Getting back to work: A framework and pivot plan to resume elective surgery and procedures after COVID-19.

INTRODUCTION: The COVID-19 pandemic has compelled a majority of hospital systems to reduce surgical and procedural volumes in an attempt to preserve resources. Elective surgery and procedures resumption has proven to be a calculated risk between COVID-19 exposure and resource depletion and patient morbidity and mortality from surgical deferral. METHODS: Within a few days of halting elective surgery and procedures, our 7-hospital (2427 in-patient beds, 26,647 inpatient surgeries) healthcare system developed a multidisciplinary Pivot Plan with the primary outcome of a phased resumption of elective surgery and procedures. The plan entailed the integration of our electronic medical record, order entry automatization, perioperative staff utilization, partnering with primary care providers, and a stepwise COVID-19 testing algorithm based on a predetermined hierarchy of case acuity and timeliness of patient care. RESULTS: The Pivot Plan was instituted on May 10, 2020. Since then, 22,624 patients have been tested for COVID-19 in anticipation of an elective surgery and procedures; 140 (0.62%) tested positive for COVID-19 and had their procedure deferred. As our testing capability has increased, we have been able to increase our added elective surgery and procedures capacity from 13 cases per day to 531 cases per day. In turn, we have seen the case volume increase by 52%. CONCLUSION: Our academic healthcare system located in one of the initial COVID-19 hotspots in the United States has successfully resumed elective surgery and procedures in part due to a receptive and supportive culture based upon nimbleness, agility, and rapid integration of multiple resources from a cohort of diverse disciplines applied to the perioperative services workflow.

13-year experience of carpal tunnel release using the Indiana Tome technique.

PURPOSE: This study evaluated the reliability and morbidity rate of carpal tunnel release with the Indiana Tome technique via a small palmar incision when used by experienced hand surgeons. METHODS: A retrospective review was performed of 1332 carpal tunnel releases using the Indiana Tome performed by 2 fellowship-trained hand surgeons at university hospitals from July 1993 to August 2006. Chart review focused on complications with this technique. RESULTS: All patients returned to preoperative activities, in employment or otherwise. Nonmanual laborers resumed regular job tasks between 2 days and 3 weeks. The 2 surgeons experienced 11 complications in 1332 cases, for an overall complication rate of 0.83%. The most common complication, in 8 cases, was numbness and hypersensitivity in the third common digital nerve distribution; 2 of these 8 patients had normal 2-point discrimination and the other 6 had persistently 2-point discrimination greater than 10 mm despite resolution of preoperative paresthesia symptoms. In the latter group, 3 patients had repeat exploration, with findings of fascicular injury and scarring in 2 patients and normal nerve in the third (who ultimately had normalized 2-point discrimination by 6 weeks after surgery). The 3 patients without re-exploration had their 2-point discrimination returned to normal by 11 months after surgery. Ultimately, only 2 patients (0.15%) had persistently increased 2-point discrimination. The remaining complications (3 cases) were transient neuropraxia of the entire median nerve (1 patient), an incomplete release (1 patient) requiring repeat surgery, and a recurrence of carpal tunnel syndrome (1 patient) with perineural scar noted at 8 months after surgery, treated successfully with a hypothenar fat pad flap. CONCLUSIONS: This is the largest retrospective review of the Indiana Tome technique to date. This technique can be used by experienced hand surgeons and offers early resumption of preoperative activities and a low complication rate. The most common complication was neurapraxia in the third common digital nerve distribution. The overall complication rate was 0.83% (11 in 1332). TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Regional anatomic and age effects on cell function of human adipose-derived stem cells.

Adipose tissue has been shown to contain adult mesenchymal stem cells that have therapeutic applications in regenerative medicine. There is evidence that the ability of adipose precursor cells to grow and differentiate varies among fat depots and changes with age. Defining these variations in cell function and molecular mechanisms of adipogenesis will facilitate the development of cell-based therapies. We compared cells harvested from 5 different subcutaneous (SC) adipose depots in 12 female patients classified into 3 age ranges (25-30, 40-45, and 55-60 years old). Capacity for differentiation of isolated adipose-derived stem cells (ASCs) with and without ciglitazone, a strong peroxisome proliferatoractivated receptors (PPAR)-gamma agonist, was assessed in vitro. ASCs were also characterized by lipolytic function, proliferation, and sensitivity to apoptosis. Additionally, PPAR-gamma-2 protein expression was determined. We observed a difference in the apoptotic susceptibility of ASCs from various SC depots, with the superficial abdominal depot (above Scarpas layer) significantly more resistant to apoptosis when compared with the 4 other depots. We have also demonstrated that a PPAR-gamma agonist aids in the induction of differentiation in cells from all depots and ages. Although sensitivity to apoptosis was linked to anatomic depot, differences in cell proliferation were related primarily to age. Stimulated free glycerol release has been shown to be highest in the arm depot. The arm depot has also consistently shown expression of PPAR-gamma-2 with and without a PPAR-gamma agonist. Younger patients have increased PPAR-gamma-2 expression in all depots, whereas the older patients have consistent elevated expression only in the arm and thigh depots. We have shown there is variability in function of ASCs that have been harvested from different SC depots. Additionally, we have shown age-related changes in function. These data will help select patients and cell harvest sites most suitable for tissue engineering therapies.