Implementation of Vertical Split Flow Model for Patient Throughput at a Community Hospital Emergency Department.

BACKGROUND: Hospitals have implemented innovative strategies to address overcrowding by optimizing patient flow through the emergency department (ED). Vertical split flow refers to the concept of assigning patients to vertical chairs instead of horizontal beds based on patient acuity. OBJECTIVE: Evaluate the impact of vertical split flow implementation on ED Emergency Severity Index (ESI) level 3, patient length of stay, and throughput at a community hospital. METHODS: Retrospective cohort study of all ESI level 3 patients presenting to a community hospital ED over a 3-month period prior to and after vertical split flow implementation between 2018 and 2019. RESULTS: In total, data were collected from 10,638 patient visits: 5262 and 5376 patient visits pre- and postintervention, respectively. There was a significant reduction in mean overall length of stay when ESI-3 patients were triaged with vertical split flow (251 min vs 283 min, p < 0.001). CONCLUSIONS: Community hospital ED implementation of vertical split flow for ESI level 3 patients was associated with a significant reduction in overall length of stay and improved throughput. This model provides a solution to increase the number of patients that can be simultaneously cared for in the ED without increasing staffing or physical space.

Handheld Point-of-Care Ultrasound: Safety Considerations for Creating Guidelines.

BACKGROUND: Compared to traditional ultrasound machines, emerging handheld point-of-care-ultrasound (HPOCUS) systems exhibit superior portability and affordability. Thus, they have been increasingly embraced in the intensive care setting. However, there is scarce data on patient safety and current regulatory body guidelines are lacking. Here, we critically appraise the literature with a focus on the merits, concerns, and framework of existing POCUS guidelines. Subsequently, we provide recommendations for future regulatory guidelines. METHODS: A comprehensive literature review was conducted using the PubMed database employing the key words "point-of-care/handheld/portable ultrasound" and "guidelines" alone, in combination, and using thesaurus terms. Eligible articles were scrutinized for description of potential benefits and concerns of HPOCUS, especially from a patient safety perspective, as well as currently existing POCUS practice guidelines. Data was extracted, reported thematically using a narrative synthesis approach, then subsequently used to guide our proposed guidelines. RESULTS: The most widely reported benefits of HPOCUS include superior portability, affordability, imaging, facilitation of expedited diagnosis and management, and integration with medical workplace flow. However, major barriers to adoption include device security/patient confidentiality and patient safety. Furthermore, except for a policy published by the American College of Emergency Physicians (ACEP) in 2018, there are few other national regulatory guidelines pertaining to handheld POCUS. In light of this, we propose a framework for HPOCUS guideline development to address these and other concerns. Such guidelines include training and credentialing, bioengineering approval, and strategic integration with electronic medical record systems. CONCLUSION: HPOCUS can be a powerful tool for expedited diagnosis and management guidance. However, there is limited data regarding patient safety and current regulatory body guidelines are lacking. Our assessment illuminates that there remain many unsolved problems about HPOCUS, and in turn, we propose guidelines to address safe regulation and implementation.

Contemporary diagnosis and management of pelvi-ureteric junction obstruction.

Pelvi-ureteric junction obstruction (PUJO) is defined as a functionally significant impairment of the flow of urine from the kidney's renal pelvis into the proximal ureter. Symptomatically, the patient may experience flank pain, recurrent infections, stone formation, and impairment of renal function. Although many cases of intrinsic PUJO are diagnosed at birth, a minority of patients may present in adulthood with previously silent disease or develop secondary PUJO to other causes. PUJO is therefore broadly categorised into both primary and secondary PUJO. A wide array of diagnostic scans and tests are available to aid in diagnosing and monitoring patients with PUJO. In patients with compromised renal function or symptomatic PUJO that require intervention, minimally invasive techniques are the 'gold standard' for surgical intervention. This review will detail the endoscopic, laparoscopic, and robotic options available to the urologist practicing in 2021, including the use of autografts and other emerging technologies.

Conservative Management of Liver Perforation During Percutaneous Nephrolithotomy: Case Couplet Presentation.

Percutaneous nephrolithotomy (PCNL) remains the recommended intervention for large kidney stones, major complications, although rare, are between 1% and 7%. Literature regarding liver injury during PCNL is sparse, and many incidences occur unnoticed. In general, most liver injuries can be treated conservatively when compared with other organ injury sustained during PCNL. Despite this, there is still significant potential for intraperitoneal bleeding as well as possible hemodynamic instability that may result secondary to the inadvertent access. Our team describes two cases of liver injury during PCNL with focus on presentation and injury management. Both cases were treated conservatively through close clinical monitoring and delayed removal of nephrostomy tube. Both liver injuries were diagnosed primarily through postprocedure axial CT imaging. In general, risk factors include supracostal access, particularly at or above the 11th rib, as well as hepatomegaly. Despite that liver injury is a rare complication of right-sided PCNL, outcomes can result in significant blood loss not diagnosed. We present in this study two instances of effective conservative management of liver injury after PCNL.

Management of Splenic Injury During Percutaneous Nephrolithotomy: Report of Two Cases.

Percutaneous nephrolithotomy (PCNL) has become the standard of care for the removal of kidney stones >2 cm. Major complications, although rare, are between 1% and 7%. Splenic injury during PCNL is rare and can often be managed conservatively, but has the potential to be devastating, necessitating the importance of early diagnosis. Our team describes two cases of splenic injury during PCNL with emphasis on diagnosis and management. Although both cases were managed conservatively through close monitoring and prolonged nephrostomy tube presence, one case had a concurrent pneumothorax. Both cases were diagnosed primarily through postprocedure CT imaging. Risk factors primarily include supracostal access and splenomegaly. Splenic injury is a rare complication that can often be managed conservatively; however, prompt recognition of injury is important. We present in this study two cases of conservative splenic injury management sustained during PCNL.

Management of Colon Perforation During Percutaneous Nephrolithotomy in Patients with Complex Anatomy: A Case Series.

Percutaneous nephrolithotomy (PCNL), first described in 1976, is the gold standard for the management of large kidney stones, with stone-free rates as high as 95% in contemporary literature. Colonic injuries during PCNL are a rare complication with an estimated incidence of 0.3%-0.5%. However, given the high morbidity incurred and the necessity of prompt operative intervention, it is imperative that practitioners have a low suspicion threshold for such injuries, particularly in those patients with altered or complex anatomy. This case series addresses peri- and postoperative outcomes of colon perforation during PCNL in patients with complex anatomy and reviews the technical challenges of surgery with potential methods to avoid injury in the future. Herein we review three instances of colonic injuries and their subsequent management to highlight both the presentation and the optimal management of these rare occurrences.

Thyroid cancer clinical trials in the United States: Understanding trends to maximize impact.

BACKGROUND: We sought to understand thyroid cancer study modalities, publications, and grants. This provides scope, resources, and dissemination patterns to inform future directions for research and policy. METHODS: A retrospective study of thyroid cancer trials using ClinicalTrials.gov was performed. Publication and grant awards were sourced using PubMed.gov and NIH RePORTER, respectively. RESULTS: Seventy-three thyroid cancer trials were identified out of 217 000 from 1998 to 2015. Drugs were studied in 96% of all trials. Only 14% of all trials included radiation, and 4% included surgery. Only 29% of trials published their results, NIH funding was reported for 26% of trials. Total funding was $1 845 567 484 (average award: $97135131). CONCLUSION: This study is the first to prove that drug trials predominate in thyroid cancer and quantify NIH dollars awarded. Radiation and surgery are underrepresented, despite being standard of care. We recommend better balance of therapeutics and peer-reviewed reporting of positive and negative results. LEVEL OF EVIDENCE: Level 1a evidence.

Functional genetic discovery of enzymes using full-scan mass spectrometry metabolomics 1.

Our understanding of metabolic networks is incomplete, and new enzymatic activities await discovery in well-studied organisms. Mass spectrometric measurement of cellular metabolites reveals compounds inside cells that are unexplained by current maps of metabolic reactions, and existing computational models are unable to account for all activities observed within cells. Additional large-scale genetic and biochemical approaches are required to elucidate metabolic gene function. We have used full-scan mass spectrometry metabolomics of polar small molecules to examine deletion mutants of candidate enzymes in the model yeast Saccharomyces cerevisiae. We report the identification of 25 genes whose deletion results in focal metabolic changes consistent with loss of enzymatic activity and describe the informatic approaches used to enrich for candidate enzymes from uncharacterized open reading frames. Triumphs and pitfalls of metabolic phenotyping screens are discussed, including estimates of the frequency of uncharacterized eukaryotic genes that affect metabolism and key issues to consider when searching for new enzymatic functions in other organisms.

Management Strategies in Opioid Abuse and Sexual Dysfunction: A Review of Opioid-Induced Androgen Deficiency.

INTRODUCTION: Over the last several decades, the opioid epidemic has become a national crisis, largely spurred by the spike in the use of prescription painkillers. With the epidemic came a concomitant rise in the incidence of opioid-induced androgen deficiency (OPIAD). Although OPIAD can significantly impact male sexual function and quality of life, it is an overlooked and poorly understood clinical entity that requires more attention from healthcare providers. AIM: The objectives of the current review are to highlight the increasing incidence of OPIAD and the importance of an integrated, multidisciplinary approach to identify and treat patients with the condition. METHODS: This review presents the epidemiology surrounding the current opioid epidemic, with a focus on its origin, followed by a literature review surrounding the pathophysiology, diagnosis, and treatment of OPIAD. MAIN OUTCOME MEASURE: Single-center studies were used to determine the safety and efficacy of various opioid and testosterone formulations on analgesia, sexual function, and quality of life. RESULTS: There should be a low threshold for obtaining laboratory studies (testosterone, luteinizing hormone [LH], follicle-stimulating hormone [FSH]) on symptomatic patients who have a history of chronic opioid use. Treatment options include opioid cessation, short-acting opioids, and testosterone replacement therapy (TRT). The patient and physician should weigh the risks and benefits of TRT against more conservative approaches. Options such as clomiphene and anastrozole are available for patients who wish to preserve fertility. CONCLUSION: Because OPIAD is an underappreciated and underdiagnosed consequence of chronic opioid abuse, healthcare providers should be particularly vigilant for signs of hypogonadism in this patient population. It is reasonable for pain specialists, urologists, and primary care physicians to closely monitor patients on prescription opioids and discuss available options for treatment of hypogonadism. Hsieh A, DiGiorgio L, Fakunle M, et al. Management strategies in opioid abuse and sexual dysfunction: A review of opioid-induced androgen deficiency. Sex Med Rev 2018;6:618-623.

Serous Borderline Tumor of the Testis and Associated Magnetic Resonance Imaging Findings.

Serous borderline tumor (SBT) of the testis is a rare, ovarian epithelial-type tumor of the testis. We present a case of SBT after radical orchiectomy in a 59-year-old man who had 3-month progressive enlargement of his right hemi-scrotum, negative testicular tumor markers and scrotal ultrasound equivocal for malignancy. Magnetic resonance imaging (MRI) of the pelvis was obtained to aid with evaluation and showed marked hyperintensity on T2-weighted images with frond-like nodular peripheral enhancement within right testis mass. These distinct MRI findings can help clinicians differentiate SBT from other testis tumors. Relapse has not been observed in 8 years of follow-up.

Expression and actions of corticotropin-releasing factor/diuretic hormone-like peptide (CDLP) and teneurin C-terminal associated peptide (TCAP) in the vase tunicate, Ciona intestinalis: Antagonism of the feeding response.

Teneurin C-terminal associated peptide (TCAP) is a neuropeptide that bears some structural similarity to the corticotropin-releasing factor (CRF) family of peptides. TCAP and CRF are both implicated in the regulation of stress-related behaviors, as established in rodent models. However, in vertebrates, both TCAP and CRF possess three additional paralogous forms making vertebrate models difficult to assess with respect to TCAP-CRF interaction. As a urochordate, this species possesses single homologs of TCAP and of a CRF/Diuretic-like peptide (CDLP) in the genome, thereby establishing Ciona intestinalis as an excellent model organism to examine the interaction of these peptide systems. However, the lack of C. intestinalis synthetic peptides and specific antisera has complicated experimentation. We, therefore, prepared synthetic versions of CDLP and TCAP to prepare specific antisera and to investigate their bioactivity in this species. To analyze stress-related behaviors, a novel behavioral assay was used to characterize different types of contraction-based behaviors, using buccal opening contractions, cloacal opening contractions, lateral contractions, longitudinal contractions and expulsions. Protein and mRNA expression data indicate that the mature versions of both peptides are present in a number of tissues. With respect to behavioral activity, both TCAP- and CDLP-treated animals had distinct contraction profiles under ambient conditions. Moreover, food stimulation tests revealed that whereas CDLP-treated animals displayed a strong expulsion behavior in response to feeding, TCAP-treated animals did not show this effect. These actions are consistent with previous studies done in vertebrates.

Prenatal diagnosis and molecular cytogenetic characterization of mosaicism for a small supernumerary marker chromosome derived from ring chromosome 2.

OBJECTIVE: To present prenatal diagnosis and molecular cytogenetic characterization of mosaicism for a small supernumerary marker chromosome (sSMC) derived from ring chromosome 2 [r(2)]. METHODS AND RESULTS: A 35-year-old woman underwent amniocentesis at 17 weeks of gestation, because of advanced maternal age. Amniocentesis revealed a de novo ring-shaped sSMC in 11 of 23 colonies of cultured amniocytes. Repeated amniocenteses were made. The sSMC was characterized by array comparative genomic hybridization (aCGH), interphase fluorescence in situ hybridization (FISH) and quantitative fluorescent polymerase chain reaction (QF-PCR) on uncultured amniocytes. In uncultured amniocytes, aCGH showed a 39.49-Mb genomic gain in chromosome 2 encompassing 2q11.2→q21.2, interphase FISH revealed a mosaic level of 52% (52/100 cells), and QF-PCR manifested a diallelic pattern for chromosome 2, with gene dosage increase in the paternal allele of proximal 2q-specific DNA markers. In cultured amniocytes, the sSMC was characterized by metaphase FISH, spectral karyotyping (SKY) and multicolor banding (MCB) to contain the centromere and proximal 2q, and the karyotype was 47,XX,+r(2)(p11.1q21.2)[14]/46,XX[11]. The pregnancy was terminated. The fetus postnatally manifested facial dysmorphisms. Postnatal cytogenetic analyses revealed the karyotypes of 47,XX,+r(2)[12]/46,XX[28] in cord blood, 47,XX,+r(2)[7]/46,XX[33] in umbilical cord, 47,XX,+r(2)[13]/47,XX,+idic r(2)[3]/46,XX[24] in placenta and 47,XX,+r(2)[8]/47,XX,+idic r(2)[1]/46,XX[31] in amnion. CONCLUSION: Molecular cytogenetic techniques such as aCGH, interphase FISH and QF-PCR on uncultured amniocytes, and SKY, MCB and metaphase FISH on cultured amniocytes are useful for characterization of the nature of a prenatally detected sSMC.

Conjoined twins detected in the first trimester: a review.

Conjoined twinning occurs in 1 in 100 sets of monozygotic twins, 1 in 50,000 gestations or 1 in 250,000 live births. With the advent of ultrasound technology, prenatal diagnosis of conjoined twins is possible. This article provides a comprehensive review of conjoined twins detected in the first trimester including fetal gender, maternal age, parity, types of fusion, related ultrasound abnormalities, perinatal outcome and association with assisted reproduction.