Randomized Prospective Study Evaluating Single-Injection Paravertebral Block, Paravertebral Catheter, and Thoracic Epidural Catheter for Postoperative Regional Analgesia After Video-Assisted Thoracoscopic Surgery.

OBJECTIVE: Video-assisted thoracoscopic surgery (VATS) has improved patient outcomes; however, postoperative pain remains potentially severe. The objective of this study was to compare adjunct analgesic modalities for VATS, including paravertebral nerve blockade (PVB) and thoracic epidural anesthesia (TEA). DESIGN: Prospective, randomized trial. SETTING: Large academic hospital, single institution. PARTICIPANTS: Adult patients undergoing VATS. INTERVENTIONS: Ultrasound-guided PVB catheter, ultrasound-guided single-injection PVB, or TEA. MEASUREMENTS AND MAIN RESULTS: Postoperative visual analog scale pain scores (at rest and with knee flexion) and opioid usage were recorded. Pain scores (with movement) for the TEA group were lower than those for either PVB group at 24 hours (p ≤ 0.008) and for the PVB catheter group at 48 hours (p = 0.002). Opioid use in TEA group was lower than that for either PVB group at 24 and 48 hours (p < 0.001) and 72 hours (p < 0.05). Single-injection PVB was faster compared with PVB catheter placement (6 min v 12 min; p < 0.001) but similar to TEA (5 min). Patient satisfaction, nausea, sedation, and 6-month postsurgical pain did not differ between groups. CONCLUSIONS: TEA led to lower pain scores and opioid requirement for VATS procedures compared with PVB techniques. Single-injection PVB was faster and equally as effective as PVB catheter, and it led to similar patient satisfaction as TEA; therefore, it should be considered in patients who are not ideal candidates for TEA.

Digital Health at Enterprise Scale: Evaluation Framework for Selecting Patient-Facing Software in a Digital-First Health System.

The digital transformation of our health care system will require not only digitization of existing tools but also a redesign of our care delivery system and collaboration with digital partners. Traditional patient journeys are reactive to symptom presentation and delayed by health care system-centric scheduling, leading to poor experience and avoidable adverse outcomes. Patient journeys will be reimagined to a digital health pathway that seamlessly integrates various care experiences from telemedicine, remote monitoring, to in-person clinic visits. Through centering the care delivery around the patients, they can have more delightful experiences and enjoy the quality of standardized condition pathways and outcomes. To design and implement digital health pathways at scale, enterprise health care systems need to develop capabilities and partnerships in human-centered design, operational workflow, clinical content management, communication channels and mechanisms, reporting and analytics, standards-based integration, security and data management, and scalability. Using a human-centered design methodology, care pathways will be built upon an understanding of the unmet needs of the patients to have a more enjoyable experience of care with improved clinical outcomes. To power this digital care pathway, enterprises will choose to build or partner for clinical content management to operationalize up-to-date, best-in-class pathways. With this clinical engine, this digital solution will engage with patients through multimodal communication modalities, including written, audio, photo, or video, throughout the patient journey. Leadership teams will review reporting and analytics functions to track that the digital care pathways will be iterated to improve patient experience, clinical metrics, and operational efficiency. On the backend, standards-based integration will allow this system to be built in conjunction with the electronic medical record and other data systems to provide safe and efficient use of the digital care solution. For protecting patient information and compliance, a security and data management strategy is critical to derisking breeches and preserving privacy. Finally, a framework of technical scalability will allow digital care pathways to proliferate throughout the enterprise and support the entire patient population. This framework empowers enterprise health care systems to avoid collecting a fragmented series of one-off solutions but develop a sustainable concerted roadmap to the future of proactive intelligent patient care.

Design and development of referrals automation, a SMART on FHIR solution to improve patient access to specialty care.

BACKGROUND: Referring patients to specialty care is an inefficient and error-prone process. Gaps in the referral process lead to delays in patients' access to care, negative patient experience, worse health outcomes, and increased operational costs. While implementation of standards-based electronic referral options can alleviate some of these inefficiencies, many referrals to tertiary and quaternary care centers continue to be sent via fax. OBJECTIVE: We describe the design process and architecture for a software application that has been developed and deployed to optimize the referrals intake process by automating the processing and digitization of incoming specialty referral faxes, extracting key data elements and integrating them into the electronic health record (EHR), and organizing referrals. METHODS: A human-centered design approach was used to identify and describe the inefficiencies in the external referral process at our large, urban tertiary care center. Referrals Automation, an application to convert referral faxes to digital referrals in the EHR, was conceptualized based on key stakeholder interviews and time and motion studies. This application was designed using Substitutable Medical Applications and Reusable Technologies (SMART) and Fast Healthcare Interoperability Resource (FHIR) platforms to allow for adaptability into other healthcare organizations. RESULTS: Referrals Automation software was developed as a healthcare information technology solution to streamline the fax to referral process. The application was implemented into several specialty clinics. Metrics were built-in to the applications to evaluate and guide the further iteration of these features. CONCLUSIONS: Referrals Automation will enhance the referrals process by further streamlining and organizing the patient referral process.

Implementation of a digital chatbot to screen health system employees during the COVID-19 pandemic.

The screening of healthcare workers for COVID-19 (coronavirus disease 2019) symptoms and exposures prior to every clinical shift is important for preventing nosocomial spread of infection but creates a major logistical challenge. To make the screening process simple and efficient, University of California, San Francisco Health designed and implemented a digital chatbot-based workflow. Within 1 week of forming a team, we conducted a product development sprint and deployed the digital screening process. In the first 2 months of use, over 270 000 digital screens have been conducted. This process has reduced wait times for employees entering our hospitals during shift changes, allowed for physical distancing at hospital entrances, prevented higher-risk individuals from coming to work, and provided our healthcare leaders with robust, real-time data for make staffing decisions.

The Influence of Airway Closure Technique for Right Pneumonectomy on Wall Tension During Positive Pressure Ventilation: An Experimental Study.

Bronchopleural fistula (BPF) remains a significant source of morbidity and mortality after right pneumonectomy (RPN). Postoperative mechanical ventilation represents a primary risk factor for BPF. We undertook an experiment to determine the influence of airway diameter on suture line tension during mechanical ventilation after RPN. RPN was performed in 6 fresh human adult cadavers. After initial standard bronchial stump closure (BSC), the airway suture lines were subjected to 5 cm H2O incremental increases in airway pressures beginning at 5-40 cm H2O. To minimize airway diameter, a carinal resection was then performed with trachea to left main bronchial anastomosis and the airway suture lines subjected to similar incremental airway pressures. Wall tension (N/m) at the suture lines was measured using piezoresistive sensors at each pressure point. As delivered airway pressure increased, there was a concomitant increase in wall tension after BSC and carinal resection. At every point of incremental positive pressure, wall tension was however significantly lower after carinal resection when compared to BSC (P < 0.05). Additionally the differences in airway tension became even more significant with higher delivered airway pressure (P < 0.001). Airway diverticulum after BSC leads to significantly increased tension on the bronchial closure with positive airway pressure as compared to a closure which minimize airway diameter after RPN. This supports the role of Laplacian Law where small increases in airway diameter result in significant increases on closure site tension. Techniques which reduce airway diameter at the airway closure will more reliably reduce the incidence of BPF following RPN.

Prospective evaluation of serum amiodarone concentrations when administered via a nasogastric tube into the stomach conduit after transthoracic esophagectomy.

BACKGROUND: Atrial fibrillation occurs in up to 46% of patients following esophagectomy; amiodarone may be used for prophylaxis or treatment in these patients. There are few data regarding drug absorption following esophagectomy. OBJECTIVE: The aim of this study was to determine serum amiodarone concentrations when the drug is administered into the stomach conduit following esophagectomy. METHODS: Patients who underwent noncardiac thoracic surgery were enrolled in this prospective, controlled study. One group of patients underwent esophagectomy, and a second group of patients comprised a control group who underwent pulmonary resection (PR). A continuous IV amiodarone infusion (0.73 mg/min) was initiated at anesthesia induction and continued for 24 hours (total IV dose 1050 mg), followed by 400 mg via a nasogastric tube (in the esophagectomy group) or orally (in the PR group) every 12 hours for 6 days. Blood samples for determination of serum amiodarone concentrations were obtained at completion of the infusion (postoperative day [POD] 1), and before the third (POD 2) and seventh (POD 4) enteral doses. RESULTS: A total of 27 patients were enrolled (esophagectomy group, 13 patients; PR group, 14 patients). Patients in the 2 groups had statistically similar ages (mean [SD], 60 [10] vs 53 [10] years; P = 0.07) and proportions of men (12/13 [92%] vs 8/14 [57%]; P = 0.08). Patients in the 2 groups were statistically similar with respect to race (white, 13/13 [100%] vs 13/14 [93%]) and preoperative weight (mean [SD], 83.3 [11.5] vs 77.7 [18.6] kg). On POD 1, age-adjusted and sex-adjusted serum amiodarone concentrations were not significantly different in the esophagectomy group versus the PR group (mean [SD] 0.65 [0.22] vs 0.84 [0.20] microg/mL). Mean (SD) serum amiodarone concentrations were significantly lower in the esophagectomy group on POD 2 (0.35 [0.27] vs 0.60 [0.18] microg/mL; P = 0.02) and on POD 4 (0.30 [0.34] vs 0.87 [0.16] microg/mL; P < 0.001). Serum amiodarone concentrations were undetectable in 33% and 50% of patients in the esophagectomy group on PODs 2 and 4, respectively, compared with 0% in the PR group (both, P = 0.03). CONCLUSIONS: Serum amiodarone concentrations were significantly lower (and in some cases undetectable) when the drug was administered via a nasogastric tube into the stomach conduit in patients after esophagectomy compared with those concentrations after oral administration in a PR population. Nasogastric administration of amiodarone should probably be avoided for prophylaxis or treatment of postesophagectomy tachyarrhythmias.

Perioperative anesthetic management for renal cell carcinoma with vena caval thrombus extending into the right atrium: case series.

Renal cell carcinoma has a tendency for vascular invasion and may extend into the inferior vena cava and even into the right-sided cardiac chambers. It has been reported that nephrectomy with thrombectomy can provide immediate palliation of symptoms with 5-year survival rates of up to 72% in the absence of nodal or distant metastasis. The location of the tumor dictates the anesthetic and surgical approach, as extension into the heart often necessitates cardiac surgical involvement. Renal cell carcinoma with vena cava tumor thrombus extending into the right cardiac chamber usually requires cardiopulmonary bypass and occasionally deep hypothermic circulatory arrest for surgical resection, and anesthetic approach should be tailored to each individual case. Thorough preoperative evaluation and the commitment of a multidisciplinary surgery team are indispensable.

Effect of sample preparation, length of time, and sample size on quantification of total lipids from bovine liver.

The objective was to evaluate the effect of sample preparation (pulverization under liquid nitrogen, homogenization, or sonication), time length of sonication (0-60 s), shaking in chloroform/methanol solvent (0, 2, 4, or 12 h), incubation in chloroform (0 or 12 h), and drying of extracted lipids at 50 degrees C (2, 4, 6, or 24 h), and sample size (50-250 mg) on quantification of total lipids from bovine liver. Pulverization under liquid nitrogen yielded the lowest recovery. Sonication was least time-consuming for sample preparation. Precise estimates and the greatest recovery were obtained with 30 s of sonication, at least 2 h of shaking in chloroform/methanol solvent, 12 h of incubation in chloroform, and at least 6 h of drying. Sample sizes of at least 150 mg gave precise estimates. The results demonstrate that sample preparation, time length of different steps of the extraction procedure, and sample size affect quantification of total lipid from bovine liver.

Bullying and victimization: prevalence and relationship to gender, grade level, ethnicity, self-esteem, and depression.

This study investigated the prevalence of bullying and victimization among students in grades 7 and 8. It also explored the relationship of bullying and victimization to gender, grade level, ethnicity, self-esteem, and depression. Three survey instruments were used to obtain data from a convenience sample of 454 public school students. Twenty-four percent reported bullying involvement. Chi-square tests indicated significantly more male than female bullying involvement, seventh graders reported more involvement than did eighth graders, and there were no statistically significant differences in involvement based on ethnicity. Both bullies and victims manifested higher levels of depression than did students who were neither bullies nor victims. There were no significant differences between groups in terms of self-esteem.

A randomized, controlled study of amiodarone for prevention of atrial fibrillation after transthoracic esophagectomy.

OBJECTIVE: Atrial fibrillation is common after esophagectomy. The objective of this study was to determine the efficacy and safety of amiodarone for prevention of atrial fibrillation after transthoracic esophagectomy. METHODS: Eighty patients undergoing transthoracic esophagectomy were randomly, prospectively assigned to receive amiodarone (n = 40) or no prophylaxis (control group, n = 40). Amiodarone-treated patients received the drug by continuous infusion, initiated at the time of induction of anesthesia, at a rate of 0.73 mg/min (43.75 mg/h), and continued for 96 hours (total dose 4200 mg). The primary end point was atrial fibrillation requiring treatment. Secondary end points included any atrial fibrillation lasting longer than 30 seconds and postoperative hospital and intensive care unit stays. RESULTS: There were no significant differences between the amiodarone and control groups in demographic characteristics, comorbid conditions, or preoperative or postoperative use of beta-blockers or calcium-channel blockers. The incidence of atrial fibrillation requiring treatment was lower in the amiodarone group than in the control group (15% vs 40%, P = .02, relative risk reduction 62.5%). There were no significant differences between the amiodarone and control groups in median hospital stay (11 days vs 12 days, P = .31) or median intensive care unit stay (68 hours vs 77 hours, p = .097). There were no significant difference between the groups in the incidences of adverse effects. CONCLUSIONS: Amiodarone prophylaxis significantly reduced the incidence of atrial fibrillation after transthoracic esophagectomy.

A randomized trial evaluating amiodarone for prevention of atrial fibrillation after pulmonary resection.

BACKGROUND: Atrial fibrillation (AF) occurs commonly after anatomic pulmonary resection. In this study, the efficacy of amiodarone for prevention of post-pulmonary resection AF was investigated. METHODS: One hundred thirty patients undergoing lobectomy, bilobectomy, or pneumonectomy were randomly assigned prospectively to receive amiodarone (n = 65) or no prophylaxis (control group, n = 65). The amiodarone group received 1,050 mg by continuous intravenous infusion over 24 hours, initiated at the time of anesthesia induction, followed by 400 mg orally twice daily until hospital discharge or for a maximum of 6 days. The primary endpoint was AF requiring treatment during hospitalization. Secondary endpoints included postoperative length of hospital and intensive care unit stays. RESULTS: There were no significant differences between the amiodarone and control groups in demographics, comorbid conditions, extent of pulmonary resection, or preoperative or postoperative use of beta-blockers or calcium-channel blockers. The incidence of AF was lower in the amiodarone group than in the control group (13.8% versus 32.3%, p = 0.02; relative risk reduction = 57%). There was no difference between the amiodarone and control groups in median length of hospital stay (7 versus 8 days, p = 0.79), but median length of intensive care unit stay was shorter in the amiodarone group (46 versus 84 hours, p = 0.03). There was no significant difference between the amiodarone and control groups in the incidence of pulmonary complications or other adverse effects. CONCLUSIONS: Amiodarone prophylaxis significantly reduces the incidence of AF after anatomic pulmonary resection, and is associated with a significant reduction in length of intensive care unit stay.

Non-invasive detection of fatty liver in dairy cows by digital analyses of hepatic ultrasonograms.

During early lactation, many dairy cows develop fatty liver, which is associated with decreased health and reproductive performance. Currently, fatty liver can be detected reliably only by using liver biopsy followed by chemical or histological analysis, which is not practical in most on-farm situations. We tested whether digital analyses of hepatic ultrasonograms can be used to detect non-invasively fatty liver and estimate liver triacylglycerol content. A total of 49 liver biopsies and ultrasonograms were taken from 29 dairy cows within 2 weeks postpartum. The usefulness of 17 first- or second-order parameters from digital analysis of B-mode ultrasonograms were evaluated by discriminant, correlation, and regression analyses. A group of linear combinations of the 17 parameters correctly classified 40 of 49 samples into normal liver as well as mild, moderate and severe fatty liver when cut-off values were 1%, 5% and 10% and correctly classified 45 of 49 samples when cut-off values were 5% and 10% triacylglycerol of wet weight. A linear combination of 16 image parameters estimated triacylglycerol concentrations of 38 of the 39 liver samples below the cut-off value of 10% within 2.5% of liver wet weight, and a linear combination of 3 parameters estimated triacylglycerol concentrations of the 10 liver samples above the cut-off value of 10% within 2% of liver wet weight. Therefore, ultrasound imaging followed by digital analysis of sonograms has potential to non-invasively detect fatty liver and estimate liver triacylglycerol content.