Invasive Outpatient Procedures Research Articles

Inhaled methoxyflurane - an explorable alternative to nitrous oxide?

Nitrous oxide is a widely used and well-established form of inhalation sedation in dentistry. Its properties have a wide margin of safety and allow for anxious, paediatric and adult patients to receive dental treatment with minimal impact upon discharge. Nitrous oxide has drawbacks, however, including its environmental impact and need for specialist equipment. Methoxyflurane is another drug which could prove to be an alternative to nitrous oxide. Methoxyflurane's use has proved popular within emergency medicine in Australia and New Zealand for its potent analgesic effects and recognition of its anxiolytic effect. As a result, its use in invasive outpatient procedures has now become popular. Unfortunately, there is very limited evidence of its use within dentistry as a form of inhalation sedation and analgesic. A wider evidence base should be established, as methoxyflurane could prove to be an effective and environmentally friendly alternative to nitrous oxide.

Dentists' Attitudes to the Preprocedural Safety Checklist "Time-Out" in Saudi Arabia.

Before performing medical procedures, there is a patient safety initiative process (also referred to as "time-out"), part of this process is the use of a preprocedural safety checklist. This initiative was envisioned by the World Health Organization, supported by various accreditation bodies who include the process in their standards. Dentistry lags behind its medical colleagues in using it presurgical or invasive procedure. Our aim was to understand dentists' attitudes and knowledge about the process and their adherence to it. A cross-sectional questionnaire was distributed between September and December 2021 and 102 dentists responded. Seventy three of the respondents (71.5%) claimed to be familiar with the time-out process, and 87 (85.3%) felt that it was an important or somewhat important process; however, only 62 (60.7%) were always performing the process before surgical or invasive outpatient procedures. Patient safety must be given priority, as such it has been shown that preprocedural checklists help reduce medical errors. Recognizing the value of performing such a process, accreditation bodies have included the process in their standards and indeed in the Joint Commission focused patient safety goals.

Risk of myocardial infarction after invasive outpatient procedures

ObjectiveTo assess the short-term risk of acute myocardial infarction (AMI) associated with procedures performed at outpatient specialised hospital clinics.MethodsIn this case-crossover, population-based study, we identified first-time AMI cases aged ≥40...

Assessing Activity and Recovery Following Benign Gynecologic Surgery Using an Activity Monitor and Validated Tool Sets: A Pilot Study

Study Objective Assessment of recovery after surgery in women following benign gynecologic surgery remains highly subjective and elusive, as the majority of patient recovery is taking place at home and outside of the hospital. However, advances in wearable technology present an opportunity for clinicians to have an objective assessment of postoperative recovery. The aims of this pilot study are to 1) feasibility of the use of an activity monitor in a gynecologic surgical patient population, 2) use activity monitor data to characterize the recovery trajectory of physical activity for laparoscopic and open surgeries. Design Pilot study. Setting Academic hospital. Patients or Participants Women aged 18-51 years undergoing elective inpatient(laparotomy) and outpatient(laparoscopic/robotic) surgeries, specifically myomectomy and hysterectomy. Interventions Physical activity was measured using an Actigraph GT3X wrist-worn activity monitor. Participants wore the activity monitor a week before the surgery to assess preoperative baseline activity and they were asked to wear them for a minimum 6 weeks postop. The total number of steps was measured for each patient per day, and the time to baseline recovery activity was measured. Measurements and Main Results Of the 15 patients enrolled, 13 patients completed the study procedures and were included in the analysis. 9 underwent laparoscopic/robotic surgery and 4 laparotomy. The mean number of days the monitor was worn was 45 days (SD27) for all procedures. For minimally invasive outpatient procedures, the total number of steps per day reached preoperative average levels on postoperative day (POD) 7.8(SD7.5). For laparotomies that required inpatient stay, the total number of steps per day reached preoperative average levels on POD33.5(SD24.5). Conclusion This study demonstrates that objective monitoring of postoperative physical activity using activity monitors is feasible in the benign gynecologic surgical population. Recovery trajectories for inpatient laparotomies and outpatient minimally invasive procedures differ. Activity monitors present clinicians with a new potential tool for assessing and managing surgical recovery. Assessment of recovery after surgery in women following benign gynecologic surgery remains highly subjective and elusive, as the majority of patient recovery is taking place at home and outside of the hospital. However, advances in wearable technology present an opportunity for clinicians to have an objective assessment of postoperative recovery. The aims of this pilot study are to 1) feasibility of the use of an activity monitor in a gynecologic surgical patient population, 2) use activity monitor data to characterize the recovery trajectory of physical activity for laparoscopic and open surgeries. Pilot study. Academic hospital. Women aged 18-51 years undergoing elective inpatient(laparotomy) and outpatient(laparoscopic/robotic) surgeries, specifically myomectomy and hysterectomy. Physical activity was measured using an Actigraph GT3X wrist-worn activity monitor. Participants wore the activity monitor a week before the surgery to assess preoperative baseline activity and they were asked to wear them for a minimum 6 weeks postop. The total number of steps was measured for each patient per day, and the time to baseline recovery activity was measured. Of the 15 patients enrolled, 13 patients completed the study procedures and were included in the analysis. 9 underwent laparoscopic/robotic surgery and 4 laparotomy. The mean number of days the monitor was worn was 45 days (SD27) for all procedures. For minimally invasive outpatient procedures, the total number of steps per day reached preoperative average levels on postoperative day (POD) 7.8(SD7.5). For laparotomies that required inpatient stay, the total number of steps per day reached preoperative average levels on POD33.5(SD24.5). This study demonstrates that objective monitoring of postoperative physical activity using activity monitors is feasible in the benign gynecologic surgical population. Recovery trajectories for inpatient laparotomies and outpatient minimally invasive procedures differ. Activity monitors present clinicians with a new potential tool for assessing and managing surgical recovery.

Burch colposuspension using minimally invasive techniques

: The Burch urethropexy, a routinely performed stress incontinence operation, was displaced by the advent of the popular minimally invasive sling. However, with controversy surrounding the use of vaginal mesh in women’s pelvic reconstructive surgery, both patients and physicians have renewed interest in pursuing the Burch urethropexy as a viable alternative to treat stress incontinence. The Burch procedure stabilizes the bladder neck as a means to restore continence. Variations of Dr. Burch’s technique have been developed over time with Dr. Tanagho’s modification as the most widely accepted method for suture location placement. Current technique typically includes permanent sutures placed lateral to the urethra and bladder neck which are then secured to the iliopectineal line (also known as Cooper’s ligament). Originally developed as an open technique, both laparoscopic and robotic approaches have negated the need for an incision. Success rates of the operation have been published for both abdominal and minimally invasive techniques. The procedure has been found to have similar success to minimally invasive outpatient sling procedures in the absence of clinical evidence of intrinsic sphincter deficiency. Although it has a somewhat longer operative time, the Burch procedure is a comparable outpatient surgery with good patient satisfaction and a low complication rate. This article will discuss the history behind the procedure, the laparoscopic technique, and provide recommendations to optimize results for the correction of stress incontinence.

Revisit, Reform, and Redesign: A Novel Dissection Approach for Demonstrating Anatomy of the Orbit for Continuing Professional Development Education.

Advanced postgraduate medical education for health-care professionals is constantly evolving. Understanding facial anatomy and especially its vascular system is crucial when performing soft tissue filler injections to avoid adverse events including tissue loss or irreversible blindness. Standard anatomical resources often fall short of elucidating clinically relevant concepts in more highly specialized areas of interest. A novel dissection approach for demonstrating the anatomy of the lateral orbit was presented at scientific meetings to participants from dermatology, plastic surgery, and general practice. Results from the post-course online survey (n=52) were analyzed. The results of the survey reveal a high educational impact and a high clinical relevance of the novel dissection approach. In addition, the majority of respondents (97.7%; n=51) felt that the exposed anatomical structure of the orbit and face improved their ability to safely perform cosmetic procedures on the face. More experienced respondents who had previously attended at least five cadaveric dissections were more likely to strongly agree that reviewing anatomy through this novel dissection approach increased their confidence in avoiding periorbital vascular danger zones. As minimally invasive outpatient procedures continue to evolve, practicing physicians and mid-level providers often face the challenge of having to reconcile preexisting anatomical knowledge with new clinical practice. Skills required to navigate high impact anatomy include visualization of structures that form the navigational landscape and avoidance of key danger zones. The novel dissection approach to the lateral orbit reflects the increasing focus on revisiting, reforming, and redesigning anatomy for continuing professional development activities.

Surgical and Clinical Reactivation for Elective Procedures during the COVID-19 Era: A Global Perspective

Surgical and Clinical Reactivation for Elective Procedures during the COVID-19 Era: A Global Perspective

90: Assessing activity and recovery following benign gynecologic surgery using an activity monitor and validated tool sets: A pilot study

Assessment of recovery after surgery in women following benign gynecologic surgery remains highly subjective and elusive, as the majority of patient recovery is taking place at home and outside of the hospital. However, advances in wearable technology present an opportunity for clinicians to have an objective assessment of postoperative recovery. The aims of this pilot study are to 1) feasibility of the use of an activity monitor in a gynecologic surgical patient population, 2) use activity monitor data to characterize the recovery trajectory of physical activity for laparoscopic and open surgeries. Women aged 18-51 years old undergoing elective inpatient and outpatient surgical procedures at an academic tertiary medical center, specifically myomectomy and hysterectomy, were invited to participate. Physical activity was measured using an Actigraph GT3X wrist worn activity monitor. Participants wore the activity monitor a week before the surgery to assess preoperative baseline activity and they were asked to wear them for a minimum 6 weeks postop. The total number of steps was measured for each patient per day, and the time (in days) to baseline recovery activity was measured. Of the 15 patients enrolled, 13 patients completed the study procedures and were included in the analysis. 9 underwent a laparoscopic or robot-assisted laparoscopic procedure; 4 underwent a laparotomy. Of the 9 minimally invasive procedures, 7 were hysterectomies and 2 were myomectomies. Of the laparotomies, 2 were hysterectomies and 2 were myomectomies. The mean number of days the activity monitor was worn was 45 days (SD 27) for all procedures. For minimally invasive outpatient procedures, the total number of steps per day reached preoperative average levels on postoperative day (POD) 7.8 (SD 7.5). For laparotomies that required inpatient stay, the total number of steps per day reached preoperative average levels on POD 33.5 (SD 24.5). An adverse event in 1 patient was associated with a decline in activity. This study demonstrates that objective monitoring of postoperative physical activity using activity monitors is feasible in the benign gynecologic surgical population. Recovery trajectories for inpatient laparotomies and outpatient minimally invasive procedures differ. Activity monitors present clinicians with a new potential tool for assessing and managing surgical recovery, and for determining if women are not recovering as expected.

Factors Associated With Emergency Department Visits and Hospital Admissions After Invasive Outpatient Procedures in the Veterans Health Administration

This study evaluates the prevalence of postprocedure emergency department visits and admissions and the association of these outcomes with relevant patient, procedure, and facility factors.

Pharmacokinetics of Lidocaine and Its Metabolites Following Vaginal Administration of Lidocaine Gel to Healthy Female Subjects.

Lidocaine vaginal bioadhesive gel is being developed as a local anesthetic for use in minimally invasive outpatient gynecological procedures and was investigated in single‐dose and multiple‐dose studies in healthy young adult women. Lidocaine doses of 2.5%, 5%, and 10% (w/w) were administered, and parent drug and metabolites monoethylglycinexylidide and glycinexylidide were measured in plasma. Lidocaine was absorbed through vaginal tissue and into the systemic circulation in a dose‐proportional manner, and there was little systemic accumulation. Plasma concentrations were 10‐ to 20‐fold lower than concentrations obtained after administration of intravenous lidocaine used to treat arrhythmic activity, thus demonstrating a wide safety margin for a vaginal lidocaine product.

Anti-Thrombotic Therapy: Implications for Invasive Outpatient Procedures in Dentistry

This article reviews the implications of traditional and novel anti-thrombotic medications in dentistry, focusing on areas relating to the prevalence of significant post procedure bleeding, measures that should be taken to minimize and manage bleeding; and current opinions regarding need for alteration of anti-thrombotic regimens prior to dental procedures in dentistry. Based on the current literature, discontinuation of anti-platelet medications, warfarin therapy, dabigatran and Factor Xa inhibitors is not needed in majority of in office dental procedures. However, it is important that treating clinician must use discretion based on the patient’s risk profile (e.g. presence of comorbidities) and extensiveness of planned dental procedures to assess each patient’s risk for significant bleeding.

Perioperative Steroid Dosing in Patients Receiving Chronic Oral Steroids, Undergoing Outpatient Hand Surgery

ISTORICALLY, PATIENTS WHO are receiving oral glucocorticoids and undergo surgical procedures were administered supplemental intravenous steroids during the perioperative period. This practice remains controversial, however, for less invasive outpatient procedures such as those performed by hand surgeons on a routine basis. 1–5 To date, there are no evidence-based treatment guidelines that provide firm recommendations for the administration of perioperative steroids; rather, present management is based on case reports and observational studies. 2,3 In this article, we discuss the pathophysiology behind acute adrenal insufficiency, the stress response and its suppression, patients who may be at risk, the effect of inhaled and topical steroids, and published data that guide our practice concerning the administration of perioperative corticosteroids to patients undergoing outpatient hand surgery. PATHOPHYSIOLOGY The “HPA axis” consists of the hypothalamus, pituitary gland, and adrenal glands. The hypothalamus secretes corticotropin-releasing hormone (CRH) in response to stress, circulating blood levels of cortisol, and the sleep/ wake cycle. CRH then stimulates the pituitary to secrete adrenocorticotropic hormone (ACTH), which in turn stimulates the release of cortisol from the adrenal cortex. Cortisol is a negative inhibitor of both CRH and ACTH. It acts through various intracellular receptors to prevent the proliferation of T-cells, counteract insulin by increasing gluconeogenesis, promote breakdown of

Preventing postoperative nausea and vomiting: A comprehensive comparison of treatments

Preventing postoperative nausea and vomiting: A comprehensive comparison of treatments

Drug Treatment of Haemorrhoids

Drug treatment for various anorectal conditions has been known since ancient times. Today, modern as well as traditional drugs are being increasingly used in all grades of symptomatic haemorrhoids. These drugs (oral and local) are used as a part of conservative management or as an adjuvant to invasive outpatient procedures. Flavonoids, in the new formulation of micronised purified flavonoid fraction (MPFF) or as part of the ancient traditional medicine derivative of the Ginkgo tree, are used for relief of acute symptoms (for control of bleeding and re-bleeding in all grades of haemorrhoids). MPFF has been recommended for control of acute bleeding in patients waiting for a definitive outpatient treatment. Similarly, better known drugs such as calcium dobisilate (used in diabetic retinopathy and chronic venous insufficiency), nitrates and nifedipine have also been effective and well tolerated in the medical treatment of haemorrhoids. However, drug treatment is not aimed at curing haemorrhoids. The prime objective of drug therapy is to control the acute phase (bleeding) so that definitive therapy (banding, injection sclerotherapy, infrared photocoagulation, cryotherapy or surgery) can be scheduled at a convenient time.

Percutaneous interventions for vascular dialysis access.

A prerequisite for the long-term patency of vascular access is early detection of a failing shunt, i.e., at the stage of stenosis. Fistulography performed to locate the lesion is followed by percutaneous transluminal angioplasty using a balloon catheter. The procedure takes 30-60 minutes to complete; the clinical success rate varies between 85% and 98%. A more serious condition of failled vascular access is its occlusion secondary to thrombosis. The high costs of hospitalisation and treatment of thrombosed shunts require effective yet less invasive outpatient procedures. Recent years have seen an explosion in the development of mechanical devices on the principle of mechanical dissolution, fragmentation, and aspiration of the clot. Post-procedural dialysis can be performed immediately thus reducing the need for a central venous catheter. The procedure, particularly in the treatment of native fistula occlusion, is more complicated and about twice as time consuming as treatment of stenosis. The clinical success rate is usually between 71% and 100%. The incidence of serious complications of percutaneous treatment is low.

Book Reviews

Book reviewed in this article: Basic Sciences for Obstetrics and Gynaecology Fifth Edition. Edited by: Tim Chard, Richard Lilford. Published by Springer Primary Care in Obstetrics and Gynaecology: A Handbook for Clinicians. Edited by: Joseph S. Sanfilippo and Roger P. Smith. Published by Springer Problems in Early Pregnancy: Advances in Diagnosis and Management. Edited by J.G. Grudsinskas and P.M.S. O'Brien. Published by RCOG Press. Critical Care Obstetrics, 3rd Edition. Edited by Steven L. Clark MD, David B. Cotton MD, Gary D.V. Hankins MD, Jeffrey P. Phelan MD. Published by Blackwell Scientific‐Publications Sports Gynaecology: Problems and Care of the Athletic Female. Edited by Michelle P. Warren, Mona M. Shangold. Published by Blackwell Science Inc Practical Procedures for the Gynaecological Oncologist. Edited by A. Peter, M. Henitx and David G. Allen. Published by Elsevier Science BV 1998 Endometrium and Endometriosis. Edited by Michael P. Diamond and Kevin G. Osteen. Published by Blackwell Science 1997 A Clinician's Guide to Menopause. Edited by Donna E. Stewart, Gail Erlick Robinson. Published by Health Press International Hysterectomy and HRT. Edited by John Studd and Linda Edwards. Published by RCOG Press The Yearbook of the Royal College of Obstetricians and Gynaecologists 1996. John Studd. Published by RCOG Press Obstetric Intensive Care. M.R. Foley, T.H. Strong. Published by Harcourt Brace & Co Australia Chromosome Abnormalities and Genetic Counselling. R.J.M. Gardner and G.R. Sutherland. Published by Oxford University Press Atlas of Gynecologic Surgery‐3rd Edition. H.A. Hirsch, O. Kaser, F.A. Lkle. Published by Georg Thieme Verlag Practical Manual of Operative Laparoscopy and Hysteroscopy. Ricardo Azziz, Ana Alvarez Murphy. Published by Springer‐Verlag GmbH & Co Kg Invasive Outpatient Procedures in Reproductive Medicine. Mark I. Evans, Mark P. Johnson and Kamran S. Moghissi. Published by MacLennan & Petty Neonatology for the MRCOG. Peter Dear and Simon Newell. Published by RCOG Press

Book Reviews

Book reviewed in this article: The Yearbook of the Royal College of Obstetricians and Gynaecologists 1996. John Studd. Published by RCOG Press Obstetric Intensive Care. M.R. Foley, T.H. Strong. Published by Harcourt Brace & Co Australia Chromosome Abnormalities and Genetic Counselling. R.J.M. Gardner and G.R. Sutherland. Published by Oxford University Atlas of Gynecologic Surgery—3rd Edition. H.A. Hirsch, O. Kaser, F.A. Lkle. Published by Georg Thieme Verlag Practical Manual of Operative Laparoscopy and Hysteroscopy. Ricardo Azziz, Ana Alvarez Murphy. Published by Springer‐Verlag GmbH & Co Kg Invasive Outpatient Procedures in Reproductive Medicine. Mark I. Evans, Mark P. Johnson and Kamran S. Moghissi Neonatology for the MRCOG. Peter Dear and Simon Newell. Published by RCOG Press