Analysis of hospital length of stay and cost savings with an in-house heparin-induced thrombocytopenia antibody assay at a midsized institution.

OBJECTIVES: Analysis of laboratory value often lacks assessment of the laboratory's impact on quality of care. In this study, we aimed to determine the impact of bringing a heparin-induced thrombocytopenia (HIT) antibody assay in-house on a quality metric-patient hospital length of stay (LOS)-and assess any associated cost savings. METHODS: A retrospective review of patient visits with a HIT antibody assay over a 7-year period determined the mean LOS in send-out vs in-house HIT antibody assay cohorts as well as cohorts of positive and negative results. Our systemwide mean LOS and metrics of acuity were analyzed. We performed a financial analysis of estimated cost savings. RESULTS: We found a mean LOS reduction of 3.97 days in the in-house cohort, with no evidence of a systemwide LOS decrease or a decline in patient acuity. This reduction was largely driven by a reduction in LOS among patients with a negative assay result. We found an estimated total cost savings of $3.9 million and an estimated mean savings per patient of $7,305, despite escalating health care costs over time. CONCLUSIONS: We demonstrated a reduction in LOS following the introduction of an in-house HIT antibody assay that cannot be attributed to either systemwide initiatives or reduced patient acuity and was driven largely by patients with negative assays. This reduction was associated with significant estimated cost savings.

Examining the efficacy of verteporfin photo-dynamic therapy (PDT) at different dose & fluence levels.

OBJECTIVES: Photodynamic therapy (PDT) is a vaso-occlusive treatment for a number of chorioretinal vascular pathologies. We aimed to retrospectively analyse efficiency and safety of PDT for different conditions (central serous retinopathy (CSR), age-related macular degeneration (AMD), macular telangiectasia type 2 and choroidal hemangioma) and with different verteporfin parameters. METHODS: Clinical parameters were ascertained from the medical records of patients undergoing PDT over a 6-year period. This included indications for PDT, dosing regimens of verteporfin PDT (which includes treatment dose of verteporfin and fluence). Response to treatment was measured by best corrected visual acuity (BCVA) and central foveal thickness (CFT) on ocular coherence tomography. Complications and side effects were recorded. RESULTS: 67.4 % (31/46) of PDT treatments performed over the last six years were for CSR. In the CSR cohort, there were significant improvements in BCVA (0.47 ± 0.24 to 0.29 ± 0.27, p < 0.05) and CFT (350.2µm ± 66.9 µm to 286.1µm ± 60.6 µm. In the AMD cohort, there was no change in BCVA (1.08 ± 0.52 to 1.07 ± 0.53, p = 0.96) but significant improvement in CFT (488.2µm ± 164.6 µm to 348.7µm ± 65.7 µm, p < 0.05). There was no significant difference in BCVA or CFT for macular telangiectasia type 2 and choroidal hemangioma. CONCLUSIONS: PDT continues to have a role in the management of medical retina conditions. Our results show PDT is most effective in improving and stabilizing visual acuity in CSR, with earlier intervention resulting in better outcomes.

The Effects of an E-learning Module on Medical Trainees Rotating on a Perioperative Medicine Clinical Service.

Introduction: Dedicated perioperative care can be cost-effective and improve patient outcomes. Training future physicians to practice perioperative medicine is an important responsibility of medical educators. An e-learning module delivered asynchronously during clinical rotations in perioperative medicine may help to better satisfy this responsibility. Method: Articulate software was used to create an interactive, 1-hour e-module based on six educational objectives. The e-module was offered as an elective self-directed learning experience to trainees on perioperative medicine clinical rotations, including third- and fourth-year medical students as well as residents from internal medicine, anesthesiology, neurology, and physical medicine and rehabilitation training programs. We assessed the effectiveness of this learning strategy as a complement to real-time clinical experiences by measuring the knowledge, confidence, and satisfaction of trainees before and after completion of the e-module. Results: Of 113 trainees invited to participate, 75 completed the module and were included in our analysis. Knowledge scores improved for student (p < .001), intern (p < .001), and resident (p < .001) subgroups. Confidence ratings also improved for student (p < .001), intern (p < .001), and resident (p < .001) subgroups. Trainees reported high satisfaction with the e-module, and 60 (87%) reported that it would alter their practice. Discussion: An e-module presenting evidence-based, interactive education to trainees during clinical rotations in perioperative medicine was an effective learning strategy. Sharing e-learning tools across institutions may help to deliver standardized education on core clinical topics, including perioperative medicine.

The Use of Pectoralis Blocks in Breast Surgery: A Practice Advisory and Narrative Review from the Society for Ambulatory Anesthesia (SAMBA).

Although pectoralis (PECS) blocks are commonly used for breast surgery, recommendations regarding the efficacy of these blocks have thus far not been developed by any professional anesthesia society. Given the potential impact of PECS blocks on analgesia after outpatient breast surgery, The Society for Ambulatory Anesthesia (SAMBA) convened a task force to develop a practice advisory on the use of this analgesic technique. In this practice advisory, we compare the efficacy of PECS blocks with systemic analgesia, local infiltration anesthesia, and paravertebral blockade. Our objectives were to advise on two clinical questions. (1) Does PECS-1 and/or -2 blockade provide more effective analgesia for breast-conserving surgery than either systemic analgesics or surgeon-provided local infiltration anesthesia? (2) Does PECS-1 and/or -2 blockade provide equivalent analgesia for mastectomy compared with a paravertebral block (PVB)? Among patients undergoing breast-conserving surgery, PECS blocks moderately reduce postoperative opioid use, prolong time to analgesic rescue, and decrease postoperative pain scores when compared with systemic analgesics. SAMBA recommends the use of a PECS-1 or -2 blockade in the absence of systemic analgesia (Strength of Recommendation A). No evidence currently exists that strongly favors the use of PECS blocks over surgeon-performed local infiltration in this surgical population. SAMBA cannot recommend PECS blocks over surgical infiltration (Strength of Recommendation C). For patients undergoing a mastectomy, a PECS block may provide an opioid-sparing effect similar to that achieved with PVB; SAMBA recommends the use of a PECS block if a patient is unable to receive a PVB (Strength of Recommendation A).

Association between Brachial-Ankle Pulse Wave Velocity as a Marker of Arterial Stiffness and Body Mass Index in a Chinese Population.

Objectives: Arterial stiffness is widely accepted as an important predictor of cardiovascular disease (CVD) development. While obesity is generally associated with increased CVD risk, there is evidence that overweight patients with existing CVD may have better clinical outcomes than their lean counterparts. Our study sought to observe any potential association between brachial−ankle pulse wave velocity (BAPWV), a marker of arterial stiffness related to CVD risk, and Body Mass Index (BMI), a crude and widely used measure of obesity. Methods: Adult individuals (n = 857) assessed for routine CV risk were included and grouped according to their BMI (<25 kg/m2: normal; 25−30 kg/m2: overweight, ≥30 kg/m2: obese). Their anthropometric parameters, brachial cuff pressures, and BAPWV were measured. Results: Brachial pressure was significantly higher as BMI increased. BAPWV showed a positive linear association with systolic (r = 0.66, p < 0.01), mean (r = 0.60, p < 0.01), diastolic (r = 0.51, p < 0.01), and pulse (r = 0.53, p < 0.01) pressures. However, a linear relationship between BMI and BAPWV was only apparent in males aged <50 years (p = 0.01) and in females aged ≥50 years (p < 0.01). In individuals with similar brachial systolic pressure, BAPWV was higher in normal-weight subjects compared to overweight−obese ones. Conclusions: This conflicting finding is attributed to an overestimation of the degree of arterial stiffness as a measure of CVD risk in individuals with a less 'healthy' BMI. This suggests that BMI may not the appropriate obesity indicator to assess CV risk. Our finding emphasizes the importance of establishing a non-linear relationship between CVD risk, age, and BMI, taking into account apparent sex differences, to predict future CV events. While this finding may suggest a lower degree of stiffness in large arteries of overweight−obese subjects compared to their normal-weight counterparts, the potential implications for individuals with higher BMI need be explored further.

Hughes flap in the management of lower lid retraction.

PURPOSE: We present a retrospective case series on the use of Hughes flap in managing acquired cicatricial lower lid retraction. METHODS: This was a multicentre, retrospective case series. Data was collected from medical records across different sites within Australia (Adelaide, Melbourne, and Sydney) and New Zealand (Hamilton). RESULTS: Fourteen patients were identified. The aetiology of cicatricial lower lid retraction included previous lid lesion excision and reconstruction, eyelid trauma, orbital fracture repair, orbital radiotherapy, and lateral canthal dystopia from previous lid surgeries. 4/14 (29%) cases had undergone other surgery to correct the retraction prior to the Hughes flap. Pre-operative lagophthalmos due to lower lid retraction was noted in 11/14 (79%) cases with a median 2 mm (range: 1-5 mm). Exposure keratopathy was present in 7/14 (50%) cases. There were no peri-operative complications during Hughes flap reconstruction. One patient had post-operative upper eyelid retraction that did not require any further intervention. One patient had persistent lagophthalmos and exposure keratopathy that is being managed conservatively. One patient had wound dehiscence and further lid retraction following flap division, which required further surgery. Median length of follow-up was 15 months (range: 0.5-84 months). At final review, improvement or resolution of symptoms was seen in 13/14 (93%) cases. CONCLUSIONS: A Hughes flap is an effective surgical technique for the management of cicatricial lower lid retraction.

Complete manuscript title: Neurological complications from sinugenic orbital cellulitis.

INTRODUCTION: This study was undertaken with an aim to identify any common factors or trends among patients of orbital cellulitis that developed neurological complications. METHODS: A 24-month retrospective review of patients was undertaken to include those showing clinical deterioration and neurological complications on radiological imaging, after being treated for orbital cellulitis at Manchester Royal Eye Hospital. The study specifically looked at the site of orbital collection, sinus involvement, types of neurological complications and whether these were detected at initial presentation, surgical input and microbiology findings. RESULTS: Nine patients (9/26) developed associated neurological complications during the study period. (February 2018 and January 2020) This included subdural empyema in six patients; leptomeningeal enhancement in two and septic emboli in one patient. All the patients had associated significant pan-sinusitis at initial presentation. Neurological complications were detected in three patients at the time of admission and after clinical deterioration and further investigations in the rest. CONCLUSION: A superior orbital abscess and Streptococcus mileri infection had higher risk of neurological complications. It is worth debating whether patients with chronic sinusitis who develop orbital cellulitis need earlier surgical input rather than a conservative treatment. Patients who fail to improve clinically need to be re-imaged to look for possible neurological complications.

An investigation of the individualized, two-point calibration method for cuffless blood pressure estimation using pulse arrival time: an historical perspective using the Casio BP-100 digital watch.

BACKGROUND: The use of wearable cuffless blood pressure (BP) devices is becoming commercially prevalent with little published validation information. Most devices rely, at least in part, on the relationship between pulse arrival time (PAT) and BP, a theoretical fundamental relationship that was first commercially exploited in 1993 with the release of the Casio BP-100 digital watch. OBJECTIVE: This study explored the PAT method of BP estimation in a commercial device where it first began, the Casio BP-100 (Model No. 900) digital watch, which employs an individualized, two-point calibration method. Device accuracy was determined by comparison to a conventional cuff-based BP device measurements. METHODS: Twenty participants (11 female, 9 male) had BP measured using both devices at rest, during a 5-minute isometric hand-grip exercise and at 1-minute post-exercise. RESULTS: Due to bidirectional scatter of BP estimation by the BP-100 device, there was no significant difference between the reference device and the BP-100. The devices showed poor correlation for both systolic BP (SBP) (R=0.36, p=0.13) and diastolic BP (DBP) (R=0.044, p=0.37). However, on average the watch was able to provide correct directional changes in SBP but not DBP with exercise. CONCLUSIONS: Despite being an industry first, the Casio BP-100 watch employed a method that gives a great chance of accuracy: a two point, individualized calibration method - more detailed than calibration methods in more modern devices. The watch, on average across a cohort, provided some information on BP directional change but was uncorrelated with cuff-based BP measurement. If the utility of beat-by-beat BP estimation is to be utilized, limitations of this method need to be addressed.

Non-Fellowship regional anesthesia training and assessment: an international Delphi study on a consensus curriculum.

BACKGROUND AND OBJECTIVES: While there are several published recommendations and guidelines for trainees undertaking subspecialty Fellowships in regional anesthesia, a similar document describing a core regional anesthesia curriculum for non-fellowship trainees is less well defined. We aimed to produce an international consensus for the training and teaching of regional anesthesia that is applicable for the majority of worldwide anesthesiologists. METHODS: This anonymous, electronic Delphi study was conducted over two rounds and distributed to current and immediate past (within 5 years) directors of regional anesthesia training worldwide. The steering committee formulated an initial list of items covering nerve block techniques, learning objectives and skills assessment and volume of practice, relevant to a non-fellowship regional anesthesia curriculum. Participants scored these items in order of importance using a 10-point Likert scale, with free-text feedback. Strong consensus items were defined as highest importance (score ≥8) by ≥70% of all participants. RESULTS: 469 participants/586 invitations (80.0% response) scored in round 1, and 402/469 participants (85.7% response) scored in round 2. Participants represented 66 countries. Strong consensus was reached for 8 core peripheral and neuraxial blocks and 17 items describing learning objectives and skills assessment. Volume of practice for peripheral blocks was uniformly 16-20 blocks per anatomical region, while ≥50 neuraxial blocks were considered minimum. CONCLUSIONS: This international consensus study provides specific information for designing a non-fellowship regional anesthesia curriculum. Implementation of a standardized curriculum has benefits for patient care through improving quality of training and quality of nerve blocks.

Preoperative Management of Opioid and Nonopioid Analgesics: Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement.

There is a lack of guidelines for preoperative dosing of opioid and nonopioid pain medications for surgical patients, which can lead to suboptimal preoperative pain control. The Society for Perioperative Assessment and Quality Improvement identified preoperative dosing of opioid and nonopioid analgesics as an area in which consensus could improve patient care. The aim of this guideline is to provide consensus that will allow perioperative physicians to make optimal recommendations regarding preoperative pain medication dosing. Six categories of pain medications were identified: opioid agonists, opioid antagonists, opioid agonist-antagonists, acetaminophen, muscle relaxants, and triptans/headache medications. We then used a Delphi survey technique to develop consensus recommendations for preoperative dosing of individual medications in each of these groups.

Evaluating integration in collaborative cross-disciplinary FDA new drug reviews using an input-process-output model.

BACKGROUND/OBJECTIVES: The US Food and Drug Administration (FDA) is responsible for assessing safety (risks) and effectiveness (benefits) of new drug products using the data provided in a Sponsor's new drug product marketing application before they can be marketed. The FDA forms cross-disciplinary review teams to conduct these assessments. Recently, the FDA began implementing more interdisciplinary approaches to its assessments, reducing redundancy in review processes and documentation by increasing team integration around review issues. METHODS: Through a phenomenological descriptive comparative case study, the impact of FDA's new interdisciplinary approach on review team integration was compared with its traditional multidisciplinary review approach. RESULTS: We identified collaborative integration occurring in one FDA review team using the new interdisciplinary review and another team using the traditional review and then modeled and analyzed the collaborative, cross-disciplinary integration in each case using an input-process-output (IPO) model drawn from the Science-of-Team-Science (SciTS). CONCLUSION: This study provides a systematic method for understanding and visualizing integration in each type of review previously and presently used at FDA and illustrates how the new interdisciplinary approach can ensure more integration than more traditional approaches previously used. In addition, our study suggests that an IPO model of integration can characterize how effectively FDA review teams are integrating around issues and assist in the evaluation of differences in integration between FDA's new interdisciplinary review and the existing multidisciplinary approach. The approach used here is a new application of SciTS scholarship in a unique sector, and it also serves as an example for measuring review team effectiveness.

A novel method to assess valvulo-arterial load in patients with aortic valve stenosis.

INTRODUCTION: Ventricular function in elderly patients with aortic stenosis is impeded both by restricted aortic flow and arterial stiffening. A number of patients continue to have exertional intolerance after relief of aortic valvular obstruction due to unrecognized ventriculo-arterial coupling mismatch. HYPOTHESIS: Quantification of valvulo-arterial load (VAL), using a simultaneous applanation tonometry/cardiac magnetic resonance (CMR) technique, can accurately assess the relative contributions of aortic stiffness and valve gradient in older patients with aortic stenosis. METHODS: Elderly patients with aortic stenosis underwent a simultaneous applanation tonometry/CMR protocol. CMR provided left ventricular volume and aortic flow simultaneously with radial applanation tonometry pressure acquisition. Central aortic pressure was derived by transformation of the radial applanation tonometry waveform. VAL was determined as the relationship of derived aortic pressure to CMR aortic flow in frequency domain (central illustration). RESULTS: Twenty patients (age 80 ±â€Š9 years; 12 males; blood pressure 140/75 ±â€Š20 mmHg) with aortic stenosis on transthoracic echocardiogram (16 severe; mean gradient 45 ±â€Š16 mmHg; aortic valve area 0.8 ±â€Š0.2 cm2) were enrolled. Derived aortic pressure and flow waveforms correlated well with invasive data. Increased VAL was significantly associated with advanced age (P = 0.04) and raised SBP (P < 0.01), irrespective of aortic stenosis severity. CONCLUSION: Difficulties in the measurement and accuracy of ventriculo-arterial coupling means that it is not routinely measured in patients with aortic stenosis. We describe a new noninvasive index that provides an accurate assessment of valvular and arterial load on the left ventricle. VAL may help detect those at risk of ventriculo-arterial coupling mismatch and assist in selection of those most likely to benefit from an invasive procedure.

Tracking of brachial and central aortic systolic pressure over the normal human lifespan: insight from the arterial pulse waveforms.

Despite multiple studies, it has not been possible to account for the normal changes of blood pressure that occur from infancy to old age. We sought a comprehensive explanation, by linking brachial pressure with the well documented changes in the arterial pulse waveform, whose peak and nadir determine systolic, diastolic and pulse pressure in brachial arteries. Changes in humans arterial pulse wave contour from birth to old age can be readily explained on (i) growth, with increasing length of the body from birth to adolescence, and adult height maintained thereafter, and (ii) degeneration and dilation of the aorta from elastic fibre fracture throughout life, causing progressive increase in aortic pressure wave amplitude from early return of wave reflection, and summation of incident with reflected waves in systole. These changes throughout life complement arterial pulse waveform analysis and explain brachial cuff pressure values, with optimal pulse wave pattern for cardiac interaction apparent in adolescence.

Bleb reconstruction using donor scleral patch graft for late bleb leak and hypotony.

PURPOSE: Bleb dysfunction may occur as a late complication following glaucoma filtration surgery. Over-filtering, thinning and cystic blebs can lead to hypotony, leak and corneal dellen. We report our surgical management and outcomes of this specific entity using donor scleral patch grafts. METHODS: This is a 10-year non-comparative, retrospective interventional case series. Bleb reconstruction involved excision of encysted conjunctiva and sclera to identify the original fistula. A functioning donor scleral patch graft was sited over this with fixed and releasable sutures and the conjunctiva advanced. Intraocular pressure, visual acuity and post-operative issues were assessed. RESULTS: A total of 18 eyes of 17 patients with mean age 65 years (standard deviation 13.5) were included. Trabeculectomy was the primary procedure in 72% (n = 13) and deep sclerectomy in 28% (n = 5). Bleb leak accounted for 61% (n = 11), hypotony 33% (n = 6) and corneal dellen 6% (n = 1). Mean pre-operative intraocular pressure was 7 mm Hg (standard deviation 4.6) which increased to 18.5 mm Hg (standard deviation 12) at day 1 (p < 0.001), 11.8 mm Hg (standard deviation 4.6) at 3 months (p < 0.05), 12.1 mm Hg (standard deviation 4.2) at 1 year (p < 0.01) which was maintained at 12.1 mm Hg (standard deviation 5.3) at last follow-up (p < 0.001). Post-operative interventions included bleb needling, re-suturing, suture removal, further glaucoma management, bleb leak and cataract surgery. Visual acuity also improved post-operatively and was maintained. CONCLUSION: Reconstruction of the filtering bleb architecture with donor sclera results in improved intraocular pressure while maintaining visual acuity. Post-operative care is required to support the restored bleb function. Our findings support the use of scleral patch graft as an effective and safe method for the long-term management of hypotony and bleb leak as a late complication of glaucoma filtration surgery.

Non-Invasive Quantification of Ventricular Contractility, Arterial Elastic Function and Ventriculo-Arterial Coupling from a Single Diagnostic Encounter Using Simultaneous Arterial Tonometry and Magnetic Resonance Imaging.

PURPOSE: Optimal assessment of cardiovascular performance requires simultaneous measurement of load independent left ventricular (LV) contractility, arterial function and LV/arterial coupling. We aimed to demonstrate feasibility of non-invasive ventricular pressure-volume and aortic pressure-flow-impedance measurements using simultaneous arterial tonometry (AT) and cardiovascular magnetic resonance imaging (CMRI). METHODS: 21 consecutive patients referred for CMRI were enrolled to undergo a simultaneous AT and CMRI protocol. A CMRI compatible AT apparatus provided aortic end-systolic pressure, taken to be equivalent to LV end-systolic pressure in the absence of aortic stenosis. CMRI provided LV volume and aortic flow at the time of pressure acquisition. Pressure-volume relationships were determined and correlated to traditional parameters of LV function including ejection fraction and circumferential strain. Aortic pressure-flow relationships were used to determine aortic characteristic impedance and systemic vascular resistance. RESULTS: Simultaneous AT and CMRI permitted measurement of LV end-systolic elastance, preload recruitable stroke work, arterial elastance, aortic characteristic impedance and systemic vascular resistance. Absolute values were within the expected range for our cohort, were highly reproducible and showed appropriately directed correlation to traditional parameters. CONCLUSION: Non-invasive assessment of LV pressure-volume and aortic pressure-flow relationships are both feasible and reproducible using simultaneous AT and CMRI. Methods permit assessment of load independent LV contractility, arterial function and LV/arterial coupling from a single non-invasive diagnostic encounter.