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mography provides a rapid simple method of distinguishing between surgically treatable superficial incompetence causing venotensive changes and a deep vein state where operation has little place. Air gastric tumourSir 1 read with interest the Surgical Workshop by Mr Abercrombie and colleagues (Br J Surg 1993; 80: 373) but would take issue with the ultimatc sentence, which implies that there are no risks with laparoscopic resection. This was a surgical procedure requiring 3 h of general anaesthesia with potential morbidity and mortality.Open resection of small gastric tumours with assessment of the liver and regional nodes is safe in experienced hands. I doubt whether there are data comparing open and laparoscopic approaches to this problem, and until such time as these become available the conclusion drawn is invalid on the basis of a single case. Photoplethysmography in the diagnosis of superficial venous valvular incompetenceLetter 1 SirThe paper by D r Rutgers and colleagues ( B r J Surg 1993; 80: 351 -3) concludes that 'photoplethysmography is not the non-invasive method of choice in the routine evaluation of superficial venous valvular incompetence'. This statement may be true for a routine examination used in a group that includes the many varicosities (even large ones) that do not allow sufficient downflow to affect refilling time; it does, however, under-rate the capabilities of photoplethysmography when there is clinical evidence of venous hypertension, such as pigmentation or ulceration. Here, substantial shortening of the refilling time recorded by photoplethysmography is always found. Essentially, photoplethysmography cannot recognize a lesser degree of superficial venous incompetence but can reliably demonstrate when a venous pumping mechanism is proving inadequate, which may be caused by overwhelming superficial incompetence or by defective deep veins. It is here, in the presence of obvious abnormality, that photoplethysmography comes into its own and is able to give positive identification of superficial incompetence as the cause. In using photoplethysmography for this purpose, preliminary clinical examination should always include a careful mapping out of enlarged superficial veins both visually and by the tapwave technique. Directional Doppler flowmetry is then applied to any suspected pathway of incompetence and in most cases will show the characteristic downflow of simple incompetence after squeezing or exercise; this may be sufficient evidence to decide on treatment. If there is a history suggesting previous deep vein thrombosis or if venotensive skin changes are present, especially ulceration, then photoplethysmography should also be carried out and repeated with fingertip compression to appropriate superficial veins. The use of a venous tourniquet or cuff is a prime source of error, which may cause artefact through venous congestion or be insufficient to prevent gravitational downflow in the superficial veins. Far better is to use localized fingertip pressure over the suspected pathway of s...

Background: Acute Kidney Injury (AKI) is a common complication after cardiac surgery and is associated with worse outcomes. Its management relies on early diagnosis, and therefore, electronic alerts have been used to alert clinicians for development of AKI. Electronic alerts are, however, associated with high rates of alert fatigue. Objectives: We designed this study to assess the acceptance of user-centered electronic AKI alert by clinicians. Methods: We developed a user-centered electronic AKI alert, that provided alerted clinicians of development of AKI in a persistent yet non-interruptive fashion. As the goal of the alert was to alert towards new or worsening AKI, it disappeared 48 hours after being activated. We assessed the acceptance of the alert using surveys at 6 months and 12 months after the alert went live. Results: At 6 months after their implementation 38.9% providers reported that they would not have recognized AKI as early as they did without this alert. This number increased to 66.7% by 12 month survey. Most providers also shared that they re-dosed or discontinued medications earlier, provided earlier management of volume status, avoided IV contrast use and evaluated patients by using point of care ultrasounds more due to the alert. Overall, 83.3% respondents reported satisfaction with the electronic AKI alerts at 6 months and 94.4% at 12 months. Conclusions: This study showed high rates of acceptance of a user-centered electronic AKI alert over time by clinicians taking of patients with AKI.