Ultrasound-Guided Supraorbital Nerve Block as a Diagnostic Tool in the Outpatient Physiatry Setting: A Case Report and Review of the Literature.

ABSTRACT: Here we describe a case in which an ultrasound-guided supraorbital nerve block was used for the purposes of confirming the diagnosis of trigeminal neuralgia associated with Herpes Zoster and determining which trigeminal nerve branch is the pain generator in a patient with clinically suggestive findings. We discuss how performing a nerve block at the site of where the affected nerve exits the skull may identify which nerve is mediating the patient's symptoms and therefore guide possible further treatment options which could potentially provide a more lasting duration of relief.

Providers' Shift to Telerehabilitation at the U.S. Veterans Health Administration During COVID-19: Practical Applications.

Telerehabilitation provides Veteran patients with necessary rehabilitation treatment. It enhances care continuity and reduces travel time for Veterans who face long distances to receive care at a Veterans Health Administration (VHA) medical facility. The onset of the COVID-19 pandemic necessitated a sudden shift to telehealth-including telerehabilitation, where a paucity of data-driven guidelines exist that are specific to the practicalities entailed in telerehabilitation implementation. This paper explicates gains in practical knowledge for implementing telerehabilitation that were accelerated during the rapid shift of VHA healthcare from out-patient rehabilitation services to telerehabilitation during the COVID-19 pandemic. Group and individual interviews with 12 VHA rehabilitation providers were conducted to examine, in-depth, the providers' implementation of telerehabilitation. Thematic analysis yielded nine themes: (i) Willingness to Give Telerehabilitation a Chance: A Key Ingredient; (ii) Creativity and Adaptability: Critical Attributes for Telerehabilitation Providers; (iii) Adapting Assessments; (iv) Adapting Interventions; (v) Role and Workflow Adaptations; (vi) Appraising for Self the Feasibility of the Telerehabilitation Modality; (vii) Availability of Informal, In-Person Support Improves Feasibility of Telerehabilitation; (viii) Shifts in the Expectations by the Patients and by the Provider; and (ix) Benefit and Anticipated Future of Telerehabilitation. This paper contributes an in-depth understanding of clinical reasoning considerations, supportive strategies, and practical approaches for engaging Veterans in telerehabilitation.

COVID-19 Tracheostomy Outcomes.

OBJECTIVES: (1) Assess overall COVID-19 mortality in ventilated patients with and without tracheostomy. (2) Determine the impact of tracheostomy on mechanical ventilation duration, overall length of stay (LOS), and intensive care unit (ICU) LOS for patients with COVID-19. STUDY DESIGN: Case series with planned chart review. SETTING: Single-institution tertiary care center. METHODS: Patients with COVID-19 who were ≥18 years old and requiring invasive positive pressure ventilation (IPPV) met inclusion criteria. Patients were stratified into 2 cohorts: IPPV with tracheostomy and IPPV with intubation only. Cohorts were analyzed for the following primary outcome measures: mortality, LOS, ICU LOS, and IPPV duration. RESULTS: An overall 258 patients with IPPV met inclusion criteria: 46 (18%) with tracheostomy and 212 (82%) without (66% male; median age, 63 years [interquartile range, 18.75]). Average LOS, time in ICU, and time receiving IPPV were longer in the tracheostomy cohort (P < .01). Ability to wean from IPPV was similar between cohorts (P > .05). The number of deaths in the nontracheostomy cohort (54%) was significantly higher than the tracheostomy cohort (29%, P < .01). CONCLUSIONS: While tracheostomy placement in patients with COVID-19 did not shorten overall LOS, mechanical ventilation duration, or ICU LOS, patients with a tracheostomy experienced a significantly lower number of deaths vs those without. One goal for tracheostomy is improved pulmonary toilet with associated shortened IPPV requirements. Our study did not identify this advantage among the COVID-19 population. However, this study demonstrates that the need for tracheostomy in the COVID-19 setting does not portent a poor prognostic factor, as patients with a tracheostomy experienced a significantly higher survival rate than their nontracheostomy counterparts.

Choosing Wisely: Decreasing the incidence of perioperative blood transfusions in gynecologic oncology.

OBJECTIVE: To evaluate the efficacy and economic impact of a transfusion reduction initiative for patients undergoing gynecologic surgery. METHODS: We conducted a prospective healthcare improvement study to align transfusion practices with the American Society of Hematology's Choosing Wisely® campaign. Baseline transfusion rates were determined retrospectively for all major gynecologic surgical cases from 3/1/14 to 6/30/14. Data for the post-intervention period from 5/15/15 to 5/16/16 were captured prospectively. The primary outcome was transfusion within 72 h of surgery. Secondary outcomes included perioperative morbidity, mortality, number of units ordered per transfusion episode and cost. RESULTS: We identified 1281 surgical cases, 334 in the baseline and 947 in the post-implementation cohort. The baseline cohort was noted to have a higher median estimated blood loss (100 v. 75 mL, P < 0.01). Otherwise, there were no differences in clinical or perioperative characteristics between the two cohorts. The perioperative transfusion rate decreased from 24% to 11% (adjusted OR 0.27, 95% CI 0.16 to 0.45; P < 0.001). The perioperative laparotomy transfusion rate decreased from 48% to 23% (adjusted OR 0.21, 95% CI 0.12, 0.37; P < 0.001). The number of occurrences in which more than one unit of blood was ordered at a time decreased from 65% to 23%, P < 0.001. The incidence of surgical site infections declined in the post-intervention group, otherwise there were no differences in 30-day mortality, cardiac, venous thromboembolism or readmission rates between the groups. The projected cost savings was $161,112 over the 12-month intervention period. CONCLUSIONS: Implementation of an educational based transfusion reduction program was associated with substantial reductions in perioperative transfusions and cost without significant changes in morbidity or mortality.

The DISINFECT Initiative: Decreasing the Incidence of Surgical INFECTions in Gynecologic Oncology.

BACKGROUND: Surgical site infections (SSIs) lead to increased patient morbidity and healthcare costs. Our objective was to decrease the SSI rate following gynecologic surgery. METHODS: Adult patients undergoing abdominal surgery for gynecologic malignancy or benign disease received the following: patient education; preoperative antibacterial soap; appropriate antibiotic prophylaxis; change of gloves and use of clean instruments at surgical closure; surgical dressing for 48 h; and a post-discharge phone call. The baseline SSI rate was determined retrospectively (1 April 2014-30 June 2014), while the post-intervention SSI rate was determined prospectively (16 February 2015-15 October 2015). The main outcome was the overall SSI rate with secondary outcomes, including the rate of superficial, deep, incisional and organ space infection, as well as the cost effectiveness of the bundle. RESULTS: A total of 232 baseline and 555 post-intervention patients were included in the study. No differences were observed between the baseline and post-intervention groups with regard to median body mass index (BMI), surgical approach, receipt of preoperative chemotherapy and/or radiation therapy, and cases including bowel surgery. Overall, the SSI rate decreased significantly from baseline [12.5 %] to post-intervention [7.4 %] (odds ratio [OR] 0.56, 90 % confidence interval [CI] 0.37-0.85; p = 0.01). A 40 % decrease was noted in the rate of superficial and deep infections (9.5 vs. 5.9 %; OR 0.60, 90 % CI 0.38-0.97; p = 0.04) and SSIs after open surgery (21.4 vs. 13.2 %; OR 0.56, 90 % CI 0.34-0.92; p = 0.03). The estimated cost of the intervention was $19.26/case and the net total amount saved during the post-intervention period was $65,625 month. CONCLUSIONS: This bundled intervention led to a significant decrease in the overall SSI rate and was cost effective. The largest decreases in SSIs were in incisional infections and following open surgery.

What Is the Real Rate of Surgical Site Infection?

PURPOSE: Surgical site infections (SSIs) are associated with patient morbidity and increased health care costs. Although several national organizations including the University HealthSystem Consortium (UHC), the National Surgical Quality Improvement Program (NSQIP), and the National Healthcare Safety Network (NHSN) monitor SSI, there is no standard reporting methodology. METHODS: We queried the UHC, NSQIP, and NHSN databases from July 2012 to June 2014 for SSI after gynecologic surgery at our institution. Each organization uses different definitions and inclusion and exclusion criteria for SSI. The rate of SSI was also obtained from chart review from April 1 to June 30, 2014. SSI was classified as superficial, deep, or organ space infection. The rates reported by the agencies were compared with the rates obtained by chart review using Fisher's exact test. RESULTS: Overall SSI rates for the databases were as follows: UHC, 1.5%; NSQIP, 8.8%; and NHSN, 2.8% (P < .001). The individual databases had wide variation in the rate of deep infection (UHC, 0.7%; NSQIP, 4.7%; NHSN, 1.3%; P < .001) and organ space infection (UHC, 0.4%; NSQIP, 4.4%; NHSN, 1.4%; P < .001). In agreement with the variation in reporting methodology, only 19 cases (24.4%) were included in more than one database and only one case was included in all three databases (1.3%). CONCLUSION: There is discordance among national reporting agencies tracking SSI. Adopting standardized metrics across agencies could improve consistency and accuracy in assessing SSI rates.

Ethical considerations in elective amputation after traumatic peripheral nerve injuries.

Traumatic peripheral nerve injuries often complicate extremity trauma, and may cause substantial functional deficits. We have encountered patients who request amputation of such injured extremities, with the goal of prosthetic replacement as a means to restore function. Data on long-term outcomes of limb salvage vs amputation are limited and somewhat contradictory, leaving how to respond to such requests in the hands of the treating physician. We present example cases, drawn from our experience with wounded soldiers in a peripheral nerve injury clinic, in order to facilitate discussion of the ways in which these patients stress the system of medical decision-making while identifying ethical questions central to responding to these requests.

Tubular heart valves: a new tissue prosthesis design--preclinical evaluation of the 3F aortic bioprosthesis.

BACKGROUND: It was hypothesized that native heart valves function as if they were simple tubes with sides that collapse when external pressure is applied. Because "form follows function," this hypothesis could theoretically be confirmed by implanting a simple tube into the anatomic position of any native heart valve and documenting that under the same anatomic constraints and physiologic conditions as the native valve, the tube would assume the form of that native valve. If the hypothesis were thus proved, it would follow that a tissue valve based on a tubular design would have superior flow dynamics and stress distribution and would therefore be expected to outlast currently available tissue valves. Such a tubular tissue valve, the 3F Aortic Bioprosthesis (3F Therapeutics, Inc, Lake Forest, Calif) was designed and tested in vitro against a commercially available stentless aortic bioprosthesis. METHODS: With the use of state-of-the-art testing equipment, some of which had to be developed especially to test this truly stentless bioprosthesis in vitro, transvalvular gradients, effective orifice areas, degree of transvalvular laminar flow, finite element analysis of the distribution of leaflet stress, and accelerated wear testing for long-term durability were evaluated for the new 3F Aortic Bioprosthesis in comparison with the St Jude Medical Toronto SPV aortic bioprosthesis (St Jude Medical, Inc, St Paul, Minn). RESULTS: The valve gradients were lower and the effective orifice areas were greater for the 3F Aortic Bioprosthesis at all valve sizes and under all test conditions, including cardiac outputs ranging from 2.0 to 7.0 L/min, mean perfusion pressures from 40 to 200 mm Hg, and aortic compliances of 4% and 16%. The transvalvular flow across the 3F Aortic Bioprosthesis in vitro was qualitatively smooth, with a minimum of surrounding vortices. Maximum stress occurred in the belly of the leaflets of the 3F Aortic Bioprosthesis, with minimum stress at the commissural posts. The 3F Aortic Bioprosthesis was superior to the Toronto SPV valve in accelerated wear tests. CONCLUSIONS: These in vitro studies show that a tissue aortic valve designed on the basis of the proved engineering principle that form follows function has better hemodynamics, flow dynamics, stress distribution, and durability when compared under identical in vitro conditions with an excellent commercially available tissue aortic valve.

Malignancy: Case Report: Muscle Involvement in Multiple Myeloma: Report of a Patient Presenting Clinically as Polymyositis.

Although bone pain is common in multiple myeloma (MM), muscular symptoms, especially myalgias, may be rare. We describe a patient who presented with generalised myopathy and elevated creatine kinase (CK) suggestive of polymyositis. Routine blood tests showed raised viscosity and marked rouleaux formation in the peripheral blood film. A serum protein electrophoresis showed IgG Lambda paraproteinemia with immunoparesis. A sternal bone marrow aspirate and a bone marrow biopsy concurrently obtained from the right posterior iliac crest showed considerable (15-20%) marrow infiltration with plasma cells confirming a diagnosis of multiple myeloma. A review of the literature suggests that generalised myopathy and elevated CK associated with MM have not been reported in the past. We believe this is the first reported case of MM presenting as polymyositis.

Murine macrophage activation with resorcyclic acid lactones (RALs): comparison with diethylstilbestrol and 17 beta-estradiol.

Zearalane, a resorcyclic acid lactone (RAL) derivative, activates murine macrophages (M phi) in vivo and in vitro. Mouse M phi incubated in vitro with different concentrations of zearalane released superoxide anion (O2-) on stimulation with either opsonized zymosan (Op-zym), phorbol myristate acetate (PMA), or Salmonella typhimurium. The levels of O2- released were similar to those released from M phi incubated in vitro with supernatants enriched in macrophage-activating factors from concanavalin A-stimulated mouse spleen cells. In contrast, 17 beta-estradiol (E2) or diethylstilbestrol (DES) induced little or no enhancement of O2- release. Zearalane, dideoxyzearalane, DES and E2 were tested for induction of host resistance to S. typhimurium infection in mice. Treatment of mice with zearalane (9 mg/kg) resulted in at least 65% survival 4 days post-infection, compared to 10% survival of mice with vehicle alone, DES, or E2. Peritoneal and alveolar M phi from the zearalane-treated mice released up to six times as much O2- on stimulation with Op-zym as M phi from the other treatment groups. M phi activation was observed for up to 7 days after intraperitoneal or subcutaneous administration of zearalane in either aqueous or organic vehicles. These results suggest that zearalane may enhance resistance to infection by increasing bactericidal activity due to increased release of toxic oxygen radicals by M phi and mononuclear phagocytes. These effects differ from the immunosuppressive effects reported for DES and E2.

Biosorption of uranium and lead by Streptomyces longwoodensis.

Biosorption of uranium and lead by lyophilized cells of Streptomyces longwoodensis was examined as a function of metal concentration, pH, cell concentration, and culture age. Cells harvested from the stationary growth phase exhibited an exceptionally high capacity for uranium (0.44 g U/g dry weight) at pH 5. Calculated values of the distribution coefficient and separation factor indicated a strong preference of the cell mass for uranyl ions over lead ions. The specific uranium uptake was similar for the cell wall and the cytoplasmic fraction. Uranium uptake was associated with an increase in hydrogen ion concentration, and phosphorus analysis of whole cells indicated a simple stoichiometric ratio between uranium uptake and phosphorus content. It is proposed that metal ions are bound to phosphodiester residues present both in the cell wall and cytoplasmic fractions. Based on this model, it was shown that uranium accumulation exhibits a maximum at pH 4.6 that is supported by experimental data from previous investigations.