Room Time Research Articles

Stress produces negative judgement bias in cuttlefish.

Judgement bias tasks (JBTs) are used to assess the emotional state and welfare of animals in zoos, farms and laboratories, based on the interpretation of an ambiguous or intermediate cue. Animals in positive affective states are more likely to interpret the ambiguous cue positively, whereas animals experiencing negative affect are more likely to interpret ambiguous cues pessimistically. Here, we developed a modified JBT assay for the stumpy-spined cuttlefish, Sepia bandensis, to determine whether cuttlefish exhibit negative affective states resulting from external stressors. Positive and neutral visual cues were presented twice daily until animals learned to associate food with the reinforced visual cue. After training, one treatment group was exposed to combined exposure and handling stress produced by 6 days of impoverished housing and simulated net capture. Our control group received no stress experience. In test trials performed after the stress experience, stressed animals showed higher latencies to approach ambiguous cues, spent significantly less time in rooms with ambiguous cues once they entered, and were less likely to enter first into the ambiguous cue-paired room compared with controls. These behaviours suggest that stress induces pessimistic judgement bias in cuttlefish, the first indication of this capacity in cephalopods.

Operative Efficiency in Military Total Joint Arthroplasty Is Superior at an External Resource Sharing Agreement Facility as Compared to a Military Treatment Facility.

Surgeries within the Military Health System (MHS) are often performed by military physicians at External Resource Sharing Agreement (ERSA) hospitals to offload the operative demand at Military Treatment Facilities (MTFs). These agreements allow physicians flexibility in selecting where to treat military service members and other TRICARE beneficiaries. However, there is a paucity of military orthopedic literature comparing ERSA hospitals and MTFs. The objective of this study is to compare operative volume, efficiency, and orthopedic resident operative experience between an ERSA hospital and an MTF in military arthroplasty. A retrospective chart review was conducted for all surgeries performed between October 1, 2022 and July 31, 2023 by three military arthroplasty-trained surgeons at an MTF and two associated ERSA hospitals (denoted as ERSA-A and ERSA-B). Details recorded include spinal time-out time, spinal end time, in-room time, case start time, case stop time, and out-of-room time. These were used to calculate the total time in room (out-of-room time minus in-room time), case time (case stop time minus case start time), extra time in room (total time in room minus case time), and time between cases (in-room time minus out-of-room time of previous case). Lastly, we compared the average daily case volume and operative time between the facilities. Only primary joint replacements with properly documented time stamps were included in the efficiency analysis. Continuous variables were assessed for normality by the Shapiro-Wilk test. Non-normal data are presented as the median and interquartile range (IQR) and were analyzed using the Mann-Whitney U test (for two group comparisons) or the Kruskal-Wallis test (three or more groups) with Dwass-Steel-Chritchlow-Fligner pairwise comparisons. The associations between categorical variables were analyzed using the chi-squared test. Significance was set to P < .05. Statistical analyses were performed using SAS version 9.4 (Statistical Analysis Software, Cary, NC, USA). This study was classified as exempt human subjects research by the authors' institutional review board. Average daily case volume was significantly higher at both ERSA-A (median of 3, IQR 2-4, P < .001) and ERSA-B (median of 2, IQR 2-3, P = .0075) compared to the MTF (median of 2, IQR 1-2). This translated to residents operating for a median of 270 minutes (IQR 170-398, n = 25 OR days) each operative day at ERSA-A compared to 234 minutes (IQR 131-304, n = 91 OR days) when at the MTF, which was not a significant difference (P = .21). Median case time was 26.5 minutes lower (P < .001), extra time in room was 5 minutes lower (P < .001), and time between cases was 67 minutes lower (P < .001) in the ERSA group as compared to the MTF group. Utilizing ERSAs can improve patient throughput and operative efficiency, which in turn enhances orthopedic resident operative experience. These findings suggest that the MHS should seek ways to improve operative efficiency at MTFs. Expanding ERSA contracts to reach a broader portion of TRICARE beneficiaries, including patients over 65 years of age and those with supplemental insurance, who are currently ineligible, should also be explored.

Impacts of different anesthetic protocols on the speed and quality of postoperative resuscitation in patients undergoing painless gastroscopy

Objective: To estimate the impacts of different anesthetic protocols on the speed and quality of postoperative resuscitation in patients undergoing painless gastroscopy. Methods: This was a prospectively designed randomized control study that included 150 patients who underwent painless gastroscopy in Hainan Cancer Hospital affiliated to Hainan Medical College between April and December of 2023. All the patients, classified as American Society of Aneshesiologists (ASA) Grade Ⅰ or Ⅱ, were randomly divided into three groups with different anesthetic protocols, including propofol group (group P), remimazolam group (group R) and remimazolam with flumazenil group (group RF). There were eventually 50 patients in each group. The three groups of patients were compared for their resuscitation time and the time that they stayed in the resuscitation room (addressed as"room time"below). At 10 min and 20 min after resuscitation, each patient was tested for recognition ability (orientation score), walking ability and fine motor skill (including reaction speed, quick-click ability and visual memory), respectively, with possible adverse reactions recorded spontaneously, such as hypotension, dizziness, nausea and vomitus. Results: There were 29 males and 21 females in group P with an average age of (34±6) years, 27 males and 23 females in group R with an average age of (36±8) years, and 26 males and 24 females in group RF with an average age of (33±7) years, respectively. All examinations for each patient were successfully completed with no interruptions. The resuscitation time and room time of group RF were (47±15) s and (26±5) min,respectively, which were both shorter than those in either group R [(489±92) s and (35±6) min] or group P [(196±61) s and (31±7) min] (all P<0.05). The orientation score of patients in group RF at 10 min after resuscitation was (79.0±10.5), which was significantly higher than that in group R (70.0±11.7) (P<0.05). The patients' walking ability score of group RF at 10 min and 20 min after resuscitation were [(23.6±10.8), (48.0±4.5)], which were better than those in group R[(15.4±11.1), (47.6±4.8)] (both P<0.05). The patients' reaction speed and quick-click scores of group RF were [(851.0±150.9), (547.0±114.0) ms] and [(758.0±73.2), (629.0±128.9) ms], which were better than those in either group R [(1 151.0±206.0), (732.0±135.1) ms], [(893.0±110.9), (765.8±125.8) ms] or group P [(985.0±225.3), (613.0±123.2) ms], [(831.0±87.7), (691.0±115.8) ms] (all P<0.05). The incidence rate of hypotension in group P was 18% (9/50), higher than that in either Group R [4% (2/50)] or group RF [2% (1/50)] (all P<0.05). The incidence rates of dizziness, nausea and vomitus were comparable among all the three groups with no statistical differences (all P>0.05). Conclusion: In patients undergoing anesthesia with remazolam, the use of flumazenil can not only shorten the resuscitation time and the time that the patients need to stay in the resuscitation room, but also speed up the recovery of the patients' recognition, walking and fine motor skill abilities.

The Impact of Pediatric Laparoscopic Inguinal Hernia Repair in a Community Based Children's Ambulatory Surgery Center – It's Safe and Effective

PurposePediatric surgery in a free-standing children's ambulatory surgery center (C-ASC) is a common practice. The implementation of minimally invasive surgery in this setting may be associated with unique challenges. The purpose of this study was to compare a cohort of children who underwent laparoscopic (LHR) and open inguinal hernia repairs (OHR) at the C-ASC as part of a quality assurance initiative to assess safety and efficacy. MethodsFrom January 2021 to December 2021, the records of all children who underwent LHR or OHR at our C-ASC were analyzed. The following data was retrieved and compared with the Student's t-test: age, weight, gender, procedure type, total room time (RT), total operative time (OT), and outcomes. ResultsEighty-eight (n = 88) children underwent LHR or OHR during this period. There was no difference between the two groups regarding their age or weight. Both groups had equal outcomes, specifically, no wound infections or recurrent hernias. (2.5 year follow-up). There was a significant reduction in RT and OT in those children who underwent unilateral LHR compared to unilateral OHR (15% and 17% respectively, p < 0.05). In those children who underwent bilateral LHR and bilateral OHR, there was a reduction in RT and OT in the LHR group compared to OHR, but it was not significant (10% and 12% respectively, p > 0.05). ConclusionsPediatric LHR is safe and effective in the C-ASC. The unilateral LHR technique is associated with a significant reduction in total room time and operative time compared to the unilateral OHR technique. Additional analyses would be important to examine the relationship of time and outcomes in this setting. Type of studyOriginal Research Retrospective Case-control study.

Efficiency of Foot and Ankle Surgeries Completed on the Preoperative Stretcher vs Operating Room Table: A Randomized Controlled Trial.

Extremity surgeons frequently operate on the preoperative stretcher rather than the operating room (OR) table. This study sought to identify differences between stretcher-based (SB) and OR table-based (TB) procedures with regard to time efficiency and OR team member preferences. We conducted a prospective randomized controlled trial comparing the efficiency of SB vs OR TB foot and ankle procedures. Fifty-two patients undergoing a hardware removal, isolated gastrocnemius recession, soft tissue procedure, or foreign body removal at our day surgery unit were included. Start time and exit time were recorded. "Start time" was the number of minutes between the patient entering the OR and first incision. "Exit time" was the number of minutes between the procedure ending and the patient exiting the OR. Surveys were disseminated to OR staff who participated in the included cases. The total measured time in the OR was an average 6 minutes shorter in the Stretcher group compared to the OR Table group (10 minutes vs 16 minutes, P < .001). SB procedures were associated with a significantly shorter start time (median difference = 4 minutes, P = .001), but not exit time (median difference = 1 minute, P = .058). No difference was found in actual surgical time. Thirty (96.8%) OR team members perceived SB procedures as enhancing OR efficiency, and 30 (96.8%) respondents considered SB procedures to be equal or superior to OR TB procedures in terms of patient safety. All would recommend or strongly recommend SB procedures. We found SB foot and ankle procedures to require less room time than OR TB procedures. Particularly for high-volume specialties, an average 6 minutes saved per case may meaningfully improve overall OR efficiency. Most OR team members believed that SB surgery improves OR efficiency and is the safer option for OR team members. Level II, randomized controlled trial, survey.

High-Frequency Jet Ventilation Versus Spontaneous Respiration for Percutaneous Cryoablation of Lung Tumors: Comparison of Adverse Events and Procedural Efficiency.

BACKGROUND. High-frequency jet ventilation (HFJV) facilitates accurate probe placement in percutaneous ablation of lung tumors but may increase risk for adverse events, including systemic air embolism. OBJECTIVE. The purpose of this study was to compare major adverse events and procedural efficiency of percutaneous lung ablation with HFJV under general anesthesia to spontaneous respiration (SR) under moderate sedation. METHODS. This retrospective study included consecutive adults who underwent CT-guided percutaneous cryoablation of one or more lung tumors with HFJV or SR between January 1, 2017, and May 31, 2023. We compared major adverse events (Common Terminology Criteria for Adverse Events grade ≥ 3) within 30 days postprocedure and hospital length of stay (HLOS) of 2 days or more using logistic regression analysis. We compared procedure time, room time, CT guidance acquisition time, CT guidance radiation dose, total radiation dose, and pneumothorax using generalized estimating equations. RESULTS. Overall, 139 patients (85 women, 54 men; median age, 68 years) with 310 lung tumors (82% metastases) underwent 208 cryoablations (HFJV, n = 129; SR, n = 79). HFJV showed greater rates than SR for the treatment of multiple tumors per session (43% vs 19%, respectively; p = .02) and tumors in a nonperipheral location (48% vs 24%, p < .001). Major adverse event rate was 8% for HFJV and 5% for SR (p = .46). No systemic air embolism occurred. HLOS was 2 days or more in 17% of sessions and did not differ significantly between HFJV and SR (p = .64), including after adjusting for probe number per session, chronic obstructive pulmonary disease, and operator experience (p = .53). Ventilation modalities showed no significant difference in procedure time, CT guidance acquisition time, CT guidance radiation dose, or total radiation dose (all p > .05). Room time was longer for HFJV than SR (median, 154 vs 127 minutes, p < .001). For HFJV, the median anesthesia time was 136 minutes. Ventilation modalities did not differ in the frequencies of pneumothorax or pneumothorax requiring chest tube placement (both p > .05). CONCLUSION. HFJV appears to be as safe as SR but had longer room times. HFJV can be used in complex cases without significantly impacting HLOS of 2 days or more, procedure time, or radiation exposure. CLINICAL IMPACT. Selection of the ventilation modality during percutaneous lung ablation should be based on patient characteristics and anticipated procedural requirements as well as operator preference.

Technical and Diagnostic Performance of Rapid MRI for Evaluation of Appendicitis in a Pediatric Emergency Department

Rationale MRI is increasingly used for diagnosis of pediatric appendicitis in theemergency care setting. Scan and room time are important to optimize workflow,especially in situations with limited MRI availability and accessibility. To describe our process to optimize and implement a rapid, non-contrast, free-breathing MRI protocol for appendicitis and to characterize the accuracy fordiagnosis. Initial MRI protocol implemented for suspected appendicitis included five respiratory-triggered axial and coronal single shot fast spin echo (SSFSE) and radialT2W sequences with and without fat suppression (FS). This protocol was reassessedbased on image quality. Subsequently, the coronal and axial T2W SSFSE FS sequence were removed. A three-sequence exam comprised the rapid MRI appendicitisprotocol used for the remainder of the study. All examinations were performed on a 1.5T scanner. For all examinations, the following information was obtained: scan time, diagnosis ofappendicitis (by radiology report), surgery and pathology reports, and alternativediagnoses documented in radiology reports. MRI examination scan durations werecompared between the five-sequence and three-sequence protocols, with Mann-Whitney U test, and proportions of false diagnoses were compared toFisher's exact test. 216 examinations were performed; 21 and 195 performed with five-and three-sequence protocol, respectively. The median duration of the five-sequence protocol was 20 (16.9-23.5) minutes vs.11 (9.5-13) minutes for the threesequence protocol (p<0.0001). The majority (n=157, 80.5% of 195) of examinations were performed in a goal time of<15min. 23 examinations took longer than 20min (n=12, n=11 for the three-and five-sequence protocols, respectively) were due to repeat sequences or addition of non-standardsequences (requested by interpreting radiologist). 27 (90%) of the 30 reported positive cases were confirmed by pathology. There were threefalse-positive diagnoses (all three-sequence protocol exams) and onefalse-negativediagnosis (five-sequence protocol exam). Alternative diagnoses, including pancreatitis,omental infarct, masses, and ovarian pathology, were made in 42 (19%) cases. A three-sequence, non-contrast, free- breathing MRI examination can beperformed in less than 15min in the emergency department and has highdiagnostic accuracy for acute appendicitis in children and young adults.

A Pilot Study of Simulation-Free Hippocampal-Avoidance Whole Brain Radiotherapy Using Diagnostic MR-Based and Online Adaptive Planning

We aimed to demonstrate the clinical feasibility and safety of a simulation-free hippocampal avoidance whole brain radiotherapy (HA-WBRT) workflow in a Phase I clinical trial (NCT05096286). Feasibility was defined as successful completion of the simulation-free HA-WBRT workflow through treatment delivery in at last 70% of treated patients. Ten candidates for HA-WBRT were enrolled for treatment on a ring gantry CT-guided Linac with online adaptive capabilities. Structures were contoured on the diagnostic brain MRI, which was then registered to a separate head computed tomography (CT) of similar head shape, obtained from an atlas-based database. A HA-WBRT "pre-plan" was generated using the atlas-based CT (AB-CT) and the NRG-CC001 constraints. At first fraction, the AB-CT was used as the primary dataset and deformed to the patient's cone-beam CT (CBCT) for dose calculation. The brain, ventricles, and brainstem contours were matched through rigid translation and rotation to the corresponding anatomy on the CBCT to aid in alignment, given the differences in rotational head positioning from diagnostic MRI to CBCT setup. Lastly, the lens, optic nerves, and brain contours were manually edited based on CBCT visualization. Plans were then optimized, and the adaptive plan was chosen for treatment if the plan met all objectives. Workflow tasks were timed. In addition, conventional plans using patients' sim CTs were created for each patient for the purpose of prospective dosimetric comparison. The dosimetric parameters were compared for each patient between the delivered sim-free plan and the conventional sim CT plan using the sign test via statistical software, with p<.05 indicating significance. Median time from approved sim order to first fraction was 4 days (range: 2-7); median time in room (door-to-door) was 49 minutes (range: 35-70). All patients successfully completed all ten fractions and 90% of the simulation-free radiation plans met all NRG-CC001 constraints. For one patient, the sim-free plan at fraction one failed the planning target volume (PTV) coverage objective (coverage of 89%); this was deemed acceptable for delivery by the treating radiation oncologist. An offline replan was then performed to meet NRG-CC001 constraints and used for the subsequent nine fractions. There was no clinically meaningful difference in dosimetric constraints between the sim-free plan (calculated on AB-CT) and conventional CT sim plan. Statistically, the sim-free plans provided improved PTV coverage to higher doses compared to the conventional plans (Table). At a median follow-up of 43 days (range: 9 -280), the intracranial progression-free survival rate was 90%. Simulation-free HA-WBRT is feasible, results in plans that are dosimetrically comparable to conventional CT sim workflows and succeeds in decreasing time to initiation of HA-WBRT by at least 50%. Further studies with a larger cohort are warranted to optimize the workflow.

Decision-to-Delivery Interval and Obstetric Outcomes of Emergency Caesarean Sections in a Nigerian Teaching Hospital

Background: Prolonged Decision-to-Delivery interval (DDI) is associated with adverse maternal-foetal outcomes following emergency Caesarean section (EmCS). Objective: To determine the DDI, predictive factors, and the foeto-maternal outcomes of patients that had EmCS in a Nigerian Teaching Hospital. Methods: A descriptive study of all EmCS performed at the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile-Ife, Nigeria, from 1st June 2020 to 31st May 2021, was conducted. Relevant data were extracted from the documentations of doctors, nurses and anaesthetists using a designed proforma. The data obtained were analysed using the IBM SPSS Statistics for Windows, version 25. Results: The median (IQR) DDI was 297 (175-434) minutes. Only one patient was delivered within the recommended DDI of 30 minutes. The most common cause of prolonged DDI was delay in procuring materials for CS by patients’ relatives(s)/caregiver(s) (264, 85.2%). Repeat CS (AOR = 4.923, 95% CI 1.09-22.36; p = 0.039), prolonged decision-to-operating room time (AOR = 8.22, 95% CI 1.87-8.66; p&lt;0.001), and junior cadre of surgeon (AOR = 25.183, 95% CI 2.698-35.053; p = 0.005) were significant predictors of prolonged DDI. Prolonged DDI &gt; 150 minutes was significantly associated with maternal morbidity (p = 0.001), stillbirth (p = 0.008) and early neonatal death (p = 0.049). Conclusion: The recommended DDI of 30 minutes for CS is challenging in the setting studied. To improve foeto-maternal outcomes, efforts to reduce the DDI should be pursued vigorously, using the recommended 30 minutes as a benchmark.

Direct to Operating Room for Decompressive Craniotomy/Craniectomy in Patients With Traumatic Brain Injury.

Emergent decompressive craniotomy/craniectomy can be a lifesaving surgical intervention for select patients with traumatic brain injury. Prompt management is critical as early decompression can impact traumatic brain injury outcomes. This study aims to describe the feasibility and clinical impact of a new pathway for transporting patients with severe traumatic brain injury directly to the operating room from the trauma bay for decompressive craniotomy/craniectomy. This is a retrospective cohort preintervention and postintervention study of severe traumatic brain injury patients undergoing decompressive craniectomy/craniotomy at a Midwestern U.S. Level I trauma center between 2016 and 2022. In the new pathway, the in-house trauma surgeon takes the patient directly to the operating room with the neurosurgery advanced practice provider to drape and prepare the patient for surgery while the neurosurgeon is en route to the hospital. A total of 44 patients were studied, five (5/44, 11.4%) of which were in the preintervention group and 39 (39/44, 88.6%) in the postintervention group. The median arrival-to-operating room time was shorter in the postintervention cohort (1.4 hr) than in the preintervention cohort (1.5 hr). In examining night shifts only, the preintervention cohort had shorter arrival-to-operating room times (1.2 hr) than the postintervention cohort (1.5 hr). The study demonstrated that the new pathway is feasible and expedites patient transport to the operating room while awaiting the arrival of the on-call neurosurgeon.

Time-Driven Activity-Based Cost Comparison of Osteoid Osteoma Ablation Techniques

ObjectiveCompare the cost of performing an osteoid osteoma ablation using cone beam CT (CBCT) with overlay fluoroscopic guidance to ablation using conventional CT (CCT) guidance and microwave ablation (MWA) to radiofrequency ablation (RFA). MethodsAn 11-year retrospective study was performed of all patients undergoing osteoid osteoma ablation. Ablation equipment included a Cool tip RFA probe (Covidien, Minneapolis, Minnesota) or a Neuwave PR MWA probe (Ethicon, Rariton, New Jersey). The room times as well as immediate recovery time were recorded for each case. Cost analysis was then performed using time-driven activity-based costing for rate-dependent variables including salaries, equipment depreciation, room time, and certain supplies. Time-independent costs included the disposable interventional radiology supplies and ablation systems. Costs were reported for each service providing care and using conventional cost accounting methods with variable and fixed expenditures. ResultsA total of 91 patients underwent 96 ablation procedures in either CBCT (n = 66) or CCT (n = 30) using either MWA (n = 51) or RFA (n = 45). The anesthesia induction (22.7 ± 8.7 min versus 15.9 ± 7.2 min, P < .001), procedure (64.7 ± 27.5 min versus 47.3 ± 15.3 min; P = .001), and room times (137.7 ± 33.7 min versus 103.9 ± 22.6. min; P < .001) were significantly longer for CBCT procedures. The procedure time did not differ significantly between MWA and RFA (62.1 ± 27.4 min versus 56.1 ± 23.3 min; P = .27). Multiple regression analysis demonstrated lower age (P = .046), CBCT use (P = .001), RFA use (P = .02), and nonsupine patient position (P = .01) significantly increased the total procedural cost. After controlling for these variables, the total cost of CBCT ($5,981.32 ± $523.93 versus $5,378.93 ± $453.12; P = .001) remained higher than CCT and the total cost of RFA ($5,981.32 ± $523.93 versus $5,674.43 ± $549.14; P = .05) approached a higher cost than MWA. ConclusionThe use of CBCT with overlay fluoroscopic guidance for osteoid osteoma ablation resulted in longer in-room times and greater cost when compared with CCT. These cost considerations should be weighed against potential radiation dose advantage of CBCT when choosing an image guidance modality. Younger age, RFA use, and nonsupine patient position additionally contributed to higher costs.

Experience of surgical treatments for abdominal inferior vena cava injuries in a regional trauma center in Korea.

Inferior vena cava (IVC) injuries are a rare type of traumatic abdominal injuries that are challenging to treat and have a very high mortality rate. This study described our experience with the surgical treatment of traumatic IVC injuries, and we investigated the demographics, clinical profiles, and surgical outcomes of cases at a regional trauma center. Among the 16 patients who were treated for a traumatic IVC injury between January 2014 and March 2022, 14 underwent surgery. The surgical outcomes included overall mortality and 24-hour mortality, and we investigated the factors associated with these surgical outcomes. The 14 patients were divided into two groups according to the location of the IVC injury (retrohepatic IVC or higher vs. subhepatic IVC), and differences between the two groups were analyzed. A body mass index (BMI) >23.0 kg/m2 (P=0.046), an elevated serum lactate level (P=0.043), and a shorter operation time (P=0.016) were associated with overall mortality. A higher BMI (P=0.050), higher serum lactate level (P=0.004), shorter operation time (P=0.005), and an injury at the retrohepatic IVC or higher level (P=0.031) were associated with 24-hour mortality. Younger age (P=0.028), higher BMI (P=0.005), more acidic pH, higher lactatemia (P=0.012), a higher hemoglobin level (P=0.012), and shorter door-to-operating room time (P=0.028) were associated with injury at the retrohepatic IVC or higher level. Patients with subhepatic IVC injuries had a high rate of direct repair (75.0%) and a significantly lower 24-hour mortality rate (37.5%, P=0.031). Subhepatic IVC injuries are easy to access and are usually expected to treat with a direct repair method. Injuries at the retrohepatic IVC or higher level are difficult to treat surgically and require a systematic and multidisciplinary treatment strategy.

CE-452771-1 IMPACT OF INTRACARDIAC VS. TRANSESOPHAGEAL ECHOCARDIOGRAPHY GUIDED LEFT APPENDAGE CLOSURE ON PROCEDURAL CHARACTERISTICS AND LAB EFFICIENCY: A META ANALYSIS

Left atrial appendage occlusion (LAAO) is frequently performed under transesophageal echocardiography (TEE) guidance, but intracardiac echocardiography (ICE) is increasingly being used given its ease of use and the possibility to perform the procedure under light sedation (as opposed to general anesthesia). The impact of ICE vs. TEE guidance on procedural characteristics and lab efficiency is yet to be determined. To evaluate the impact of ICE vs. TEE guidance during LAAO on procedural efficacy and safety; fluoroscopy procedural and in room time; and the presence of peridevice leaks and residual septal defects during follow-up. Pubmed, Embase and Cochrane were searched using the term "left atrial appendage" AND (closure OR occlusion) AND "intracardiac echocardiography". No language restriction was applied. Single arm studies, review articles, abstracts, letters to the editor and studies using database claims were excluded. All articles were evaluated by 3 independent reviewers (JCD, OB, JR) and the risk of bias established using the Newcastle-Ottawa scale with a score >6 considered a high-quality study; differences were solved by consensus. Statistical analysis was performed using Revman 5.4 (Cochrane collaboration). Eleven observational studies (n=3034; 976 using ICE guided LAAO) were included. Nine studies were considered high quality, with 2 studies having a score of 6. There were no statistically significant differences in procedural success (OR 1.38 95% CI 0.76-2.51, p=0.29) or procedure related major adverse events (OR 0.77 95% CI 0.53-1.12) in ICE guided vs. TEE guided LAAO. The use of ICE guidance resulted in a statistically significant reduction in in-room time (mean difference -35.5 minutes; 95% CI -44.9 to -26 min. p <0.0001). No significant differences were found in procedural time or fluoroscopy time. During follow-up imaging, there were no differences in peridevice leak (OR 0.9 95% CI 0.66-1.23). A trend towards increased prevalence of residual interatrial septal defects was observed with ICE guided vs. TEE guided LAAO (OR 1.43, 95% CI 0.99-2.07, p =0.05). ICE guidance is associated with improved lab efficiency (as established by a significant 35-minute reduction in in-room time), without any significant differences in procedural success or safety. During follow-up, there were no differences of the rate of periprocedural leaks. A non-significant trend towards a higher prevalence of residual interatrial septal defects was observed.

Disparities in eye clinic patient encounters among patients requiring language interpreter services

BackgroundCommunication barriers are a major cause of health disparities for patients with limited English proficiency (LEP). Medical interpreters play an important role in bridging this gap, however the impact of interpreters on outpatient eye center visits has not been studied. We aimed to evaluate the differences in length of eyecare visits between LEP patients self-identifying as requiring a medical interpreter and English speakers at a tertiary, safety-net hospital in the United States.MethodsA retrospective review of patient encounter metrics collected by our electronic medical record was conducted for all visits between January 1, 2016 and March 13, 2020. Patient demographics, primary language spoken, self-identified need for interpreter and encounter characteristics including new patient status, patient time waiting for providers and time in room were collected. We compared visit times by patient’s self-identification of need for an interpreter, with our main outcomes being time spent with ophthalmic technician, time spent with eyecare provider, and time waiting for eyecare provider. Interpreter services at our hospital are typically remote (via phone or video).ResultsA total of 87,157 patient encounters were analyzed, of which 26,443 (30.3%) involved LEP patients identifying as requiring an interpreter. After adjusting for patient age at visit, new patient status, physician status (attending or resident), and repeated patient visits, there was no difference in the length of time spent with technician or physician, or time spent waiting for physician, between English speakers and patients identifying as needing an interpreter. Patients who self-identified as requiring an interpreter were more likely to have an after-visit summary printed for them, and were also more likely to keep their appointment once it was made when compared to English speakers.ConclusionsEncounters with LEP patients who identify as requiring an interpreter were expected to be longer than those who did not indicate need for an interpreter, however we found that there was no difference in the length of time spent with technician or physician. This suggests providers may adjust their communication strategy during encounters with LEP patients identifying as needing an interpreter. Eyecare providers must be aware of this to prevent negative impacts on patient care. Equally important, healthcare systems should consider ways to prevent unreimbursed extra time from being a financial disincentive for seeing patients who request interpreter services.

A Comparative Study between Surgical Techniques by Local Excisional debridement with a Xylocaine Block and Excisional Debridement under General Anesthesia, in Necrotizing Fasciitis

Objective: This study aimed to compare the clinical and economic outcomes between excisional debridement with a local xylocaine block (LAD) and excisional debridement under general anesthesia (GAD). Material and Methods: This retrospective medical record review was designed to review records of excisional debridement in necrotizing fasciitis (NF) at Sisaket Hospital from January 1, 2017, to December 31, 2019. Outcome measures were clinical outcomes at the preoperative time (baseline data, door-to-operating room), peri-operative time (operating time, blood loss, number of reoperations), postoperative time (mortality rate, length of stay, pain score, opioid drug use), types of NF, and direct costs of treatment by the provider’s perspective. Descriptive statistics, chi-square and Mann-Whitney U test were used. Results: The results of 245 patients showed that LAD was superior to GAD in terms of door-to-operating room time, lower operating time and blood loss, shorter length of hospital stay and lower cost of treatment. Moreover, the LAD showed a lower postoperative pain score, and less opioid drug use when compared to GAD. There were no significant differences in mortality rate, sites of infection and types of NF. Conclusion: LAD showed better clinical outcomes and lower cost of treatment when compared to GAD in the treatment of NF. Nevertheless, excisional debridement under a LAD could be a choice for small wounds at the lower extremities in hospitals with limited resources, and insufficient numbers of anesthesiologists.

A Novel Laser Angle Selection System for Computed Tomography-Guided Percutaneous Transthoracic Needle Biopsies.

Purpose: To evaluate a novel laser angle selection system (LASS) for improving the efficiency of a computed tomography (CT)-guided percutaneous transthoracic needle biopsy (PTNB). Methods: Thirty-eight patients referred for CT-guided PTNB were randomly separated into a LASS-assisted puncture group (18 patients) or conventional freehand control group (20 patients). The puncture time, number of control CT scans, and patients' radiation dose were compared for each group. Results: The lesion size, target-to-pleural distance, planned puncture depth, and angle of the two groups were not significantly different. LASS-assisted PTNB significantly reduced the number of control scans (1.7 ± 0.8 vs 3.5 ± 1.5, P < .001) and the mean operation time (12.0 ± 4.3min vs 28.8 ± 13.3min, P < .001) compared with the conventional method. The corresponding room time (27.1 ± 6.6min vs 44.1 ± 14.4min, P < .001) and total radiation dose (7.9 ± 1.0mSv vs 10.1 ± 1.7mSv, P < .001) of each procedure also decreased significantly. Fifty-six percent (10/18) of the operations hit the target on the first needle pass when using LASS compared with 10% (2/20) using the conventional method. Conclusions: Compared with a conventional method, this novel laser angle simulator improves puncture efficiency with fewer needle readjustments and reduces patient radiation dose.

The Impact of Scripted Self-Hypnotic Relaxation on the Periprocedural Experience and Anesthesiologist Sedation Use in the Pediatric Cardiac Catheterization Suite: A Prospective Randomized Controlled Trial.

To assess the impact on children of self-hypnotic relaxation scripts read by trained staff prior to the induction of anesthesia and/or extubation on the periprocedural experience. A total of 160 children aged 7-18 years undergoing a cardiac catheterization intervention under general anesthesia were randomized into 4 groups: (1) a pre-procedure (PP-script) read prior to entering the procedural room, (2) a script read prior to extubation (PX-Script), (3) both PP- and PX-Scripts read and (4) no script read. Anxiety and pain were rated on self-reported 0-10 scales. The modified Yale Preoperative AnxietyScale was used for preoperative anxiety. The effect of script reading was associated with outcomes by linear regression for continuous variables, and logistic regression for binary variables in two-sided tests at a significance level of 0.05. Results are given in odds ratios (OR) and 95% confidence intervals (CI). Data were available for 158 patients. Reading the PP-Script prior to anesthesia was associated with a significant reduction in the use of intraoperative sedatives from 30% to 14% (OR 0.40; CI 0.18-0.88; p = 0.02) by the anesthesiologists, who were blinded to group attribution until extubation. This was despite the children not self-reporting significantly lower levels of anxiety or pain. The PX-Script did not change outcomes. Among groups, there was no significant difference in room time, postoperative recovery time and pain. Reading a PP-Script for guidance in self-hypnotic relaxation can result in less need for intravenous sedation in the judgment of the anesthesiologist, independent of the children's self-reported anxiety and pain. This raises interesting questions about subconscious patient-physician interactions affecting pain management. NCT02347748.

Hybrid Clinics: A New Model for Ambulatory Care to Reduce Infection Risk.

Objectives: To assess the viability of a hybrid clinic model combining in-person examination with video-based consultation to minimize viral transmission risk. Methods: Data were collected prospectively in a pediatric urology clinic for in-person visits from January to April 2018 ("classic") and hybrid visits from October to December 2020 of the COVID-19 pandemic ("hybrid"). Variables included provider, diagnosis, patient type, time of day, prior surgery, postoperative status, and decision-making for surgery. The primary outcome was "room time" or time in-person. The secondary outcome was "total time" or visit duration. Proportion of visits involving close contact (room time ≥15 min) was assessed. Univariate analyses were performed using the Wilcoxon rank-sum test and Fisher's exact test. Mixed models were fitted for visit approach and other covariates as fixed effects and provider as random effect. Results: Data were collected for 346 visits (256 classic, 90 hybrid). Hybrid visits were associated with less room time (median 3 min vs. 10 min, p < 0.001) but greater total time (median 13.5 min vs. 10 min, p = 0.001) as compared with classic visits. On multivariate analysis, hybrid visits were associated with 3 min less room time (95% confidence intervals [CIs]: -5.3 to -1.7, p < 0.001) but 3.8 min more total time (95% CI: 1.5-6.1, p = 0.001). Close contact occurred in 6.7% of hybrid visits, as compared with 34.8% of classic visits (p < 0.001). Conclusions: Hybrid clinic visits reduce room time as compared with classic visits. This approach overcomes the examination limitations of telemedicine while minimizing viral transmission, and represents a viable model for ambulatory care whenever close contact carries infection risk.

LEARNING TO TEACH IN THE ERA OF UNCERTAINTIES: CHALLENGES AND LESSONS LEARNT BY STUDENT TEACHERS DURING COVID-19 PANDEMIC IN UGANDA

&lt;p&gt;The global impact of the COVID-19 pandemic is not only being felt by different social classes of people, but also across levels of education systems. There was a paradigm shift from the traditional teaching approaches to a more flexible one, including remote teaching. This crisis uncovered the many challenges in the education system such as access and lack of supportive environments for both teachers and learners. The teacher trainees were greatly affected as they could hardly complete their teacher training programme in time. The purpose of this study was to investigate student teachers’ perception of teaching during the COVID-19 pandemic. Specifically, to explore challenges faced by student teachers; document lessons learnt and coping strategies improvised while teaching during the COVID-19 pandemic. A concurrent mixed method design was adopted. Both quantitative and qualitative data were collected from 46-year three student teachers of Muni University. Data were collected using student teachers’ reflective journals and reflective meetings. Challenges experienced by student teachers were related to placement, supervisor-supervisee relationship, inadequate support from school authorities, inadequate skills in classroom room management and time management. Student teachers adopted coping strategies like teamwork, collaborative and adaptive skills, classroom and discipline management. Four categories of lessons learnt were adaptiveness, collaboration, creativity and uniqueness of learners. They learnt how to incorporate modern approaches including those embedded in Bloom’s taxonomy. The study recommended that teacher training institutions should ensure adequate and wholistic preparation of student teachers prior to school practice; school practice supervisors should treat school practice supervision as a non-judgemental exercise meant to enhance student teachers’ professional growth, and school authorities should provide required materials and mentorship to student teachers.&lt;/p&gt;&lt;p&gt; &lt;/p&gt;&lt;p&gt;&lt;strong&gt; Article visualizations:&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;&lt;img src="/-counters-/edu_01/0955/a.php" alt="Hit counter" /&gt;&lt;/p&gt;

Effect of Four-in-One Optimized Emergency Nursing Procedure on Symptoms and Vital Signs of Patients with Mushroom Poisoning.

Most members of the general public find it difficult to identify poisonous wild mushrooms, resulting in family food poisoning. Toxic mushroom poisoning can produce nausea, vomiting, abdominal pain, and other severe symptoms 30 minutes or more after ingestion that can even lead to death. Using a “four-in-one” optimized emergency nursing procedure to treat mushroom poisoning can reduce the rescue time and improve the survival rate of patients. This study aimed to analyze the influence of a “four-in-one” optimized emergency nursing procedure to treat patients with toadstool poisoning. A prospective randomized study was conducted. Sixteen cases of toadstool poisoning, corresponding to 78 patients admitted to our hospital from January 2017 to July 2020, were selected and divided into a study group and a control group of 39 cases each using a random number table. The control group was provided with routine emergency care, and the study group was given a “four-in-one” treatment that optimized the emergency care process; both groups were subjected to basic treatment + blood purification and other treatment measures, and the treatment time in the rescue room and the first blood purification time of the two groups were compared. Differences in routine blood tests, liver and kidney function indices, hospitalization time, coma time, treatment outcome, and nursing satisfaction before and after treatment were found. The treatment time and the first blood purification time of the study group were lower than those of the control group, and the difference was statistically significant (P < 0.05); ALT, AST, TBIL, TBA, and ALB were measured upon admission for the study and the control groups. The measured values of PT, APTT, CK, CK-MB, and BUN were compared for the two groups, but the difference in the values between the two groups was not statistically significant (P > 0.05); after 7 days of treatment, the ALT, TBA, and APTT indicators of the study group were lower than those of the control group, and the difference was statistically significant (P < 0.05); the measured values of ALT, AST, TBIL, TBA, ALB, PT, APTT, CK, CK-MB, BUN, and Scr after 7 days of treatment were significantly lower than those before treatment for both groups (P < 0.05). The length of stay for the study group was lower than that for the control group, and the difference was statistically significant (P < 0.05); the treatment efficiency was 87.18% for the study group, compared with 82.05% for the control group, but the difference was not statistically significant (P > 0.05). The study group rated nursing care as follows: very satisfactory, 79.49%; relatively satisfactory, 15.38%; and acceptable, 5.13%; the control group rated nursing care as follows: very satisfactory, 51.28%; relatively satisfactory, 30.77%; and acceptable, 12.82%; the results were statistically significant (P < 0.05). Using a “four-in-one” optimized emergency care process to treat patients with mushroom poisoning can significantly reduce the rescue room treatment time and the first blood purification time and improve nursing satisfaction, but has a limited effect on improving the treatment efficiency.