A Multidisciplinary Intubation Algorithm for Suspected COVID-19 Patients in the Emergency Department.

INTRODUCTION: Intubation of patients suspected of having coronavirus disease 2019 (COVID-19) is considered to be a high-risk procedure due to the aerosolization of viral particles. In an effort to minimize the risk of exposure and optimize patient care, we sought to develop, test, provide training, and implement a standardized algorithm for intubating these high-risk patients at our institution. METHODS: We developed an initial intubation algorithm, incorporating strategic use of equipment and incorporating emerging best practices. By combining simulation-based training sessions and rapid-cycle improvement methodology with physicians, nurses, and respiratory therapists, and incorporating their feedback into the development, we were able to optimize the process prior to implementation. Training sessions also enabled the participants to practice the algorithm as a team. Upon completion of each training session, participants were invited to complete a brief online survey about their overall experience. RESULTS: An algorithm and training system vetted by simulation and actual practice were developed. A training video and dissemination package were made available for other emergency departments to adopt. Survey results were overall positive, with 97.92% of participants feeling confident in their role in the intubation process, and many participants citing the usefulness of the multidisciplinary approach to the training. CONCLUSION: A multidisciplinary, team-based approach to the development and training of a standardized intubation algorithm combining simulation and rapid-cycle improvement methodology is a useful, effective process to respond to rapidly evolving clinical information and experiences during a global pandemic.

Intra-discal drain insertion for culture and drainage of pyogenic spondylodiscitis: A one-step diagnostic and therapeutic procedure.

BACKGROUND: Pyogenic spondylodiscitis is diagnosed in recent years at higher rates due to the aging population, increased survival of chronic and immune suppressed patients, and the higher rate of invasive procedures leading to bacterial seeding or direct contamination of the disc space. Treatment guidelines encourage bacterial sampling before initiation of antibiotic therapy, and drainage of pus collections. We present our experience with percutaneous CT-guided drain insertion into the disc space itself as a one-step procedure for both culturing and subsequent continuous drainage of the infected disc space. MATERIALS AND METHODS: We retrospectively reviewed all cases of pyogenic spondylodiscitis admitted to our spine surgery unit during the past five years and treated with CT-guided percutaneous drain insertion into the infected disc space. All patients were followed until complete resolution of the infection. RESULTS: We retrieved electronic records of 12 patients, none presenting with neurological compression symptoms. Cultures taken at the time of drain insertion were positive in 10 patients (83.3%), much higher than the reported yield for needle aspiration (14-48%) and comparable to the yield of open biopsy. In all patients complete resolution of the infection was reached, determined by clinical, laboratory, and imaging parameters. CONCLUSIONS: Our retrospective case series demonstrates the feasibility and effectiveness of intra-discal CT-guided drainage of an infected disc space. The procedure does not add much burden to current practice as disc-space sampling for culture is commonly performed anyway, and adds the benefit of direct drainage of the pus at its source.

Two approaches for placenta accreta spectrum: B-lynch suture versus pelvic artery endovascular balloon.

Purpose: Management of patients with placenta accreta spectrum (PAS) varies widely, and scarce data exist concerning its management. The current study compared two different surgical approaches in the management of PAS: the B-lynch approach (Group A) compared to the endovascular balloon catheters (Group B)Methods: A retrospective cohort study in two tertiary university-affiliated hospitals between the years 2004 and 2015. Elective cesarean section was planned at 35-37 weeks of gestation. One center utilized the B-lynch approach and the second utilized the endovascular balloon catheter approach.Results: The cesarean hysterectomy rate was significantly higher in the Group A approach compared to Group B (36.1 versus 29.2%, p = .00). The number of packed cells units administered during and postoperatively were higher in the Group A compared with Group B (p = .006 and .043, respectively). Overall, surgery length and hospitalization duration were shorter in patients who underwent cesarean hysterectomy compared with those who underwent uterine preservation (B-lynch or endovascular balloon catheters) (p = .000 and p = .004, respectively).Conclusions: The endovascular balloon technique seems to be a better option for uterine preservation due to less blood loss and higher postoperative hemoglobin level. Nevertheless, for those women who have completed their family planning, cesarean hysterectomy with the placenta left in situ is the safer and more suitable option.

Simphony: simulating large-scale, rhythmic data.

Simulated data are invaluable for assessing a computational method's ability to distinguish signal from noise. Although many biological systems show rhythmicity, there is no general-purpose tool to simulate large-scale, rhythmic data. Here we present Simphony, an R package for simulating data from experiments in which the abundances of rhythmic and non-rhythmic features (e.g., genes) are measured at multiple time points in multiple conditions. Simphony has parameters for specifying experimental design and each feature's rhythmic properties (e.g., amplitude and phase). In addition, Simphony can sample measurements from Gaussian and negative binomial distributions, the latter of which approximates read counts from RNA-seq data. We show an example of using Simphony to evaluate the accuracy of rhythm detection. Our results suggest that Simphony will aid experimental design and computational method development. Simphony is thoroughly documented and freely available at https://github.com/hugheylab/simphony.

LimoRhyde: A Flexible Approach for Differential Analysis of Rhythmic Transcriptome Data.

Unraveling the effects of genetic or environmental perturbations on biological rhythms requires detecting changes in rhythmicity across multiple conditions. Although methods to detect rhythmicity in genome-scale data are well established, methods to detect changes in rhythmicity or changes in average expression between experimental conditions are often ad hoc and statistically unreliable. Here we present LimoRhyde (linear models for rhythmicity, design), a flexible approach for analyzing transcriptome data from circadian systems. Borrowing from cosinor regression, LimoRhyde decomposes circadian or zeitgeber time into multiple components to fit a linear model to the expression of each gene. The linear model can accommodate any number of additional experimental variables, whether discrete or continuous, making it straightforward to detect differential rhythmicity and differential expression using state-of-the-art methods for analyzing microarray and RNA-seq data. In this approach, differential rhythmicity corresponds to a statistical interaction between an experimental variable and circadian time, whereas differential expression corresponds to the main effect of an experimental variable while accounting for circadian time. To validate LimoRhyde's performance, we applied it to simulated data. To demonstrate LimoRhyde's versatility, we applied it to murine and human circadian transcriptome datasets acquired under various experimental designs. Our results show how LimoRhyde systematizes the analysis of such data, and suggest that LimoRhyde could prove valuable for assessing how circadian systems respond to perturbations.

The use of pre-caesarean prophylactic intra-arterial balloon catheters for suspected placenta accreta.

INTRODUCTION: The incidence of placenta accreta (PA) has markedly increased in the United States, from 1/30 000 in 1950 to 1/731 deliveries in 2011. Although placenta praevia after prior caesarean sections (CS) is the most important risk factor for PA, other risk factors make up 1-5% of PA occurrences. At our referral hospital, we use the pre-caesarean prophylactic balloon catheter with or without post-surgery embolisation in a hybrid room. Here, we evaluate the role of prior CS and placenta praevia on the outcome of this procedure. MATERIALS AND METHODS: This retrospective cohort analysis included 61 women during the years 2004-2016 with sonographic suspicion of PA who underwent balloon catheterisation prior to CS. RESULTS: Eleven women had no previous CS (18%). Mean previous CS rate was 1.85. Six women (9.8%) had previous dilatation and curettage (D&C); 36.4% of women with no previous CS had previous D&C compared with 4% of women with previous CS (P = 0.008). Placenta praevia was sonographically diagnosed in 55 women (90.2%). There was a higher rate of caesarean hysterectomy in women with previous CS than in those without (32% vs 0%, P = 0.052) but no significant difference in blood product requirements (45.5% vs 66%, P = 0.303). There was no significant difference in hysterectomy rate, blood transfusion or surgery duration between women with and without placenta praevia (P = 0.648, 0.594, 0.995, respectively). CONCLUSION: Previous CS rather than placenta praevia is a strong indicator of hysterectomy in cases of PA. Different risk factors for PA do not affect blood transfusion rates or surgery duration.

Predictive Factors for the Migration of Endoscopic Self-Expanding Metal Stents Placed in the Foregut.

BACKGROUND: With recent advancements in endoscopy, self-expandable metal stents (SEMS) have been used to treat gastrointestinal leaks, perforations, and strictures. Stent migration frequently complicates management and often requires additional treatments to reach resolution. Our study aimed to determine predictive factors for stent migration. METHODS: Consecutive procedures involving SEMS placed with and without fixation after upper gastrointestinal surgery between 2009 and 2014 were retrospectively reviewed. Demographic, surgical history, rate of stent migration, and stent characteristic data were collected. Rates of stent migration were compared. RESULTS: We reviewed 214 consecutive procedures involving stents placed in the foregut. Median duration of stent placement was 4.0 ± 10.3 weeks. Forty-three (20%) stents migrated after placement. Of those, 27 (63%) required stent replacement. Eleven (5%) procedures utilized stent fixation and 203 (95%) did not. Fixation techniques included endoscopic clips (9%), endoscopic sutures (73%), and transnasal sutures (18%). Stent migration rate was not different between those with and those without fixation ( P = .2). Rate of migration was significantly higher in procedures involving fully covered stents ( P < .001). Migration occurred after esophagectomy and gastric bypass ( P < .001 and P < .05, respectively) and in patients with diabetes ( P < .01). CONCLUSIONS: A challenge with SEMS use is stent migration. Diabetes and using fully covered stents were associated with migration as were SEMS used to treat complications of esophagectomy and gastric bypass. Stent fixation was not associated with the prevention of stent migration. No pattern was found that favors an approach to reduce stent migration.

Efficacy of endoscopic management of leak after foregut surgery with endoscopic covered self-expanding metal stents (SEMS).

INTRODUCTION: Anastomotic or staple-line leak after foregut surgery presents a formidable management challenge. In recent years, with advancement of endoscopy, self-expanding covered stents have been gaining popularity. In this study, we aimed to determine the safety and effectiveness of self-expanding covered stents in management of leak after foregut surgery. METHODS: Consecutive patients who received a fully covered self-expandable metal stent (SEMS) due to an anastomotic leak after upper gastrointestinal surgery between 2009 and 2014 were retrospectively reviewed. Demographic data, stent placement and removal, clinical success, time to resolution, and complications were collected. Predictive factors for clinical success rate were assessed. RESULTS: A total of 20 consecutive patients underwent placement of fully covered SEMS for anastomotic leak, following esophagectomy (n = 5), esophageal diverticulectomy (n = 1), gastric sleeve (n = 4), gastric bypass (n = 3), partial gastrectomy (n = 4), and total gastrectomy (n = 3). All the stents were removed successfully, and clinical resolution was achieved in 18 patients (90 %) after a median of two (range 1-3) procedures and a mean of 6.2 weeks (range 0.4-14). Complications presented in 12 patients (60 %), including stent migration (n = 8), mucosal friability (n = 4), tissue integration (n = 2), and bleeding (n = 2). Two (10 %) patients' treatment was complicated by aorto-esophageal fistula formation resulting in one death. Demographic factors, comorbidities, and type of surgery were not predictive of clinical success rate or time to resolution. CONCLUSION: SEMS are effective tools for the management of leaks after foregut surgery. The biggest challenge with this approach is stent migration. Caution is warranted due to the risk of fatal complications such as aorto-esophageal fistula formation. No type of surgery or particular patient factor, including age, sex, BMI, albumin, history of radiation, malignancy, and comorbid diabetes or coronary artery disease, appeared to be correlated with success rate. Larger studies are needed to determine factors predictive of clinical success.

Angiographic Embolization in Pediatric Abdominal Trauma.

BACKGROUND: Trauma is the leading cause of childhood morbidity and mortality. Abdominal bleeding is one of the common causes of mortality due to trauma. Angiography and embolization are well recognized as the primary treatments in certain cases of acute traumatic hemorrhage in adults; however, evidence is lacking in the pediatric population. OBJECTIVES: To assess the safety and efficacy of transcatheter arterial embolization (TAE) for blunt and penetrating abdominal and pelvic trauma in the pediatric age group. METHODS: Three children with blunt abdominal trauma and one child with iatrogenic renal injury (age 4-13 years) were managed with TAE for lacerated liver (one patient), pelvic fractures (one patient) and renal injuries (two patients). The first two patients, victims of road accidents, had multisystem injuries and were treated by emergency embolization after fluid resuscitation in the Emergency Department (ED). The other two patients had renal injuries: a 4 year old boy with blunt abdominal trauma was diagnosed on initial computed tomography with an unexpected Wilms tumor and was treated with embolization 1 day after admission due to hemodynamic deterioration caused by active arterial tumor bleeding. The following day he underwent successful nephrectomy. The other patient was 13 year old boy with nephrotic syndrome who underwent renal biopsy and developed hemodynamic instability. After fluid resuscitation, he underwent an initial negative angiography, but second-look angiography the following day revealed active bleeding from an aberrant renal artery, which was then successfully embolized. RESULTS: In all four patients, TAE was diagnostic as well as therapeutic, and no child required surgical intervention for control of bleeding. CONCLUSIONS: We propose that emergency transcatheter angiography and arterial embolization be considered following resuscitation in the ED as initial treatment in children with ongoing bleeding after blunt abdominal trauma or iatrogenic renal injury. Implementation of this policy demands availability and cooperation of the interventional radiology services.

Abnormal placental invasion--a novel approach to treatment case report and review.

The incidence of abnormal placental invasion has increased 10-fold in the past 50 years, reflecting the increased number of cesarean sections performed. Management relies on accurate early diagnosis with appropriate perioperative multidisciplinary planning to anticipate and avoid massive obstetric hemorrhage at delivery. Women at risk should plan to deliver at an institution with appropriate expertise and resources for managing this condition. We report a case of placenta increta management comprising preoperative placement of a pelvic artery balloon catheter, prophylactic balloon occlusion after delivery of the fetus, and embolization-assisted resection of the invaded uterine wall. We review incidence, methods of prenatal diagnosis, risk factors, and management of abnormally invasive placenta.

Cutting balloon angioplasty for primary treatment of hemodialysis fistula venous stenoses: preliminary results.

PURPOSE: To assess the efficacy of the cutting balloon as the primary tool in percutaneous transluminal angioplasty of hemodialysis access stenoses. MATERIALS AND METHODS: A prospective study of symptomatic patients with stenoses of 50% or more in their hemodialysis accesses was undertaken. Provided that no contraindication to the use of cutting balloons existed, the stenoses were treated with the cutting balloon with use of a maximum of a 1:1.1 ratio between expected vessel diameter and balloon diameter. In cases in which dilation to the full diameter of the cutting balloon left a greater than 30% residual stenosis, postprocedural dilation with conventional balloons was carried out. Patient access function was followed. Twenty-nine patients with 42 stenoses have now reached 6 months of follow-up after cutting balloon angioplasty. RESULTS: Technical and clinical success rates were 100%. Slight local extravasation occurred in three cases: two had continued pain after the balloon was deflated and were therefore treated with balloon compression with resolution of symptoms and angiographic findings. In two cases, elastic recoil required stent placement to correct the stenosis. At 6 months, 22 patients (76%) remain in the primary patency category. Inclusion of those with primary assisted patency yields 26 patients (90%), and an additional patient had secondary patency, for a total of 93%. Two patients died of causes not directly related to dialysis. CONCLUSION: The high degree of technical and clinical success likely reflects the lack of major complications. The 6-month follow-up results match those of other series. Further follow-up will show whether this technique produces better results over the long term.

Uterine artery embolization for management of interstitial twin ectopic pregnancy: case report.

Interstitial pregnancy is rare and dangerous variation of ectopic pregnancy. We describe a case of unilateral interstitial viable twin pregnancy treated by selective uterine artery embolization. A 23-year-old women with clinical and ultrasonic diagnosis of viable twin interstitial pregnancy was treated by selective uterine artery embolization after failure of systemic methotrexate treatment. Her serum beta-HCG was undetectable 2 months after the procedure and the ultrasound scan 70 days after embolization showed only multiple echogenic spots in the right uterine cornua. This therapeutic modality seems to be effective for conservative management of interstitial ectopic pregnancy, and as a prophylactic measure before surgical intervention to prevent major bleeding.

The laparoscopic approach to abdominal hydatid cysts: a prospective nonselective study using the isolated hypobaric technique.

HYPOTHESIS: The laparoscopic isolated hypobaric technique that we developed and use is safe and feasible for almost all kinds of hepatic and extrahepatic abdominal hydatid cysts. DESIGN: A case series. PATIENTS: Between August 1992 and December 1999, 31 patients with no selection criteria underwent 32 consecutive laparoscopic operations for 52 symptomatic hydatid cysts located in the liver (49), spleen (1), and pelvis (2). Eleven patients underwent surgery for between 2 to 5 cysts. INTERVENTIONS: The main surgical maneuvers (puncture, parasite neutralization, and complete evacuation) were performed through an assembled transparent cannula, in which a vacuum was created, while its tip adhered firmly to the cyst wall. Following evacuation of the cyst contents, we attempted to perform partial pericystectomy, omentoplasty, and closed-suction drainage. MAIN OUTCOME MEASURES: Surgical complications and postoperative disease recurrence. RESULTS: Mean cyst diameter was 8.4 cm (range, 3.5-25 cm). Seven cysts were subdiaphragmatic, and 6 were on the posterior (hidden) aspect of the liver. Mean postoperative follow-up was 49 months. Forty-one cysts contained live parasites, and 11 were secondarily infected. Twenty-four cysts were complex. Perioperative complications occurred in 5 patients, including 1 patient who died 1 month after surgery owing to Candida sepsis. Mean hospital stay was 6 days. No evidence of recurrence was recorded during follow-up. CONCLUSIONS: The isolated hypobaric laparoscopic technique described provides a safe and efficacious approach to almost all types of abdominal hydatid cysts and takes advantage of the recognized benefits of the laparoscopic approach.

Clinical experience with Hexabrix in cerebral angiography.

Sixty patients from the University of British Columbia, Vancouver General Hospital, and University of Alberta Hospitals Edmonton participated in an open-labelled clinical study on the safety, tolerability and efficacy of ioxaglic acid (Hexabrix) in cerebral angiography. Only 4% of patients experienced significant pain during carotid and brachiocephalic injections of Hexabrix. No increased incidence of side effects or adverse effects were encountered. In addition, radiographic film quality overall was excellent and comparable to that obtained using conventional contrast agents. Hexabrix is a safe and effective contrast agent for cerebral angiography.