Academic Hospital Setting Research Articles

PD53-12 CENTRALIZATION OF CARE PROMOTES TRAINING DISPARITIES WITH REGARD TO THE TEACHING OF RETROPERITONEAL LYMPHADENECTOMY

You have accessJournal of UrologySexual Function/Dysfunction: Penis/Testis/Urethra: Benign Disease & Malignant Disease II1 Apr 2017PD53-12 CENTRALIZATION OF CARE PROMOTES TRAINING DISPARITIES WITH REGARD TO THE TEACHING OF RETROPERITONEAL LYMPHADENECTOMY Ryan Owen, Stephanie Dresner, James Bienvenu, and W. Bedford Waters Ryan OwenRyan Owen More articles by this author , Stephanie DresnerStephanie Dresner More articles by this author , James BienvenuJames Bienvenu More articles by this author , and W. Bedford WatersW. Bedford Waters More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2409AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In 2007, Lowrance et al published a manuscript in the Journal of Urology, which stated that the majority of United States trained urology residents have minimal experience with Retroperitoneal Lymphadenectomy. The purpose of our study is to evaluate if the current trend in retroperitoneal lymphadenectomy training has declined further. METHODS After permission from the American Board of Urology, a retrospective review of operative log reports from 2005-2015 was performed. Using CPT code designation, total cases performed were quantified and further stratified by log year, practice region, practice type and recertification versus primary certification. RESULTS A total of 1227 open retroperitoneal transabdominal lymphadenectomy; extensive, including pelvic, aortic and renal nodes (CPT 38780) were logged by 500 physicians. 247 (49.4%) physicians applying for primary certification logged at least 1 lymphadenectomy compared to 253 (50.6%) applicants for recertification. Of the 500 certifying physicians, 321 (64.2%) reported only 1 lymphadenectomy, 144 (28.8%) reported 2-5 procedures and 35 (7.0%) performed more than 5. When stratified by geographic location, most procedures were recorded in the North Central (27.5%) and Western section (24.4%). There were 793 (64.6%) cases performed in an Academic hospital setting. CONCLUSIONS A significant number of recently trained urologists continue to demonstrate minimal experience with retroperitoneal lymph node dissection. With limited exposure to an operation that was once considered an index case, there is a significant negative impact on the quality of urologic resident education. Additionally, this review demonstrates an already visible trend toward the centralization of care with the majority of procedures performed at major academic institutions. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1045 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Ryan Owen More articles by this author Stephanie Dresner More articles by this author James Bienvenu More articles by this author W. Bedford Waters More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Antioxidant Capacity and Superoxide Dismutase Activity in Adrenoleukodystrophy

X-linked adrenoleukodystrophy (ALD) may switch phenotype to the fatal cerebral form (ie, cerebral ALD [cALD]), the cause of which is unknown. Determining differences in antioxidant capacity and superoxide dismutase (SOD) levels between phenotypes may allow for the generation of a clinical biomarker for predicting the onset of cALD, as well as initiating a more timely lifesaving therapy. To identify variations in the levels of antioxidant capacity and SOD activity between ALD phenotypes in patients with cALD or adrenomyeloneuropathy (AMN), heterozygote female carriers, and healthy controls and, in addition, correlate antioxidant levels with clinical outcome scores to determine a possible predictive value. Samples of monocytes and blood plasma were prospectively collected from healthy controls, heterozygote female carriers, and patients with AMN or cALD. We are counting each patient as 1 sample in our study. Because adrenoleukodystrophy is an X-linked disease, the affected group populations of cALD and AMN are all male. The heterozygote carriers are all female. The samples were assayed for total antioxidant capacity and SOD activity. The data were collected in an academic hospital setting. Eligibility criteria included patients who received a diagnosis of ALD and heterozygote female carriers, both of which groups were compared with age-matched controls. The prospective samples (n = 30) were collected between January 2015 to January 2016, and existing samples were collected from tissue storage banks at the Kennedy Krieger Institute (n = 30). The analyses were performed during the first 3 months of 2016. Commercially available total antioxidant capacity and SOD assays were performed on samples of monocytes and blood plasma and correlated with magnetic resonance imaging severity score. A reduction in antioxidant capacity was shown between the healthy controls (0.225 mmol trolox equivalent) and heterozygote carriers (0.181 mmol trolox equivalent), and significant reductions were seen between healthy controls and patients with AMN (0.102 mmol trolox equivalent; P < .01), as well as healthy controls and patients with cALD (0.042 mmol trolox equivalent; P < .01). Superoxide dismutase activity in human blood plasma mirrored these reductions between prospectively collected samples from healthy controls (2.66 units/mg protein) and samples from heterozygote female carriers (1.91 units/mg protein), patients with AMN (1.39 units/mg protein; P = .01), and patients with cALD (0.8 units/mg protein; P < .01). Further analysis of SOD activity in biobank samples showed significant reductions between patients with AMN (0.89 units/mg protein) and patients with cALD (0.18 units/mg protein) (P = .03). Plasma SOD levels from patients with cALD demonstrated an inverse correlation to brain magnetic resonance imaging severity score (R2 = 0.75, P < .002). Longitudinal plasma SOD samples from the same patients (n = 4) showed decreased activity prior to and at the time of cerebral diagnosis over a period of 13 to 42 months (mean period, 24 months). Plasma SOD may serve as a potential biomarker for cerebral disease in ALD following future prospective studies.

Real-world treatment patterns and characteristics in patients with chronic lymphocytic leukemia.

65 Background: CLL is the most prevalent form of adult leukemia. In recent years, there have been a number of newly approved therapies for the management of patients with CLL in both the 1st line (1L) and relapsed/refractory settings, including ibrutinib (approved for 1L CLL, March 2016). Methods: USphysicians involved in CLL treatment decision-making were recruited into the Adelphi CLL Disease Specific Programme (February-May 2016). Physicians completed record forms on consecutively presenting patients &gt; 18 years currently on active CLL treatment. Descriptive statistics analyzed demographics, clinical characteristics, and antineoplastic treatment patterns. Results: 700 patients diagnosed with CLL for an average of 3.0 years were captured. Patients’ mean age was 68.3 years, 53% were male, 75% were Caucasian, 25% had 17p deletion, and 55% were Medicare insured. Of the 81 physicians, 35% were based in an academic hospital setting, 51% in a non-academic hospital setting, 4% in both, and 9% were office-based. Within the overall cohort, BR was the most common 1L regimen (25%), while ibrutinib was the most common 2nd line (2L) regimen (42%). Among patients with 17p deletion, BR was the most common 1L regimen (25%) and ibrutinib was the most common 2L regimen (50%). Older patients ( ≥ 65) were most likely to receive BR at 1L (28%), while 1L younger patients ( &lt; 65) received FCR (24%). Conclusions: This analysis of real world treatment patterns identified BR, FCR, and ibrutinib as the most common 1L regimens in US CLL patients. Ibrutinib, BR, and idelalisib + rituximab were the most common 2L regimens. Choice of therapy varied depending on age and 17p deletion status. For example, FCR was more frequently used as 1L therapy in patients &lt; 65 years, and the proportion of ibrutinib use as 1L therapy was higher in those with 17p deletion. [Table: see text]

105 Factors Associated with Testicular Prostheses Availability and Implantation

Testis cancer is the most common solid malignancy in men less than 45 years old. Because of excellent long-term survival in this young population, the effects of orchiectomy on quality of life and body-image perception are significant. Testicular prosthesis has been shown to be safe and associated with high rates of patient satisfaction. Despite this, most patients are not offered a prosthesis. Our study aims to identify factors that predict which patients are offered prosthesis and choose to have them implanted. Using an IRB-approved testis cancer database, patients at a tertiary referral center were asked a questionnaire covering demographics, whether or not they were offered a prosthesis at the time of orchiectomy, knowledge of the availability of testicular prostheses, and subjective assessments of their perceptions of prostheses and why they may or may not be interested in having one. Over 3 months, 35 patients were surveyed. 6 patients received a testicular prosthesis at the time of orchiectomy and 29 did not. The patients with a prosthesis were younger (mean: 25) at the time of orchiectomy compared to those without (mean: 29). We found an academic hospital setting to be a significant predictor of having a prosthesis placed at the time of orchiectomy. Patients that were single were more likely to have a prosthesis. All of the patients with a prosthesis reported that they chose their prosthesis for symmetry. Of those who did not have a prosthesis, 69% reported that they knew a prosthesis was available but only 45% were offered one at the time of orchiectomy. 5 of the patients (17%) without a prosthesis were interested in having one. In patients that did not want a prosthesis, most reported they “didn’t care” (77%), 15% felt it did not look natural, and 15% were worried about infection.

Strengthening of Quadriceps by Neuromuscular Magnetic Stimulation in Healthy Subjects

BackgroundQuadriceps muscle strengthening is one of the rehabilitation strategies for improving walking in some people with gait impairments, and neuromuscular electrical stimulation (NMES) has been used for that reason. The strengthening effect of neuromuscular magnetic stimulation (NMMS) on the quadriceps has been demonstrated in various conditions, but not specifically for gait training. The purpose of this study was to determine whether the effect of NMMS is clinically applicable. ObjectiveTo determine the effect of NMMS on quadriceps muscle strength, cross-sectional area (CSA) and thickness in healthy subjects. DesignSingle-blind, prospective, case-control study. SettingTertiary academic hospital setting. ParticipantsA total of 40 healthy volunteers were randomly assigned to an NMMS (n = 20) or control group (n = 20). InterventionsFifteen minutes of quadriceps NMMS of at maximum tolerable intensity, 3 times per week for 5 weeks. Main Outcome MeasurementsAt baseline and after the intervention, the CSA and thicknesses of the rectus femoris and vastus intermedius were measured by ultrasound. Isometric and isokinetic maximal and average peak torques of the dominant side knee extensors were also measured at pre- and postintervention. ResultsThere were no between-group differences in strength, CSA, or muscle thickness at baseline. Isometric maximum and average peak torque of NMMS group were increased significantly after 5 weeks of intervention (P < .001). The isokinetic maximum and average peak torque of NMMS group were increased significantly at both angle velocities of 60°/sec and 120°/sec after 5 weeks of intervention (P < .001). However, neither group showed a significant difference in cross-sectional area or thickness after training. ConclusionNMMS can be a useful strengthening method for large skeletal muscles such as the quadriceps. Level of EvidenceII

Implementation of Electronic Medical Record Hard Stop Alerts for Inappropriate Clostridium difficile Tests in Academic and Community Hospital Setting; Impact on Testing Rates and Clinical Outcomes

BackgroundEnsuring appropriate C. diff nucleic acid amplification testing is increasingly important. We implemented electronic medical record (EMR) hard stop alerts across our health-system to reduce inappropriate tests. We review the impact on testing rates and outcome of those where testing was not pursed.Methods C. diff order in a patient with previous test (14 or 7 days for positive or negative), or receipt of laxative in past 48 hours triggered an EMR alert; test could only proceed with micro lab approved test code. The initiative was rolled out at an academic (October 2016) and two community hospitals (December 2016, January 2017). Statistical control charts (SPC) tracked changes in number of tests over time. Wilcoxon rank-sum tests were used to examine pre-post changes. Forward stepwise logistic regression models was used to explore factors associated pursuit of testing post EMR alert. Clinical outcomes of patients at the academic hospital whose testing attempt triggered an alert and testing was not pursued were reviewed.ResultsFor the 3 hospitals, mean weekly C. diff testing rate pre and post-intervention was 146 (SD 12.5) and 119 (SD 12.9), P <0.001. Average number of weekly EMR alerts was 51; 26 for laxative, 14 for previous negative, 3 for previous positive est, 8 for undetermined reason. Figure shows SPC chart weekly testing rate for each hospital.Table shows factors associated with C. diff test pursuit at the academic hospital.OR95% CI P value≥3 unformed stools within 24 hours5.55(2.84 − 10.81)<0.001ID consult team following No1.00 Yes, agreed/recommended test11.33(2.73 − 47.01)0.001 Yes, disagreed/did not recommend test3.42(1.36 − 8.61)0.009Order reason: leukocytosis3.14(1.45 − 6.80)0.004Alert reason: laxatives3.15(1.41 − 7.03)0.005Comorbidity: cirrhosis2.32(1.15 − 4.67)0.019Outcome review of 83 patients who had EMR alert and did not pursue testing was as follows: 36 diarrhea resolved, 21 an alternate cause found, 3 died from non CDI related etiology, 11 had subsequent c diff testing later in the admission (6 negative, 5 positive results), 12 patients were discharged home.ConclusionIn academic and community hospital setting, EMR hard stop alerts educed inappropriate C. diff test, without impact on patient outcomes.Disclosures K. C. Carroll, GenePOC, Inc.: Grant Investigator, Grant recipient

A Comparison of Staphylococcus aureus Bacteremia (SAB) Diagnosis and Management: Differences Between Academic and Community Hospital Settings

A Comparison of Staphylococcus aureus Bacteremia (SAB) Diagnosis and Management: Differences Between Academic and Community Hospital Settings

Managing Incidental Lung Nodules in Patients With a History of Oncologic Disease: A Survey of Thoracic Radiologists.

The aim of this study was to analyze the impact that a clinical history of an oncologic disease may have on the management decisions for incidentally detected lung nodules on chest computed tomographic (CT) examinations. An electronic survey was sent to all 796 members of the Society of Thoracic Radiology regarding criteria for the management of incidentally detected lung nodules in oncologic patients, as well as recommendations for nodule follow-up. Nodule characteristics and clinical parameters used by respondents were analyzed. Differences between variables were examined using the χ test. Of the 796 Society of Thoracic Radiology members, 178 (22.36%) replied. Most respondents were subspecialized in cardiothoracic imaging (92.70%) and practiced in an "academic or teaching hospital setting" (75.28%) with a "dedicated oncology center" (94.03%). "History of oncologic disease" was the most important factor (98.87%) for management decisions. In patients with such a history, respondents most commonly used "experience and common sense" (56.74%) and reported "all incidentally found lung nodules" (65.73%, P<0.0001). "Size" and "shape" were the 2 most important nodule characteristics (33.61% and 27.05%, respectively) used to consider a nodule "clinically relevant," and "size" (44.07%) was also the most important nodule characteristic prompting recommendation for short-term CT follow-up. Follow-up CT examinations in oncologic patients were recommended by 75.84% of respondents. In patients with a history of oncologic disease, radiologists tend to report every detected nodule and to routinely recommend follow-up CT examinations. Although most radiologists rely on "experience and common sense" in managing these nodules, greater standardization of lung nodule management in oncologic patients is needed, ideally through guidelines tailored to this patient population.

Stevens–Johnson syndrome and toxic epidermal necrolysis in an academic hospital setting: a 5-year retrospective study

Stevens–Johnson syndrome and toxic epidermal necrolysis in an academic hospital setting: a 5-year retrospective study

A Toolkit for Pediatric CT Dose Reduction in Community Hospitals

Pediatric CT radiation dose optimization is a challenging process for pediatric-focused facilities and community hospitals alike. Ongoing experience and trial-and-error approaches to dose reduction in the large academic hospital setting may position these centers to help community hospitals that strive for CT quality improvement. We describe our hands-on approach in a pilot project to create a partnership between an academic medical center and a community hospital to develop a toolkit for implementing CT dose reduction. Our aims were to (1) assess the acceptability of an interactive educational program and electronic toolkit booklet, (2) conduct a limited test of the efficacy of the toolkit in promoting knowledge and readiness to change, and (3) assess the acceptability and practicality of a collaborative approach to implementing dose reduction protocols in community hospitals. In partnering with the community hospital, we found that they had size-specific radiation doses two to three times higher than those at our center. Survey results after a site visit with interactive educational presentations revealed an increase in knowledge, stronger opinions about the health risks of radiation from CT scans, and willingness and perceived ability to reduce pediatric CT doses.

Feedback as a means to improve clinical competencies: Registrars’ perceptions of the quality of feedback provided by consultants in an academic hospital setting

Background. The training of novices, in any field, to achieve the optimum state of cognitive, clinical, technical and professional development requires a variety of teaching methodologies, including the process of feedback. Feedback is defined as a process where the desired standard of proficiency in a task has already been established and communicated to the student before gaps in performing the task or in the level of knowledge are identified. The process of feedback has often been evaluated and has consistently revealed students’ dissatisfaction with the amount and type of feedback they receive in their clinical and postgraduate training, as they perceive it to be inadequate, inappropriate or non-existent. Objectives. To investigate the perceptions of the quality of feedback received by a diverse, heterogeneous population of registrars in postgraduate training at an academic hospital. Methods. A study was conducted using a questionnaire to determine the perceptions of all registrars in the six major clinical training programmes with regard to the quality, efficacy and effectiveness of feedback received during clinical training. Descriptive statistics were used to interpret the responses of the registrars, with mean values being calculated. Results. Perceptions of the quality of feedback received differed across disciplines. Overall, the registrars rated the feedback they received as poor. The majority (51.4%) reported that both formal and informal feedback was only sometimes, even rarely, received during all encounters with consultants. Others (51.3%) felt that the feedback received was unacceptable, and did not perceive it to be based on concrete observations of performance. The proficiency of consultants in giving feedback was scored as unacceptable by 64.8% of registrars. Conclusion. Registrars in training regard feedback as an essential component of their postgraduate medical education and as an important component of achieving clinical competence. More formalised processes need to be implemented. The majority of registrars agreed that consultants required training in providing feedback effectively.

Feedback as a means to improve clinical competencies: Consultants’ perceptions of the quality of feedback given to registrars

Background . Effective supervision by consultants in postgraduate medical education involves the process of feedback. Giving feedback may be challenging for consultants who have no formal training in this process, which may be further compounded in heterogeneous diverse settings. Objective. To explore consultants’ perceptions of feedback to registrars in a multicultural, multilingual diverse academic hospital setting. Methods. Thirty-seven consultants consented to completing a questionnaire on what, when, where, how often, and how feedback was provided, as well as on the type and effect of feedback to registrars. Descriptive statistics were used to analyse the data. Differences between groups were calculated using Pearson’s χ² test for independent variables, with a p-value of <0.05 regarded as being statistically significant. Results. Only 40% of consultants reported that they provided feedback often or always and 62.2% reported that standards were not predetermined and communicated to registrars. When feedback was provided, it was based on concrete observations of performance (78.4%), it incorporated a plan for improvement (72.9%) and it supplied information on techniques performed incorrectly (72.9%). Only 40.5% of consultants provided feedback on procedures performed correctly. Moreover, only half of the consultants believed they were proficient at giving feedback. Conclusion . Consultants need to develop the art of giving feedback through appropriate training so that they are more comfortable and proficient with the various aspects of feedback, leading to a positive effect on enhancing registrar training.

A Clinical Trial Evaluation of Pager vs Smart-device Efficacy in an Academic Hospital Setting

ABSTRACT Introduction Health care delivery is contingent on efficient communication among providers. We hypothesized that using smart-device two-way communication would result in faster provider responses when compared with alphanumeric paging among resident physicians in an academic medical center. Methods Resident physicians were given an Apple iPad Mini smart device with a Health Insurance Portability and Accountability Act-compliant smart-device two-way communication application. Patient care messages were randomized for transmission via smart-device two-way texting or standard one-way paging. Physician response time was recorded as the primary outcome measure. Results The study was halted after participation of the first 24 residents due to safety concerns. A technical glitch was identified in which the smart devices automatically powered off to conserve battery life. The first 72 smart devices to first 37 pager communication response times were similar (8 vs 6 minutes, p = 0.43). In analysis of responses within 5 minutes of communication (the time smart devices powered off), smart-device responses occurred significantly faster (1 vs 2 minutes, p &lt; 0.05) but the response frequency was less in the smart-device group (33 vs 62%, p&lt; 0.05), and thus the study was ended early due to safety concerns. Discussion Based on our initial findings, smart devices have potential to improve communication but technical issues must be addressed prior to usage as the sole means of communication. Hamid KS, Nwachukwu BU, Hsu E, Dutta S, Babcock SN, Baker BW, Wohler AD, D’Agostino RB Jr, Lang JE. A Clinical Trial Evaluation of Pager vs Smart-device Efficacy in an Academic Hospital Setting. The Duke Orthop J 2016;6(1):1-6.

Time to talk about work-hour impact on anesthesiologists: The effects of sleep deprivation on Profile of Mood States and cognitive tasks.

A physician's fatigue raises significant concerns regarding personal and patient safety. Effects of sleep deprivation on clinical performance and the quality of patient care are major considerations of today's health care environment. To evaluate the impact of partial sleep deprivation after a 17-h overnight call (3 pm-7 am) on the mood status and cognitive skills of anesthesiologists in an academic clinical hospital setting, as compared to these parameters during regular working hours. Taking circadian rhythm into account, the following measures were assessed in 21 pediatric anesthesiologists at two time points over the course of the study; (i) between 7 and 8 am on a regular non call day, and (ii) between 7 and 8 am after a 17-h in-house call (3 pm-7 am). Six mood states were assessed using the Profile of Mood States. A Total Mood Disturbance (TMD) score was obtained as the sum of all mood scores minus vigor. The total score provides a global estimate of affective state. Simple cognitive tests were similarly administered to assess cognitive skills. A two-tailed paired t-test was used to compare data between regular and post call days. A P < 0.05 was used. The study cohort included 21 pediatric anesthesiologists at a tertiary care children's hospital. Tension, anger, fatigue, confusion, TMD, irritability, feeling jittery, and sleepiness were significantly affected (P < 0.05). A decrease in vigor, energy, and confidence was observed after a night call shift (P < 0.05). There was also a decrease in being "talkative" after the call shift (P < 0.05). Partial sleep deprivation affects the total mood status of anesthesiologists and impacts their cognitive skills. These findings are particularly relevant in a context of increased work expectation, particularly on clinical performance in our modern medical system. Such observations suggest that there may be changes that impact the safety of our patients and the quality of health care that is provided.

Dissemination of an innovative mastery learning curriculum grounded in implementation science principles: a case study.

Dissemination of a medical education innovation, such as mastery learning, from a setting where it has been used successfully to a new and different medical education environment is not easy. This article describes the uneven yet successful dissemination of a simulation-based mastery learning (SBML) curriculum on central venous catheter (CVC) insertion for internal medicine and emergency medicine residents across medical education settings. The dissemination program was grounded in implementation science principles. The article begins by describing implementation science which addresses the mechanisms of medical education and health care delivery. The authors then present a mastery learning case study in two phases: (1) the development, implementation, and evaluation of the SBML CVC curriculum at a tertiary care academic medical center; and (2) the dissemination of the SBML CVC curriculum to an academic community hospital setting. Contextual information about the drivers and barriers that affected the SBML CVC curriculum dissemination is presented. This work demonstrates that dissemination of mastery learning curricula, like all other medical education innovations, will fail without active educational leadership, personal contacts, dedication, hard work, rigorous measurement, and attention to implementation science principles. The article concludes by presenting a set of lessons learned about disseminating an SBML CVC curriculum across different medical education settings.

Lung cancer diagnosis and staging in the minimally invasive age with increasing demands for tissue analysis.

The diagnosis and staging of patients with lung cancer in recent decades has increasingly relied on minimally invasive tissue sampling techniques, such as endobronchial ultrasound (EBUS) or endoscopic ultrasound (EUS) needle aspiration, transbronchial biopsy, and transthoracic image guided core needle biopsy. These modalities have been shown to have low complication rates, and provide adequate cellular material for pathologic diagnosis and necessary ancillary molecular testing. As an important component to a multidisciplinary team approach in the care of patients with lung cancer, these minimally invasive modalities have proven invaluable for the rapid and safe acquisition of tissue used for the diagnosis, staging, and molecular testing of tumors to identify the best evidence-based treatment plan. The continuous evolution of the field of lung cancer staging and treatment has translated into improvements in survival and quality of life for patients. Although differences in clinical practice between academic and community hospital settings still exist, improvements in physician education and training as well as adoption of technological advancements should help narrow this gap going forward.

Rescue dose orders as an alternative to range orders: an evidence-based practice project.

Relief of pain is a fundamental aspect of optimal patient care. However, pain management in the inpatient setting is often constrained by concerns related to regulatory oversight, particularly with regard to the use of opioid dose range orders. These concerns can inadvertently result in the development of policies and practices that can negatively impact the health care team's ability to deliver optimal and individualized pain management. An evidence-based practice project was undertaken to address concerns about regulatory oversight of pain management processes by changing the way pain was managed in a large academic hospital setting. A novel pain management approach using rescue dose medications was established as an alternative to opioid dose range orders. The use of the rescue dose protocol was successfully implemented. Outcomes included an overall reduction in the administration of inappropriate intravenous opioids and opioid-acetaminophen combination medications, with a subsequent increase in single-entity first-line opioid analgesics. Rescue dose protocols may offer an alternative to opioid dose range orders as a means of effectively managing pain.

MP16-10 EQUITABLE COMMUNITY UTILIZATION OF PARTIAL NEPHRECTOMY NATIONALLY FOR MANAGEMENT OF T1A RENAL TUMORS

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Practice Patterns, Cost Effectiveness I1 Apr 2015MP16-10 EQUITABLE COMMUNITY UTILIZATION OF PARTIAL NEPHRECTOMY NATIONALLY FOR MANAGEMENT OF T1A RENAL TUMORS Dhruti Patel and Robert Abouassaly Dhruti PatelDhruti Patel More articles by this author and Robert AbouassalyRobert Abouassaly More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.817AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Previous outcomes research based on the NIS and SEER data has indicated continued underuse of partial nephrectomy as a management strategy for T1a renal masses. Part of this was attributed to the poor diffusion into the community, which we sought to further analyze with the National Cancer Database. METHODS The National Cancer Database captures over seventy percent of newly diagnosed cancer cases in the United States. The national utilization of partial nephrectomy for localized T1a renal masses from 1998 to 2011 was evaluated based on hospital type, either Comprehensive Community Cancer Centers (CCCC) or Academic Cancer Centers (ACC). Only clear cell adenocarcinoma, renal cell carcinoma, papillary adenocarcinoma, chromophobe renal cell carcinoma, sarcomatoid renal cell carcinoma, cystic renal cell carcinoma, and collecting duct renal cell carcinoma were included. Multivariate linear regression and chi-square analyses were performed to evaluate the differences between variables. RESULTS 240,309 cases were identified from 1998 to 2011 with 52% undergoing partial nephrectomy. At both hospital types, utilization of partial nephrectomy annually for T1a renal cancers has statistically significantly (p<0.0001) increased to become the treatment of over half (53%) of all newly diagnosed cases. Based on a multivariate logistic regression, there are a number of factors that affect the utilization of partial nephrectomy. Younger age, white race, private insurance, male gender, hospital type and year all affect the likelihood of partial nephrectomy utilization for T1a tumors. The c statistic for the multivariate linear regression was 0.75. The likelihood of partial nephrectomy is still higher at ACC compared to CCCC (p<0.0001), though a significant number are performed at each hospital type. Both hospital types have similar length of stay, positive surgical margin, 30 day mortality and readmission rates. CONCLUSIONS There has been in a clear shift in the management of T1a renal masses with continued increases in the utilization of partial nephrectomy. This surgical treatment continues to be prevalent in the academic hospital setting and has diffused into the community. This shift may be indicative of the rigorous residency training across the country. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e171 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Dhruti Patel More articles by this author Robert Abouassaly More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Cognitive-behavioral group treatment for perinatal anxiety: a pilot study.

Along with physical and biological changes, a tremendous amount of upheaval and adjustment accompany the pregnancy and postpartum period of a woman's life that together can often result in what is commonly known as postpartum depression. However, anxiety disorders have been found to be more frequent than depression during pregnancy and at least as common, if not more so, during the postpartum period, e.g., Brockington et al., (Archieves Women's Ment Health 9:253-263, 2006; Wenzel et al. (J Anxiety Disord, 19:295-311, 2005). Cognitive-behavioral therapy (CBT) is a well-established psychological treatment of choice for anxiety; however, few studies have specifically examined a cognitive-behavioral intervention targeting perinatal anxiety. This pilot study examined the effectiveness of a cognitive-behavioral group treatment (CBGT) program specifically tailored to address perinatal anxiety in 10 women who were either pregnant or within 12months postpartum. Participants were recruited from a women's clinic at an academic hospital setting, with anxiety identified as their principal focus of distress. Following a diagnostic interview confirming a primary anxiety disorder and completion of assessment measures, participants completed a 6-week CBGT program. There was a statistically significant reduction in anxiety and depressive symptoms following the CBGT program (all p < 0.05). Participants also reported high acceptability and satisfaction with this treatment for addressing their perinatal anxiety. These findings suggest that CBGT for perinatal anxiety is a promising treatment for both anxiety and depressive symptoms experienced during the perinatal period. Further studies are needed to evaluate the treatment efficacy through larger controlled trials.

Single-Site Robotic Cholecystectomy at an Inner-City Academic Center.

Introduction:We investigate the safety and efficacy of single-site robotic cholecystectomy compared to laparoscopic cholecystectomy at an inner-city academic medical center.Materials and Methods:Retrospective analysis comparing single-site robotic to laparoscopic cholecystectomies from August 1, 2013, to January 31, 2015, was conducted. Age, gender, race, body mass index (BMI), total operative time (docking and console time for robotic cases), length of stay, comorbidities, and conversion to open procedures were examined. The χ2 and Student's t test were used for categorical and continuous data, respectively. A P ≤ 0.05 was considered statistically significant.Results:From August 2013 to January 2015, 70 single-site robotic cholecystectomies and 70 laparoscopic cholecystectomies were performed. Patients were older (mean age, 40.3 years vs 47.6 years; P = .0084), had a higher mean BMI (29.5 vs 32.4 kg/m2; P = .011), and had a higher assigned ASA (American Society of Anesthesiologists) classification (P = .024) in the laparoscopic than in the single-site group. Hypertension was more common in the laparoscopic group (P = .0078). Average docking time was 11.5 (SD 5.7) minutes, and the average console time was 52.8 (SD 22.5) minutes in the single-site group. Total operating time for the laparoscopic and single-site groups was not significantly different (111.5 minutes vs 106.0 minutes; P = .38). There were more conversions to open procedures in the laparoscopic compared to the single-site group (11 vs 1; P = .007). There were no biliary tree injuries and no deaths in either group.Conclusion:Single-site robotic cholecystectomy is safe to perform in an inner-city academic hospital setting. Surgical resident involvement does not adversely affect outcomes.