Outpatient Total Joint Arthroplasty at a High-Volume Academic Center: An Analysis of Failure to Launch.

BACKGROUND: Unanticipated failure to discharge home (failure to launch, FTL) following scheduled same-day discharge (SDD) total joint arthroplasty (TJA) is problematic for the surgical facility with respect to staffing, care coordination, and reimbursement concerns. The aim of this study was to review rates, etiologies, and contributing factors for FTL in SDD TJA at an inpatient academic medical center. METHODS: All patients who underwent primary TJA between February 2021 and February 2023 were retrospectively reviewed. Of those scheduled for SDD, risk factors for FTL were compared with successful SDD. Readmission and emergency department (ED) visits were compared with historical cohorts. There were 3,093 consecutive primary joint arthroplasties performed, of which 2,411 (78%) were scheduled for SDD. RESULTS: Overall, SDD was successful in 94.2% (n = 2,272) of patients who had an FTL rate of 5.8%. Specifically, SDD was successful in 91.4% with total hip arthroplasty, 96.0% with total knee arthroplasty, and 98.6% with unicompartmental knee arthroplasty. Factors that significantly increased the risk of FTL included general anesthesia versus spinal anesthesia (P < .0001), later surgery start time (P < .0001), longer surgical time (P = .0043), higher estimated blood loss (P < .0001), women (P = .0102), younger age (P = .0079), and lower preoperative mental health patient-reported outcomes scores (P = .0039). Readmission and ED visit rates were not higher in the SDD group when compared to historical controls (P = .6830). CONCLUSIONS: With a comprehensive multidisciplinary approach dedicated to improving SDDs at an academic medical center, we have seen successful SDD in nearly 80% of primary TJA, with an FTL rate of 5.8%, and no increased risk of readmission or ED visits. Without adding many personnel, hospital recovery units, or other resources, simple interventions to help decrease FTL have included enhanced preoperative education and expectation settings, improved perioperative communications, reallocating personnel from the inpatient to the outpatient setting, the use of short-acting spinal anesthetics, and earlier scheduled surgery times.

High-Fidelity Bell-State Preparation with

Entanglement generation in trapped-ion systems has relied thus far on two distinct but related geometric phase gate techniques: Mølmer-Sørensen and light-shift gates. We recently proposed a variant of the light-shift scheme where the qubit levels are separated by an optical frequency [B. C. Sawyer and K. R. Brown, Phys. Rev. A 103, 022427 (2021)PLRAAN2469-992610.1103/PhysRevA.103.022427]. Here we report an experimental demonstration of this entangling gate using a pair of ^{40}Ca^{+} ions in a cryogenic surface-electrode ion trap and a commercial, high-power, 532 nm Nd:YAG laser. Generating a Bell state in 35 µs, we directly measure an infidelity of 6(3)×10^{-4} without subtraction of experimental errors. The 532 nm gate laser wavelength suppresses intrinsic photon scattering error to ∼1×10^{-5}.

Strengthening a Culture to Address Bullying and Incivility in the Care Environment.

The safety of our patients and our workforce is paramount to elevating the health and wellness of the global communities we serve. The health and well-being of our frontline staff directly influences the environment of care, and it is our job as healthcare leaders to address workplace bullying, incivility, and lateral and horizontal violence. From patient to provider violence, to peer-peer bullying, these acts of incivility erode at the core of the care environment and impact an organization's culture of safety, influence nursing engagement scores, negatively impact patient outcomes, and decrease overall retention. Magnet® organizations help to elevate the practice of nursing and ensure world-class interprofessional care. Therefore, the Commission on Magnet has included new language in the 2023 Magnet Application Manual in the Organizational Overview (OO7), which directly addresses the organization's structure and processes aimed at addressing workplace violence, bullying, and incivility.

The effect of audiovisual distraction on patient-controlled sedation under spinal anesthesia: a prospective, randomized trial.

Audiovisual distraction (AVD) has been used to augment or replace procedural sedation. We investigated whether AVD in patients having total hip (THA) or total knee arthroplasty (TKA) under spinal anesthesia would reduce self-administered propofol consumption during surgery. 50 participants were randomized equally into a patient-controlled sedation (PCS) group or AVD group. All participants were given a spinal block and a propofol PCS device prior to surgery. In addition, Group AVD participants selected and watched a movie or documentary film on a tablet device with noise-cancelling headphones during surgery. The primary outcome of this study was total propofol consumption standardized as mcg/kg/min. Secondary outcomes evaluated increased supplemental oxygen use, rescue airway interventions, hypotension, disruptive movement events during surgery, sedation, and satisfaction with anesthesia scores. Historical clinician-controlled propofol usage at our institution over the previous 2 years were recorded. There was no significant difference in median propofol consumption between Groups PCS and AVD, 8.4 mcg/kg/min (1.6-18.9) vs 4 mcg/kg/min (0-9) (P = 0.29), respectively. Historical clinician-controlled usage of propofol demonstrated a median of 39.3 mcg/kg/min (29.2-51.2). There were few differences in the secondary outcome measures. The use of AVD did not reduce patient-controlled propofol consumption in patients having a THA or TKA surgery under spinal anesthesia.

Continuous Transversus Abdominis Plane Block for Primary Open Inguinal Hernia Repair: A Randomized, Double-Blind, Placebo-Controlled Trial.

OBJECTIVE: Patients undergoing open inguinal hernia repair may experience moderate to severe postoperative pain. We assessed opioid consumption in subjects who received a continuous transversus abdominis plane block in addition to standard multimodal analgesia. DESIGN: Randomized, double-blind, placebo-controlled. SETTING: Tertiary academic medical center. SUBJECTS: Adult patients undergoing open inguinal hernia repair at Virginia Mason Medical Center. A total of 90 patients were enrolled. METHODS: Subjects presenting for surgery were randomized to receive either a continuous transversus abdominis plane block or a subcutaneous sham block. The primary outcome was opioid consumption within the first 48 hours after surgery. Secondary outcomes included pain scores, activities assessment scores, and opioid-related adverse events. Multimodal analgesia utilized in both groups included acetaminophen, nonsteroidal anti-inflammatory drugs, and surgical local anesthetic infiltration. RESULTS: Eighty-two subjects, 42 from the block group and 40 from the sham group, completed the study, per protocol. The intention-to-treat analysis demonstrated no difference in 48-hour postoperative oxycodone equivalent consumption between the block and sham groups (27.8 mg ± 26.8 vs 32 mg ± 39.2, difference -4.4 mg, P = 0.55). There was a statistically significant reduction in pain scores at 24 hours in the block group. There were no other differences in secondary outcomes. CONCLUSIONS: Continuous transversus abdominis plane blocks provide modest improvements in pain after open inguinal hernia repair but fail to significantly reduce opioid consumption or improve functional activity levels in the setting of multimodal analgesia use.

Nurse and Patient Satisfaction.

The American Nurses Credentialing Center's Magnet Recognition Program 2019 Magnet Application Manual "continue(s) to raise the bar as the gold standard for nursing" (p. IX). In this column, the authors, who are Magnet commissioners, provide background and guidance on the standards for nurse satisfaction and patient satisfaction.

Case Report of a Massive Thigh Hematoma after Adductor Canal Block in a Morbidly Obese Woman Anticoagulated with Apixaban.

Hematoma formation after peripheral nerve block placement is a rare event. We report a case of a morbidly obese patient who was anticoagulated with apixaban and developed a massive thigh hematoma after an ultrasound-guided adductor canal block. Despite continuous visualization of the block needle, an unrecognized vascular injury occurred leading to a 14-cm hematoma in the anterolateral thigh. Morbid obesity warrants additional risk consideration when placing nerve blocks in an anticoagulated patient. In addition, early recognition and expert consultation are both important in the management of block-related hematomas.

Stepwise Aggregation of Cholate and Deoxycholate Dictates the Formation and Loss of Surface-Available Chirally Selective Binding Sites.

Bile salts are facially amphiphilic, naturally occurring chemicals that aggregate to perform numerous biochemical processes. Because of their unique intermolecular properties, bile salts have also been employed as functional materials in medicine and separation science (e.g., drug delivery, chiral solubilization, purification of single-walled carbon nanotubes). Bile micelle formation is structurally complex, and it remains a topic of considerable study. Here, the exposed functionalities on the surface of cholate and deoxycholate micelles are shown to vary from one another and with the micelle aggregation state. Collectively, data from NMR and capillary electrophoresis reveal preliminary, primary, and secondary stepwise aggregation of the salts of cholic (CA) and deoxycholic (DC) acid in basic conditions (pH 12, 298 K), and address how the surface availability of chirally selective binding sites is dependent on these sequential stages of aggregation. Prior work has demonstrated sequential CA aggregation (pH 12, 298 K) including a preliminary CMC at ca. 7 mM (no chiral selection), followed by a primary CMC at ca. 14 mM that allows chiral selection of binaphthyl enantiomers. In this work, DC is also shown to form stepwise preliminary and primary aggregates (ca. 3 mM DC and 9 mM DC, respectively, pH 12, 298 K) but the preliminary 3 mM DC aggregate is capable of chirally selective solubilization of the binaphthyl enantiomers. Higher-order, secondary bile aggregates of each of CA and DC show significantly degraded chiral selectivity. Diffusion NMR reveals that secondary micelles of CA exclude the BNDHP guests, while secondary micelles of DC accommodate guests, but with a loss of chiral selectivity. These data lead to the hypothesis that secondary aggregates of DC have an exposed binding site, possibly the 7α-edge of a bile dimeric unit, while secondary CA micelles do not present binding edges to the solution, potentially instead exposing the three alcohol groups on the hydrophilic α-face to the solution.

Comparison of Continuous Proximal Versus Distal Adductor Canal Blocks for Total Knee Arthroplasty: A Randomized, Double-Blind, Noninferiority Trial.

BACKGROUND AND OBJECTIVES: Adductor canal blocks (ACBs) are associated with improved analgesia, preserved quadriceps strength, and decreased length of hospitalization after total knee arthroplasty (TKA). However, controversy remains regarding the ideal location of a continuous block within the adductor canal, and it remains unclear whether similar clinical benefits are obtained irrespective of block location. In this randomized, double-blind, noninferiority study, we hypothesized that a continuous proximal ACB provides postoperative analgesia that is no worse than a continuous distal ACB. METHODS: Subjects presenting for unilateral TKA were randomized in a 1:1 ratio to either a continuous proximal or distal ACB group. The primary outcome of this noninferiority study was opioid consumption within the first 24 hours following surgery. Secondary outcomes included quadriceps strength, pain scores, distance ambulated, and patient satisfaction. RESULTS: Seventy-three subjects, 36 from the proximal group and 37 from the distal group, completed the study per protocol. The intention-to-treat analysis demonstrated a cumulative mean intravenous morphine equivalent consumption difference between the proximal and distal groups of -7.2 mg (95% confidence interval, -14.8 to 0.4; P < 0.001), demonstrating noninferiority of the proximal approach. The per-protocol analysis yielded similar results: -6.2 mg (95% confidence interval, -14.1 to 1.6; P < 0.001). No secondary outcomes showed statistically significant differences between the proximal and distal groups. CONCLUSIONS: This study demonstrates that a continuous proximal ACB offers noninferior postoperative analgesia compared with a distal continuous ACB in the first 24 hours after TKA. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov (NCT02701114).

Rapid Voltammetric Measurements at Conducting Polymer Microelectrodes Using Ultralow-Capacitance Poly(3,4-ethylenedioxythiophene):Tosylate.

UNLABELLED: We use a vapor-phase synthesis to generate conducting polymer films with low apparent capacitance and high conductance enabling rapid electrochemical measurements. Specifically, oxidative chemical vapor deposition was used to create thin films of poly(3,4-ethylenedioxythiophene):tosylate ( PEDOT: tosylate). These films had a conductance of 17.1 ± 1.7 S/cm. Furthermore, they had an apparent capacitance of 197 ± 14 µF/cm(2), which is an order of magnitude lower than current commercially available and previously reported PEDOT. Using a multistage photolithography process, these films were patterned into PEDOT: tosylate microelectrodes and were used to perform fast-scan cyclic voltammetry (FSCV) measurements. Using a scan rate of 100 V/s, we measured ferrocene carboxylic acid and dopamine by FSCV. In contrast to carbon-fiber microelectrodes, the reduction peak showed higher sensitivity when compared to the oxidation peak. The adsorption characteristics of dopamine at the polymer electrode were fit to a Langmuir isotherm. The low apparent capacitance and the microlithographic processes for electrode design make PEDOT: tosylate an attractive material for future applications as an implantable biosensor for FSCV measurements. Additionally, the integration of PEDOT: tosylate electrodes on plastic substrates enables new electrochemical measurements at this polymer using FSCV.

A Novel Approach to Brachial Plexus Catheter Management: A Brachial Plexus Test Dose for Phrenic Nerve Paralysis and Patient-Controlled, Demand-Only Dosing for a Patient With Extreme Obesity.

A 53-year-old woman with extreme obesity (body mass index = 82 kg/m) presented for an open reduction and internal fixation of the proximal humerus. This report describes the novel management of her continuous brachial plexus catheter in the setting of her comorbidities. Phrenic nerve paralysis from brachial plexus blocks can cause clinically significant dyspnea in obese patients. Brachial plexus catheters can be used effectively for these patients with some modification to routine management. We detail our use of a short-acting chloroprocaine test dose for phrenic paralysis and demand-only dosing to provide effective analgesia while avoiding respiratory complications associated with these blocks.

Role functioning is associated with survival in patients with hepatocellular carcinoma.

BACKGROUND: Prior studies assessing quality of life (QOL) in patients with hepatocellular carcinoma (HCC) primarily included patients with preserved liver function and/or early HCC, leading to overestimation of QOL. Our study's aim was to evaluate the association of QOL with survival among a cohort of cirrhotic patients with HCC that was diverse with respect to liver function and tumor stage. METHODS: We conducted a prospective cohort study among cirrhotic patients with HCC from a large urban safety-net hospital between April 2011 and September 2013. Patients completed two self-administered surveys, the EORTC QLQ-C30 and QLQ-HCC18, prior to the treatment. We used generalized linear models to identify correlates of QOL. Survival curves were generated using Kaplan-Meier analysis and compared using log rank test to determine whether QOL is associated with survival. RESULTS: A total of 130 treatment-naïve patients completed both surveys. Patients reported high cognitive and social function (median scores 67) but poor global QOL (median score 50) and poor role function (median score 50). QOL was associated with cirrhosis-related (p = 0.02) and tumor-related (p = 0.02) components of Barcelona Clinic Liver Cancer (BCLC) tumor stage. QOL was associated with survival on univariate analysis (HR 0.37, 95 % CI 0.16-0.85) but became nonsignificant (HR 0.82, 95 % CI 0.37-1.80) after adjusting for BCLC stage and treatment. Role functioning was significantly associated with survival (HR 0.40, 95 % CI 0.20-0.81), after adjusting for Caucasian race (HR 0.31, 95 % CI 0.16-0.59), BCLC stage (HR 1.51, 95 % CI 0.21-1.89), and treatment (HR 0.57, 95 % CI 0.33-0.97). CONCLUSIONS: Role function has prognostic significance and is important to assess in patients with HCC.

Preferential accumulation within tumors and in vivo imaging by functionalized luminescent dendrimer lanthanide complexes.

We have created a dendrimer complex suitable for preferential accumulation within liver tumors and luminescence imaging by substituting thirty-two naphthalimide fluorophores on the surface of the dendrimer and incorporating eight europium cations within the branches. We demonstrate the utility and performance of this luminescent dendrimer complex to detect hepatic tumors generated via direct subcapsular implantation or via splenic injections of colorectal cancer cells (CC531) into WAG/RijHsd rats. Luminescence imaging of the tumors after injection of the dendrimer complex via hepatic arterial infusion revealed that the dendrimer complex can preferentially accumulate within liver tumors. Further investigation indicated that dendrimer luminescence in hepatic tumors persisted in vivo. Due to the incorporation of lanthanide cations, this luminescence agent presents a strong resistance against photobleaching. These studies show the dendrimer complex has great potential to serve as an innovative accumulation and imaging agent for the detection of metastatic tumors in our rat hepatic model.