ObjectiveThis study aimed to compare seizure outcomes and complication rates in patients treated with only responsive neurostimulation (RNS) strip leads with those treated with only RNS depth leads. MethodsA retrospective cohort study was performed using the institutional epilepsy surgery database. Included was any patient implanted with the RNS system between August 2015 and May 2018 with either two depth (2D) or two strip (2S) leads connected to the device and at least 6 months follow-up. Excluded were those with a combination of active depth and strip leads. Data extracted from the charts comprised demographic information, duration of epilepsy, presence of a magnetic resonance imaging (MRI) lesion, prior resective surgery, clinically disabling seizures at baseline and follow-up, prior invasive monitoring, location (mesial temporal or neocortical) and number of seizure foci, unilateral or bilateral RNS lead placement, and postoperative complications. ResultsOf 48 screened patients, 34 met study inclusion criteria. Of these, 15 were treated with 2D leads and 19 with 2S leads. Groups 2D and 2S were comparable with respect to age at onset, duration of epilepsy, baseline seizure frequency, and exposure time to RNS. After adjustment for patient age and duration of epilepsy, seizure frequency in 2S patients was noted to be decreased by 83% (p = 0.046), while it was reduced by 51% (p = 0.080) in 2D patients. The complication rate was not significantly different between the two groups. ConclusionIn our small retrospective population, patients with RNS strip leads experienced a significantly greater seizure reduction than patients with RNS depth leads, without a difference in complication rate.

OBJECTIVE. The purpose of this quality improvement project was to create sustained improvement in the frequency of more complete imaging histories provided with imaging examinations submitted directly by ordering providers. A secondary purpose was increasing the number of characters submitted by ordering providers with imaging examinations. MATERIALS AND METHODS. A multidisciplinary team defined the components of a complete imaging history, a process that underwent several improvement cycles. Audits were regularly performed using consensus, and the project team regularly evaluated the completeness of the imaging histories. The final components of the definition of a complete imaging history included responses regarding what happened, when it happened, where the patient was experiencing pain, and the ordering provider's concern. Prompts were inserted into the electronic physician order entry process, and performance was monitored for an additional 18 months. RESULTS. A total of 10,236 orders were placed by providers in the study clinic from March 13, 2017, to December 16, 2018. Of the orders audited in the baseline period, 16.0% (64/397) of orders audited in the baseline period contained all four history components, which increased to 52.0% (2200/4234; absolute increase of 36.0%, relative increase of 225.0%; p < 0.0001) in the subsequent time periods, and improvement was sustained. The mean number of characters providers entered in the imaging histories they submitted increased from 45.4 characters per order during the baseline period to 75.4 (66.1% increase, p < 0.0001) after the intervention. CONCLUSION. By collaborating with a multidisciplinary team, we created a standardized definition of an imaging history, engineered our systems to include supportive prompts in the order entry interface, and sustainably improved the quality of imaging histories provided.

The aim of this study was to compare the efficacy of a peer learning program to score-based peer review in a radiology department. Our score-based peer review program was transitioned to an open, inclusive, education- and improvement-oriented peer learning program. Program performance was evaluated by learning opportunity submissions, program participation, number of learning opportunity distributions to radiologists, number of practice improvement projects resulting from program, and radiologist survey results before and after interventions. Outcomes for the score-based peer review program compared with those of the peer learning program were as follows. The mean number of radiologists participating monthly increased from 5.0 to 35.2 (p < 0.01); submissions increased from 3.0 discrepancies per month to 36.0 learning opportunities per month (p < 0.01); the mean monthly learning opportunity distributions to radiologists increased from 18 to 352 (p < 0.01); improvement projects performed during the study periods increased from 5 to 61 (p < 0.01); and mean monthly continuing medical education credits earned by radiologists increased from 7.7 to 50.6 (p < 0.01). Radiologists felt peer learning accomplished goals better than did score-based peer review. In transitioning our score-based peer review program to a peer learning program, our radiologists identified, discussed, and converted more learning opportunities into practice improvement and perceived peer learning to be of higher value than score-based peer review.

Tinnitus is the perception of sound in the absence of an external source. It is a common symptom that can be related to hearing loss and other benign causes. However, tinnitus may be disabling and can be the only symptom in a patient with a central nervous system process disorder. History and physical examination are crucial first steps to determine the need for imaging. CT and MRI are useful in the setting of pulsatile tinnitus to evaluate for an underlying vascular anomaly or abnormality. If there is concomitant asymmetric hearing loss, neurologic deficit, or head trauma, imaging should be guided by those respective ACR Appropriateness Criteria® documents, rather than the presence of tinnitus. Imaging is not usually appropriate in the evaluation of subjective, nonpulsatile tinnitus that does not localize to one ear.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Two hundred and forty-six patients infected with human immunodeficiency virus (HIV) who also had disseminated Mycobacterium avium complex received either azithromycin 250 mg every day, azithromycin 600 mg every day, or clarithromycin 500 mg twice a day, each combined with ethambutol, for 24 weeks. Samples drawn from patients were cultured and clinically assessed every 3 weeks up to week 12, then monthly thereafter through week 24 of double-blind therapy and every 3 months while on open-label therapy through the conclusion of the trial. The azithromycin 250 mg arm of the study was dropped after an interim analysis showed a lower rate of clearance of bacteremia. At 24 weeks of therapy, the likelihood of patients' developing 2 consecutive negative cultures (46% vs. 56%, P=.24) or 1 negative culture (59% vs. 61%, P=.80) was similar for azithromycin 600 mg (n=68) and clarithromycin (n=57), respectively. The likelihood of relapse was 39% versus 27% (P=.21) on azithromycin compared with clarithromycin, respectively. Of the 6 patients who experienced relapse, none of those randomized to receive azithromycin developed isolates resistant to macrolides, compared with 2 of 3 patients randomized to receive clarithromycin [corrected]. Mortality was similar in patients comprising each arm of the study (69% vs. 63%; hazard, 95.1% confidence interval, 1.1 [0.7, 1.7]). Azithromycin 600 mg, when given in combination with ethambutol, is an effective agent for the treatment of disseminated M. avium disease in patients infected with HIV.

Objective: We evaluated the effect of maternal administration of ampicillin/sulbactam on colonization and bacteremia in newborn rabbits after intracervical inoculation of mothers with group B streptococci (GBS). Methods: New Zealand white rabbits on day 30 of a 31-day gestation were inoculated intracervically with 104−105 colony forming units (cfu) GBS. Two hours after inoculation mothers received ampicillin/sulbactam (50 mg/kg) or saline (control) intramuscularly as a single dose, in a randomized double-blinded manner. We induced labor 4 h later with intramuscular oxytocin. At delivery, cultures for GBS were taken from neonatal oropharynx. Thereafter, cultures were taken from neonatal oropharynx and anorectum daily and from neonatal heart at death or after 96 h. Sample size analysis showed a need for 17 pups in each group. Results: In the control group, induction failed in one animal that was excluded from analysis. At birth, 0 of 39 pups of treated does had positive oropharyngeal cultures compared to 26 of 27 (96%) pups of saline-treated does (P < 0.0001). Pups treated with antibiotic in utero were also significantly less likely to have positive oropharyngeal cultures at 24, 48, and 72 h after birth compared to controls (24 h, 0% vs. 100%, P < 0.0001; 48 h, 8% vs. 100%, P < 0.0001; 72 h, 16% vs. 100%, P < 0.0001). Treated pups were significantly less likely to have positive anorectal cultures at 24, 48, and 72 h after birth compared to control animals (24 h, 0% vs. 100%, P < 0.0001; 48 h, 0% vs. 95%, P < 0.0001; 72 h, 0% vs. 92%, P < 0.0001). Treated pups were significantly less likely to have positive heart cultures at 72 h after birth compared to controls (11% vs. 92%, P < 0.0002). Cumulative neonatal survival was higher in treated pups compared to controls at 72 and 96 h after birth (72 h, 32% vs. 0%, P = 0.0003; 96 h, 26% vs. 0%, P = 0.015). Conclusions: Single dose transplacental prophylaxis given 4 h before delivery resulted in decreased neonatal GBS colonization and bacteremia and improved neonatal survival in rabbits.

Objective We evaluated the effect of maternal administration of ampicillin/sulbactam on colonization and bacteremia in newborn rabbits after intracervical inoculation of mothers with group B streptococci (GBS). Methods New Zealand white rabbits on day 30 of a 31-day gestation were inoculated intracervically with 104–105 colony forming units (cfu) GBS. Two hours after inoculation mothers received ampicillin/sulbactam (50 mg/kg) or saline (control) intramuscularly as a single dose, in a randomized double-blinded manner. We induced labor 4 h later with intramuscular oxytocin. At delivery, cultures for GBS were taken from neonatal oropharynx. Thereafter, cultures were taken from neonatal oropharynx and anorectum daily and from neonatal heart at death or after 96 h. Sample size analysis showed a need for 17 pups in each group. Results In the control group, induction failed in one animal that was excluded from analysis. At birth, 0 of 39 pups of treated does had positive oropharyngeal cultures compared to 26 of 27 (96%) pups of saline-treated does (P < 0.0001). Pups treated with antibiotic in utero were also significantly less likely to have positive oropharyngeal cultures at 24, 48, and 72 h after birth compared to controls (24 h, 0% vs. 100%, P < 0.0001; 48 h, 8% vs. 100%,P < 0.0001; 72 h, 16% vs. 100%, P < 0.0001). Treated pups were significantly less likely to have positive anorectal cultures at 24, 48, and 72 h after birth compared to control animals (24 h, 0% vs. 100%, P < 0.0001; 48 h, 0% vs. 95%, P < 0.0001; 72 h, 0% vs. 92%, P < 0.0001). Treated pups were significantly less likely to have positive heart cultures at 72 h after birth compared to controls (11% vs. 92%, P < 0.0002). Cumulative neonatal survival was higher in treated pups compared to controls at 72 and 96 h after birth (72 h, 32% vs. 0%, P = 0.0003; 96 h, 26% vs. 0%, P = 0.015). Conclusions Single dose transplacental prophylaxis given 4 h before delivery resulted in decreased neonatal GBS colonization and bacteremia and improved neonatal survival in rabbits. Infect. Dis. Obstet. Gynecol. 5:355–358, 1997. © 1998 Wiley-Liss, Inc.