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Objectives: Transitions to new care environments may have unexpected consequences that threaten patient safety. We undertook a quality improvement project using in situ simulation to learn the new patient care environment and expose latent safety threats before transitioning patients to a newly built adult ICU., Design: Descriptive review of a patient safety initiative., Setting: A newly built 24-bed neurocritical care unit at a tertiary care academic medical center., Subjects: Care providers working in neurocritical care unit., Interventions: We implemented a pragmatic three-stage in situ simulation program to learn a new patient care environment, transitioning patients from an open bay unit to a newly built private room-based ICU. The project tested the safety and efficiency of new workflows created by new patient- and family-centric features of the unit. We used standardized patients and high-fidelity mannequins to simulate patient scenarios, with "test" patients created through all electronic databases. Relevant personnel from clinical and nonclinical services participated in simulations and/or observed scenarios. We held a debriefing after each stage and scenario to identify safety threats and other concerns. Additional feedback was obtained via a written survey sent to all participants. We prospectively surveyed for missed latent safety threats for 2 years following the simulation and fixed issues as they arose., Measurements and Main Results: We identified and addressed 70 latent safety threats, including issues concerning physical environment, infection prevention, patient workflow, and informatics before the move into the new unit. We also developed an orientation manual that highlighted new physical and functional features of the ICU and best practices gleaned from the simulations. All participants agreed or strongly agreed that simulations were beneficial. Two-year follow-up revealed only two missed latent safety threats., Conclusions: In situ simulation effectively identifies latent safety threats surrounding the transition to new ICUs and should be considered before moving into new units., Competing Interests: Dr. Morris’ institution received the Faculty Innovation in Education Award from the American Board of Psychiatry and Neurology. Dr. Johnson disclosed they are a co-inventor with CVRx, Inc., for a cardiac neurostimulation device. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Background and Objectives: During its monthly morbidity and mortality conference (MMC), the University of Colorado Division of Cardiology reviewed a "near-miss" patient safety event involving the delayed completion of a Stat-priority (ie, statim, meaning high priority) electrocardiogram (ECG). Because critical and interprofessional stakeholders participated in the conference, we hypothesized that the MMC would be associated with reduced ECG completion times., Methods: Data were collected for in-hospital ECGs performed at the University of Colorado Hospital between January 1, 2017, and June 30, 2018. An interrupted time series analysis was used to estimate the immediate and ongoing impact of the MMC (held on February 28, 2018) on ECG completion times, stratified by order priority (Stat, Now, or Routine). The percentage of delayed Stat-priority ECGs was analyzed as a secondary outcome., Results: Before the MMC, ECG completion times were stable for all order priorities ( P > .2), but the proportion of delayed Stat-priority ECGs increased from 5% in January 2017 to 20% in February 2018 ( P < .01). The MMC was associated with an immediate reduction in average daily ECG completion times for Routine (-18.4 minutes, P = .03) and Now (-8 minutes, P = .024) priority ECGs. No reduction was seen for Stat ECGs ( P = .97), though the percentage of delayed Stat ECGs stopped increasing ( P = .63). In the post-MMC period, completion times for Routine-priority ECGs increased and approached pre-MMC levels., Conclusions: The MMC was associated with an immediate, but temporary, improvement in ECG completion times. Although the observed clinical benefit of the MMC is novel, these data support the need for more durable reforms to sustain initial improvements., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Complementary integrative health therapies have a perioperative role in the reduction of pain, analgesic use, and anxiety, and increasing patient satisfaction. However, long implementation lags have been quantified. The Consolidated Framework for Implementation Research (CFIR) can help mitigate this translational problem., Methods: We reviewed evidence for several nonpharmacological treatments (CFIR domain: characteristics of interventions) and studied external context and organizational readiness for change by surveying providers at 11 Veterans Affairs (VA) hospitals (domains: outer and inner settings). We asked patients about their willingness to receive music and studied the association between this and known risk factors for opioid use (domain: characteristics of individuals). We implemented a protocol for the perioperative use of digital music players loaded with veteran-preferred playlists and evaluated its penetration in a subgroup of patients undergoing joint replacements over a 6-month period (domain: process of implementation). We then extracted data on postoperative recovery time and other outcomes, comparing them with historic and contemporary cohorts., Results: Evidence varied from strong and direct for perioperative music and acupuncture, to modest or weak and indirect for mindfulness, yoga, and tai chi, respectively. Readiness for change surveys completed by 97 perioperative providers showed overall positive scores (mean >0 on a scale from -2 to +2, equivalent to >2.5 on the 5-point Likert scale). Readiness was higher at Durham (+0.47) versus most other VA hospitals (range +0.05 to +0.63). Of 3307 veterans asked about willingness to receive music, approximately 68% (n = 2252) answered "yes." In multivariable analyses, a positive response (acceptability) was independently predicted by younger age and higher mean preoperative pain scores (>4 out of 10 over 90 days before admission), factors associated with opioid overuse. Penetration was modest in the targeted subset (39 received music out of a possible 81 recipients), potentially reduced by device nonavailability due to diffusion into nontargeted populations. Postoperative recovery time was not changed, suggesting smooth integration into workflow., Conclusions: CFIR-guided implementation of perioperative music was feasible at a tertiary VA hospital, with moderate penetration in a high-risk subset of patients. Use of digital music players with preferred playlists was supported by strong evidence, tension for change, modest readiness among providers, good acceptability among patients (especially those at risk for opioid overuse), and a protocolized approach. Further study is needed to identify similar frameworks for effective knowledge-translation activities.

A paradigm shift has occurred in the approach to enterocele repair and vaginal vault suspension. This change in our approach is based on anatomic dissections that demonstrate that the loss of the upper suspensory fibers of the paracolpium and parametrium lead to uterine prolapse and vaginal prolapse after hysterectomy. In addition, the separation of the pubocervical from the rectovaginal fascia results in apical enterocele where the peritoneum is in contact with the vaginal mucosa. These fascial defects are hernias, and appropriate herniorraphy techniques will correct these defects and result in successful reconstruction of the vaginal tube and its reattachment to the suspensory cardinal uterosacral complex.

Neurofilaments are the characteristic intermediate filaments of mature neurons; during development and in some neuronal cell lines and neuroendocrine tumors, neurofilament proteins are expressed together with vimentin or cytokeratins. In some cell types, the filamentous arrays formed by neurofilaments and vimentin or cytokeratins do not coincide. However, individual neurofilament proteins co-assemble with vimentin in transfected non-neuronal cells. In order to determine whether individual neurofilament proteins could also co-assemble with cytokeratins in a cellular environment, the light chain of neurofilaments, NF-L, was transfected into MCF-7 cells, in which the only cytoplasmic intermediate filament proteins expressed are cytokeratins. In transfected MCF-7 cells, human NF-L was localized to a prominent filamentous network. This pattern most probably reflected the incorporation of NF-L into the endogenous keratin cytoskeleton as it is unlikely to be due to human NF-L self-assembly since, like its rodent counterpart, human NF-L accumulated into punctate aggregates when transiently transfected in intermediate filament-deficient SW13 vim- cells. These results suggest the existence of a specific mechanism of segregation of neurofilaments and keratin filaments in some cell types.

Background and Purpose: The relation between anterior ischemic optic neuropathy and carotid artery atherosclerotic disease is unclear. We studied patients with anterior ischemic optic neuropathy to determine if they had an increased occurrence of carotid artery stenosis., Methods: Fifteen consecutive patients with anterior ischemic optic neuropathy were evaluated prospectively for cervical carotid artery stenosis and compared with 30 age- and sex-matched asymptomatic patients and also with 11 age- and sex-matched patients experiencing transient monocular blindness., Results: There was no difference in the mean stenosis of the internal carotid artery between patients with anterior ischemic optic neuropathy (mean carotid stenosis, 19%) and asymptomatic patients (mean carotid stenosis, 9%; p > 0.05), whereas patients with transient monocular blindness had significantly more stenosis (mean, 77%) in the cervical carotid arteries than both control subjects (p < 0.0001) and patients with anterior ischemic optic neuropathy (p < 0.0001). There was also no difference in the percentage of patients with stenosis > or = 30% in anterior ischemic optic neuropathy (two of 15) and asymptomatic patients (five of 30), whereas 10 of 11 patients with transient monocular blindness had stenoses > or = 30%, significantly more than patients with anterior ischemic optic neuropathy (p < 0.0001) and asymptomatic patients (p < 0.0001)., Conclusions: Anterior ischemic optic neuropathy is not a marker for atherosclerotic carotid artery stenosis. The pathogenesis of nonarteritic anterior ischemic optic neuropathy does not involve carotid artery stenosis in most patients.

Clinical experience with the Hancock porcine bioprosthetic heart valve was reviewed in 150 consecutive patients (82 men and 69 women), 13-83 years of age (mean 65 years and 65% older than 60 years), who underwent aortic valve replacement from February 1977 to December 1979. Thirty-eight percent of the patients had associated procedures, including aortocoronary bypass grafting (CABG), valvuloplasty and multiple valve replacement. Overall early mortality was 5% (eight of 150 patients): three of 98 who had isolated aortic valve replacement (AVR), two of 21 who had aortic and mitral valve replacement (AVR/MVR), one of 26 who had AVR/CABG and two four who had AVR/MVR/CABG. In a follow-up period of 6-42 months (mean 26 months), 10 patients have died. Predicted 3-year survival for the study population was 80%. Ninety percent of surviving patients in New York Heart Association functional class I. Incidence of emboli has been 1.5/100 patient-years. Of the five cases of endocarditis, three were fatal and all required reoperation. There have been no primary valve failures. In 43 patients, transvalvular intraoperative peak systolic gradients (left ventricular to aorta) were measured. In those with 19-mm valves (two patients), the gradient was 12.5 +/- 3.5 mm Hg; in those with 21-mm valves (16 patients), it was 10.0 +/- 6.5 mm Hg; in those with 23-mm valves (18 patients), it was 10.8 +/- 5.9 mm Hg; and in those with 25-mm valves (seven patients), it was 9.8 +/- 5.8 mm Hg. Thus, the Hancock modified orifice valve has good hydraulic performance and a low embolic rate without the need for anticoagulation, so it is acceptable for the elderly patient with a small aortic root.

Pulsatile perfusion has been reported to be of value in intraoperative myocardial protection. To evaluate this technique, we studied 26 patients undergoing aortocoronary bypass grafting. Ejection fraction determinations from multigated cardiac blood pool scans, serial hemodynamic monitoring, and total CPK and MB-CPK sampling were performed early (4, 6 and 8 hours after bypass) and 10 days after operation. In 12 patients, pulsatile perfusion was started immediately after aortic cannulation and continued until 10 minutes after cessation of bypass; 14 patients had standard nonpulsatile perfusion. All patients had a single aortic cross-clamping and potassium cardioplegia. Cross-clamp time (46 +/- 3 and 46 +/- 3 minutes [+/- SEM]), total bypass time (94 +/- 4 and 89 +/- 6 minutes), and mean perfusion pressure (82 +/- 5 and 83 +/- 3 mm Hg) were comparable in the pulsatile and nonpulsatile groups, respectively, as were extent of coronary disease and number of bypass grafts. Preoperative and postoperative ejection fractions for pulsatile and nonpulsatile groups, respectively, were 0.57 +/- 0.03 and 0.55 +/- 0.04 before operation, 0.37 +/- 0.03 and 0.40 +/- 0.04 4 hours after bypass, 0.40 +/- 0.03 and 0.46 +/- 0.04 at 6 hours, 0.51 +/- 0.05 and 0.52 +/- 0.07 at 8 hours and 0.56 +/- 0.05 and 0.53 +/- 0.04) 10 days after operation. Mean arterial pressure, left atrial pressure and serial cardiac indexes were similar in both groups. There were no perioperative myocardial infarctions by ECG in either group. Total CPK (586 +/- 78 and 617 +/- 140 IU/l) and peak MB-CPK (73 +/0 14 and 61 +/- 11 IU/l) were comparable in the pulsatile and nonpulsatile groups, respectively. Pulsatile perfusion offers no advantage in myocardial preservation after aortocoronary bypass grafting in patients with normal left ventricular function.

This study sought to determine whether ad libitum drinking of a carbohydrate-electrolyte (CE) beverage would minimize the physiological disturbances associated with prolonged (3 h) continuous exercise in the heat (Tdb = 31.5 degrees C, percent RH = 22.3). Seven male subjects performed two bouts of cycle exercise (60% VO2max) drinking either a CE beverage (4.85% polycose, 2.65% fructose) or distilled water. Subjects continued to drink ad libitum for 3 h during recovery in the heat. No significant differences were observed between drinks for rectal temperature, heart rate, or sweat rate during exercise. Subjects tended to drink more (P less than 0.0565) water than the CE beverage during exercise, but plasma volume (percent PV) decreased less (P less than 0.0253) and plasma [( glucose], P less than 0.0001 and [K+], P less than 0.0047) were higher when subjects drank the CE solution. At the end of exercise, plasma osmolality and [Na+] were also higher (P less than 0.05) when subjects drank the CE beverage rather than water. Rating of perceived exertion was higher (P less than 0.0001) when drinking water. In recovery, ingesting the CE beverage, 1) subjects drank more (P less than 0.0012); 2) plasma volume increased to a higher level (P less than 0.0017); 3) plasma osmolality (P less than 0.0001), [Na+] (P less than 0.0001), glucose (P less than 0.0001), and [K+] (P less than 0.0015) were greater; and 4) body weight increased more (P less than 0.0422) than when water was ingested. Thus, in terms of minimizing physiological disturbances, ad libitum drinking of the CE beverage was as effective as drinking water during exercise but was more effective in recovery.

Eight trained male cyclists (age 20-33 yr) completed four 3-h bouts of cycling at 60% peak VO2 in the heat (33 degrees C) drinking either water (W), 5% glucose (G), 5% glucose polymer (GP), or 3.2% glucose polymer + 1.8% fructose (GP/F) at a rate of 350 ml every 20 min (3.15 l total volume). Similar changes in heart rate, sweat rate, rectal and mean skin temperatures, and plasma [Na+], [K+], and osmolality were observed during all trials. Mean changes in plasma volume, although not significantly different between trials, were lowest for the GP/F drink (-2.6%) and greatest for the G (-8.1%) drink. Plasma volume decreased (P less than 0.05) below pre-exercise control values during the W, G, and GP trails but was maintained at control values during the GP/F trials. In contrast to water ingestion, G, GP, and GP/F ingestion maintained plasma glucose and respiratory exchange ratios throughout the 3-h exercise bouts. Gastric residual volume (GRV) obtained at the end of exercise was similar for the W, GP, and GP/F trials. The G trials yielded greater (P less than 0.05) GRV than W trials. For all drinks ingested, over 90% of the 3.15 l consumed was emptied from the stomach during the 3-h exercise bouts. At a mean sweat rate of 1.2 l.h-1, cyclists replaced 73% of fluid lost and experienced only a 1.6% loss in body weight. This study demonstrates that, during prolonged (3-h) cycling exercise in the heat, large volumes of W and 5% carbohydrate can be emptied from the stomach to help minimize the effects of dehydration.

The Hancock (H) and Carpentier-Edwards (CE) porcine xenografts are the most commonly used bioprostheses hemodynamic performance of these valves at each valve size was assessed by intraoperative measurement of transvalvular gradients and cardiac outputs in 122 patients undergoing aortic or mitral valve replacement. At comparable cardiac outputs, peak aortic valve gradients (+/- DS) were: 23-mm valve - H (modified orifice) 10.8 +/- 5.9 mm Hg, CE 7.6 +/- 6.2 mm Hg; 25-mm valve - H 11.9 +/- 5.5 mm Hg, CE 8.3 +/- 5.9 mm Hg; 27/29-mm valve - H 11.0 +/- 6.0 mm Hg, CE 6.6 +/- 5.0 mm Hg. Mitral valve gradients were: 29-mm valve - H 3.7 +/- 1.2 mm Hg, CE 2.8 +/- 1.1 mm Hg; 31-mm valve - H 3.5 +/- 1.0 mm Hg, CE 2.6 +/- 0.7 mm Hg, 33/35-mm valve - H 3.2 +/- 1.9 mm Hg. In both the mitral and aortic positions, Carpentier-Edwards porcine bioprostheses had significantly lower (p less than 0.01 and P less than 0.05, respectively) transvalvular gradients than Hancock porcine xenografts.

Venous stasis retinopathy and ischemic oculopathy are ocular manifestations of ischemia in the distribution of the carotid artery. While not as common as transient monocular blindness or retinal arterial emboli, they are readily recognizable and indicate the presence of severe, often bilateral, carotid occlusive disease. Patterns of occlusion vary but usually include complete occlusion of at least one common or internal carotid artery, often accompanied by occlusion or narrowing in the opposite carotid system. The ocular findings in venous stasis retinopathy and ischemic oculopathy indicate ongoing ocular ischemia and may progress to intractable neovascular glaucoma. Therapy, individualized for the specific pattern of occlusive changes, may be directed toward prevention of stroke or may be indicated primarily for the reversal of ocular ischemia and prevention of blindness secondary to neovascular glaucoma.