Tunnelled central venous catheters for incident haemodialysis patients: a Victorian survey exploring reasons for use.

BACKGROUND: Tunnelled central venous catheters (T-CVCs) are used globally as vascular access for patients on haemodialysis (HD) but are associated with increased sepsis, mortality, cost and length of hospitalisation compared with more permanent HD vascular access. The reasons for using T-CVC are varied and poorly understood. A significant and increasing proportion of incident HD patients in Victoria, Australia, have required T-CVC over the last decade. AIM: To explore reasons for a significant and increasing proportion of incident HD patients in Victoria, Australia, having required T-CVC over the last decade. METHODS: With rates of starting HD with definitive vascular access consistently below a Victorian quality indicator target of 70%, an online survey was developed to explore reasons why the rate remained lower than desired and to help inform future decisions about this quality indicator. The survey was completed by dialysis access coordinators over an 8-month period and involved all public nephrology services in Victoria. RESULTS: Of the 125 surveys completed, 101 incident HD patients had no attempt at permanent vascular access prior to T-CVC insertion. For almost half of these (48 patients), there was no active medical decision not to create permanent vascular access prior to commencing dialysis. Reasons for insertion of the T-CVC included deterioration of kidney function faster than anticipated, surgical referral being overlooked, complications related to peritoneal dialysis requiring a change in dialysis modality and changes to initial decisions regarding dialysis modality for kidney failure. CONCLUSIONS: These survey results provide an opportunity for quality improvement initiatives with respect to dialysis access planning and care.

Megahertz-rate background-oriented schlieren tomography in post-detonation blasts.

The understanding and predictive modeling of explosive blasts require advanced experimental diagnostics that can provide information on local state variables with high spatiotemporal resolution. Current datasets are predominantly based on idealized spherically symmetric explosive charges and point-probe measurements, although practical charges typically involve multidimensional spatial structures and complex shock-flow interactions. This work introduces megahertz-rate background-oriented schlieren tomography to resolve transient, three-dimensional density fields, as found in an explosive blast, without symmetry assumptions. A numerical evaluation is used to quantify the sources of error and optimize the reconstruction parameters for shock fields. Average errors are ∼3% in the synthetic environment, where the accuracy is limited by the deflection sensing algorithm. The approach was experimentally demonstrated on two different commercial blast charges (Mach ∼1.2 and ∼1.7) with both spherical and multi-shock structures. Overpressure measurements were conducted using shock-front tracking to provide a baseline for assessing the reconstructed densities. The experimental reconstructions of the primary blast fronts were within 9% of the expected peak values. The megahertz time resolution and quantitative reconstruction without symmetry assumptions were accomplished using a single high-speed camera and light source, enabling the visualization of multi-shock structures with a relatively simple arrangement. Future developments in illumination, imaging, and analysis to improve the accuracy in extreme environments are discussed.

Proliferative Glomerulonephritis With Fibrils, Monoclonal κ Light Chain, and C3 Deposits.

There is increasing recognition of monoclonal gammopathy as a cause of proliferative glomerulonephritis (GN), including cases in which glomerular deposition of monoclonal immunoglobulin is demonstrated. Recently, proliferative GN with monoclonal immunoglobulin deposits (PGNMID) has incorporated a light chain variant of the disease (termed PGNMID-LC). Intriguingly, glomerular co-deposition of C3 is found in addition to monotypic light chain, implying complement activation via the alternative pathway (AP). We present a unique case of proliferative GN in a 42-year-old man who presented with nephrotic syndrome and was found to have κ light chain multiple myeloma. Immune staining of the glomerulus was positive only for κ light chain and C3, with the striking appearance of nonamyloid fibrils on electron microscopy. Following clonally targeted therapy for myeloma, the renal clinical abnormalities resolved completely. We present detailed molecular studies for light chain and complement and consider local mechanisms whereby monoclonal κ light chain fibrils may have triggered AP activation within the glomerulus.

Bayesian framework for THz-TDS plasma diagnostics.

Terahertz time-domain spectroscopy (THz-TDS) is an optical diagnostic used to noninvasively measure plasma electron density and collision frequency. Conventional methods for analyzing THz-TDS plasma diagnostic data often do not account for measurement artifacts and do not quantify parameter uncertainties. We introduce a novel Bayesian framework that overcomes these deficiencies. The framework enables computation of both the density and collision frequency, compensates for artifacts produced by refraction and delay line errors, and quantifies parameter uncertainties caused by noise and imprecise knowledge of unmeasured plasma properties. We demonstrate the framework with sample measurements of a radio frequency inductively-coupled plasma discharge.

Linear absorption tomography with velocimetry (LATV) for multiparameter measurements in high-speed flows.

We present a linear model for absorption tomography with velocimetry (LATV) to reconstruct 2D distributions of partial pressure, temperature, and streamwise velocity in a high-speed flow. Synthetic measurements are generated by multi-beam tunable diode laser absorption spectroscopy (TDLAS). The measurement plane is tilted relative to the streamwise direction and absorbance spectra are Doppler-shifted by the gas flow. Reconstruction comprises two stages. First, the thermodynamic state is obtained by reconstructing two or more integrated absorption coefficients and evaluating local Boltzmann plots. Second, the velocity field is directly reconstructed from absorbance-weighted linecenters. Absorbance data are inferred by Voigt fitting and reconstructions are quickly computed by matrix-vector multiplication. Nonlinear parameter combinations, such as the mass flow, are more accurate when computed by LATV than estimates obtained by assuming uniform gas properties along each beam.

A comprehensive model for pain management in patients undergoing pelvic reconstructive surgery: a prospective clinical practice study.

BACKGROUND: Postoperative opioid prescription patterns play a key role in driving the opioid epidemic. A comprehensive system toward pain management in surgical patients is necessary to minimize overall opioid consumption. OBJECTIVE: This study aimed to evaluate the efficacy of a pain management model in patients undergoing pelvic reconstructive surgery by measuring postdischarge narcotic use in morphine milligram equivalents. STUDY DESIGN: This is a prospective clinical practice study that included women undergoing inpatient pelvic reconstructive surgery from December 2018 to June 2019 with overnight stay after surgery. As a routine protocol, all the patients followed an enhanced recovery after surgery protocol that included a preoperative multimodal pain regimen. Brief Pain Inventory surveys were collected preoperatively and on postoperative day 1. Brief pain inventory and activities assessment scale scores were collected at postoperative week 1 and postoperative weeks 4-6 after surgery. Patients were discharged with 15 tablets of an oral narcotic using an electronic prescription for controlled substances software platform, which is mandated in the state of Connecticut for all controlled substances, prescriptions, and refills. Patients were called at postoperative week 1 and postoperative weeks 4-6 to answer questions regarding their pain, the number of remaining narcotic tablets, and patient satisfaction regarding pain management. Patient electronic medical records and the Connecticut Prescription Monitoring and Reporting System were reviewed to determine whether patients received narcotic refills. Primary outcome was postdischarge narcotic use measured in morphine milligram equivalents. Secondary outcomes evaluated refill rate, brief pain inventory and activities assessment scale scores, and patient satisfaction with pain management. Descriptive statistics were described as mean and standard deviation and median and interquartile range. Bivariate comparisons used Spearman's rho (ρ) with α=0.05. RESULTS: A total 113 patients were enrolled; the median (interquartile range) morphine milligram equivalent prescribed (including refills) was 112.5 (112.5-112.5). The median postdischarge narcotic use was 24.0 (0-82.5) morphine milligram equivalent, which is equivalent to fewer than 4 oxycodone (5 mg) tablets. About 75% of our participants required fewer than 11 oxycodone tablets. The median unused morphine milligram equivalent was 90.0 (45-112.5). 81.4% (92/113), and 83.2% (94/113) of patients at postoperative week 1 and postoperative weeks 4-6, respectively, reported being satisfied or extremely satisfied with their postdischarge pain control. About 88.5% (100/113) of patients felt that the number of opioids they were discharged with was sufficient for their pain needs at the postoperative 1 and postoperative weeks 4-6 time points. At postoperative weeks 4-6, 19.5% of patients said that they filled the narcotic prescription but did not use any of the pills. The overall refill rate was 10.6% (12/113). All patients who needed a refill described the refill process as easy. In-hospital narcotic use was not predictive of postdischarge narcotic use (ρ0.065, P=.495). Patients reported median brief pain inventory scores for "average pain" of 0 (no pain) at postoperative week 1 and postoperative weeks 4-6; however, the scores did not clinically correlate with postdischarge narcotic use. Activities assessment scale scores were not correlated with postdischarge narcotic use. CONCLUSION: Most patients after pelvic reconstructive surgery used fewer than 11 oxycodone (5 mg) tablets, averaging less than 4 tablets, with a third of patients not requiring any opioids. Pain and activities scores did not correlate with narcotic use. A minimal number of opioids can be prescribed because the secure electronic prescribing system allows for convenient electronic refill if required. Our practical and comprehensive pre- and postoperative protocol for pain management minimizes opioid consumption in addition to maximizing patient satisfaction.

Cocaine-associated atypical haemolytic uraemic syndrome in a genetically susceptible individual.

Atypical haemolytic uraemic syndrome (aHUS) is a severe, life-threatening condition that requires early recognition and urgent treatment. In aHUS rare genetic variants in CFH, CFI, CD46, C3 and CFB predispose to complement over activation. This case describes a case of aHUS in which there was a strong temporal association between disease onset and the use of smoked cocaine. The patient was found to have a rare genetic variant in the CFI gene which may have been unmasked by first-time exposure to cocaine. The patient stabilized and improved with early administration of eculizumab, supporting the notion of an underlying immunological pathogenesis and the importance of early intervention.

Randomized double-blind trial of short- versus long-acting analgesia at the sacrospinous ligament.

INTRODUCTION AND HYPOTHESIS: Pain control is a key component of postoperative care; our objective was to evaluate if use of long-acting local anesthesia at the sacrospinous ligament leads to decreased postoperative pain versus short-acting local anesthesia in patients undergoing sacrospinous ligament fixation. METHODS: Women ≥ 18 years old undergoing sacrospinous ligament fixation to treat pelvic organ prolapse were eligible to participate in this randomized trial. Enrolled patients were randomized 1:1 to one of two study arms: (1) lidocaine arm (LA) or (2) liposomal bupivacaine arm (LBA). Patients in the LA received 30 ml 0.5% lidocaine with 1:200,000 epinephrine local injection at the sacrospinous ligament. Patients in the LBA received 20 ml 1.3% bupivacaine liposomal mixed with 10 ml 0.5% bupivacaine at the sacrospinous ligament. All patients received 50 ml 0.5% lidocaine with 1:200,000 epinephrine for anterior and/or posterior colporrhaphy. The primary outcome of this study was postoperative buttock pain. RESULTS: Of the 37 patients enrolled, 33 completed study procedures. Mean age (± SD) was 62.3 years (± 11.6) in the LA and 66.8 years (± 14.4) in the LBA (p = 0.32). All participants underwent sacrospinous ligament fixation; the rate of concomitant procedures did not differ between study arms. Visual analog scale scores for buttock-specific pain were compared between arms at 1, 3, 6, 12, 24, 36, 48, 72, 96, and 120 h postoperatively, and no differences were found. CONCLUSIONS: Use of long-acting local analgesia at the sacrospinous ligament at the time of sacrospinous ligament fixation does not provide any benefit over short-acting local analgesia.

Decreasing postoperative narcotics in reconstructive pelvic surgery: a randomized controlled trial.

BACKGROUND: Postoperative pain control is crucial to any successful recovery plan. Many currently used medication regimens are narcotic-focused. OBJECTIVE: The objective of our study was to evaluate the efficacy of a multimodal pain regimen after pelvic reconstructive surgery. STUDY DESIGN: The primary outcome measure was narcotic use. Secondary outcomes included pain, nausea, and constipation. Patients were randomized to either usual care postoperative treatment or multimodal pain regimen. Usual care included no specific preoperative or intraoperative medications, and postoperative narcotics with ibuprofen. Multimodal pain regimen included preoperative and postoperative celecoxib, gabapentin, intraoperative and postoperative intravenous and oral acetaminophen and ibuprofen, and narcotics as needed. All narcotics were converted to milligram equivalents of oral morphine for standardization according to Centers for Disease Control and Prevention guidelines where conversion factors for oral hydrocodone = 1, oral oxycodone = 1.5, and oral hydromorphone = 4. Patients were given the validated Brief Pain Inventory survey preoperatively (baseline), at postoperative day 1, and 1 week postoperatively. At 1 week, bowel function and narcotics usage was assessed. RESULTS: Seventy patients were randomized to the usual care arm and 68 to the multimodal pain regimen arm. Patients in the multimodal pain regimen arm used significantly fewer intravenous narcotics in the operating room (90.7 ± 39.1 mg vs 104.6 ± 33.5 mg; P = .026) and while in the hospital (10.8 ± 15.1 mg vs 31.2 ± 29.6 mg; P < .001) and were more likely to use 0 oral narcotics after discharge to home (34.8% of patients vs 10.6%; P = .001). Of the patients who did use oral narcotics after discharge to home, there was no difference in amount used between groups (121.3 ± 103.7 mg in the multimodal pain regimen arm vs 153.0 ± 113.8 mg in the usual care arm; P = .139). Total narcotic usage (operating room + hospital + home) was significantly less in the multimodal pain regimen arm of the study (195.5 ± 147.2 mg vs 304.0 ± 162.1 mg; P < .001). There were no significant differences in pain scores between the 2 arms of the study on either postoperative time point. There were no significant differences in antiemetic use while in hospital, consistency of first bowel movement, length of stay, or number of telephone calls to nurses in first 3 weeks postoperatively. CONCLUSION: A multimodal pain regimen in pelvic reconstructive surgery was found to decrease postoperative opioid requirements, while providing equivalent pain control.

Preemptive analgesia for postoperative hysterectomy pain control: systematic review and clinical practice guidelines.

OBJECTIVE: The objective of the study was to investigate the effectiveness of preemptive analgesia at pain control in women undergoing total abdominal hysterectomy. DATA SOURCES: Eligible studies, published through May 31, 2016, were retrieved through Medline, Cochrane Central Register for Controlled Trials, and Cochrane Database of Systematic Reviews. STUDY ELIGIBILITY: We included randomized controlled trials with the primary outcome of pain control in women receiving a preemptive medication prior to total abdominal hysterectomy. Comparators were placebo, different doses of the same medication as intervention, or other nonnarcotic or narcotic medication. STUDY APPRAISAL AND SYNTHESIS METHODS: Study data were extracted by one reviewer and confirmed by a second reviewer. For each outcome we graded the quality of the evidence. Studies were classified by the type of medication used and by outcome type. RESULTS: Eighty-four trials met eligibility, with 69 included. Among nonnarcotic medications, paracetamol, gabapentin, and rofecoxib combined with gabapentin resulted in improvements in pain assessment compared with placebo and other nonnarcotic medications. Patient satisfaction was higher in patients who were given gabapentin combined with paracetamol compared with gabapentin alone. Use of preemptive paracetamol, gabapentin, bupivacaine, and phenothiazine resulted in less narcotic usage than placebo. All narcotics (ketamine, morphine, fentanyl) resulted in improved pain control compared with placebo. Narcotics had a greater reduction in pain assessment scores compared with nonnarcotics, and their use resulted in lower total narcotic usage. CONCLUSION: Preemptive nonnarcotic and narcotic medications prior to abdominal hysterectomy decrease total narcotic requirements and improve patient postoperative pain assessment and satisfaction scores.

Effect of B³âº-N³â» on YAG:Dy thermographic phosphor luminescence.

The use of thermographic phosphors for high-temperature (>1000 K) thermometry currently is limited by loss of signal due to thermal quenching. This work demonstrates a new phosphor generated by substituting tetrahedral site Al(3+)-O(2-) in YAG:Dy with B(3+)-N(3-) to produce YABNG:Dy. Conventional YAG:Dy and YABNG:Dy phosphors were synthesized using identical solgel synthesis techniques. X-ray diffraction measurements showed that both had nearly pure crystalline phases, with a minor secondary yttrium-aluminum-monoclinic (YAM) phase present in the YABNG:Dy. The YABNG:Dy sample had a larger and more spherical primary grain than did the YAG:Dy in scanning electron microscopy images. Tests of the thermal response showed that the YABNG:Dy had much stronger phosphorescence emissions than did YAG:Dy, likely due to the morphological differences. Furthermore, the onset of thermal quenching was delayed by approximately 100 K for YABGN:Dy compared to YAG:Dy, and the rate of signal decrease with temperature was reduced. This resulted in greater signal-to-noise ratios and less uncertainty in the temperature measurements, particularly at high temperatures.

Systematic review of robotic surgery in gynecology: robotic techniques compared with laparoscopy and laparotomy.

The Society of Gynecologic Surgeons Systematic Review Group performed a systematic review of both randomized and observational studies to compare robotic vs nonrobotic surgical approaches (laparoscopic, abdominal, and vaginal) for treatment of both benign and malignant gynecologic indications to compare surgical and patient-centered outcomes, costs, and adverse events associated with the various surgical approaches. MEDLINE and the Cochrane Central Register of Controlled Trials were searched from inception to May 15, 2012, for English-language studies with terms related to robotic surgery and gynecology. Studies of any design that included at least 30 women who had undergone robotic-assisted laparoscopic gynecologic surgery were included for review. The literature yielded 1213 citations, of which 97 full-text articles were reviewed. Forty-four studies (30 comparative and 14 noncomparative) met eligibility criteria. Study data were extracted into structured electronic forms and reconciled by a second, independent reviewer. Our analysis revealed that, compared with open surgery, robotic surgery consistently confers shorter hospital stay. The proficiency plateau seems to be lower for robotic surgery than for conventional laparoscopy. Of the various gynecologic applications, there seems to be evidence that renders robotic techniques advantageous over traditional open surgery for management of endometrial cancer. However, insofar as superiority, conflicting data are obtained when comparing robotics vs laparoscopic techniques. Therefore, the specific method of minimally invasive surgery, whether conventional laparoscopy or robotic surgery, should be tailored to patient selection, surgeon ability, and equipment availability.

An incoherent Thomson scattering system for measurements near plasma boundaries.

Laser Thomson scattering (LTS) is a minimally invasive measurement technique used for determining electron properties in plasma systems. Sheath model closure validation requires minimally invasive measurements of the electron properties that traverse the boundaries between the bulk plasma, the presheath, and the plasma sheath. Several studies have probed the radial properties along the surface of discharge electrodes with laser-based diagnostics and electrostatic probes. These measurements provide valuable insight into the electron properties in this dynamic region. However, sheath model calibration requires plasma property measurements perpendicular to plasma bounding surfaces, in this case, along the electrode normal vector between discharge electrodes. This work presents the development of a discharge plasma cell and laser Thomson scattering system with a measurement volume step of 1 mm normal to plasma bounding surfaces. The laser Thomson scattering measurements are made between a set of discharge electrodes separated by ∼25 mm that are used to generate a pulsed argon plasma. The spatial distribution of electron temperature and density is measured at several discharge voltages between 8 and 20 kV at a pressure of 8 Torr-Ar. It is determined that the system is statistically stationary and resembles a classic DC discharge plasma. The results are some of the first laser diagnostic-based "between electrode" measurements made along the plasma bounding electrode normal vector. A one-dimensional sheath model is applied to determine the near cathode electron properties, and it is determined that the edge of the presheath is probed in the high-voltage cases. As the lengths of the presheath and sheath decrease with decreasing voltage, the region recedes below the closest probed point to the cathode. To improve the performance of the diagnostic, the step size of the interrogation volume should decrease by an order of magnitude from 1 mm to less than 100 µm, and the data acquisition strategy should be revised to increase the signal-to-noise ratio.

Bayesian plasma model selection for Thomson scattering.

Laser Thomson scattering (LTS) is a measurement technique that can determine electron velocity distribution functions in plasma systems. However, accurately inferring quantities of interest from an LTS signal requires the selection of a plasma physics submodel, and comprehensive uncertainty quantification (UQ) is needed to interpret the results. Automated model selection, parameter estimation, and UQ are particularly challenging for low-density, low-temperature, potentially non-Maxwellian plasmas like those created in space electric propulsion devices. This paper applies Bayesian inference and model selection to a Raman-calibrated LTS diagnostic in the context of such plasmas. Synthetic data are used to explore the performance of the method across signal-to-noise ratios and model fidelity regimes. Plasmas with Maxwellian and non-Maxwellian velocity distributions are well characterized using priors that span a range of accuracy and specificity. The model selection framework is shown to accurately detect the type of plasmas generating the electron velocity distribution submodel for signal-to-noise ratios greater than around 5. In addition, the Bayesian framework validates the widespread use of 95% confidence intervals from least-squares inversion as a conservative estimate of the uncertainty bounds. However, epistemic posterior correlations between the variables diverge between least-squares and Bayesian estimates as the number of variable parameters increases. This divergence demonstrates the need for Bayesian inference in cases where accurate correlations between electron parameters are necessary. Bayesian model selection is then applied to experimental Thomson scattering data collected in a nanosecond pulsed plasma, generated with a discharge voltage of 5 and 10 kV at a neutral argon background pressure of 7 Torr-Ar. The Bayesian maximum a posteriori estimates of the electron temperature and number density are 1.98 and 2.38 eV and 2.6 × 1018 and 2.72 × 1018 m-3, using the Maxwellian and Druyvesteyn submodels, respectively. Furthermore, for this dataset, the model selection criterion indicates strong support for the Maxwellian distribution at 10 kV discharge voltage and no strong preference between Maxwellian and Druyvesteyn distributions at 5 kV. The logarithmic Bayes' factors for these cases are -35.76 and 1.07, respectively.

A New Force-Activated Separation Device for the Prevention of Peripheral Intravenous Restarts.

The high failure rate (46%) of peripheral intravenous catheters (PIVCs) is well-documented. There is limited research examining the effect of forces/pulls on PIVC complications. New breakaway connectors called force-activated separation devices (FASD) separate when a damaging force is placed on a PIVC. In a randomized, controlled trial, patients were assigned 1:1 to a control group receiving PIVC standard of care (SOC) or SOC with FASD added to the catheter. The primary outcome was total mechanical complications requiring a PIVC restart. Secondary outcomes were delay in therapy, PIVC restarts, and adverse events. Outcomes were compared in an intention-to-treat analysis (N = 302) and per-protocol analysis (N = 287). There were less total mechanical complications in FASD compared with SOC (22 vs 41, respectively; P < .01). The treatment group was a predictor of total delay in therapy (minutes), indicating a greater estimated total delay in therapy in SOC than FASD (B = 69.53; 95% CI, 28.32-110.73; P = .001). There were more adverse events in SOC (127) than FASD (76; P = .001). Results were consistent in the per-protocol analysis. Use of a FASD showed a reduction in total mechanical complications. These results support use of the FASD as a safer and time-saving alternative to current SOC.

The Value of a Support Person During the Surgical Consent Process: A Prospective Cohort Study.

OBJECTIVE: The objective of this study is to investigate the impact of support person participation during the preoperative appointment. METHODS: This is a prospective cohort study involving patients scheduled to undergo pelvic reconstructive surgery. Eligible patients were enrolled at the preoperative appointment and compared by presence or absence of a support person. Questionnaires were completed before and after the preoperative appointment, 1-3 days before surgery, and at the postoperative appointment. Previsit questionnaires included the Generalized Anxiety Disorder-7, 6-item short form of the Spielberger State-Trait Anxiety Inventory (STAI-6), and Brief Health Literacy screen. Postvisit questionnaires included the STAI-6, satisfaction with decision scale for pelvic floor disorders, preoperative preparedness questionnaire, and knowledge questionnaire. At the postoperative appointment, participants completed the patient global impression of improvement and postoperative symptom and satisfaction questionnaire. Primary outcome was patient anxiety measured by the STAI-6. RESULTS: Seventy-six patients participated in the study: 37 were categorized in the support person cohort and 39 were categorized in the no support person cohort. The mean scores of the STAI-6 did not differ between the support person and no support person cohorts at all time points (previsit: 42.97 ± 13.23 vs 41.53 ± 17.11, P = 0.68; postvisit: 38.11 ± 12.76 vs 36.33 ± 11.72, P = 0.53, and 1-3 days before surgery: 42.61 ± 13.0 vs 41.05 ± 16.39, P = 0.65). Overall preparedness, satisfaction with decision scale for pelvic floor disorders, and knowledge questionnaire did not differ between cohorts at both time points. Perioperative phone calls were similar between cohorts. CONCLUSION: Our study suggests that the presence of a support person at preoperative counseling for pelvic floor surgery should be a personal preference and not a recommendation.

Getting back to work: A framework and pivot plan to resume elective surgery and procedures after COVID-19.

INTRODUCTION: The COVID-19 pandemic has compelled a majority of hospital systems to reduce surgical and procedural volumes in an attempt to preserve resources. Elective surgery and procedures resumption has proven to be a calculated risk between COVID-19 exposure and resource depletion and patient morbidity and mortality from surgical deferral. METHODS: Within a few days of halting elective surgery and procedures, our 7-hospital (2427 in-patient beds, 26,647 inpatient surgeries) healthcare system developed a multidisciplinary Pivot Plan with the primary outcome of a phased resumption of elective surgery and procedures. The plan entailed the integration of our electronic medical record, order entry automatization, perioperative staff utilization, partnering with primary care providers, and a stepwise COVID-19 testing algorithm based on a predetermined hierarchy of case acuity and timeliness of patient care. RESULTS: The Pivot Plan was instituted on May 10, 2020. Since then, 22,624 patients have been tested for COVID-19 in anticipation of an elective surgery and procedures; 140 (0.62%) tested positive for COVID-19 and had their procedure deferred. As our testing capability has increased, we have been able to increase our added elective surgery and procedures capacity from 13 cases per day to 531 cases per day. In turn, we have seen the case volume increase by 52%. CONCLUSION: Our academic healthcare system located in one of the initial COVID-19 hotspots in the United States has successfully resumed elective surgery and procedures in part due to a receptive and supportive culture based upon nimbleness, agility, and rapid integration of multiple resources from a cohort of diverse disciplines applied to the perioperative services workflow.

Use of a beef tongue model and instructional video for teaching residents fourth-degree laceration repair.

INTRODUCTION AND HYPOTHESIS: This study seeks to compare the utility of the beef tongue model versus an instructional video in teaching obstetric and gynecology residents how to repair a fourth-degree laceration. METHODS: Twenty-seven residents were randomized to participate in a workshop with a beef tongue model or assigned to watch an instructional video on repair of fourth-degree lacerations and read a chapter on the repair. All subjects were tested with a pre- and postintervention written test. These scores were compared with paired t test at 0.05 significance level. RESULTS: Residents with no prior experience in fourth-degree laceration repairs showed an improvement in knowledge (49.5% versus 64.1%, p<0.001) on written exams about the repairs. CONCLUSIONS: An instructional video or beef tongue model and textbook chapter on fourth-degree laceration repair can improve skills in repair of a fourth-degree laceration among residents with no experience in these repairs.

Patient-Initiated Telephone Calls in the Postoperative Period After Female Pelvic Reconstructive Surgery.

OBJECTIVE: The aim of this study was to evaluate reasons and factors associated with patient calls in the postoperative period after female pelvic medicine and reconstructive surgery. METHODS: A retrospective review using electronic medical records was performed on consecutive patients who underwent surgery within our academic female pelvic medicine and reconstructive surgery practice during a 6-month period. Calls after postoperative discharge until first scheduled postoperative visit were included. Reasons and number of calls were tabulated. Clinical and surgical factors were extracted. Continuous data were evaluated with a Student t test or analysis of variance; categorical data were evaluated with a χ test. P < 0.05 was considered significant. RESULTS: During the designated period, 302 patients underwent surgery, and 173 (57.3%) patients made 345 calls (mean ± SD, 2.0 ± 1.5 calls). Reasons were categorized under 6 distinct domains: bowel, pain, activity, medication regimen, urinary, and bleeding. The most frequent concern within each domain was constipation (11.6%), abdominal pain (6.4%), physical activity (8.7%), pain regimen (14.5%), urinary catheter related (13.3%), and vaginal bleeding (12.1%), respectively. A greater number of phone calls were recorded among patients discharged home with catheters (P = 0.015), and patients who underwent posterior colporrhaphy (P = 0.005) and retropubic urethropexy (P = 0.014). Patients discharged with home nursing (11, 6.4%) demonstrated a significantly higher number of phone calls (3.8 ± 2.5, P < 0.001). Evaluations were required for 37% of callers. Twelve patients were seen in the emergency department, of whom 3 (1.7%) were readmitted to the hospital. CONCLUSIONS: Postoperative patient-initiated telephone calls after pelvic reconstructive surgery are common. Bowel-, urinary-, and medication-based phone calls account for the highest frequency and volume.