Citations

The prevailing first‐come‐first‐served approach to outpatient appointment scheduling ignores differing urgency levels, leading to unnecessarily long waits for urgent patients. In data from a partner healthcare organization, we found in some departments that urgent patients were inadvertently waiting longer for an appointment than non‐urgent patients. This study develops a capacity allocation optimization methodology that reserves appointment slots based on urgency in a complicated, integrated care environment where multiple specialties serve multiple types of patients. This optimization reallocates network capacity to limit access delays (indirect waiting times) for initial and downstream appointments differentiated by urgency. We formulate this problem as a queueing network optimization and approximate it via deterministic linear optimization to simultaneously smooth workloads and guarantee access delay targets. In a case study of our industry partner we demonstrate the ability to (i) reduce urgent patient mean access delay by 27% with only a 7% increase in mean access delay for non‐urgent patients, and (ii) increase throughput by 31% with the same service levels and overtime.

We report a unique case and presentation of a 77-year-old man with atrial fibrillation who presented with complex imaging features, including bifrontal cerebral hematomas that progressed to multifocal macro- and microhemorrhages, vasogenic edema, and cortical/meningeal enhancement. Cerebrospinal fluid analysis was only remarkable for a protein elevation of 65 mg/dL. Leptomeningeal vessel biopsy failed to demonstrate evidence of amyloid angiopathy but did show concentric obstructive intimal fibroplasia, suggestive of chronic venous congestion. Conventional cerebral angiography showed a Cognard type IV dural arteriovenous fistulae fed by bilateral ethmoidal arteries draining directly into ectatic cortical veins. A chronic occlusion of the anterior third of the superior sagittal sinus was also noted. The fistula was successfully surgically obliterated via an uncomplicated left frontal craniotomy approach. After rehabilitation therapy, he was discharged home with a modified Rankin Scale score of 3. Because effective treatment exists, this case underscores the importance of identifying this rare etiology of intracerebral hemorrhage and pursuing adequate workup.

Background The nasal muscles and their function are not clearly defined. The nasal muscles generally are thought to act synergistically to produce mimetic motion and affect the nasal airway. We proposed direct examination of the effects of the nasal muscles on the nasal airway. Methods Rhinomanometry was performed on volunteers. After paralysis of the nasal muscles with lidocaine, rhinomanometry was performed again to measure nasal airway function with the patient at rest and attempting to flare his/her nostrils. Each patient's rhinomanometric results (at rest and attempting to flare the nostrils) taken before injection of lidocaine served as the control for comparison of his/her results postinjection. The structural tension of the ala at rest and with active flaring of the nostril was measured also, and the results pre- and postparalysis with lidocaine were compared. Results The data from both the stiffness (structural tension) and the airflow portions, taken together, support the following conclusions. First, the paralysis was significant, although not complete. Clinical and stiffness data supported complete paralysis. Airflow data, which we think most sensitive, support a statistically significant affect of the injection, although incomplete paralysis. Conclusion All of the evidence supports an important role for the nasal muscles when actively used to increase nasal airflow. Second, the majority of the evidence supports an important resting nasal muscle tension that opens the nasal airway.

Objectives: Ultrasound guided fascia-Iliaca blocks have been used for pain control following hip arthroscopy. There is little evidence regarding their effectiveness in comparison to other pain control modalities in hip arthroscopy patients. To compare efficacy of ultrasound guided fascia iliac block with intra-articular ropivacaine in controlling pain after hip arthroscopy. Methods: Between 2015 and 2017, 95 patients undergoing hip arthroscopy were randomly assigned to 2 groups. The first group received an ultrasound-guided fascia-iliaca block with 50-60mLs of 0.35% ropivacaine. The second group received intra-articular injection of 20 mL of 0.5% ropivacaine at the completion of the surgical case. Primary outcomes were post-operative pain scores in the recovery room, at PACU discharge, at 2 weeks, 6 weeks, and 3 months. Secondary outcomes included intraoperative and PACU narcotic usage (converted to morphine equivalent use) as well as readmission rates, PACU recovery time and postoperative nausea and vomiting (PONV). Results: Postoperative pain across all points did not significantly differ between the 2 groups. Intraoperative and PACU narcotics did not differ significantly between the 2 groups. Readmission rates, PACU recovery time and PONV did not significantly differ between the 2 groups. There were no associated complications in either group. Conclusion: Ultrasound guided fascia iliaca block for hip arthroscopy had no clinical advantage when compared to one time intra-articular ropivacaine injection. Furthermore, an intraarticular injection decreases costs and is a safe and more efficient modality for postoperative pain control following hip arthroscopy.

Objectives To present early safety and feasibility data from a multicentre prospective study (WATER II) of aquablation in the treatment of symptomatic men with large‐volume benign prostatic hyperplasia ( BPH ). Methods Between September and December 2017, 101 men with moderate‐to‐severe BPH symptoms and prostate volume of 80–150 mL underwent aquablation in a prospective multicentre international clinical trial. Baseline demographics and standardized postoperative management variables were carefully recorded in a central independently monitored database. Surgeons answered analogue scale questionnaires on intra‐operative technical factors and postoperative management. Adverse events up to 1 month were adjudicated by an independent clinical events committee. Results The mean (range) prostate volume was 107 (80–150) mL. The mean (range) operating time was 37 (15–97) min and aquablation resection time was 8 (3–15) min. Adequate adenoma resection was achieved with a single pass in 34 patients and with additional passes in 67 patients (mean 1.8 treatment passes), all in a single operating session. Haemostasis was achieved using either a Foley balloon catheter placed in the bladder under traction ( n = 98, mean duration 18 h) or direct tamponade using a balloon inflated in the prostate fossa ( n = 3, mean duration 15 h). No patient required electrocautery for haemostasis at the time of the primary procedure. The mean length of stay after the procedure was 1.6 days (range same day to 6 days). The Clavien–Dindo grade ≥2 event rate observed at 1 month was 29.7%. Bleeding complications were recorded in 10 patients (9.9%) during the index procedure hospitalization prior to discharge, and included six (5.9%) peri‐operative transfusions. Conclusions Aquablation is feasible and safe in treating men with men with large prostates (80–150 mL). The 6‐month efficacy data are being accrued and will be presented in future publications (ClinicalTrials.gov number, NCT 03123250).

Objectives Helicopter air ambulance (HAA) of pediatric trauma patients is a life-saving intervention. Triage remains a challenge for both scene transport and interhospital transfer of injured children. We aimed to understand whether overtriage or undertriage was a feature of scene or interhospital transfer and how in or out of state transfers affected these rates. Methods Children (<18 years) who underwent trauma activation at a level I trauma center between 2011 and 2013 were identified and reviewed. Patients transported by HAA were compared with those transported by ground ambulance (GA). Results Of 399 pediatric patients (median age, 10.4 years; range, 0.1–17 years; 264 male [66%]), 71 (18%) were transported by HAA. Seventy-two percent of HAA patients went to the intensive care unit or the operating room from the trauma bay or suffered in-hospital mortality (vs 42% GA, P < 0.001). More patients were overtriaged (HAA with injury severity score [ISS] of <15) from interhospital transfers than from the scene (25% vs 3%, P = 0.002). Undertriage (GA with ISS >15) was acceptable at 5% from the scene and 14% from interhospital transfers (P = 0.08). Overtriage of patients with ISS less than 15 to HAA was significantly lower from in-state hospitals (22%) than out-of-state hospitals (45%) (P = 0.02). Undertriage of patients with ISS greater than 15 to GA was also lower from in-state hospitals (20%) versus out-of-state hospitals (38%) (P = 0.03). Conclusions Triage of pediatric trauma patients to HAA remains difficult. There remains potential for improvement, particularly as regards interhospital HAA overtriage, but well developed transfer protocols (such in-state protocols) may help.