Just-in-Time In Situ Simulation Training as a Preparedness Measure for the Perioperative Care of COVID-19 Patients.

INTRODUCTION: Routine workflows were redesigned during the first surge of the COVID-19 pandemic to standardize perioperative management of patients and minimize the risk of viral exposure and transmission to staff members. Just-in-time (JIT), in situ simulation training was adopted to implement urgent change, the value of which in a public health crisis has not previously been explored. METHODS: Implementation of workflow changes in the setting of the COVID-19 pandemic was accomplished through JIT, in situ simulation training, delivered over a period of 3 weeks to participants from anesthesia, nursing, and surgery, within our healthcare network. The perceived value of this training method was assessed using a postsimulation training survey, composed of Likert scale assessments and free-text responses. The impact on change in practice was assessed by measuring compliance with new COVID-19 workflows for cases of confirmed or suspected COVID-19 managed in the operating room, between March and August 2020. RESULTS: Postsimulation survey responses collected from 110 of 428 participants (25.7%) demonstrated significant positive shifts along the Likert scale on perceived knowledge of new workflow processes, comfort in adopting them in practice and probability that training would have an impact on future practice (all P s < 0.001). Free-text responses reflected appreciation for the training being timely, hands-on, and interprofessional. Compliance with new COVID workflows protocols in practice was 95% (121 of 127 cases) and was associated with lower than expected healthcare worker test positive rates (<1%) within the network during this same period. CONCLUSIONS: These findings support JIT, in situ simulation training as a preparedness measure for the perioperative care of COVID-19 patients and demonstrate the value of this approach during public health crises.

Relief of Secondary Headaches with High Thoracic Erector Spinae Plane Block.

Intractable headaches can be debilitating, often leading to significant distress, prolonged medical treatment, and unanticipated hospital admissions. There have been significant advances in the treatment of primary intractable headaches such as migraines, tension headaches, and cluster headaches beyond medical management. Treatments may now include interventional strategies such as trigger-point injections, peripheral nerve stimulators, or peripheral nerve and ganglion blocks. There are few studies, however, describing the use of interventional techniques for the management of intractable secondary headaches, including those attributed to injury or infection. A new regional anesthetic technique, the erector spinae plane (ESP) block, was initially used for neuropathic thoracic pain. ESP block has since been reported to provide acute and chronic pain relief of the shoulder, spine, abdomen, pelvis, thorax, and lower extremity. Additionally, there has been one case report to describe the use of the ESP block in the treatment of refractory tension headache. We report four cases of effective analgesia for intractable secondary headache resistant to medical management with high thoracic ESP blocks. In each case, the ESP block provided instant pain relief. We suggest that the findings of this case series indicate that the ESP block may be a useful intervention in patients with severe secondary headache or posterior cervical pain where conventional therapies have limited success, though more studies are necessary.

A simplified blood culture sampling protocol for reducing contamination and costs: a randomized controlled trial.

OBJECTIVES: Blood culture contamination carries risks for patients, such as unnecessary antimicrobial therapy and other additional hazards and costs. One method shown to be effective in reducing contamination is initial blood specimen diversion during collection. We hypothesized that initial blood specimen diversion without a designated device or procedure would suffice for reduction in blood culture contamination rate. METHODS: From 1 September 2017 through to 6 September 2018, we conducted a randomized controlled trial to assess the effect of an initial-specimen diversion technique (ISDT) on the rate of blood-culture contamination by changing the order of sampling using regular vacuum specimen tubes instead of commercially available sterile diversion devices. We included adults from whom the treating physician planned to take blood cultures and additional blood chemistry tests. Additionally, we evaluated the potential economic benefits of an ISDT. This was a researcher-initiated trial, Clinicaltrials.gov NCT03088865. RESULTS: In all, 756 patients were enrolled. This method, compared with the standard procedure in use at our medical centre, reduced contamination by 66% (95% CI 17%-86%), from 20/400 (5%) with the standard method to 6/356 (1.6%) with the ISDT, without compromising detection of true bloodstream infection and at no additional cost. Hospital-wide implementation of ISDT was associated with a 1.1% saving in hospitalization days. CONCLUSIONS: We offer this novel approach as a simple, cost-effective measure to reduce risks to patient safety from contaminated blood cultures, without the need for using costly devices.

Reasons for operation cancellations at a teaching hospital: prioritizing areas of improvement.

PURPOSE: To report rates of and reasons for operation cancellation, and to prioritize areas of improvement. METHODS: Retrospective data were extracted from the monthly reports of cancelled listed operations. Data on 14 theatres were collected by the office of quality assurance at Jordan University Hospital from August 2012 to April 2016. Rates and reasons for operation cancellation were investigated. A Pareto chart was constructed to identify the reasons of highest priority. RESULTS: During the period of study, 6,431 cases (9.31%) were cancelled out of 69,066 listed cases. Patient no-shows accounted for 62.52% of cancellations. A Pareto analysis showed that around 80% of the known reasons for cancellation after admission were due to a lack of surgical theatre time (30%), incomplete preoperative assessment (21%), upper respiratory tract infection (19%), and high blood pressure (13%). CONCLUSION: This study identified the most common reasons for operation cancellation at a teaching hospital. Potential avoidable root causes and recommended interventions were suggested accordingly. Future research, available resources, hospital policies, and strategic measures directed to tackle these reasons should take priority.

Reasons for operation cancellations at a teaching hospital: prioritizing areas of improvement

PURPOSE: To report rates of and reasons for operation cancellation, and to prioritize areas of improvement. METHODS: Retrospective data were extracted from the monthly reports of cancelled listed operations. Data on 14 theatres were collected by the office of quality assurance at Jordan University Hospital from August 2012 to April 2016. Rates and reasons for operation cancellation were investigated. A Pareto chart was constructed to identify the reasons of highest priority. RESULTS: During the period of study, 6,431 cases (9.31%) were cancelled out of 69,066 listed cases. Patient no-shows accounted for 62.52% of cancellations. A Pareto analysis showed that around 80% of the known reasons for cancellation after admission were due to a lack of surgical theatre time (30%), incomplete preoperative assessment (21%), upper respiratory tract infection (19%), and high blood pressure (13%). CONCLUSION: This study identified the most common reasons for operation cancellation at a teaching hospital. Potential avoidable root causes and recommended interventions were suggested accordingly. Future research, available resources, hospital policies, and strategic measures directed to tackle these reasons should take priority.

ANESTHESIA FOR CHARCOT-MARIE-TOOTH DISEASE: CASE REPORT.

Charcot-Marie-Tooth disease comprises a group of disorders characterized by progressive muscle weakness and wasting. Reviewing the anaesthetic literature produced conflicting reports about the best anaesthetic options for patients with CMTD; as they are at increased risk of prolonged response to muscle relaxants, malignant hyperthermia and risks of regional anaesthesia. We present a case of the successful use of total intravenous anaesthesia with dexmedetomidine and propofol combined with caudal block using bupivacaine mixed with dexmedetomidine without any complications, for a 17 year old male patient with Charcot Marie-Tooth disease who underwent a lower limb orthopedic surgery.

Adhesion mechanisms of the contact interface of TiO2 nanoparticles in films and aggregates.

Fundamental knowledge about the mechanisms of adhesion between oxide particles with diameters of few nanometers is impeded by the difficulties associated with direct measurements of contact forces at such a small size scale. Here we develop a strategy based on AFM force spectroscopy combined with all-atom molecular dynamics simulations to quantify and explain the nature of the contact forces between 10 nm small TiO(2) nanoparticles. The method is based on the statistical analysis of the force peaks measured in repeated approaching/retracting loops of an AFM cantilever into a film of nanoparticle agglomerates and relies on the in-situ imaging of the film stretching behavior in an AFM/TEM setup. Sliding and rolling events first lead to local rearrangements in the film structure when subjected to tensile load, prior to its final rupture caused by the reversible detaching of individual nanoparticles. The associated contact force of about 2.5 nN is in quantitative agreement with the results of molecular dynamics simulations of the particle-particle detachment. We reveal that the contact forces are dominated by the structure of water layers adsorbed on the particles' surfaces at ambient conditions. This leads to nonmonotonous force-displacement curves that can be explained only in part by classical capillary effects and highlights the importance of considering explicitly the molecular nature of the adsorbates.

[Retroperitoneal tumor on the left side: double stomach]. / Retroperitonealer Tumor links: Magen-Duplex.

We report about an uncertain retroperitoneal tumor on the left side without certain origin. During surgery and proved by histological data we found a heterotopic second stomach, an extremely rare abnormality.