Select Procedures Research Articles

Association between social determinants of health and select neurosurgical procedures in the National Spina Bifida Patient Registry.

Myelomeningocele (MMC) is a lifelong condition requiring complex multidisciplinary management. Using the National Spina Bifida Patient Registry (NSBPR), the authors tested the association between sociodemographic variables and odds of undergoing neurosurgical procedures. The authors extracted sociodemographic, clinical, and neurosurgical procedure data on participants with MMC aged ≥ 1 year who visited an NSBPR clinic between 2009 and 2020. The zip code of the participant's residence at the time of the last spina bifida clinic visit was linked to the Distressed Communities Index (DCI) tier. Multivariate models were built to identify factors associated with undergoing CSF diversion, shunt revision, tethered cord release (TCR), and Chiari decompression. There were 7924 participants with a median visit age of 13 years (IQR 7-20 years); 49.1% were male, 30.2% were non-Hispanic Black or Hispanic, 54.5% had public/supplemental insurance, and 16.9% were from distressed communities. CSF diversion, shunt revision, TCR, and Chiari decompression were performed in 81.8%, 47.7%, 22.9%, and 8.7% of participants, respectively. In multivariate analyses controlling for age, sex, insurance, DCI tier, lesion level, and surgical closure timing, Hispanic individuals were less likely than their non-Hispanic White counterparts to undergo shunt revision (p = 0.013). Non-Hispanic Black and Hispanic individuals were less likely to undergo TCR (p < 0.001 each) or Chiari decompression (p < 0.001 each). Compared with privately insured individuals, publicly insured individuals were more likely to undergo CSF diversion (p = 0.031). Those in distressed communities had increased odds of undergoing CSF diversion (p = 0.004) than those in prosperous communities. Among individuals with MMC participating in the NSBPR, there were differences in receiving neurosurgical procedures by race/ethnicity, insurance type, and DCI tier. Additional prospective studies are necessary to elucidate the reasons for these variations and their impact on long-term outcomes for this patient population in order to created targeted interventions.

Opioid-free anesthesia improves postoperative recovery quality of small and medium-sized surgery: a prospective, randomized controlled study.

Opioid anesthesia (OA) is currently the predominant anesthetic method. However, its associated side effects, such as nausea and vomiting, coupled with the principle of enhanced recovery after surgery (ERAS), have spurred the adoption of opioid-free anesthesia (OFA) in select surgical procedures. For small and medium-sized operations, ERAS is particularly important. The aim of this study was to investigate the effect of OFA, utilizing esketamine in combination with dexmedetomidine and sevoflurane, on postoperative recovery quality following small and medium-sized surgical interventions. A total of 120 patients who underwent various small and medium-sized operations were randomly allocated to OFA and OA groups. The OA group received sufentanyl and sevoflurane, while the OFA group received esketamine, dexmedetomidine, and sevoflurane. The primary outcome measure was the postoperative quality of recovery-40 scores (QoR-40) 24 hours after surgery. Secondary outcomes included hemodynamic changes at different time intervals, the incidences of adverse events were recorded. Patients in the OFA group exhibited a higher QoR-40 score of 184.0 (182.0, 186.2) compared to 182.0 (180.0, 184.0) in the OA group (P<0.001). The disparities were particularly noble in terms of Physical comfort and Emotional status. Multivariable analysis identified postoperative nausea and vomiting (PONV) as a significant independent factor impacting QoR-40 (β=-4.49 [-6.1, -2.87], P<0.001). Hemodynamic stability was more pronounced in the OFA than in the OA group. The incidence of PONV was substantially lower in the OFA group (one [1.6%] vs. 14 [25%], P<0.001), with a reduced need for vasoactive drugs (five [7.8%] vs. 15 [26.8%], P=0.005), and a lower incidence of respiratory depression (0 [0%] vs. six [10.7%], P=0.009). OFA improves the postoperative recovery quality in small and medium-sized surgical procedures, potentially attributed to decreased incidence of PONV. Additionally, OFA facilitates the maintenance of more stable hemodynamics throughout the operation.

2020 CMS prior authorization for hospital outpatient departments: Associated surgical volume impact

BackgroundPrior authorization is common for privately administered Medicare Advantage plans but is rarely used for surgical care when considering publicly administered plans. A 2020 Centers for Medicare and Medicaid services (CMS) policy, CMS-1717-FC, requires prior authorization for Medicare Fee-for-Service beneficiaries undergoing select procedures (blepharoplasty, abdominoplasty, botulinum toxin injection, rhinoplasty, and vein ablation) in hospital outpatient departments. The impact of this policy on surgical volume at hospital outpatient departments and shifts in care to ambulatory surgery centers is unknown. MethodsThis study used a segmented interrupted time series and pre-post logistic regression model. This study was a retrospective cohort study using data from the Healthcare Cost and Utilization Project state ambulatory surgery database and state inpatient database. ResultsFrom 2016 through 2021, a total of 272,879 patients underwent the affected procedures. Pre–CMS-1717-FC, a trend of decreasing hospital outpatient department utilization was found for Medicare Fee-for-Service beneficiaries (–10.82, 95% confidence interval: –18.32 to –3.33, P = .01). In the post-implementation period, no change in the rate of decreasing hospital outpatient department utilization was found for Medicare Fee-for-Service beneficiaries (–3.45, 95% confidence interval: –36.15 to 29.25, P = .83). In the pre-policy period, Medicare Fee-for-Service beneficiaries were 46% less likely to use freestanding ambulatory surgery centers but 27% less likely to use hospital-owned ambulatory surgery centers. ConclusionCMS-1717-FC was not associated with significant changes in hospital outpatient department volume beyond baseline trends. Policy aiming to right-size prior authorization for these procedures and considering site-of-service will balance the need to ensure medical necessity while constraining costs.

Three-dimensional motion analysis of pre- and postoperative thumb movement in trapeziometacarpal joint osteoarthritis-Comparison of arthrodesis and trapeziectomy with suspensionplasty.

Trapeziometacarpal osteoarthritis (TMC-OA) reduces the range of motion (ROM) of the thumb. However, the kinematic change achieved through surgical treatment remains unclear. Therefore, to quantify the kinematic change following TMC-OA surgery, we performed a three-dimensional motion analysis of the thumb using an optical motion capture system preoperatively and 1 year postoperatively in 23 patients with TMC-OA scheduled for arthrodesis (AD) or trapeziectomy with suspensionplasty (TS). Eighteen hands of nine healthy volunteers were also included as controls. Both procedures improved postoperative pain and Disability of the Arm, Shoulder and Hand scores, and AD increased pinch strength. The ROM of the base of the thumb was preserved in AD, which was thought to be due to the appearance of compensatory movements of adjacent joints even if the ROM of the TMC joint was lost. TS did not improve ROM. Quantifying thumb kinematic changes following TMC-OA surgery can improve our understanding of TMC-OA treatment and help select surgical procedures and postoperative assessment.

Pediatric Plastic Surgery Under Local Anesthesia.

Increasing research has shown that select surgical procedures can be performed in an office-based environment with low complication rates. Within the field of plastic surgery, these findings have mainly been studied in adult populations. However, studies regarding the safety and efficacy of office-based plastic surgery in the pediatric population are lacking. In the present study, we demonstrate that appropriately selected office-based pediatric plastic surgery procedures can be performed under local anesthesia for a variety of common surgical indications with low complication rates. A retrospective case series of pediatric plastic surgery patients who underwent in-office procedures under local anesthesia at a single academic institution from September 2014 to June 2020 was performed. Five hundred nine patients were treated in an office setting for various etiologies over the study period. A total of 48.9% of the patients were male and 51.1% were female. Patient age at time of procedure ranged from 24 days to 17 years of age with a median age of 13 years. A total of 778 lesions were treated. There were 10 total complications (1.29%) over the study period with only one surgical site infection that resolved with antibiotic treatment. Our work indicates that select pediatric plastic surgery procedures can be performed under local anesthesia with low complication rates.

Spinal Anaesthesia Using Hypobaric Drugs: A Review of Current Evidence.

Spinal anesthesia is one of the most widely used techniques in modern anesthesia practice. It involves the injection of local anesthetic drugs into the cerebrospinal fluid (CSF) within the subarachnoid space. The choice of drug, its concentration, and baricity play a crucial role in determining the characteristics of the spinal block and has evolved over the years with continuous advancements in drug formulations and administration methods. Spinal anesthesia with hypobaric drugs represents a valuable technique in the armamentarium of anesthesiologists, offering distinct advantages in terms of targeted action, reduced systemic toxicity, and enhanced hemodynamic stability. This review aims to scan the characteristics of hypobaric drugs, factors influencing their spread within the spinal canal, challenges associated with their use, clinical applications in various surgical scenarios, and potential implications for patient outcomes and healthcare practice. PubMed and Google Scholar databases were searched for relevant articles and a total of 23 relevant articles were selected for the review based on inclusion and exclusion criteria. Hypobaric drugs have many advantages in high-risk morbidly ill patients for some select surgical procedures and daycare surgeries. The concentration and volume of hypobaric drugs need to be selected according to the extensiveness of the surgery and the desired block can be achieved by giving spinal injection in specific positions. The dynamic field of anesthesiology encompasses the integration of emerging technologies and evidence-based practices, which will contribute to further refining the safety and efficacy of spinal anesthesia with hypobaric drugs.

Trends, outcomes, and factors associated with in-hospital opioid overdose following major surgery

BackgroundWith the growing opioid epidemic across the US, in-hospital utilization of opioids has garnered increasing attention. Using a national cohort, this study sought to characterize trends, outcomes, and factors associated with in-hospital opioid overdose (OD) following major elective operations. MethodsWe identified all adult (≥18 years) hospitalizations entailing select elective procedures in the 2016–2020 National Inpatient Sample. Patients who experienced in-hospital opioid overdose were characterized as OD (others: Non-OD). The primary outcome of interest was in-hospital OD. Multivariable logistic and linear regression models were developed to evaluate the association between in-hospital OD and mortality, length of stay (LOS), hospitalization costs, and non-home discharge. ResultsOf an estimated 11,096,064 hospitalizations meeting study criteria, 5375 (0.05 %) experienced a perioperative OD. Compared to others, OD were older (66 [57–73] vs 64 [54–72] years, p < 0.001), more commonly female (66.3 vs 56.7 %, p < 0.001), and in the lowest income quartile (26.4 vs 23.2 %, p < 0.001). After adjustment, female sex (Adjusted Odds Ratio [AOR] 1.68, 95 % Confidence Interval [CI] 1.47–1.91, p < 0.001), White race (AOR 1.19, CI 1.01–1.42, p = 0.04), and history of substance use disorder (AOR 2.51, CI 1.87–3.37, p < 0.001) were associated with greater likelihood of OD. Finally, OD was associated with increased LOS (β +1.91 days, CI [1.60–2.21], p < 0.001), hospitalization costs (β +$7500, CI [5900–9100], p < 0.001), and greater odds of non-home discharge (AOR 2.00, CI 1.61–2.48, p < 0.001). ConclusionPerioperative OD remains a rare but costly complication after elective surgery. While pain control remains a priority postoperatively, protocols and recovery pathways must be re-examined to ensure patient safety.

A Profile of Orthopedic Education in Emergency Medicine Residency Programs in the United States.

Introduction Emergency medicine (EM) residents throughout the United States are required to become skilled at performing a robust list of select orthopedic procedures, as well as learn how to diagnose and manage patients with musculoskeletal complaints. However, EM residency programs vary significantly in how they teach orthopedics and the content they cover. The purpose of this study was to profile the orthopedic education received by emergency medicine residents in United States residency programs. Methods We developed a survey based on accreditation requirements and The Model of the Clinical Practice of Emergency Medicine. The survey was designed to gather detailed information about the orthopedic education provided to EM residents. The survey was sent to EM program directors or their designees at all 263 accredited EM residency programs across the United States between October 2020 to January 2021. Results We attained a 34.6% (91 of 260) adjusted response rate with adequate representation of relevant program characteristics such as region, accreditation status, program length, size, and setting. Most (63.7%) responding programs required an orthopedics rotation during the intern year. These required orthopedic rotations were primarily four weeks in duration. The most common methods for teaching orthopedic topics included didactics (97.8%), procedures on live patients under supervision (73.3%), and assigned reading materials in textbooks or manuals (68.9%). Conclusion The orthopedic education received by EM residents in the United States is strikingly variable, with residency programs having to develop custom curricula to teach orthopedics content based on the resources available to them. Future efforts should be directed toward creating a universal curriculum that addresses accreditation and EM practice standards.

Pengelolaan Wisata pada Kawasan Strategis Pariwisata Nasional di Padang

The city of Padang has great tourism potential and is part of the KSPN. Therefore, community service activities aim to prepare the tourism management community. The method used in strengthening community capacity is contextual teaching and learning (TCL) to connect material with real conditions that exist in partner communities, especially for targeting tourism actors and Pokdarwis. The service is carried out in two stages and ends with an evaluation. Based on the evaluation results, participants not only know but also have the ability to identify, select procedures, and solve problems related to tourism management. Community service activities produce solutions to community problems regarding the limited understanding of KSPN and tourism management. Furthermore, the community needs to get assistance in designing and implementing creative tourism strategies with participatory methods. calculation of the level of achievement of respondents. The results of this study indicate that overall, the attractiveness of City Tourism is still being developed, and also strengthened by a tourist questionnaire which shows the ability of Padang City Tourism attractiveness.

Evaluating Access to Laser Eye Surgery by Driving Times Using Medicare Data and Geographical Mapping

Recently, several states have granted optometrists privileges to perform select laser procedures (laser peripheral iridotomy, selective laser trabeculoplasty, and YAG laser capsulotomy) with the aim of increasing access. However, whether these changes are associated with increased access to these procedures among each state's Medicare population has not been evaluated. To compare patient access to laser surgery eye care by estimated travel time and 30-minute proximity to an optometrist or ophthalmologist. This retrospective cohort database study used Medicare Part B claims data from 2016 through 2020 for patients accessing new patient or laser eye care (laser peripheral iridotomy, selective laser trabeculoplasty, YAG) from optometrists or ophthalmologists in Oklahoma, Kentucky, Louisiana, Arkansas, and Missouri. Analysis took place between December 2021 and March 2023. Percentage of each state's Medicare population within a 30-minute travel time (isochrone) of an optometrist or ophthalmologist based on US census block group population and estimated travel time from patient to health care professional. The analytic cohort consisted of 1 564 307 individual claims. Isochrones show that optometrists performing laser eye surgery cover a geographic area similar to that covered by ophthalmologists. Less than 5% of the population had only optometrists (no ophthalmologists) within a 30-minute drive in every state except for Oklahoma for YAG (301 470 [7.6%]) and selective laser trabeculoplasty (371 097 [9.4%]). Patients had a longer travel time to receive all laser procedures from optometrists than ophthalmologists in Kentucky: the shortest median (IQR) drive time for an optometrist-performed procedure was 49.0 (18.4-71.7) minutes for YAG, and the the longest median (IQR) drive time for an ophthalmologist-performed procedure was 22.8 (12.1-41.4) minutes, also for YAG. The median (IQR) driving time for YAG in Oklahoma was 26.6 (12.2-56.9) for optometrists vs 22.0 (11.2-40.8) minutes for ophthalmologists, and in Arkansas it was 90.0 (16.2-93.2) for optometrists vs 26.5 (11.8-51.6) minutes for ophthalmologists. In Louisiana, the longest median (IQR) travel time to receive laser procedures from optometrists was for YAG at 18.5 (7.6-32.6) minutes and the shortest drive to receive procedures from ophthalmologists was for YAG at 20.5 (11.7-39.7) minutes. Although this study did not assess impact on quality of care, expansion of laser eye surgery privileges to optometrists was not found to lead to shorter travel times to receive care or to a meaningful increase in the percentage of the population with nearby health care professionals.

Effects of mindfulness training on decision-making in critical and high-demand situations: A pilot study in combat aviation

The current study investigated the effects of a mindfulness-based training program (Attentional Regulation Optimization) on decision-making in an elite population operating in a highly-demanding context, namely the actions of fighter pilots in critical flight situations that lead to ejection. Our hypothesis was that both mindfulness skills and decision-making performance would improve in pilots who participated in the ARO program (n = 7), compared to a control group (n = 8). Mindfulness skills were measured with the FFMQ-15. Decision-making performance was evaluated in two tests that were implemented in scenarios in a full flight simulator. Five dependent variables were assessed, corresponding to the phases of the decision-making process when faced with an in-flight failure: reaction time after the first failure input, correctness of the first action, emergency procedure score, ejection procedure score, and quality of ejection. Adherence to the ARO program was assessed with the number of out-of-class individual mindfulness sessions and the number of out-of-class body-mind scans.No statistically significant improvement in mindfulness skills for the ARO group compared to the control group were found. Reaction time was significantly shortened for the ARO group compared to the control group—but only for complex failures. A positive effect on the correctness of the first action was also found. On the other hand, ARO training had no significant effect on the downstream phases of decision-making (emergency procedure score, ejection procedure score and quality of ejection).Given the small sample size, these results must be considered with caution. However, they open up interesting avenues for future work, notably with regard to the benefits of mindfulness training on perceptual and attentional skills (to detect flight failure cues) and cognitive control skills (to diagnose and select appropriate procedures). From an operational perspective, the program appears to have beneficial effects on safety and performance in elite populations who must face critical situations.

Analisis Kemampuan Pemahaman Konsep Matematis Siswa MAN 1 Sungai Penuh Pada Materi Bangun Ruang

The background of this research was lowerness of th students’ conceptual understanding ability in mathematics. The purpose of this study was to describe the students' mathematical conceptual understanding ability in geometry material. The type of this study is descriptive qualitative research. The subjects of this research were 26 students of XI IPA 2 grade in MAN 1 Sungai Penuh. The data collection techniques used include: (1) test of mathematical conceptual understanding ability; (2) observation sheet; (3) interview; and (4) documentation. The results of this study indicate that the average of students' mathematical conceptual understanding ability is 89,65 with very good category. From the seven indicators there are four indicators with very good category, namely restating a concept, presenting concepts in various forms of mathematical representations, developing necessary or sufficient requirements of a concept, and apply the concept or problem-solving algorithm. There is one indicator with good category, namely classify objects according to certain properties according to the concept. Then there are two indicators with enough category, namely provide examples and non-examples and use, utilize, and select certain procedures.

Outcomes for 41 260 pediatric surgical patients with opioid-free anesthesia: One center's experience.

Opioid use is common and associated with side effects and risks. Consequently, analgesic strategies to reduce opioid utilization have been developed. Regional anesthesia and multimodal strategies are central tenets of enhanced recovery pathways and facilitate reduced perioperative opioid use. Opioid-free anesthesia (OFA) protocols eliminate all intraoperative opioids, reserving opioids for postoperative rescue treatment. Systematic reviews show variable results for OFA. In a series of Quality Improvement (QI) projects, multidisciplinary teams developed interventions to test and spread OFA first in our ambulatory surgery center (ASC) and then in our hospital. Outcome measures were tracked using statistical process control charts to increase the adoption of OFA. Between January 1, 2016, and September 30, 2022, 19 872 of 28 574 ASC patients received OFA, increasing from 30% to 98%. Post Anesthesia Care Unit (PACU) maximum pain score, opioid-rescue rate, and postoperative nausea and vomiting (PONV) treatment all decreased concomitantly. The use of OFA now represents our ambulatory standard practice. Over the same timeframe, the spread of this practice to our hospital led to 21 388 of 64 859 patients undergoing select procedures with OFA, increasing from 15% to 60%. Opioid rescue rate and PONV treatment in PACU decreased while hospital maximum pain scores and length of stay were stable. Two procedural examples with OFA benefits were identified. The use of OFA allowed relaxation of adenotonsillectomy admission criteria, resulting in 52 hospital patient days saved. Transition to OFA for laparoscopic appendectomy occurred concomitantly with a decrease in the mean hospital length of stay from 2.9 to 1.4 days, representing a savings of >500 hospital patient days/year. These QI projects demonstrated that most pediatric ambulatory and select inpatient surgeries are amenable to OFA techniques which may reduce PONV without worsening pain.

A National Needs Assessment in Simulation Based Training in Vascular Surgery

The aim of this research was to ascertain the highest need areas for vascular simulation, in order to tailor training for the highest impact. A needs assessment was conducted according to best practices using the Delphi method. All consultant vascular surgeons/trainers in the training jurisdiction (n=33) were approached through an independent intermediary to contribute and generate a prioritized list of procedures for training. The research team were blinded to participant identities. Three rounds were conducted according to the Delphi process and scored according to the Copenhagen Needs Assessment Formula (CAMES-NAF). A final list of 34 vascular procedures was selected and prioritized by surgical trainers. Principles of arterial repair and endarterectomy/patching were considered the highest priority. Complex major interventions such as open abdominal aortic aneurysm (AAA) repair, carotid endarterectomy, and endovascular aortic repair (EVAR) consistently ranked higher than rarer, such as first rib resection and more basic procedures, such as foam injection for varicose veins. Major lower limb amputations typically ranked lower overall compared to arterial interventions. Surgical trainers generally agreed with the ranking according to the CAMES-NAF. There was some disagreement for a select few procedures such as iliac stenting (which rose 13 places) and open radial artery exposure (which fell 6 places) on subsequent iterations. Core operative principles and common major operative cases should remain the priority for vascular technical skills training. Other procedures which may be less invasive, but have the potential for major complications should also not be overlooked. In designing simulators the main focus should center on specific skill acquisition for commonly performed major procedures and management of the recognized potential complications. Lower limb amputations are considered adequately taught in clinical practice, or are too challenging to simulate in simulator models apart from cadaveric models.

Utilization of a Clinic-Based Hand Surgery Procedure Room in the US Military Health System: A Performance Improvement Analysis of Resource Savings and Patient Satisfaction

Recent studies examining the implementation of clinic-based procedure rooms (PRs) for wide-awake hand surgery have reported cost reduction, decreased burden on hospital systems, and improved patient satisfaction. This study evaluates other resource savings, primarily time spent by patients in the hospital. Thirty-two patients were enrolled in a PR or the operating room group for prospective evaluation. Time spent in the hospital on the day of surgery, several preprocedure appointments, complications, and cost comparisons were evaluated between the two groups. Patient-reported outcomes were also evaluated with postoperative surveys assessing anxiety, pain, and satisfaction. Significant time savings were noted between the groups. The median time spent in the hospital on the day of surgery for the patients in the operating room group was 256 minutes versus 90 minutes for the PR group, a time savings of approximately 3 hours. Eight additional preoperative clinic visits for operating room patients were generated compared with no additional preoperative visits for PR patients. Cost savings for surgeries performed in the clinic-based procedure amounted to $232,411. No postoperative complications were observed in the clinic setting. Continued utilization of the clinical PR for select hand surgery procedures will reduce the cost and time burdens for procedures while maintaining satisfaction and safety. A clinic-based PR for performing minor hand surgeries saves the patient time and ostensibly allows the operating room to be used for more complex surgeries that are not easily amenable to a wide-awake in-clinic procedure.

Nomograms for intraoperative prediction of lymph node metastasis in clinical stage IA lung adenocarcinoma.

Accurate prediction of lymph node metastasis (LNM) is critical for selecting optimal surgical procedures in early-stage lung adenocarcinoma (LUAD). This study aimed to develop nomograms for intraoperative prediction of LNM in clinical stage IA LUAD. A total of 1227 patients with clinical stage IA LUADs on computed tomography (CT) were enrolled to construct and validate nomograms for predicting LNM (LNM nomogram) and mediastinal LNM (LNM-N2 nomogram). Recurrence-free survival (RFS) and overall survival (OS) were compared between limited mediastinal lymphadenectomy (LML) and systematic mediastinal lymphadenectomy (SML) in the high- and low-risk groups for LNM-N2, respectively. Three variables were incorporated into the LNM nomogram and the LNM-N2 nomogram, including preoperative serum carcinoembryonic antigen (CEA) level, CT appearance, and tumor size. The LNM nomogram showed good discriminatory performance, with C-indexes of 0.879 (95% CI, 0.847-0.911) and 0.880 (95% CI, 0.834-0.926) in the development and validation cohorts, respectively. The C-indexes of the LNM-N2 nomogram were 0.812 (95% CI, 0.766-0.858) and 0.822 (95% CI, 0.762-0.882) in the development and validation cohorts, respectively. LML and SML had similar survival outcomes among patients with low risk of LNM-N2 (5-year RFS, 88.1% vs. 89.5%, Pp = 0.790; 5-year OS, 96.0% vs. 93.0%, p = 0.370). However, for patients with high risk of LNM-N2, LML was associated with worse survival (5-year RFS, 64.0% vs. 77.4%, p = 0.036; 5-year OS, 66.0% vs. 85.9%, p = 0.038). We developed and validated nomograms to predict LNM and LNM-N2 intraoperatively in patients with clinical stage IA LUAD on CT. These nomograms may help surgeons to select optimal surgical procedures.

Safety and Efficacy of In-Office Hand Procedures

BackgroundThe primary concerns with operating on patients in the office setting are insufficient sterility and lack of appropriate resources in case of excessive bleeding or other surgical complications. This study serves to investigate these concerns and determine whether in-office hand surgeries are safe and clinically effective. MethodsA retrospective review of patients who underwent minor hand operations in the office setting between December 2020 and December 2021 was performed. The surgical procedures included in this analysis are needle aponeurotomy, trigger finger release, foreign body removal, mass removal, and reduction in a finger fracture with or without percutaneous pinning. All fractures, which primarily included metacarpal and phalangeal fractures, were subsequently splinted. Sterility and hemostatic support were achieved via the Wide-Awake Local Anesthesia No Tourniquet (WALANT) method. Major complications were defined as infection, major bleeding, and neurological deficits. Minor complications were defined as prolonged pain, prolonged inflammation, residual symptoms, and recurrence of symptoms within 1 month. ResultsFive patients (3.8%) returned to the office for pain, inflammation, or stiffness of the affected finger, with two of the five returning with symptoms associated with osteoarthritis or pseudogout flare-ups. Five additional patients returned due to residual symptoms or recurrence of the primary complaint within 1 month of surgery. No patients experienced exogenous infection. ConclusionThe absence of major complications and high success rate for minor hand procedures shows the high degree of safety and efficacy that can be achieved via the in-office setting for select procedures. While proper patient selection is key, our result shows the in-office procedure room setting can offer the necessary elements of sterility and hemostatic support for several common hand surgeries.

SAFETY AND EFFICACY OF IN-OFFICE HAND PROCEDURES

In-office surgeries have the potential to offer high quality medical care in a more efficient, cost-effective setting than outpatient surgical centers for certain procedures. The primary concerns with operating on patients in the office setting are insufficient sterility and lack of appropriate resources in case of excessive bleeding or other surgical complications. This study serves to investigate these concerns and determine whether in-office hand surgeries are safe and clinically effective.A retrospective review of patients who underwent minor hand operations in the office setting between December 2020 and December 2021 was performed. The surgical procedures included in this analysis are needle aponeurotomy, trigger finger release, mass/foreign body removal and reduction of hand/wrist fracture with or without percutaneous pinning.No major complications requiring extended observation or hospital admission occurred. 122 of the 132 patients (92.4%) were successfully treated with no complications and only mild symptoms within one month of surgery. Five patients (3.8%) returned to the office for pain, inflammation and/or stiffness of the affected finger, with two of the five returning due to osteoarthritis and/or pseudogout flare-ups. Five additional patients returned due to incomplete treatment with continued presence of Dupuytren's contracture (3), trigger finger (1) or infected foreign body (1). One patient (0.8%) developed infection, due to incomplete removal of an infected foreign body, which was subsequently treated with antibiotics and complete foreign body removal.The absence of major complications and high success rate for minor hand procedures shows the high degree of safety and efficacy which can be achieved via the in-office setting for select procedures. While proper patient selection is key, our result shows the in-office procedure room setting can offer the necessary elements of sterility and hemostatic support for several common hand surgeries.

412 A Protocol for Reducing Intensive Care Utilization After Craniotomy: A Three-Year Assessment

INTRODUCTION: Craniotomy patients have traditionally received intensive care unit (ICU) care postoperatively. Our institution developed the “Non-Intensive CarE” (NICE) protocol to identify craniotomy patients that did not require postoperative ICU care. METHODS: Our institution’s electronic medical record (EMR) was queried to identify craniotomies prior to protocol deployment (May 2014-May 2018), and after deployment (May 2018-December 2021). Patients are considered for the protocol if they are having an elective craniotomy for select procedures (e.g. microvascular decompressions, extra-axial tumor resection), are under age of 65, have no history of coagulopathy, and have no other medical contraindications. Reason for readmission or reoperation among NICE protocol patients was collected via chart review. The primary endpoints were average POLS and ICU utilization; secondary endpoints included readmission, reoperation, and postoperative complications rates. Endpoints were compared among pre- and post-protocol cohorts. RESULTS: 4,837 craniotomies were performed from May 2014-December 2021 (2,302 pre-protocol, 2,535 post-protocol). 21% percent of post-protocol craniotomies were enrolled in the NICE protocol. After protocol deployment, overall POLS decreased from 4.0 to 3.5 days (p = 0.0031), which was driven by deceased POLS among protocol patients (average 2.4 days).ICU utilization decreased from 57% of patients to 42% (p &lt; 0.0001), generating ∼$760,000 in savings. Return to the ICU and complications decreased after protocol deployment. 5.8% of protocol patients had a readmission within thirty days; none could have been prevented through ICU stay. CONCLUSIONS: The NICE protocol is an effective, sustainable method to increase ICU bed availability and decrease costs without changing outcomes. To our knowledge, this study features the largest series of patients enrolling in an ICU utilization reduction protocol. Careful patient selection is a requirement for the success of this approach.

ANALYSIS OF ABILITY IN UNDERSTANDING MATHEMATICS CONCEPTS ON THE CIRCULAR MATERIAL OF STUDENTS OF CLASS VIII OF SMP NEGERI 2 BAY IN THE 2020/2021 STUDY YEAR

This research is motivated by the ability to understand students' mathematical concepts which are still in the low category. This study aims to 1) describe the ability to understand mathematical concepts in the circle material for class VIII students of SMP Negeri 2 Telukdalam, 2) describe the students' difficulties in solving questions about the ability to understand mathematical concepts in the circle material. This research uses a type of qualitative research with descriptive research methods. The informants in this study were all students of class VIII SMP Negeri 2 Telukdalam, namely 25 people. Data were analyzed by data reduction, data presentation and conclusion. Research data collection techniques through tests of ability to understand mathematical concepts and interviews. The research findings showed that students were unable to restate the circle concept, students were unable to classify objects according to the nature of the circle, students were unable to distinguish examples of circles and non-circles, students were unable to select and use procedures or operations (formulas) according to the circle concept, and students still unable to apply the circle concept in solving simple problems.