The Protocol-Personalized Perioperative Hemodynamic Management as Part of the ERAS Protocol in Abdominal Surgeries

One of the options for solving the problem of a “non-standard” patient undergoing a major and traumatic operation, perhaps, is the protocol-personalized approach to hemodynamic management.The objective: to study the efficacy and safety of using a modified protocol-personalized approach to hemodynamic management during surgical interventions on abdominal organs in elderly and senile patients.Subjects and Methods. A randomized prospective-retrospective clinical trial was conducted in parallel groups: Group 1 (control) - standard management of the perioperative period; Group 2 - standard management supplemented by the protocol-personalized approach to hemodynamic management.Results. Patients in the main group had the best parameters as per MACE outcomes (RR: 0.462, [95% CI: 0.251-0.850] p = 0.038). In the intra- and postoperative period, patients in the control group had a relatively higher risk of arrhythmias (RR: 2.517 [95% CI: 1.218; 5,200] p = 0.017).Conclusion. The use of the protocol-personalized approach results in better MACE outcomes (RR: 0.462, 95% CI: 0.251-0.850; p = 0.038) during surgical interventions on the abdominal organs in elderly and senile patients, and also, reduces the risk of arrhythmias (RR: 2.517, 95% CI:1.218; 5.200) p = 0.017.

Excessive unbound cefazolin concentrations in critically ill patients receiving veno-arterial extracorporeal membrane oxygenation (vaECMO): an observational study

The scope of extracorporeal membrane oxygenation (ECMO) is expanding, nevertheless, pharmacokinetics in patients receiving cardiorespiratory support are fairly unknown leading to unpredictable drug concentrations. Currently, there are no clear guidelines for antibiotic dosing during ECMO. This study aims to evaluate the pharmacokinetics (PK) of cefazolin in patients undergoing ECMO treatment. Total and unbound plasma cefazolin concentration of critically ill patients on veno-arterial ECMO were determined. Observed PK was compared to dose recommendations calculated by an online available, free dosing software. Concentration of cefazolin varied broadly despite same dosage in all patients. The mean total and unbound plasma concentration were high showing significantly (p = 5.8913 E−09) greater unbound fraction compared to a standard patient. Cefazolin clearance was significantly (p = 0.009) higher in patients with preserved renal function compared with CRRT. Based upon the calculated clearance, the use of dosing software would have led to lower but still sufficient concentrations of cefazolin in general. Our study shows that a “one size fits all” dosing regimen leads to excessive unbound cefazolin concentration in these patients. They exhibit high PK variability and decreased cefazolin clearance on ECMO appears to compensate for ECMO- and critical illness-related increases in volume of distribution.

Efficacy of Intense Pulsed Light and Meibomian Gland Expression Treatments in Meibomian Gland Dysfunction: A Meta-Analysis of Randomized Controlled Trials

Purpose: This review aimed to evaluate the efficacy and safety of intense pulsed light treatment (IPLT) combined with meibomian gland expression treatments(MGXT) in meibomian gland dysfunction.Methods: We conducted a meta-analysis of randomized controlled trials that compared the efficacy of IPLT and MGXT in the treatment of dry eye disease (DED). The meibomian gland yielding secretion score was the primary outcome, whereas the secondary outcomes included the Meiboscore, tear breakup time in seconds, Standard Patient Evaluation for Eye Dryness and Corneal Fluorescein Staining .Results: This study consisted of 6 trials with 326 patients. Significantly greater improvement was observed in meibomian gland yielding secretion score at 1 month [MD: 13.69 (95% CI, 11.98, 15.40)] and at 3 months [MD: 11.03 (95% CI, 10.27, 11.80)], low meibomian gland yielding secretion score at 1 month [MD: 6.92 (95% CI, 5.49, 8.34)] and at 3 months MD: 6.80 (95% CI, 5.01, 8..59)], up meibomian gland yielding secretion score at 1 month [MD: 6.41 (95% CI, 4.12, 8.70)] and at 3 months [MD: 8.06 (95% CI, 5.70, 10.42)] and tear breakup time at 1 month [MD: 2.38 (95% CI, 1.83, 2.92)] and at 3 months [MD: 1.82 (95% CI, 1.48, 2.19)] in the IPL-MGX group than in the MGX group.Conclusions: IPL-MGX is safer and more efficacious as compared to the MGX alone in the treatment of patients with MGD-related dry eye. We recommend discussing the decision with the ophthalmologist for an appropriate choice.

Rear 4-minute Schirmer Test, A Modified Indicator of Schirmer Test in Diagnosing Dry Eye

This study was desgined to find a reliable and convenient indicator (a modified Schirmer test) to improve the accuracy of assessing tear secretion and diagnosing dry eye. This is a prospective continuous study on 180 volunteers. Schirmer test I without anesthesia was performed once on both eyes to determine the value of normal Schirmer test. The values of tear secretion were recorded in each minute. Examined individuals also underwent other examinations: the standard patient evaluation of eye dryness (SPEED), the Ocular Surface Disease Index (OSDI), fluorescein stain, tear film breakup time (BUT), and Meibomian gland (MG)grading. The participants were divided into two groups: dry eye (DE) groupand non-dry eye (ND) group. The mean age was 39.41±14.05 years in DE group and 37.62±13.17 in ND group. The value of 2-minute Schirmer test, rear 3-minute Schirmer test, rear 4-minute Schirmer test and 5-minute Schirmer test was 5.36±4.63, 5.57±2.11, 7.21±4.13 and 10.93±6.30 respectively in DE group. And these indicators was 8.25±6.80, 2.73±2.31, 7.36±3.42, 11.84±6.16 in ND group. The rear 4-minute ST has significant correlation with OSDI and SPEED in DE group (r =-0.242/-0.183) and in ND gruop(r =-0.316 /-0.373). Meanwhile, rear 4-minute ST had stronger connection with fBUT(r =0.159) and MG (r =-0.162) in DE gruop. And rear 4-minute ST also had higher accuracy in diagnosing severe dry eye and borderline dry eye.The rear 4-minute Schirmer test may be a supplement indicator in assessing tear secretion and diagnosing dry eye.

The Deterioration of Meibomian Gland Over the Duration of Sjögren Syndrome

Purpose: To investigate the correlation between Sjögren syndrome (SS) duration and ocular surface parameters in patients with SS-related dry eye. Methods: We analyzed 108 eyes of 108 female patients with primary SS-related dry eye. Meibomian gland (MG) dysfunction, MG dropout, lipid layer thickness (LLT), partial and total blinking, and partial blinking rate (PBR) were measured using a LipiView® II ocular surface interferometer (TearScience, Morrisville, NC, USA). All patients underwent rheumatoid serologic tests and ocular surface assessments. The ocular surface assessment included the Standard Patient Evaluation of Eye Dryness (SPEED), Schirmer’s I test, non-invasive tear break-up time, and grading of corneal/conjunctival staining. The correlations between SS duration and MG dropout rates as well as other ocular surface parameters were determined. Results: The mean SS duration was 54.1±41.3 months. There was a strong positive correlation between SS duration and MG dropout (r = 0.766, p < 0.001). The average, maximum, and minimum LLTs showed a weak negative correlation with SS duration (r = -0.310, -0.211, and - 0.304, respectively, p = 0.014, 0.028, and 0.022, respectively) and MG dropout (r = -0.191, -0.326, and -0.299, respectively, p = 0.049, 0.002, and 0.009, respectively). Significant positive correlations were also observed between the SPEED scores and SS duration (r = 0.303, p = 0.042) and MG dropout (r = 0.450, p = 0.029). Conclusions: Longer durations of primary SS-related dry eye were associated with worse MG dysfunction.

Implications for the Physical Design of the Postnatal Care Unit from a Targeted Analysis of Issues With Accessing the Bathroom at Night in the Acute Setting: A Secondary Analysis

Assessing hospital environment conditions is necessary for healthcare providers and patients to coordinate safe care. The aims of this research included: a) identifying patterns in hospital visit feedback transcripts regarding bathroom doors and lights in the hospital room and b) interpreting the results to make recommendations for more enabling clinical environments. The methods used by the research team included organizing transcript data, assigning codes, and conducting an interrater reliability test to assess codebook efficacy. Finally, working with maternal and infant mortality experts, recommendations for the hospital were developed. We identified four possible interventions to address barriers: a) implement low-height, dimmable lighting along the base of the patient room, b) provide personal lights, such as penlights, to staff for nighttime assessments, c) install and improve on existing grab bars in patient room bathrooms and d) replace the standard patient room bathroom door with a different kind of auditory/visual privacy barrier.

Analysis of the Level of Patient Satisfaction on Out-Patient Installation Based on Hospital Minimum Service Standard in Dr. Pirngadi Regional Public Hospital Medan City

Minimum service standard is intended to provide guidelines for the regions in implementing the planning implementation and control as well as supervision and accountability for the implementation of hospital minimum service standards. Hospital minimum service standard includes types of service indicators and standards for achieving hospital service performance, one of which is out-patient services. According to The Decree of the Minister of Health of the Republic of Indonesia No. 560/Menkes/SK/IV/2003, that out-patient services are patient services for observation, diagnosis, treatment, medical rehabilitation and other health services without being hospitalize. The research is conducted on 100 out-patient respondents at the Dr. Pirngadi Regional Public Hospital in Medan City. This research used quantitative descriptive method, the analysis carried out using statistical tests of the data collected, using the help of the SPSS programme. The result of the research found that patients are satisfied with the hospital's minimum service standard with the dimensions of service quality summarized by the hospital service standard indicators based on government regulations. Keywords: Service Standard, Patient Satisfaction.

Restoration of Joint Inclination in Total Knee Arthroplasty Offers Little Improvement in Joint Kinematics in Neutrally Aligned Extremities

Kinematically aligned total knee replacements have been shown to better restore physiological kinematics than mechanical alignment and also offer good postoperative satisfaction. The purpose of this study is to evaluate the extent to which an inclined joint line in a kinematically aligned knee can alter the postoperative kinematics. A multi-body dynamic simulation was used to identify kinematic changes in the joint. To accurately compare mechanical alignment, kinematic alignment and a natural knee, a “standard” patient with neutral alignment of the lower extremities was selected for modeling from a joint database. The arthroplasty models in this study were implanted with a single conventional cruciate-retaining prosthesis. Each model was subjected to a flexion movement and the anteroposterior translation of the femoral condyles was collected for kinematic analysis. The results showed that the mechanical alignment model underwent typical paradoxical anterior translation of the femoral condyles. Incorporating an inclined joint line in the model did not prevent the paradoxical anterior translation, but a 3° varus joint line in the kinematic alignment model could reduce the peak value of this motion by about 1 mm. Moreover, the inclined joint line did not restore the motion curve back to within the range of the kinematic curve of the natural knee. The results of this study suggest that an inclined joint line, as in the kinematic alignment model, can slightly suppress paradoxical anterior translation of the femoral condyles, but cannot restore kinematic motions similar to the physiological knee. This finding implies that prostheses intended to be used for kinematic alignment should be designed to optimize knee kinematics with the intention of restoring a physiological motion curve.

Reliability of heart rate and respiration rate measurements with a wireless accelerometer in postbariatric recovery

Recognition of early signs of deterioration in postoperative course could be improved by continuous monitoring of vital parameters. Wearable sensors could enable this by wireless transmission of vital signs. A novel accelerometer-based device, called Healthdot, has been designed to be worn on the skin to measure the two key vital parameters respiration rate (RespR) and heart rate (HeartR). The goal of this study is to assess the reliability of heart rate and respiration rate measured by the Healthdot in comparison to the gold standard, the bedside patient monitor, during the postoperative period in bariatric patients. Data were collected in a consecutive group of 30 patients who agreed to wear the device after their primary bariatric procedure. Directly after surgery, a Healthdot was attached on the patients’ left lower rib. Vital signs measured by the accelerometer based Healthdot were compared to vital signs collected with the gold standard patient monitor for the period that the patient stayed at the post-anesthesia care unit. Over all patients, a total of 22 hours of vital signs obtained by the Healthdot were recorded simultaneously with the bedside patient monitor data. 87.5% of the data met the pre-defined bias of 5 beats per minute for HeartR and 92.3% of the data met the pre-defined bias of 5 respirations per minute for RespR. The Healthdot can be used to accurately derive heart rate and respiration rate in postbariatric patients. Wireless continuous monitoring of key vital signs has the potential to contribute to earlier recognition of complications in postoperative patients. Future studies should focus on the ability to detect patient deterioration in low-care environments and at home after discharge from the hospital.