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Background Gender-affirming pelvic surgery (GAPS) can be associated with significant postoperative pelvic pain. Given the lack of available peripheral nerve blocks to the perineum, intrathecal morphine (ITM) injection could offer a potent analgesic modality for this patient population. No prior studies to date have been performed examining the analgesic effects of intrathecal morphine for these patients. Methods This retrospective case-control study aims to understand the postoperative analgesic effects of intrathecal morphine for these patients with a historical comparison group of patients who did not receive intrathecal morphine. Results Fourteen patients presented for gender-affirming pelvic surgery over an eight-month period at a single institution and were offered intrathecal morphine for postoperative analgesia. Their analgesic results were compared to a similar historical group of 13 patients who were not offered or declined intrathecal morphine. Conclusions Intrathecal morphine injection is a potent analgesic modality for patients presenting for gender-affirming pelvic surgery.

BackgroundParavertebral and serratus plane blocks are both used to treat pain following breast surgery. However, it remains unknown if the newer serratus block provides comparable analgesia to the decades-old paravertebral technique.MethodsSubjects undergoing unilateral or bilateral non-mastectomy breast surgery were randomized to a single-injection serratus or paravertebral block in a subject-masked fashion (ropivacaine 0.5%; 20 mL unilateral; 16 mL/side bilateral). We hypothesized that (1) analgesia would be non-inferior in the recovery room with serratus blocks (measurement: Numeric Rating Scale), and (2) opioid consumption would be non-inferior with serratus blocks in the operating and recovery rooms. In order to claim that serratus blocks are non-inferior to paravertebral blocks, both hypotheses must be at least non-inferior.ResultsWithin the recovery room, pain scores for participants with serratus blocks (n=49) had a median (IQR) of 4.0 (0-5.5) vs 0 (0-3.0) for those with paravertebral blocks (n=51): 0.95% CI -3.00 to -0.00; p=0.001. However, the difference in morphine equivalents did not reach statistical significance for superiority with the serratus group consuming 14 mg (10-19) vs 10 mg (10-16) for the paravertebral group: 95% CI -4.50 to 0.00, p=0.123. Since the 95% CI lower limit of -4.5 was less than our prespecified margin of -2.0, we failed to conclude non-inferiority of the serratus block with regard to opioid consumption.ConclusionsSerratus blocks provided inferior analgesia compared with paravertebral blocks. Without a dramatic improvement in safety profile for serratus blocks, it appears that paravertebral blocks are superior to serratus blocks for postoperative analgesia after non-mastectomy breast surgery.Trial registration numberNCT03860974.

BackgroundCardiovascular electronic consultation is a new service line in consultative medicine and enables care without in-person office visits. We aimed to evaluate accessibility and time saved as measures of efficiency, determine the safety of cardiology electronic consultations, and assess satisfaction by responding cardiologists.MethodsUsing a mixed-methods approach and a modified time-driven, activity-based, costing framework, we retrospectively analysed cardiology electronic consultations. A random subset of 500 electronic consultations referred between 2013-2017 were reviewed. Accessibility was determined based upon increased number of patients served without the need for an in-person clinic visit. To assess safety, medical records were reviewed for emergency room visits or hospital admission at six months from the initial electronic consultation date. Responding cardiologist satisfaction was assessed by voluntary completion of an online survey.ResultsThe majority of electronic consultations were related to medication advice, clearance for surgery, evaluation of images, or guidance after abnormal testing. Recommendations included echo (10.8%), stress testing (5.0%), other imaging (4.0%) and other subspecialist referrals (3.8%). Electronic consultations were completed within 0.7±0.5 days of the request, with a time to completion of 5-30 min. Over a six-month follow-up, 13.9% of patients had an in-person visit and 2.2% of patients were hospitalised, but none were directly related to the electronic consultation question. Satisfaction by responding cardiologists was modest.ConclusionIn conclusion, within a single-payer system, cardiology electronic consultations represent a convenient and safe alternative for providing consultative cardiovascular care, but further optimization is necessary to minimise electronic consultation fatigue experienced by cardiologists.

PurposeDuring anesthesia, maneuvers which cause the least disturbance of cerebral oxygenation with the greatest decrease in intracranial pressure would be most beneficial to patients with intracranial hypertension. Both head-up tilt (HUT) and hyperventilation are used to decrease brain bulk, and both may be associated with decreases in cerebral oxygenation. In this observational study, our null hypothesis was that the impact of HUT and hyperventilation on cerebral tissue oxygen saturation (SctO2) and cerebral blood volume (CBV) are comparable.MethodsSurgical patients without neurological disease were anesthetized with propofol-remifentanil. Before the start of surgery, frequency-domain near-infrared spectroscopy was used to measure SctO2 and CBV at the supine position, at the 30° head-up and head-down positions, as well as during hypoventilation and hyperventilation.ResultsThirty-three patients were studied. Both HUT and hyperventilation induced small decreases in SctO2 [3.5 (2.6)%; P

The determination of a representative particle impacting velocity, is an important component in calculating solid particle erosion inside pipe geometry. Currently, most commercial computational fluid dynamics (CFD) codes allow the user to calculate particle trajectories using a Lagrangian approach. Additionally, the CFD codes calculate particle impact velocities with the pipe walls. However, these commercial CFD codes normally use a wall function to simulate the turbulent velocity field in the near-wall region. This wall-function velocity field near the wall can affect the small particle motion in the near-wall region. Furthermore, the CFD codes assume that particles have zero volume when particle impact information is being calculated. In this investigation, particle motions that are simulated using a commercially available CFD code are examined in the near-wall region. Calculated solid particle erosion patterns are compared with experimental data to investigate the accuracy of the models that are being used to calculate particle impacting velocities. While not considered in particle tracking routines in most CFD codes, the turbulent velocity, profile in the near-wall region is taken into account in this investigation, and the effect on particle impact velocity is investigated. The simulation results show that the particle impact velocity is affected significantly when near-wall velocity profile is implemented. In addition, the effects of particle size are investigated in the near-wall region of a turbulent flow in a 90 deg sharp bend. A CFD code is modified to account for particle size effects in the near-wall region before and after the particle impact. It is found from the simulations that accounting for the rebound at the particle radius helps avoid nonphysical impacts and reduces the number of impacts by more than one order-of-magnitude .for small particles (25 [micro]m) due to turbulent velocity fluctuations. For large particles (256 [micro]m), however, nonphysical impacts are not observed in the simulations. Solid particle erosion is predicted before and after introducing these modifications, and the results are compared with experimental data. It is shown that the near-wall modification and turbulent particle interactions significantly affect the simulation results. Modifications can significantly improve the current CFD-based solid particle erosion modeling. [DOI: 10.1115/1.3077139] Keywords: CFD, particle tracking, particle-wall interaction, erosion modeling

Erosion damage in the pipe wall due to solid particle impact can cause severe problems in fluid handling industries. Repeated impact of the suspended small solid particles to the inner wall of process equipment and piping removes material from the metal surface. The reduced wall thickness of high pressure equipment and piping can no longer withstand the operating pressure that they were originally designed for and may cause premature failure of the system components. This results in production downtime, safety, and environmental hazards with significant loss to the industry and economy. Prediction of erosion in single-phase flow with sand is a difficult problem due to the effect of different parameters and their interactions that cause erosion. The complexity of the problem increases significantly in multiphase flow where the spatial distribution of the liquid and gas phases and their corresponding velocities change continuously. Most of the currently available erosion prediction models are developed for single-phase flow using empirical data with limited accuracy. A mechanistic model has been developed for predicting erosion in elbows in annular multiphase flow (gas-liquid-solid) considering the effects of particle velocities in gas and liquid phases of the flow. Local fluid phase velocities in multiphase flow are used to calculate erosion rates. The effects of erosion due to impacts of solid particles entrained in the liquid and gas phases are computed separately to determine the total erosion rate. Erosion experiments were conducted to evaluate the model predictions. Comparing the model predicted erosion rates with experimental erosion data showed reasonably good agreement validating the model. [DOI: 10.1115/1.2824284] Keywords: erosion, multiphase flow, annular flow, solid particle erosion, elbow