankle centre displacement relative to the knee centre from supine to standing were produced to allow three-dimensional visualisation. RESULTS: All groups showed a trend towards varus and extension when going from supine to standing. Mean change for asymptomatic knees was 1.2° more varus (p = 0.001) and 3.8° more extended (p < 0.001). For OA knees this was 1.1° more varus (p = 0.009) and 5.9° more extended (p < 0.001) and TKA knees 1.9° more varus (p < 0.001) and 5.6° more extended (p < 0.001). CONCLUSION: The observed consistent changes in lower limb alignment between supine and standing positions across knee types suggests the soft tissue envelope restraining the knee may have a greater influence on dynamic alignment changes than the underlying bony deformity. This highlights the importance of quantifying soft tissue behaviour when planning, performing and evaluating alignment dependent surgical interventions of the knee. When routinely assessing any type of knee, clinicians should be aware that subtle consistent alignment changes occur under weightbearing conditions and tailor their treatments accordingly. LEVEL OF EVIDENCE: II.

Pilot feasibility study of the Walking Away from Diabetes programme for adults with intellectual disabilities in two further education colleges: Process evaluation findings.

BACKGROUND: People with intellectual disabilities remain at high risk of developing type 2 diabetes (T2D) due to lifestyle-associated risk factors. Educational programmes have been adapted for people with intellectual disabilities targeting ongoing T2D self-management. However, there are no adapted programmes which aim to prevent T2D through reducing risk factors. The present study initiates addressing this gap. METHODS: Further education (FE) colleges in Scotland were recruited for feasibility study using the Walking Away (WA) from Diabetes programme. Process evaluation assessed recruitment, retention, baseline physical activity levels, and acceptability and accessibility using focus groups. RESULTS: Ninety six percent of invited students agreed to participate. WA was positively received, and some short-term impact was described. Suggestions for further adaptations regarding materials, delivery and content were provided, including delivery embedded within FE college curriculum. CONCLUSIONS: Recruitment, retention and acceptability provide rationale for further research on T2D prevention in FE colleges.

An evaluation of mainstream type 2 diabetes educational programmes in relation to the needs of people with intellectual disabilities: A systematic review of the literature.

BACKGROUND: Risk reduction and self-management programs for type 2 diabetes (T2D) are commonplace. However, little is known about their appropriateness for people with intellectual disabilities (ID). This review evaluates successful components and theoretical basis of interventions and preventions in relation to the needs of people with ID with or at risk of T2D. METHOD: Characteristics of 23 randomised controlled trialled T2D educational programs were systematically assessed alongside the needs of people with ID, and evaluated in terms of study design and theoretical application. RESULTS: Successful components of programs align to the needs of people with ID. Further adaptations are required to ensure accessibility of materials and social support to enable reflection on illness perceptions and self-efficacy, as underpinned by Self-regulation and Social-cognitive theories. CONCLUSIONS: Support is provided for further trials of self-management and preventative adaptations under development. Impact may be enhanced through preventions aimed at younger groups in educational settings.

Assessing the Safety of Overlapping Surgery at a Children's Hospital.

IMPORTANCE: Media reports have questioned the safety of overlapping surgical procedures, and national scrutiny has underscored the necessity of single-center evaluations of its safety; however, sample sizes are likely small. We compared the safety profiles of overlapping and nonoverlapping pediatric procedures at a single children's hospital and discussed methodological considerations of the evaluation. DATA AND DESIGN: Retrospective analysis of inpatient pediatric surgical procedures (January 2013 to September 2015) at a single pediatric referral center. Overlapping and nonoverlapping procedures were matched in an unbalanced manner (m:n) by procedure. Mixed models adjusting for Vizient-predicted risk, case-mix, and surgeon compared inpatient mortality and length of stay (LOS). RESULTS: Among 315 overlapping procedures, 256 (81.3%) were matched to 645 nonoverlapping procedures. There were 6 deaths in all. The adjusted odds ratio for mortality did not differ significantly between nonoverlapping and overlapping procedures (adjusted odds ratio = 0.94 vs overlapping; 95% CI, 0.02-48.5; P = 0.98). Wide confidence intervals were minimally improved with Bayesian methods (95% CI, 0.07-12.5). Adjusted LOS estimates were not clinically different by overlapping status (0.6% longer for nonoverlapping; 95% CI, 9.7% shorter to 12.2% longer; P = 0.91). Among the 87 overlapping procedures with the greatest overlap (≥60 min or ≥50% of operative duration), there were no deaths. CONCLUSIONS: The safety of overlapping and nonoverlapping surgical procedures did not differ at this children's center. These findings may not extrapolate to other centers. LOS or intraoperative measures may be more appropriate than mortality for safety evaluations due to low event rates for mortality.

Safety of Overlapping Surgery at a High-volume Referral Center.

OBJECTIVE: To compare safety profiles of overlapping and nonoverlapping surgical procedures at a large tertiary-referral center where overlapping surgery is performed. BACKGROUND: Surgical procedures are frequently performed as overlapping, wherein one surgeon is responsible for 2 procedures occurring at the same time, but critical portions are not coincident. The safety of this practice has not been characterized. METHODS: Primary analyses included elective, adult, inpatient surgical procedures from January 2013 to September 2015 available through University HealthSystem Consortium. Overlapping and nonoverlapping procedures were matched in an unbalanced manner (m:n) by procedure type. Confirmatory analyses from the American College of Surgeons-National Surgical Quality Improvement Program investigated elective surgical procedures from January 2011 to December 2014. We compared outcomes mortality and length of stay after adjustment for registry-predicted risk, case-mix, and surgeon using mixed models. RESULTS: The University HealthSystem Consortium sample included 10,765 overlapping cases, of which 10,614 (98.6%) were matched to 16,111 nonoverlapping procedures. Adjusted odds ratio for inpatient mortality was greater for nonoverlapping procedures (adjusted odds ratio, OR = 2.14 vs overlapping procedures; 95% confidence interval, CI 1.23-3.73; P = 0.007) and length of stay was no different (+1% for nonoverlapping cases; 95% CI, -1% to +2%; P = 0.50). In confirmatory analyses, 93.7% (3712/3961) of overlapping procedures matched to 5,637 nonoverlapping procedures. The 30-day mortality (adjusted OR = 0.69 nonoverlapping vs overlapping procedures; 95% CI, 0.13-3.57; P = 0.65), morbidity (adjusted OR = 1.11; 95% CI, 0.92-1.35; P = 0.27) and length of stay (-4% for nonoverlapping; 95% CI, -4% to -3%; P < 0.001) were not clinically different. CONCLUSIONS: These findings from administrative and clinical registries support the safety of overlapping surgical procedures at this center but may not extrapolate to other centers.

Preoperative platelet transfusions and perioperative red blood cell requirements in patients with thrombocytopenia undergoing noncardiac surgery.

BACKGROUND: Perioperative hemorrhage impacts patient outcomes and health care resource utilization, yet the risks of transfusion therapies are significant. In patients with preoperative thrombocytopenia, the effects of prophylactic preoperative platelet (PLT) transfusion on perioperative bleeding complications remain uncertain. STUDY DESIGN AND METHODS: This is a retrospective cohort study of noncardiac surgical patients between January 1, 2008, and December 31, 2011. Propensity-adjusted analyses were used to evaluate associations between preoperative thrombocytopenia, preoperative PLT transfusion, and the outcomes of interest, with a primary outcome of perioperative red blood cell (RBC) transfusion. RESULTS: A total of 13,978 study participants were included; 860 (6.2%) had a PLT count of not more than 100 × 10(9) /L with 71 (8.3%) receiving PLTs preoperatively. Administration of PLTs was associated with higher rates of perioperative RBC transfusion (66.2% vs. 49.1%, p = 0.0065); however, in propensity-adjusted analysis there was no significant difference between groups (odds ratio [OR] [95% confidence interval {95% CI}], 1.68 [0.95-2.99]; p = 0.0764]. Patients receiving PLTs had higher rates of intensive care unit (ICU) admission (OR [95% CI], 1.95 [1.10-3.46]; p = 0.0224) and longer hospital lengths of stay (estimate [95% bootstrap CI], 7.2 [0.8-13.9] days; p = 0.0006) in propensity-adjusted analyses. CONCLUSION: Preoperative PLT transfusion did not attenuate RBC requirements in patients with thrombocytopenia undergoing noncardiac surgery. Moreover, preoperative PLT transfusion was associated with increased ICU admission rates and hospital duration. These findings suggest that more conservative management of preoperative thrombocytopenia may be warranted.

Definitive airway management of patients presenting with a pre-hospital inserted King LT(S)-D laryngeal tube airway: a historical cohort study.

PURPOSE: The King LT(S)-D laryngeal tube (King LT) has gained popularity as a bridge airway for pre-hospital airway management. In this study, we retrospectively reviewed the use of the King LT and its associated airway outcomes at a single Level 1 trauma centre. METHODS: The data on all adult patients presenting to the Mayo Clinic in Rochester, Minnesota with a King LT in situ from July 1, 2007 to October 10, 2012 were retrospectively evaluated. Data collected and descriptively analyzed included patient demographics, comorbidities, etiology of respiratory failure, airway complications, subsequent definitive airway management technique, duration of mechanical ventilation, and status at discharge. RESULTS: Forty-eight adult patients met inclusion criteria. The most common etiology for respiratory failure requiring an artificial airway was cardiac arrest [28 (58%) patients] or trauma [9 (19%) patients]. Four of the nine trauma patients had facial trauma. Surgical tracheostomy was the definitive airway management technique in 14 (29%) patients. An airway exchange catheter, direct laryngoscopy, and video laryngoscopy were used in 11 (23%), ten (21%), and ten (21%) cases, respectively. Seven (78%) of the trauma patients underwent surgical tracheostomy compared with seven (18%) of the medical patients. Adverse events associated with King LT use occurred in 13 (27%) patients, with upper airway edema (i.e., tongue engorgement and glottic edema) being most common (19%). CONCLUSION: In this study of patients presenting to a hospital with a King LT, the majority of airway exchanges required an advanced airway management technique beyond direct laryngoscopy. Upper airway edema was the most common adverse observation associated with King LT use.

Anthrax toxin protective antigen integrates poly-γ-D-glutamate and pH signals to sense the optimal environment for channel formation.

Many toxins assemble into oligomers on the surface of cells. Local chemical cues signal and trigger critical rearrangements of the oligomer, inducing the formation of a membrane-fused or channel state. Bacillus anthracis secretes two virulence factors: a tripartite toxin and a poly-γ-d-glutamic acid capsule (γ-DPGA). The toxin's channel-forming component, protective antigen (PA), oligomerizes to create a prechannel that forms toxic complexes upon binding the two other enzyme components, lethal factor (LF) and edema factor (EF). Following endocytosis into host cells, acidic pH signals the prechannel to form the channel state, which translocates LF and EF into the host cytosol. We report γ-DPGA binds to PA, LF, and EF, exhibiting nanomolar avidity for the PA prechannel oligomer. We show PA channel formation requires the pH-dependent disruption of the intra-PA domain-2-domain-4 (D2-D4) interface. γ-DPGA stabilizes the D2-D4 interface, preventing channel formation both in model membranes and cultured mammalian cells. A 1.9-Šresolution X-ray crystal structure of a D2-D4-interface mutant and corresponding functional studies reveal how stability at the intra-PA interface governs channel formation. We also pinpoint the kinetic pH trigger for channel formation to a residue within PA's membrane-insertion loop at the inter-PA D2-D4 interface. Thus, γ-DPGA may function as a chemical cue, signaling that the local environment is appropriate for toxin assembly but inappropriate for channel formation.

Implementation of an intraoperative blood transport and storage initiative and its effect on reducing red blood cell and plasma waste.

BACKGROUND: The national waste rate for hospital-issued blood products ranges from 0% to 6%, with operating room-responsible waste representing up to 70% of total hospital waste. A common reason for blood product waste is inadequate intraoperative storage. STUDY DESIGN AND METHODS: Our transfusion service database was used to quantify and categorize red blood cell (RBC) and fresh-frozen plasma (FFP) units issued for intraoperative transfusion that were wasted over a 27-month period. Two cohorts were created: 1) before implementation of a blood transport and storage initiative (BTSI)-RBC and plasma waste January 1, 2011-May 31, 2012; 2) after implementation of BTSI-RBC and plasma waste June 1, 2012, to March 31, 2013. The BTSI replaced existing storage coolers (8-hr coolant life span with temperature range of 1-10°C) with a cooler that had a coolant life span of 18 hours and a temperature range of 1 to 6°C and included an improved educational cooler placard and an alert mechanism in the electronic health record. Monthly median RBC and plasma waste and its associated cost were the primary outcomes. RESULTS: An intraoperative BTSI significantly reduced median monthly RBC (1.3% vs. 0.07%) and FFP (0.4% vs. 0%) waste and its associated institutional cost. The majority of blood product waste was due to an unacceptable temperature of unused returned blood products. CONCLUSION: An intraoperative BTSI significantly reduced median monthly RBC and FFP waste. The cost to implement this initiative was small, resulting in a significant estimated return on investment that may be reproducible in institutions other than ours.

Motor evoked potential monitoring during cryoablation of musculoskeletal tumors.

PURPOSE: To describe the use of intraprocedural motor evoked potential (MEP) monitoring to minimize risk of neural injury during percutaneous cryoablation of perineural musculoskeletal tumors. MATERIALS AND METHODS: A single-institution retrospective review of cryoablation procedures performed to treat perineural musculoskeletal tumors with the use of MEP monitoring between May 2011 and March 2013 yielded 59 procedures to treat 64 tumors in 52 patients (26 male). Median age was 61 years (range, 4-82 y). Tumors were located in the spine (n = 27), sacrum (n = 3), retroperitoneum (n = 4), pelvis (n = 22), and extremities (n = 8), and 21 different tumor histologies were represented. Median tumor size was 4.0 cm (range, 0.8-15.0 cm). Total intravenous general anesthesia, computed tomographic guidance, and transcranial MEP monitoring were employed. Patient demographics, tumor characteristics, MEP findings, and clinical outcomes were assessed. RESULTS: Nineteen of 59 procedures (32%) resulted in decreases in intraprocedural MEPs, including 15 (25%) with transient decreases and four (7%) with persistent decreases. Two of the four patients with persistent MEP decreases (50%) had motor deficits following ablation. No functional motor deficit developed in a patient with transient MEP decreases or no MEP change. The risk of major motor injury with persistent MEP changes was significantly increased versus transient or no MEP change (P = .0045; relative risk, 69.8; 95% confidence interval, 5.9 to > 100). MEP decreases were 100% sensitive and 70% specific for the detection of motor deficits. CONCLUSIONS: Persistent MEP decreases correlate with postprocedural sustained motor deficits. Intraprocedural MEP monitoring helps predict neural injury and may improve patient safety during cryoablation of perineural musculoskeletal tumors.

Improving operating room productivity via parallel anesthesia processing.

PURPOSE: Parallel processing of regional anesthesia may improve operating room (OR) efficiency in patients undergoes upper extremity surgical procedures. The purpose of this paper is to evaluate whether performing regional anesthesia outside the OR in parallel increases total cases per day, improve efficiency and productivity. DESIGN/METHODOLOGY/APPROACH: Data from all adult patients who underwent regional anesthesia as their primary anesthetic for upper extremity surgery over a one-year period were used to develop a simulation model. The model evaluated pure operating modes of regional anesthesia performed within and outside the OR in a parallel manner. The scenarios were used to evaluate how many surgeries could be completed in a standard work day (555 minutes) and assuming a standard three cases per day, what was the predicted end-of-day time overtime. FINDINGS: Modeling results show that parallel processing of regional anesthesia increases the average cases per day for all surgeons included in the study. The average increase was 0.42 surgeries per day. Where it was assumed that three cases per day would be performed by all surgeons, the days going to overtime was reduced by 43 percent with parallel block. The overtime with parallel anesthesia was also projected to be 40 minutes less per day per surgeon. RESEARCH LIMITATIONS/IMPLICATIONS: Key limitations include the assumption that all cases used regional anesthesia in the comparisons. Many days may have both regional and general anesthesia. Also, as a case study, single-center research may limit generalizability. PRACTICAL IMPLICATIONS: Perioperative care providers should consider parallel administration of regional anesthesia where there is a desire to increase daily upper extremity surgical case capacity. Where there are sufficient resources to do parallel anesthesia processing, efficiency and productivity can be significantly improved. ORIGINALITY/VALUE: Simulation modeling can be an effective tool to show practice change effects at a system-wide level.

Examining patient demographics and major adverse cardiac events following noncardiac surgery: Applying a health equity lens.

BACKGROUND: Major adverse cardiac events (MACE) are a major contributor to postoperative complications. This study employed a health equity lens to examine rates of postoperative MACE by race and ethnicity. METHODS: This single-center, retrospective observational cohort study followed patients with and without pre-existing coronary artery stents from 2008 to 2018 who underwent non-cardiac surgery. MACE was the primary outcome (death, acute MI, repeated coronary revascularization, in-stent thrombosis) and self-reported race and ethnicity was the primary predictor. A propensity score model of a 1:1 cohort of non-Hispanic White (NHW) patients and all other racial and ethnic minority populations (Hispanic and Black) was used to compare the rate of perioperative MACE in this cohort. RESULTS: During the study period, 79,686 cases were included in the analytic sample; 950 patients (1.2 %) had pre-existing coronary artery stents. <1 % of patients experienced MACE within 30 days following non-cardiac surgery (0.8 %). After confounder adjustment and propensity score matching, there were no statistically significant differences in MACE among racial and ethnic minority patients compared to NHW patients (OR = 0.77; 95 % CI: 0.48, 1.25). In our sensitivity analyses, stratifying by sex, there were no differences in MACE by race and ethnicity. CONCLUSIONS: The study found no statistically significant differences in MACE by race and ethnicity among patients who underwent non-cardiac surgery. Access to a high-volume, high-quality hospital such as the one studied may reduce the presence of healthcare disparities and may explain why our findings are not consistent with previous studies.

Arthroscopic assisted brachial plexus catheter placement: an alternative to the percutaneous interscalene approach.

Background: Brachial plexus catheter placement at the interscalene level is beneficial for shoulder analgesia but presents logistical challenges due to the superficial nature of the plexus at this level, increased patient movement in the neck, and therefore higher likelihood for catheter dislodgement. Methods: Patients requiring shoulder arthroscopy and suprascapular nerve decompression were identified. Under arthroscopic guidance, a catheter was placed percutaneously into the scalene medius muscle next to the suprascapular nerve and the upper trunk of the brachial plexus. Patients were followed postoperatively for perioperative analgesic outcomes. Results: Ten patients were identified and consented for intraoperative brachial plexus catheter placement. Patient demographics and surgical details were determined. Postoperative adjunctive pain management and pain scores were variable. Two patients required catheter replacement using ultrasound guidance in the perioperative anesthesia care unit due to poorly controlled pain. There were no incidents of catheter failure due to dislodgement. Discussion: This study presents the first description of arthroscopically-assisted brachial plexus catheter placement. This method may present an alternative to traditional ultrasound guided interscalene catheter placement. Further study is needed to determine if analgesic outcomes, block success, and dislodgement rates are improved with this method.

Electrostatic ratchet in the protective antigen channel promotes anthrax toxin translocation.

Central to the power-stroke and brownian-ratchet mechanisms of protein translocation is the process through which nonequilibrium fluctuations are rectified or ratcheted by the molecular motor to transport substrate proteins along a specific axis. We investigated the ratchet mechanism using anthrax toxin as a model. Anthrax toxin is a tripartite toxin comprised of the protective antigen (PA) component, a homooligomeric transmembrane translocase, which translocates two other enzyme components, lethal factor (LF) and edema factor (EF), into the cytosol of the host cell under the proton motive force (PMF). The PA-binding domains of LF and EF (LF(N) and EF(N)) possess identical folds and similar solution stabilities; however, EF(N) translocates ∼10-200-fold slower than LF(N), depending on the electrical potential (Δψ) and chemical potential (ΔpH) compositions of the PMF. From an analysis of LF(N)/EF(N) chimera proteins, we identified two 10-residue cassettes comprised of charged sequence that were responsible for the impaired translocation kinetics of EF(N). These cassettes have nonspecific electrostatic requirements: one surprisingly prefers acidic residues when driven by either a Δψ or a ΔpH; the second requires basic residues only when driven by a Δψ. Through modeling and experiment, we identified a charged surface in the PA channel responsible for charge selectivity. The charged surface latches the substrate and promotes PMF-driven transport. We propose an electrostatic ratchet in the channel, comprised of opposing rings of charged residues, enforces directionality by interacting with charged cassettes in the substrate, thereby generating forces sufficient to drive unfolding.