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Matthew A Crain,1 Amy L Bush,2 Heather Hayanga,3 Annelee Boyle,4 Merv Unger,3 Matthew Ellison,3 Pavithra Ellison3 1West Virginia University School of Medicine, Morgantown, WV, USA; 2West Virginia University Medicine Children’s Hospital, Morgantown, WV, USA; 3Department of Anesthesiology, West Virginia University Medicine, Morgantown, WV, USA; 4Department of Obstetrics & Gynecology, West Virginia University Medicine, Morgantown, WV, USACorrespondence: Pavithra EllisonDepartment of Anesthesiology, West Virginia University Medicine, 1 Medical Center Drive, Morgantown, WV, 26506, USATel +1 304-598-4929Fax +1 304-598-4930Email pavithra.ellison@hsc.wvu.eduPurpose: In pandemics, centralized healthcare leadership is a critical requirement. The objective of this study was to analyze the early development, operation, and effectiveness of a COVID-19 organizational leadership team and transformation of healthcare services at West Virginia University Hospitals and Health System (WVUHS). The analysis focused on how Kotter’s Leading Change eight-stage paradigm could contribute to an understanding of the determinants of successful organizational change in response to the COVID-19 pandemic.Methods: The fifteen core leaders of WVUHS COVID-19 strategic system were interviewed. A qualitative thematic analysis of the interviews was used to evaluate key aspects of leadership dynamics and system-wide changes in healthcare policies and protocols to contain the pandemic. Outcome measures included the degree to which WVUHS could handle and contain COVID-19 cases as well as COVID-19 death and vaccination rates in West Virginia compared with other states.Results: The leadership team radically and rapidly revamped nearly all healthcare policies, procedures, and protocols for WVUHS hospitals and clinics, and launched a Hospital Incident Command System. As a result of this effective leadership team and strategic plan, WVUHS surge capacity was adequate for COVID-19 cases. In addition, West Virginia was an early frontrunner in COVID-19 vaccination rates as well as lower death rates.Conclusion: WVUHS’s leadership response to the COVID-19 pandemic followed Kotter’s eight-stage paradigm for Leading Change in organizations, including the establishment of a sense of urgency, formation of a powerful guiding coalition, creation of a vision, communication of the vision, empowerment of others to act on the vision, plan for and creation of short-term wins, consolidation of improvements and production of more changes, and institutionalization of new approaches. This approach was effective in limiting the spread and impact of COVID-19 within the hospital network and across the state, with many lessons learned along the way.Keywords: hospital incident command system, organizational change, hospital management, leading change, COVID-19

We report results from a blind comparison of six analytical laboratories ISO/IEC 17025 accredited for the implementation of the analytical element of EN 1911, which involves the quantification of chloride in deionised water collected from HCl emitting industrial processes regulated under the EU's Industrial Emissions Directive (IED). Both "synthetic" (sodium chloride dissolved in deionised water) and "real" (extracted and collected from a stack simulator facility) samples were prepared across ranges which were equivalent to concentrations in the stack of 0 - 10 mg.m-3 and 0 - 60 mg.m-3, respectively. Laboratory measurements of the real samples showed significantly poorer performance than the synthetic, implying that the use of synthetic samples in national proficiency testing schemes may be leading to an overly optimistic view of the uncertainties that can routinely be achieved in measurements of real industrial processes. In addition, at the applicable emission limits (10 mg.m-3 and 3 mg.m-3) and measurement ranges (0 - 15 mg.m-3 and 0 - 4.5 mg.m-3) under the IED and more recent BAT Conclusions legislation it was found that of the real samples 22 out of 102 (21.6%) and 28 out of 51 (54.9%), respectively, of the measurements would not comply with the overall uncertainty that at least one national regulator considers as necessary for EN 1911 to be an "effective tool" for the calibration of automated measuring systems (AMSs - process plant operator analysers providing continuous monitoring of emissions). Hence, it is proposed that at the next revision of EN 1911 the standard should be revised to give the same degree of consideration to the analytical element of the method as the sampling element. Key analytical laboratory uncertainty sources should be identified, numerical uncertainty requirements should be placed on key analytical uncertainty sources, and there should be an overall uncertainty requirement for the analytical element.

A 70-year-old man presented for repair of an ear avulsion injury sustained from an all-terrain vehicle accident. A continuous technique using a catheter for a greater auricular nerve (GAN) block was performed in the preoperative area followed by general anesthesia in the operating room. No opioids were administered during the surgical procedure or in the immediate postoperative period. The GAN catheter was kept in place for 3 days with near-complete pain relief per the patient. To our knowledge, there are no case reports that describe a continuous GAN technique for surgery and postoperative pain.

We report results from a blind comparison of five analytical laboratories ISO/IEC 17025 (International Organization for Standardization/International Electrotechnical Commission) accredited for the analysis of sulfate collected in H2O2(aq) from industrial stacks in accordance with the European Standard Reference Method (SRM) for sulfur dioxide (SO2) (EN 14791): the method produced under European Commission mandate to support the enforcement of the Industrial Emissions Directive (IED). Both "synthetic" (sodium sulfate dissolved in aqueous hydrogen peroxide [H2O2(aq)]) and "real" (extracted and collected from a stack simulator facility in accordance with EN 14791) samples were prepared across 2-10 and 10-290 mg·m0-3 emission equivalent concentration ranges, respectively. From the measurements returned by the laboratories, it was found that in 35% of the former and 28% of the latter the stated expanded uncertainty limits did not intersect with the mean. It was also found with the real samples that in 30% of the 46 different concentration test levels the stated expanded uncertainty of at least two of the laboratories did not intersect. With respect to compliance monitoring, it was found that EN 14791 was capable of enforcing emission limits under the IED associated with waste incinerators (i.e., 50 mg·m0-3), as only 3% of the deviations were in excess of the required uncertainty (commensurate with a 95% level of confidence). However, with respect to the use of EN 14791 for calibration of automated measuring systems (AMSs), it was found that 38.5% of the deviations were in excess of the uncertainty recommended by at least one national regulator as being necessary for EN 14791 to be an "effective tool" for the calibration of AMSs. With emission limits under the IED and the Best Available Technique Reference (BREF) documents it adopts becoming increasingly stringent, it is clear that more work is needed to determine the capability of the SRM and also alternative methods based on portable instruments. Implications: The deviations observed between laboratories ISO/IEC 17025 accredited for sulfate analysis bring into question the monitoring communities' ability to routinely meet the uncertainty requirements associated with increasingly stringent SO2 emission limits under the European Union's Industrial Emissions Directive. Furthermore, with even further reductions in the near future due to legislative adoption of BREF documents, such issues are only likely to be exacerbated. If the European monitoring community is to have confidence in the capability of the existing Standard Reference Method described in EN 14791 for enforcing increasingly stringent limits, work is needed to validate this method at these lower emission levels.

Patient: Male, 34-year-old Final Diagnosis: Infective endocarditis of the tricuspid valve Symptoms: Lethargy • weakness Medication: — Clinical Procedure: Tricuspid valve repair • tricuspid valve replacement Specialty: Anesthesiology • Cardiac Surgery • Infectious Diseases • Psychiatry Objective: Unusual clinical course Background: Intravenous drug use is an epidemic in the United States. One of the complications of intravenous drug use can be infective endocarditis. The treatment for this disease is a combination of intravenous antibiotics, cardiac surgery consultation, and multidisciplinary psychiatric care. Despite surgical intervention, recurrence of disease is common. In the setting of recurrent infective endocarditis in the setting of intravenous drug use, the ethics of redo cardiac surgery has not been well-established. Case Report: A 34-year-old man with history of intravenous drug use presented on 3 separate occasions with infective endocarditis resulting in 3 tricuspid valve surgeries within fewer than 7 months. He said he had not injected drugs since before his first operation, he was considered to have a strong social support system, and he completed his postoperative antibiotic regimens each time. However, prior to his last operation, the patient had a urine drug screen positive for opiates without recorded prescribed opioids. Pathology reports from the 3 intraoperative specimens showed different pathogens each time. An extensive interprofessional discussion ensued. Conclusions: Infective endocarditis in the setting of intravenous drug use and its treatments continue to be a point of ethical and medical discussion for all professionals involved with the care of these patients. This case could be used as an example of individualized decision-making, with rigorous ethical and medical discussion factoring into each decision for cardiac surgery. The ongoing treatment for patients with recurrent endocarditis in the setting of intravenous drug use requires more research and guidelines to help medical professionals better care for this patient population.

Kawasaki disease (KD), also known as mucocutaneous lymph node syndrome, is an acute vasculitis that frequently affects medium-sized blood vessels. The disease is usually self-limiting and most commonly affects children under five years of age. It often affects the coronary arteries and is the leading cause of acquired heart disease in developed countries. We report the case of a teenage boy who had a long-standing diagnosis of Kawasaki disease, underwent coronary artery bypass grafting surgery, and had a complicated medical course following the surgery.

Quadricuspid aortic valve (QAV) is a rare congenital anomaly often associated with aortic insufficiency. The exact anatomy of QAV is variable, and most cases have undergone aortic valve replacement. With the recognition that aortic valve repair achieves superior patient outcomes as compared to replacement, a systematic approach to autologous reconstruction of QAV is needed. This article reports 2 cases having successful repair utilizing geometric aortic annuloplasty rings, and describes a proposed scheme for repairing most QAV defects, based on relative leaflet and commissural characteristics. Using either tri-leaflet or bicuspid ring annuloplasty, the normal sub-commissural triangles can be remodeled into a 120° or 180° configuration, respectively, and then the leaflets can be sutured and plicated to fit annular geometry. With this approach, most quadricuspid valves potentially could undergo autologous reconstruction.

Background Appalachian rural pediatric trauma has its unique incidence, presentation, and distribution due to the mechanisms of injury, geographic location, access to care, and social issues. Purpose To review, analyze, and understand pediatric trauma in West Virginia during the period 2017-2019. Materials and methods After institutional review board approval, the statewide trauma database was queried and analyzed in a retrospective cohort study for all pediatric trauma ages zero to 18 from 2017-2019 in the Appalachian regions one through four in West Virginia. The following were analyzed: gender, injury mechanism, Glasgow Coma Scale Score (GCS) at admission, injury severity score (ISS), toxicology screen results, hospital length of stay, duration of ventilatory support, number of procedures performed during admission, presence of non-accidental trauma, cardiac arrest, patient discharge disposition, and mortality. Results One-thousand eighty-two (1182) patients between the ages of zero to 18 were admitted to the trauma center. An average of 37% was female and 63% male. In the 11-18 age group, 24% were female and 76% were male. Most injuries were due to blunt force (89%), followed by penetrating injuries (7.2%) and burns (1.4%). The majority had minor or moderate injuries with 95% receiving a Glasgow Coma Scale (GCS) >13 and 72% listed as minor on the injury severity score (ISS). Children in ages 0-2 years had the highest proportion of poor (0-8) GCS scores, high ISS (>14) scores, most hospital admission days, most days on a ventilator, highest mortality, most pre-hospital cardiac arrests, child abuse, burns, and placement with child protective services. An average of 31% of children tested, and 17% in the age group of 0-2 had a positive toxicology screen. There were 3670 procedures done in total and the most common procedure performed was an ultrasound of the abdomen. Procedures were performed in 90% of the patients. Conclusions and relevance Based on our study, the zero to two-year-old pediatric trauma patients are most vulnerable to poor outcomes and may need targeted preventative interventions. Toxicology screens may need to be more widely implemented in pediatric trauma in the Appalachian region. Rural trauma in Appalachia has endemic issues related to substance abuse, poverty, and a lower degree of social support as compared to urban areas. Although the distribution of injury may follow a national distribution, mechanism, management, and outcomes can vary.

BACKGROUND Intravenous drug use is an epidemic in the United States. One of the complications of intravenous drug use can be infective endocarditis. The treatment for this disease is a combination of intravenous antibiotics, cardiac surgery consultation, and multidisciplinary psychiatric care. Despite surgical intervention, recurrence of disease is common. In the setting of recurrent infective endocarditis in the setting of intravenous drug use, the ethics of redo cardiac surgery has not been well-established. CASE REPORT A 34-year-old man with history of intravenous drug use presented on 3 separate occasions with infective endocarditis resulting in 3 tricuspid valve surgeries within fewer than 7 months. He said he had not injected drugs since before his first operation, he was considered to have a strong social support system, and he completed his postoperative antibiotic regimens each time. However, prior to his last operation, the patient had a urine drug screen positive for opiates without recorded prescribed opioids. Pathology reports from the 3 intraoperative specimens showed different pathogens each time. An extensive interprofessional discussion ensued. CONCLUSIONS Infective endocarditis in the setting of intravenous drug use and its treatments continue to be a point of ethical and medical discussion for all professionals involved with the care of these patients. This case could be used as an example of individualized decision-making, with rigorous ethical and medical discussion factoring into each decision for cardiac surgery. The ongoing treatment for patients with recurrent endocarditis in the setting of intravenous drug use requires more research and guidelines to help medical professionals better care for this patient population.

Background Tracheal intubation carries an elevated risk of exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) due to the generation of aerosols containing high concentrations of the virus. An airway box was designed to mitigate the exposure of healthcare professionals performing intubations. Aim We evaluated usability and sustainability in the routine practice of the "airway box" as a protective device during high-risk airway procedures. Materials and methods After institutional review board approval, clinicians were educated on using the device through simulation, intranet learning modules, and emailed resources. The airway box was made available in the emergency department, critical care units, perioperative area, and operating rooms. QR codes affixed to the box, emailed, and displayed in common areas provided easy access to complete a REDcap survey (Vanderbilt University Nashville, USA) eliciting providers’ experience. Data was collected and analyzed between April 1 and July 31, 2020, on REDcap, and the results were analyzed. Results 687 emergent intubations took place. 232 were performed by anesthesiologists, 315 by emergency department providers, and 140 by critical care specialists. 39 surveys were completed, 29 from intubations in the operating room, three from the critical care units, five from interventional radiology suites, and two perioperatively. Providers found the device to be readily available, with a score of 4.51/5, and the majority of providers, 60%, found the device easy to use, rating it either a 4 or 5 out of 5. Providers acquired a mean Mallampati score of 1.75 and 1.40 mean laryngoscopic grade view. Conclusion Intubation boxes may effectively mitigate high-risk viral exposure during airway procedures. Survey responses show that devices were easy to use and did not significantly affect visualization of the airway. Similar to mask use, enclosure devices in clinical practice could become a vital part of medical protective equipment even after the SARS-CoV-2 pandemic if they are effectively implemented.

Two series of sterically encumbered gold(I)-acyclic diaminocarbene (ADC) complexes were prepared by reaction of mono- and dialkylamines with gold-bound 2-mesitylphenyl isocyanide (monomesityl series) and 2,6-dimesitylphenyl isocyanide (dimesityl series). X-ray crystal structures and solution 1H NMR data showed that the ADC-gold complexes adopt major rotameric conformations with the bulky biaryl/terphenyl group and one alkyl group located syn to gold. This engenders substantial steric hindrance at the metal, as evidenced by percent buried volume (%Vbur) parameters of 35.7 – 37.2 for the monomesityl series and 46.4 – 52.4 for the dimesityl series. Modest out-of-plane distortions of the ADC N-substituents in the dimesityl series were attributed to attractive CH···π interactions between alkyl groups and mesityl rings on the basis of dispersion-corrected density functional theory calculations. Gold-catalyzed regiodivergent domino cyclization/hydroarylation reactions of a 1,6-enyne with indole revealed that the bulky biaryl/terphenyl substituents of the ligands exert a strong influence on product selectivity, with the bulkier dimesityl ADC-Au catalysts inducing a shift away from the cyclopropane-fused product toward the normally disfavored alkene product. Incorporation of a yet bulkier bis(2,6-diisopropylphenyl)-substituted terphenyl moiety into the ADC led to a gold catalyst that provided exclusive selectivity for the alkene product. Computational modeling suggested that bulky terphenyl groups hinder attack at the a carbon in the initially formed organogold intermediate, allowing steric effects to override the intrinsic electronic preference for the cyclopropane product.

A 61-year-old male with severe aortic valve stenosis was scheduled for a minimally invasive bioprosthetic aortic valve replacement. Intraoperative transesophageal echocardiography (TEE) showed a unicuspid aortic valve and extensive aortic atheromatous disease. A large atheroma with mobile components existed near the distal aortic arch. A 17-French aortic cannula was successfully placed using TEE guidance with the tip proximal to the mobile atheroma to avoid inadvertent disruption and subsequent embolic sequelae. The patient had no evidence of perioperative stroke or other complications postoperatively. This case demonstrates one strategy to manage severe atheromatous disease intraoperatively. We also review additional management options.

The authors evaluated the type of anesthesia administered in atrial fibrillation ablation, hypothesizing that monitored anesthesia care is used less frequently than general anesthesia.A retrospective study.National Anesthesia Clinical Outcomes Registry data, which are multi-institutional from across the United States.Adult patients who underwent elective atrial fibrillation ablation between 2013 and 2018.None.National Anesthesia Clinical Outcomes Registry data were evaluated, and covariates were selected a priori within multivariate models to assess for predictors of anesthetic type. A total of 54,321 patients underwent atrial fibrillation ablation; 3,251 (6.0%) received monitored anesthesia care. Patients who received monitored anesthesia care were more likely to be80 years old (12.4% v 4.9%; p0.0001), female (36.1% v 34.3%; p0.0001), have American Society of Anesthesiologists physical statusIII (17.28% v 10.48%; p0.0001), and reside in urban areas (62.23% v 53.37%; p0.0001). They received care in the Northeast (17.6% v 10.1%; p0.0001) at low-volume centers (median 224 v 284 procedures; p0.0001). Multivariate analysis revealed that each five-year increase in age, being female, and having an American Society of Anesthesiologists physical statusIII resulted in a 7% (p0.0001), 9% (p = 0.032), and 200% (p0.0001) increased odds of receiving monitored anesthesia care, respectively. Requiring additional ablation of atria or of a second arrhythmia and residing outside the Northeast resulted in a decreased odds of monitored anesthesia care (adjusted odds ratio 0.24 [p=0.002] and0.5 [p0.03], respectively). For each 50 cases performed annually at a center, the odds decreased by 5% (p = 0.005).General anesthesia is the most common type of anesthesia administered for atrial fibrillation ablation. The type of anesthesia administered, however, varies with patient, procedural, and hospital characteristics.

A 73-year-old female patient presented for mitral valve replacement and coronary artery bypass grafting secondary to multivessel coronary disease and severe mitral valve regurgitation with moderate stenosis. After bypass, the patient developed refractory hypotension with decreased biventricular volume and elevated central venous pressure (CVP). Transesophageal echocardiography (TEE) was utilized to make the diagnosis of acute intraoperative superior vena cava (SVC) syndrome. The SVC cannulation site was revised, resulting in resolution of the hypotension and a decrease in the CVP. Intraoperative TEE was vital in recognizing, managing, and ultimately repairing the acute intraoperative SVC stenosis.

We have shown that the amount fraction of carbon dioxide in a nitrogen or synthetic air matrix stored in cylinders increases as the pressure of the gas mixture reduces, while the amount fraction of methane remains unchanged. Our measurements show the initial amount fraction of carbon dioxide to be lower than the gravimetric value after preparation, which we attribute to the adsorption of a proportion of the molecules to active sites on the internal surface of the cylinder and the valve. As the mixture is consumed, the pressure in the cylinder reduces and the amount fraction of the component is observed to increase. The effect is less pronounced in the presence of water vapor. More dramatic effects have been observed for hydrogen chloride. These findings have significant implications for the preparation of high accuracy gaseous reference materials with unprecedented uncertainties which underpin a broad range of requirements, in particular atmospheric monitoring of high impact greenhouse gases.

Jean-Luc Nancy's thought consistently positions itself against political forms grounded in ideas of essence or belonging. Accordingly, it sometimes portrays the concept of identity in a negative light, tending instead to gesture towards the ontological exposure at the heart of any political configuration. This tendency has led critics to claim that Nancy regards identity as a priori disastrous and to be dismissed outright. Nonetheless, a careful reading of Nancy's work reveals a recurring preoccupation with the question of collective identity. As this article suggests, Nancy's critique is directed less against identity as such than the 'infinite identity' that would bestow a totalizing 'work' on the collective. Indeed, Nancy constantly insists that politics cannot do without some degree of identity or figure, however skeletal. The question we must then ask is how we are to conceive this minimal figuration. One way of approaching such a figuration, I shall argue, lies in Nancy's treatment of the proper name. This article develops Nancy's thinking of identity and the name, showing how it allows us to think a limited coherence of the collective—here of a 'people'—in a way that nevertheless resists its closure, ultimately to think identity as this resistance.

Background: We sought to evaluate differences in primary anesthetic type used in arteriovenous access creation with the hypothesis that administration of regional anesthesia and monitored anesthesia care (MAC) with local anesthesia as the primary anesthetic has increased over time. Methods: National Anesthesia Clinical Outcomes Registry data were retrospectively evaluated. Covariates were selected a priori within multivariate models to determine predictors of anesthetic type in adults who underwent elective arteriovenous access creation between 2010 and 2018. Results: A total of 144,392 patients met criteria; 90,741 (62.8%) received general anesthesia. The use of regional anesthesia and MAC decreased over time (8.0%–6.8%, 36.8%–27.8%, respectively; both p III and to reside in rural areas (52.3% and 12.9%, respectively; both p III, and each 5-year increase in age resulted in increased odds of receiving alternatives to general anesthesia (regional anesthesia adjusted odds ratios (AORs) 1.06, 1.12, and 1.26, MAC AORs 1.09, 1.2, and 1.1, respectively; all p Conclusions: Use of regional anesthesia and MAC with local anesthesia for arteriovenous access creation has decreased over time with general anesthesia remaining the primary anesthetic type. Anesthetic choice, however, varies with patient characteristics and geography.

Ultrasound is widely used in all medical specialties. There are multiple reasons for the increased use of ultrasound including its ease of use, point-of-care determination, and rapid confirmation of clinical diagnoses. Ultrasound is a valuable tool that can assist in the diagnosis and treatment of obstetric patients for both obstetric and non-obstetric conditions. In this review, we will describe the common applications for point-of-care ultrasound in the perioperative period including intravenous placement and guidance for vascular access, head and neck evaluation (airway exam, difficult airway), lung and chest evaluation (pleural effusions, pneumonia), echocardiography (transthoracic echocardiography and transesophageal echocardiography), evaluation of gastric contents, postoperative pain management (transversus abdominis plane block) and regional anesthesia, neuraxial (spinal and epidural conduction), bladder volume estimation, and trauma evaluation (focused assessment with sonography in trauma) exam for detection of intraperitoneal fluid and hemorrhage.

Background There are many camps available to support young people who are currently suffering from symptoms from an illness or condition, but little availability of camps for those with parents suffering from an illness where the young people are at risk for developing the same illness. The Huntington’s Disease Youth Organization (HDYO) has hosted eight camps around the world over the course of five years for young people impacted by HD. The aim of these camps is to provide the camper respite, a space for peer and professional support as well as access to education that is age and stage appropriate. Case history Campers overwhelming spoke to camp helping them feel less isolated and more in control of their journey with HD. Over 50% of campers in our study (only 10 campers completed all pre and post surveys) stated they had more specific knowledge about HD, there was also a statistically significant increase in the campers sense of social support and an increase positive sense of self-esteem (Kavanaugh et al, 2017). Conclusion There is still limited data on camps for young people at-risk of HD, but early information points to the existence of these camps to be hugely important for healthy outcomes. Furthermore, feeling educated about the disease, and research leads to young people feeling empowered and less afraid of the disease. They can also get practical information to help them make critical decisions (testing, family planning, symptom management etc) for their own journey with HD.

Background Dexmedetomidine (DMET), a selective a2-adrenergic agonist, is an opioid-sparing adjuvant sedative that avoids respiratory depression and has been shown to be beneficial in bariatric surgery patients. Although benefit has been shown, prior studies have not evaluated the pain control effects of a single intraoperative bolus. Objectives To evaluate the postoperative effects of a single intraoperative dose of DMET. Settings University Hospital, United States. Methods This is a prospective, randomized, double-blinded study registered with clinicaltrials.gov (#NCT02604940). Patients undergoing laparoscopic Roux-en-Y gastric bypass surgery were randomized and given either a placebo or an intraoperative DMET bolus, where 1 mg/kg was delivered over 10 minutes at the time of surgical closure. Measured outcomes included the following: postoperative pain scores, patient-controlled analgesia (PCA) opioid consumption, PCA demand bolus attempts, duration of postanesthesia care unit (PACU) stay, and vital signs. Descriptive statistics were recorded as frequencies and compared using Χ2 analysis, and a Welch's 2-sample t test was used to compare continuous variables. Results Forty-six participants undergoing laparoscopic Roux-en-Y gastric bypass surgery were randomized into placebo (n = 20) or DMET (n = 26) groups. There were no statistical differences in age (45.1 versus 43.2 yr, P = .522), sex (80% versus 81% female, P = .948), and body mass index (46.1 versus 45.6 kg/m2, P = .818) between the 2 groups. There were no statistically significant differences in vital signs (heart rate, blood pressure, oxygen saturation, and respiration rate) between DMET and placebo groups in the preoperative and intraoperative period. During the initial 4 hours in the PACU postoperatively, mean heart rate (70 ± 12 versus 86 ± 14, P Conclusions A single bolus of DMET (1 mg/kg delivered over 10 min) administered at the time of surgical closure did not reduce immediate PACU usage of opioids but significantly reduced reported pain scores and caused a significant decrease in the number of attempts made by patients; this is a trend of decreased attempts over time (P = .04) in the DMET group. The trend of the mean total medication used over time indicates that there is neither an increasing nor decreasing trend for the DMET group, but there is an increasing trend in the total used over time for the placebo group. There was no statistically or clinically significant bradycardia, hypotension, hypoxia, respiratory depression intraoperative duration, or PACU stay. Reduced single bolus dosing of DMET required for analgesia in bariatric surgery patients is optimal from physiologic, level of care, and cost perspectives.

A 48-year-old male underwent elective pulmonary vein Cryoablation for symptomatic persistent atrial fibrillation. Transseptal puncture was performed with a brockenbrough-1 needle and a Mullins shea...

The Decision Between Us engages the philosophy of Jean-Luc Nancy, among others, to consider scenes in ‘art's work’ that ineluctably retreat from the protocols of the art historian. John Paul Ricco ...

This chapter covers the challenges young people impacted by Huntington's disease (HD) experience on a daily basis. Research suggests young people in HD families are twice as likely to struggle with issues such as self-harm, depression, anxiety etc. Yet support for young people in HD families is generally lacking. Young people in HD families have to face their own genetic risk for HD, caregiving responsibilities, social isolation, financial woes, educational impact on top of witnessing their family member progressing with HD and gradually losing one ability after another until they are unable to do anything. There are plenty of challenges when you're a young person impacted by HD. This chapter covers most.

In February 2015, the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNSF) published the Allergic Rhinitis Clinical Practice Guideline (AR-CPG). The objective of this study was to assess otolaryngologists' perception of the accuracy and adherence to the AR-CPG.A survey was distributed to fellows of the American Academy of Otolaryngic Allergy and members of the American Academy of Otolaryngology-Head and Neck Surgery Foundation. A total of 601 otolaryngologists responded. The survey evaluated otolaryngologists' demographic data, perception of the accuracy of the guideline, and adherence to the guideline action statements.The majority of respondents were actively practicing (544 [90.5%]), for a duration of 11-30 years (308 [51.2%]), in a private practice setting (387 [64.4%]). The cohort was largely fellowship trained (348 [57.9%]) and had reviewed the guideline (428 [71.2%]). Most respondents perceived the guideline as being correct "a great deal" (295 [69.7%]) and deviated from the guideline "only a little" (302 [71.6%]). High rates of adherence to the strong guideline recommendations were observed. Respondents "always/most of the time" recommended intranasal steroids (581 [97.6%]), and oral antihistamines (439 [74%]) as primary therapy. Otolaryngologists in practice for longer were more likely to deviate from the guideline recommendations by obtaining sinonasal imaging (p = 0.007) and recommending oral leukotriene receptor antagonists as primary therapy (p = 0.0001).Overall perception of the correctness of and adherence to the AR-CPG was high in this cohort. Targeted education resources should be provided to otolaryngologists in practice for longer in efforts to reduce harmful or unnecessary variations in care.

This chapter covers the challenges young people impacted by Huntington's disease (HD) experience on a daily basis. Research suggests young people in HD families are twice as likely to struggle with issues such as self-harm, depression, anxiety etc. Yet support for young people in HD families is generally lacking. Young people in HD families have to face their own genetic risk for HD, caregiving responsibilities, social isolation, financial woes, educational impact on top of witnessing their family member progressing with HD and gradually losing one ability after another until they are unable to do anything. There are plenty of challenges when you're a young person impacted by HD. This chapter covers most.

Dr. Ellison leads the residents at Duke University in performing a dacryocystorhinostomy while identifying the relevant nasolacrimal anatomy. Use of picture-in-picture offers our viewers insight into how the lower canaliculus probe is managed with endoscopic assistance.

ONE-LUNG VENTILATION (OLV) can be achieved through several methods when a tracheostomy is present. Chen et al described using a Foley catheter for lung isolation in a patient with a tracheostomy. A commercially available bronchial blocker (BB) often is used for OLV in the setting of a tracheostomy. Although they are appropriate for many cases, BBs have disadvantages including technical difficulties related to right bronchial anatomy, frequent dislodgement, limited ability to suction, and slow lung collapse. It is possible to place a double-lumen endotracheal tube (DLT) into a tracheostomy stoma. DLTs avoid many of the problems associated with BBs but require removal of the tracheostomy tube, which, in the case of a recent percutaneous tracheostomy, carries a risk of false passage and failed airway. In this case report, the authors describe a simple and effective method for achieving lung isolation in a patient with a recent percutaneous tracheostomy.

Prolonged paralysis due to a quantitative or qualitative deficiency of pseudocholinesterase activity is an uncommon but known side effect of succinylcholine. We describe a patient who experienced prolonged paralysis following administration of succinylcholine for general anesthesia and endotracheal intubation for an emergent cesarean section despite laboratory evidence of normal enzyme function. The patient required mechanical ventilation in the intensive care unit for several hours following surgery. The patient was extubated following return of full muscle strength and had a good outcome. The enzyme responsible for the metabolism of succinylcholine, pseudocholinesterase, was determined to be low in quantity in this patient but was functionally normal. This low level, by itself, was unlikely to be solely responsible for the prolonged paralysis. The patient likely had an abnormal pseudocholinesterase enzyme variant that is undetectable by standard laboratory tests.

Modern cementing techniques in total hip arthroplasty routinely include the use of cement restrictor plugs to occlude the femoral canal, which enable cement containment and help in pressurized cement application. Formation of emboli from within the intramedullary canal is of great concern. We investigated the insertion force profile and distal femoral canal pressurization as a result of the introduction of different sizes of cement restrictor plugs from three different manufacturers on artificial femora. No significant difference in insertion force profiles were observed for the different restrictors tested. However, the Stryker Howmedica cement restrictor plugs generated the highest pressure in the distal intramedullary canal.

Background: Ischemic optic neuropathy resulting in visual loss is a rare but devastating complication of spine surgery. Elevated intraocular pressure (IOP) results in decreased perfusion and possibly ischemic optic neuropathy. We performed a randomized, prospective trial to evaluate the effect of head positioning on IOP during lumbar spine fusion. Methods: The study included fifty-two patients treated at one institution. Inclusion criteria were a lumbar spine fusion and an age of eighteen to eighty years. Exclusion criteria were a diagnosis of tumor, infection, or traumatic injury or a history of eye disease, ocular surgery, cervical spine surgery, chronic neck pain, or cervical stenosis. The control group underwent the surgery with the head in neutral and the face parallel to the level operating room table whereas, in the experimental group, the neck was extended so that the face had a 10° angle of inclination in relation to the table. IOP measurements were recorded along with the corresponding blood pressure and PCO2 values at the same time points. The primary outcome measure was the change in intraocular pressure (ΔIOP, defined as the maximum IOP minus the initial IOP). Results: Analysis of covariance (ANCOVA) was used for categorical risk factors, and regression analysis was used for continuous risk factors. The mean ΔIOP, corrected for duration of surgery, was significantly (p = 0.0074) lower in the group treated with the head elevated than it was in the group treated with the head in neutral (difference between the two groups, 4.53 mm Hg [95% confidence interval, 1.29 to 7.79 mm Hg]). No patient sustained visual loss or any cervical-spine-related complications. Conclusions: Head elevation for adult lumbar spine fusion performed with the patient prone resulted in significantly lower IOP measurements than those seen when the operation was done with the patient’s head in neutral. As lower IOP correlates with increased optic nerve perfusion, this intervention could mitigate the risk of perioperative blindness after spine surgery done with the patient prone. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Background Health related youth respite camps traditionally target the youth with an illness or disability (cancer, diabetes, Downs syndrome etc), providing support, guidance and disease based education. However, little published evaluation data exists on effect of camps that serve youth with a parental or other family illness. Living in a family with chronic or acute illness impacts the child well-being, stress levels and isolation from youth not tasked with dealing with an ill family member. This paper provides evaluation data on one unique camp in North America, targeting children and youth who have a family member with Huntington’s disease (HD). The North American HD Youth Summer Camp was designed to provide young people ages 15–23 a break from home life and an opportunity to gain peer and professional support around HD issues and HD education. Through a mix of activities and educational sessions, the camp offers young people the opportunity to build coping skills, peer relations, support and HD education. Campers must have a parent/family member with Huntington’s disease, live in the US or Canada, and complete an application. A total of 55 applications were received and all offered admission. 45 campers were accepted. All gender, races, and ethnicities were eligible for inclusion in attending the camp. Aims To describe the impact of the first North American camp on several measures of youth well-being in youths who have a family member affected by HD. Specific research questions addressed: 1) Do youth report an increase in knowledge about HD and support in dealing with HD; 2) Are resilience, self-esteem, and life satisfaction increased as a function of attending the camp? Methods The camp evaluation consisted of a survey administered at four time points, 6-weeks baseline, pre camp, post camp and 6-weeks post, assessing differences in self-esteem, social support, resilience, health related quality of life, and HD issues. Results/outcome At total of 35 campers completed the pre-camp survey (23 = female, 12 = male), range from 14 to 23, with average age 18. Campers are predominately white (N = 33) and from the US (N = 29). Campers describe isolation from friends (N = 24), felling less “normal” than other kids (N = 22), having not enough information about testing (N = 25), or relationships and HD (N = 13). Only four had any contact with an HD organisation (HDYO, HDSA or HSC). Female participants increased their self-esteem score significantly from baseline to post-camp by 0.28 (SE = 0.08, p = 0.013), and overall camp participants’ life satisfaction score changed significantly throughout the study (p Conclusions Findings from the study suggest youth affected by HD are an isolated group, in need of not only HD specific information, but also support around issues of self-esteem and well-being. These results highlight the stated goals of the camp, to provide support and education, while underscoring the need for the provision of HD youth focused programming.

A greater auricular nerve (GAN) block was used as the sole anesthetic for facial surgery in an 80-year-old male patient with multiple comorbidities which would have made general anesthesia challenging. The GAN provides sensation to the ear, mastoid process, parotid gland, and angle of the mandible. In addition to anesthesia for operating room surgery, the GAN block can be used for outpatient or emergency department procedures without the need for a separate anesthesia team. Although this nerve block has been performed using landmark-based techniques, the ultrasoundguided version offers several potential advantages. These advantages include increased reliability of the nerve block, as well as prevention of inadvertent vascular puncture or blockade of the phrenic nerve, brachial plexus, or deep cervical plexus. The increasing access to ultrasound technology for medical care providers outside the operating room makes this ultrasound guided block an increasingly viable alternative.