Background:Diabetes mellitus (DM) is risk factor for complications after orthopedic surgery.Objectives:We tested the hypothesis that anesthesia preoperative clinic (APC) referral for elevated glycosylated hemoglobin (HbA1c) reduces complication rate after total joint arthroplasty (TJA).Patients and Methods:Patients (n = 203) with and without DM were chosen from 1,237 patients undergoing TJA during 2006 - 12. Patients evaluated in the APC had surgery in 2006 - 8 regardless of HbA1c (uncontrolled). Those evaluated between in subsequent two-year intervals were referred to primary care for HbA1c ≥ 10% and ≥ 8%, respectively, to improve DM control before surgery. Complications and mortality were quantified postoperatively and at three, six, and twelve months. Length of stay (LOS) and patients requiring a prolonged LOS (> 5 days) were recorded.Results:Patients (197 men, 6 women) underwent 71, 131, and 1 total hip, knee, and shoulder replacements, respectively. Patients undergoing TJA with uncontrolled HbA1c and those with HbA1c < 10%, but not those with HbA1c < 8%, had a higher incidence of coronary disease and hypercholesterolemia than patients without DM. An increase in complication rate was observed in DM patients with uncontrolled HbA1c versus patients without DM (P < 0.001); the complication rate progressively decreased with tighter HbA1c control. More DM patients with preoperative HbA1c that was uncontrolled or ≥ 10% required prolonged LOS versus those without DM (P < 0.001 and P = 0.0404, respectively).Conclusions:APC referral for elevated HbA1c reduces complication rate and the incidence of prolonged hospitalization during the first year after surgery in diabetics undergoing TJA.

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Introduction:The authors performed videolaryngoscopy during the preoperative anesthesia clinic evaluation of a patient with chronic dyspnea, stridor, and a previous hemilaryngectomy scheduled to undergo a series of orthopedic surgery procedures for an infected knee arthroplasty. The findings proved crucial for determining airway management.Case Presentation:A 68-year-old man presented to the preoperative anesthesia clinic for work-up before anticipated removal of infected total knee arthroplasty hardware, placement of antibiotic spacers, incision and drainage procedures, and revision arthroplasty. The patient had previously undergone a hemilaryngectomy and tracheostomy (now closed) for squamous cell carcinoma of the right true vocal cord. The patient described chronic dyspnea with minimal exertion. Inspiratory and expiratory wheezes and intermittent inspiratory stridor were present. A transnasal videolaryngoscopy examination was performed using topical anesthesia and demonstrated significant supraglottic scarring, a narrowed glottis, and subglottic stenosis. A computed tomography study confirmed the presence of tracheomalacia with subglottic stenosis. A permanent tracheostomy was performed to establish a definitive airway before the knee arthroplasty was removed.Conclusions:The case illustrates that transnasal videolaryngoscopy conducted in the preoperative anesthesia clinic is capable of providing key information to guide airway management in patients with significant upper airway pathology.

Satisfaction remains one of the most frequently used and inconsistent measures in Information Systems research. These inconsistencies can create challenges for interpreting the results of satisfaction measures. These challenges are noticeable in the telemedicine literature where researchers often rely on single item measures of overall satisfaction. While researchers have attempted to address these issues by studying satisfaction's measurements and methodologies there remain gaps in the knowledge on how variations in measures may be interpreted regarding decision making. This research seeks to contribute to the knowledge in this area by investigating medical provider perspectives on single versus multidimensional measures of telemedicine satisfaction. Through a thematic analysis this research shows variations and similarities in decision making between measures across eleven themes. The results show not only variations in views but indicate subjective experiential interpretations of results. Findings along with implications for researchers and medical providers are discussed.

Confirming the relevance of measures through content validity can be among the most important but often overlooked aspects of measurement design. With the growing need to evaluate telemedicine satisfaction it is important that researchers pay more consideration to the relevance of measures used to represent studied constructs. This research discusses a content-validity effort using a formative approach for designing measures. By presenting insights gained during this process this research contributes to the knowledge by demonstrating both the importance and challenges of content validity and measure development in practice. Results identify several issues with differences in nonexpert views, measurement modifications, participant matching strategies and form usability.

Hazard Analysis, Critical Control Point (HACCP) method is a pre-emptive safety strategy whereby critical control points (CCP) are idenitified and risk mitigation strategies are employed to eliminate or reduce that risk. Mortality risk is the most critical immediate complication for initial identification in pre-procedural clearance for planned procedures. The American Society of Anesthesiologists' Physical Status (ASA-PS) classification system has historically been used as a grading tool for preoperative health of surgical patients to identify postoperative complication risk. Our objective was to perform a systematic review of current studies for the purpose of defining the accuracy and predictive value of ASA-PS scoring with regard to adult patients undergoing scheduled procedures to determine if the ASA-PS score could be used as a first CCP (risk of mortality) in order to apply risk mitigation pre-emptively. METHODS: Three databases were searched (PubMed, Ovid Medline, and CINAHL) between 2009 and 2019 by the research team. We included published English language, randomized control trials, systematic reviews, meta-analysis, and cohort studies that considered the ASA-PS classification for patients undergoing scheduled surgeries and their postoperative mortality.The Joanna Briggs Institute Clinical Appraisal tools were used by student and faculty researchers to rate study quality after inclusion and exclusion criteria were applied. RESULTS: 11 studies met the inclusion criteria; they provided a total of 3,092,064 patients undergoing scheduled elective surgery. American Society of Anesthesiologist (ASA) physical status score had a stepwise increase in risk of mortality with concurrent increases in ASA-PS. Of the 11 studies included for final analysis, 6 studies assessed mortality rates by ASA class, ranging from 0%-0.02% for ASA 1, 0.14%-0.02% for ASA 2, 1.41%-4.41% for ASA 3, 9.8%-16.67% for ASA 4, and 13%-50.87% for ASA 5. CONCLUSIONS: A literature review using data from the past 10 years, reaffirmed the relationship between ASA-PS score and perioperative mortality. As the initial critical control point in a HACCP patient safety model for pre-procedural clearance, identification of an ASA-3 score defined a cutoff that should trigger risk mitigation measures. Specific evidence-based and professional society consensus recommendations are available for patients defined as ASA-3 or above and should be implemented as part of an optimal pre-procedural clearance and risk mitigation strategy. CLINICAL IMPLICATIONS: In a HACCP model, patient ASA-PS score is an excellent initial CCP, showing a significant increase in mortality at > or ¼ 3 in patients who are undergoing procedures requiring moderate-to-deep anesthesia. Evidencebased risk mitigation strategies are available and include pre-op evaluation by anesthesia practice prior to admission for the procedure and additional CCP screenings.

BackgroundNasal fiberoptic videoendoscopy is an established technique to assess upper airway pathology in conscious and sedated patients.ObjectivesThe authors conducted a prospective proof-of-concept pilot study to evaluate whether airway narrowing detected using nasal fiberoptic videoendoscopy in the anesthesia preoperative clinic was capable of defining the severity of obstructive sleep apnea (OSA) in patients scheduled for elective surgery.MethodsAfter application of topical local anesthesia (4% lidocaine with phenylephrine), sixteen patients (ASA physical status 2 or 3) underwent nasal fiberoptic videoendoscopy in sitting position. The magnitudes of retropalatal and retrolingual luminal narrowing were assessed as predictors of OSA. Patients also underwent polysomnography and completed STOP-Bang questionnaires. The endoscopist’s clinical impression of OSA severity based on the history and airway examination was quantified.ResultsRetropalatal luminal narrowing and STOP-Bang score ≥ 4 predicted OSA severity as either “none or mild” or “moderate to severe” in 13 (81%) and 9 (56%) of 16 patients who underwent polysomnography, respectively. OSA severity was significantly (Spearman’s rank correlation coefficient) associated with retropalatal airway narrowing (P = 0.0048), STOP-BANG score (P = 0.0072), and body mass index (P = 0.0091), whereas clinical impression and retrolingual pharyngeal narrowing were not (P=0.093 and P = 0.11, respectively).ConclusionsThe current results suggest that nasal fiberoptic videoendoscopy quantification of retropalatal airway narrowing may be a useful tool for assessing the severity of OSA in the anesthesia preoperative clinic. The current findings document a proof-of-concept feasibility of nasal fiberoptic videoendoscopy as a screening tool for OSA in conscious patients during preoperative evaluation that may justify further prospective clinical trials of this technique.

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