Tertiary Academic Medical Center Research Articles

Liver injury in paraquat poisoning: A retrospective cohort study.

Liver injury is one of the common complications of paraquat (PQ) poisoning, but whether the degree of liver injury is related to patient prognosis is still controversial. This study aimed to investigate whether liver injury was a risk factor for death in PQ-poisoned patients. We conducted a retrospective cohort study of PQ-poisoned patients from the past 10 years (2011-2020) from a large tertiary academic medical centre in China. PQ-poisoned patients were divided into a normal liver function group (n = 580) and a liver injury group (n = 60). Propensity score matching (PSM) analysis was then performed. A total of 640 patients with PQ poisoning were included in this study. To reduce the impact of bias, dose of PQ, urinary PQ concentration and time from poisoning to hospital admission were matched between the two groups. A 3:1 PSM analysis was performed, ultimately including 240 patients. Compared with the normal liver function group, patients in the liver injury group were older, had a higher R value ([ALT/ULN]/[ALP/ULN]) (p < .001) and had a higher mortality rate. Cox regression analysis showed that there was no significant association between alanine aminotransferase, alkaline phosphatase, total bilirubin levels and hazard of death, but age, PQ dose, creatine kinase isoenzyme, creatine kinase, white blood cell count, neutrophil percentage and lymphocyte percentage were associated with mortality in patients with PQ poisoning. The occurrence of liver injury within 48 h after PQ poisoning was a risk factor for mortality, and such liver injury was likely of a hepatocellular nature. Age, PQ dose, creatine kinase isoenzyme and white blood cell count were positively correlated with mortality, while creatine kinase, percentage of neutrophils and lymphocytes were inversely correlated.

Optimized high-dose granulocyte transfusions for the treatment of infections in neutropenic patients: A single-center retrospective analysis.

Granulocyte transfusions for patients with prolonged neutropenia and severe infections has been a controversial practice. Previous studies suggest a benefit of high-dose granulocyte transfusions (≥0.6 × 109/kg), although, until recently, the consistent production of high-dose units has been challenging. Here, we present our experience and results utilizing high-dose granulocyte transfusions at a large, tertiary academic medical center for the treatment of infections in adult, neutropenic patients. A retrospective chart review (2018-2021) was conducted for all patients who received high-dose granulocyte transfusions from donors stimulated with granulocyte colony-stimulating factor (G-CSF) and dexamethasone. Gathered parameters included patient demographics, clinical history, infection status, dose, clinical outcomes, pre- and post-absolute neutrophil count (ANC), and transfusion times including time between granulocyte collection, administration, and posttransfusion ANC count. Gathered parameters were summarized using descriptive statistics, outcomes were assessed utilizing Kaplan-Meier curves/log-rank/regression testing. Totally 28 adult, neutropenic patients refractory to antimicrobial agents and/or G-CSF received a total of 173 granulocyte concentrates. Median ANC increased from 0.7 × 109/L pre-transfusion to 1.6 × 109/L posttransfusion. The mean granulocyte yield was 77.4 × 109 resulting in an average dose per kilogram of 0.90 × 109 ± 0.30 × 109 granulocytes. Composite day 42 survival and microbial response was 42.9% (n = 12/28) without significant adverse reactions. Here, we demonstrate the successful and safe implementation of high-dose granulocyte transfusions for neutropenic patients. Given the rapid and consistent production, distribution, and improved granulocyte quality, further investigations to determine the clinical efficacy of G-CSF primed granulocyte transfusions is now possible.

Obstetric Anal Sphincter Injury: Interpregnancy Interval and Route of Subsequent Delivery.

Knowledge on the interpregnancy interval (IPI) among women with an obstetric anal sphincter injury (OASI) is both limited and not well understood. The objectives of this study were to describe the IPI among women with OASI and to compare women with OASI based on the route of subsequent obstetric delivery and OASI recurrence. This was a retrospective single-cohort study of women who had an OASI between 2013 and 2015 at a tertiary academic medical center. Demographics, obstetric delivery data, postpartum sequelae, and subsequent pregnancy delivery data from 2013 to 2021 were collected. The IPI was defined as the time from date of first vaginal delivery to date of conception of the subsequent pregnancy. Women without a subsequent pregnancy were censored at the date of last contact. The IPI was evaluated using a survival analysis (Kaplan-Meier estimator). A total of 287 women experienced an OASI, and subsequent pregnancy occurred for 178 (62.0%) women. The median IPI was 26.4 months (95% confidence interval: 23.7-29.9) for women with a prior OASI. Of the 97 women who did not have a subsequent pregnancy documented during the study, the median follow-up was 64.0 months (interquartile range: 5.7-80.0). Subsequent delivery route data were available for 171 women; of those, 127 (74.3%) experienced a subsequent vaginal delivery and 44 (25.7%) experienced a cesarean delivery. Of the 127 women who experienced a subsequent vaginal delivery, 3 (2.4%) experienced a recurrent OASI. The IPI among women with OASI is similar to the IPI for all women in Ohio and in the United States.

Impact of Flap Size and Comorbidities on Supraclavicular Artery Island Flap Outcomes.

Use of the supraclavicular artery island flap (SCAIF) in head and neck reconstruction has increased in recent years. Limited but improving experience among reconstructive surgeons with the procedure have exposed numerous issues associated with flap success. The objective of this study is to examine the role of flap size on viability. Retrospective case series. Tertiary Academic Medical Center. Review of patients undergoing SCAIF reconstruction between January 2014 and March 2022 was performed. Flap failure was defined as >50% skin paddle loss. The total flap surface area was examined. Multivariable analysis was performed to evaluate the association of other variables associated with flap failure. Eighty-nine supraclavicular island flaps were reviewed. Mean patient age was 63.2 ± 11.4 years. Fifty-five (61.2%) were male. Forty-five flaps (50.6%) were used for the reconstruction of defects of the skin of the neck/face. Twenty-nine flaps (32.6%) were utilized for defects of the pharynx/oropharynx, and 15 (16.9%) were utilized for oral cavity defects. Flap success rate was 94% (73/89). Flap site was not associated with flap failure (P = .46). Flaps >25 cm2 were 75% more likely to be successful. Multivariable logistic regression to assess the association of flap size in the context of other co-morbidities indicated flaps >25 cm2 were 3.6 times more likely to succeed regardless of co-morbidities, and patients with chronic obstructive pulmonary disease (COPD) have a 7-fold risk of flap failure (odds ratio: 7.3, 1.72-30.98, P = .007). An association with improved flap outcomes and larger skin paddles was observed in this series. The applicability of these observations to smaller flaps and larger series with more surgeons requires further study. Co-morbidities, particularly, COPD, continue to impact flap outcomes.

Applying Machine Learning Models Derived From Administrative Claims Data to Predict Medication Nonadherence in Patients Self-Administering Biologic Medications for Inflammatory Bowel Disease.

Adherence to self-administered biologic therapies is important to induce remission and prevent adverse clinical outcomes in Inflammatory bowel disease (IBD). This study aimed to use administrative claims data and machine learning methods to predict nonadherence in an academic medical center test population. A model-training dataset of beneficiaries with IBD and the first unique dispense of a self-administered biologic between June 30, 2016 and June 30, 2019 was extracted from the Commercial Claims and Encounters and Medicare Supplemental Administrative Claims Database. Known correlates of medication nonadherence were identified in the dataset. Nonadherence to biologic therapies was defined as a proportion of days covered ratio <80% at 1 year. A similar dataset was obtained from a tertiary academic medical center's electronic medical record data for use in model testing. A total of 48 machine learning models were trained and assessed utilizing the area under the receiver operating characteristic curve as the primary measure of predictive validity. The training dataset included 6998 beneficiaries (n = 2680 nonadherent, 38.3%) while the testing dataset included 285 patients (n = 134 nonadherent, 47.0%). When applied to test data, the highest performing models had an area under the receiver operating characteristic curve of 0.55, indicating poor predictive performance. The majority of models trained had low sensitivity and high specificity. Administrative claims-trained models were unable to predict biologic medication nonadherence in patients with IBD. Future research may benefit from datasets with enriched demographic and clinical data in training predictive models.

Poster 330: Graft Selection and Lateral Augmentation in Revision ACL Reconstruction: Experience of a Large Tertiary Academic Center

Objectives: Primary purpose of this study was to assess failure rates in revision ACL reconstruction and to determine the influence of graft selection and lateral augmentation procedures. A secondary purpose was to identify a subset of patients for whom reconstruction with allograft yields equivalent failure rates to autograft. Methods: This was a retrospective study at a tertiary academic medical center. The electronic medical record was queried for current procedural terminology codes for ACL reconstructions (29888) from June 2011 – October 2022. Data was reviewed to ensure that only revision ACL reconstructions were included. Demographic information including age, gender, and BMI were obtained from the EMR query as well. Graft types used and lateral augmentation procedures performed were identified through manual review of operative notes. Failure rates were recorded based on documentation of ACL graft re-tear in the database. Results: Three-hundred thirty patients who underwent revision ACL reconstruction at our institution were included in the final analysis. Patients were 30.2% female with a mean age of 31.9 years (SD 10.5). Mean follow up was 21.7 months (SD 25.8). Overall re-tear rate at final follow up was 6.7%. Lateral augmentation procedures were performed in 42.1% of patients (48.2% anterolateral ligament reconstruction [ALL], 51.8% lateral extraarticular tenodesis [LET]). The most common graft types were bone patella bone (BTB) allograft (40.3%) and BTB autograft (36.1%). Other graft types included quadriceps tendon autograft (6.4%), hamstring tendon allograft (5.2%), hamstring tendon autograft (4.5%), tibialis anterior allograft (4.2%), Graftlink allograft (1.5%), quadriceps tendon allograft (1.5%), and Achilles tendon allograft (0.3%). Age, gender, and BMI were not significantly different between patients who retore their ACL graft vs. those who did not (p&gt; .05). Patients who underwent a LET procedure had significantly lower failure rates (0%) than those who underwent an ALL reconstruction (10.4%) or no lateral augmentation procedure (7.9%), (p=.029). Failure rates for the three most common grafts used are shown in Figure 1. The rate of re-tear was significantly higher in patients who underwent reconstruction with allograft as compared to autograft (10.3% vs. 2.6%, p=.007). When only patients above 40 years of age were analyzed (n=67), the rate of re-tear was not significantly different in patients who underwent reconstruction with allograft as compared to autograft (8.8% vs. 10.0%, p=.999). There was a higher proportion of patients over 40 with allograft who underwent LET (22.8% vs. 10.0%), but this was not statistically significant (p=.675). Among patients under 40 who underwent reconstruction with allograft, a lower proportion of patients who had a re-tear underwent LET than those who did not re-tear (0% vs. 16.3%), but this was not statistically significant (p=.210). Conclusions: Overall re-tear rates were higher in patients who underwent revision ACL reconstruction with allograft. However, in older patients who may be less active, re-tear rates were comparable for allograft and autograft. Additionally, patients who underwent lateral extraarticular tenodesis had lower re-tear rates. Careful consideration of patient demographics and clinical characteristics is necessary for graft selection and indication for lateral augmentation in revision ACL reconstruction.

Defining the Value of Vascular Surgery Service at a Tertiary Academic Medical Center

BackgroundVascular surgeons play a critical role in the functioning of a healthcare system. As a service line, vascular surgery not only performs its own complex operations but also provides support to other surgical specialties by assisting in the management of vascular-related complications. Previous reports have acknowledged the value of consulting vascular surgeons; however, these studies have primarily been limited to single-center series. In this study, we aim to contribute to the existing literature by sharing our experience and highlighting the financial value of consulting vascular surgeons at a large tertiary academic medical center. MethodsInstitutional electronic medical records were retrospectively queried for all operations performed by vascular surgeons from 2020-2022. Two separate procedural groups were identified. The first group comprised all surgeries where vascular surgery was listed as a co-surgeon for other surgical specialties. The second group comprised all surgeries where vascular surgery was the primary surgeon for service-level cases. Service cases were defined as operations resulting directly from (1) iatrogenic complications from other services, (2) consultations for traumatic injury, or (3) primary surgeon for non-vascular cases. The Centers for Medicare and Medicaid Services (CMS) Physician Fee Schedule was used to calculate work relative value units (wRVU) per primary procedure code. ResultsA total of 7821 surgeries were performed with vascular involvement over the study period. Of these, 726 operations (9.3%) were co-surgeon cases requiring intraoperative vascular assistance, from 109 surgeons across all 16 surgical specialties. There was no missing data. The most common specialties requesting vascular assistance included cardiac surgery (n=247, 34.0%), orthopedic surgery (n=152, 20.9%), and neurosurgery (n=131, 18.0%). Total procedural wRVU for co-surgeon cases was 16,220, and total charges exceeded $77.5 million dollars. Vascular surgery served in a primary surgeon role in an additional 154 service-level cases (2.0%) resulting from ten non-surgical services. The most common service-level indication was iatrogenic vascular injury (n=87, 56.4%), and the majority of service-level cases required urgent or emergent surgery (n=123, 79.9%). These procedures generated an additional 2,150 wRVU and $1.1 million dollars in charges for the hospital system. Of all co-surgeon or service-level cases, 19.1% (n=168) occurred after-hours and 10.3% (n=91) occurred on a holiday or weekend. ConclusionVascular surgery is crucial to the operation of all surgical services and many non-surgical service lines within an academic medical center. Apart from providing essential services for primary vascular diseases, the vascular surgery service line offers substantial financial benefits to the healthcare system through its consulting role. A considerable portion of operative consultations are performed under urgent or emergent circumstances, often necessitating surgical intervention outside regular working hours or on holidays/weekends. These findings have significant implications for assessing the value and compensation of vascular surgeons in today's healthcare landscape.

Application of Time-Driven Activity-Based Costing for Head and Neck Microvascular Free Flap Reconstruction.

Traditional hospital accounting fails to provide an accurate cost of complex surgical care. Here we describe the application of time-driven activity-based costing (TDABC) to characterize costs of head and neck oncologic procedures involving free tissue transfer. Retrospective cohort study. Single tertiary academic medical center. An analysis of head and neck oncologic procedures involving microvascular free flap reconstruction from 2018 to 2020 (n = 485) was performed using TDABC methodology to measure cost across operative case and postoperative admission, using quantity of time and cost per unit of each resource to characterize resource utilization. Univariate and generalized linear mixed models were used to examine associations between patient and hospital characteristics and cost of care delivery. The total cost of care delivery was $41,905.77 ± 21,870.27 with operating room (OR) supplies accounting for only 10% of the total cost. Multivariable analyses identified significant cost drivers including operative time, postoperative length of stay, number of return trips to the OR, postoperative complication, number of free flaps performed, and patient transfer from another hospital or via emergency department admission (P < .05). Operative time and postoperative length of stay, but not operative supplies, were primary drivers of cost of care for head and neck oncology cases involving free tissue transfer. TDABC offers granular cost characterization to inform cost optimization through unused capacity identification and postoperative admission efficiencies.

Leveraging machine learning to develop a postoperative predictive model for postoperative urinary retention following lumbar spine surgery.

Postoperative urinary retention (POUR) is the inability to urinate after a surgical procedure despite having a full bladder. It is a common complication following lumbar spine surgery which has been extensively linked to increased patient morbidity and hospital costs. This study hopes to development and validate a predictive model for POUR following lumbar spine surgery using patient demographics, surgical and anesthesia variables. This is a retrospective observational cohort study of 903 patients who underwent lumbar spine surgery over the period of June 2017 to June 2019 in a tertiary academic medical center. Four hundred and nineteen variables were collected including patient demographics, ICD-10 codes, and intraoperative factors. Least absolute shrinkage and selection operation (LASSO) regression and logistic regression models were compared. A decision tree model was fitted to the optimal model to classify each patient's risk of developing POUR as high, intermediate, or low risk. Predictive performance of POUR was assessed by area under the receiver operating characteristic curve (AUC-ROC). 903 patients were included with average age 60 ± 15 years, body mass index of 30.5 ± 6.4 kg/m2, 476 (53%) male, 785 (87%) white, 446 (49%) involving fusions, with average 2.1 ± 2.0 levels. The incidence of POUR was 235 (26%) with 63 (7%) requiring indwelling catheter placement. A decision tree was constructed with an accuracy of 87.8%. We present a highly accurate and easy to implement decision tree model which predicts POUR following lumbar spine surgery using preoperative and intraoperative variables.

Application of the Sepsis-3 criteria to describe sepsis epidemiology in the Amsterdam UMCdb intensive care dataset.

Sepsis is a major cause of morbidity and mortality worldwide. In the updated, 2016 Sepsis-3 criteria, sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection, where organ dysfunction can be represented by an increase in the Sequential Organ Failure Assessment (SOFA) score of 2 points or more. We sought to apply the Sepsis-3 criteria to characterise the septic cohort in the Amsterdam University Medical Centres database (Amsterdam UMCdb). We examined adult intensive care unit (ICU) admissions in the Amsterdam UMCdb, which contains de-identified data for patients admitted to a mixed surgical-medical ICU at a tertiary academic medical centre in the Netherlands. We operationalised the Sepsis-3 criteria, defining organ dysfunction as an increase in the SOFA score of 2 points or more, while infection was defined as a new course of antibiotics or an escalation in antibiotic therapy, with at least one antibiotic given intravenously. Patients with sepsis were determined to be in septic shock if they additionally required the use of vasopressors and had a lactate level >2 mmol/L. We identified 18,221 ICU admissions from 16,408 patients in our cohort. There were 6,312 unique sepsis episodes, of which 30.2% met the criteria for septic shock. A total of 4,911/6,312 sepsis (77.8%) episodes occurred on ICU admission. Forty-seven percent of emergency medical admissions and 36.7% of emergency surgical admissions were for sepsis. Overall, there was a 12.5% ICU mortality rate; patients with septic shock had a higher ICU mortality rate (38.4%) than those without shock (11.4%). We successfully operationalised the Sepsis-3 criteria to the Amsterdam UMCdb, allowing the characterization and comparison of sepsis epidemiology across different centres.

Systemic lidocaine versus erector spinae plane block for improving quality of recovery after laparoscopic cholecystectomy: A randomized controlled trial

Study objectiveTo compare intravenous lidocaine, ultrasound-guided erector spinae plane block (ESPB), and placebo on the quality of recovery and analgesia after laparoscopic cholecystectomy. DesignA prospective, triple-arm, double-blind, randomized, placebo-controlled non-inferiority trial. SettingA single tertiary academic medical center. Patients126 adults aged 18–65 years undergoing elective laparoscopic cholecystectomy. InterventionsPatients were randomly allocated to one of three groups: intravenous lidocaine infusion (1.5 mg/kg bolus followed by 2 mg/kg/h) plus bilateral ESPB with saline (25 mL per side); bilateral ESPB with 0.25% ropivacaine (25 ml per side) plus placebo infusion; or bilateral ESPB with saline (25 ml per side) plus placebo infusion. MeasurementsThe primary outcome was the 24-h postoperative Quality of Recovery-15 (QoR-15) score. The non-inferiority of lidocaine versus ESPB was assessed with a margin of −6 points and 97.5% confidence interval (CI). Secondary outcomes included 24-h area under the curve (AUC) for pain scores, morphine consumption, and adverse events. Main results124 patients completed the study. Median (IQR) 24-h QoR-15 scores were 123 (117–127) for lidocaine, 124 (119–126) for ESPB, and 112 (108–117) for placebo. Lidocaine was non-inferior to ESPB (median difference –1, 97.5% CI: −4 to ∞). Both lidocaine (median difference 9, 95% CI: 6–12, P < 0.001) and ESPB (median difference 10, 95% CI: 7–13, P < 0.001) were superior to placebo. AUC for pain scores and morphine use were lower with lidocaine and ESPB versus placebo (P < 0.001 for all), with no significant differences between lidocaine and ESPB. One ESPB patient reported a transient metallic taste; no other block-related complications occurred. ConclusionsFor patients undergoing laparoscopic cholecystectomy, intravenous lidocaine provides a non-inferior quality of recovery compared to ESPB without requiring specialized regional anesthesia procedures. Lidocaine may offer a practical and accessible alternative within multimodal analgesia pathways.

The effects of a Teddybear Hospital project on prescool childrens' knowledge and medical students' professionalism: a prospective cohort study.

The Teddybear Hospital (TH) Project is an effort to increase children's knowledge and decrease their anxiety. It is also intended to improve medical students' pediatric communication skills. This study evaluated the educational effects on participating preschool children and medical students. Preschool children were offered to bring their stuffed toys to the TH at our tertiary academic medical center. Medical students who had completed the pediatric surgery rotation staffed the TH, performed examinations, and interacted with the children. The children's knowledge of anatomy, medical equipment, and healthy lifestyle, along with their level of anxiety towards hospitalization, was assessed using pre- and post-interventional validated survey tools. Preschool peers who did not participate in the TH served as controls. Participating medical students were tested on professionalism and pediatric surgical knowledge during, and 3 weeks after the intervention, and compared to their non-participating peers. A total of 131 children (63 intervention, 68 control) and 48 medical students (16 intervention, 32 control) participated in the study. Children's state anxiety decreased by 0.98 points (95% Confidence Interval [CI] -0.3 to -1.8, P<0.001), while knowledge increased significantly on "healthy lifestyle" by 1.4 points (95% CI 1.01 to 1.79, P<0.05), on "medical equipment" by 4.5 points (95% CI 3.8 to 5.2, P <0.0001), and on "anatomy" by 5.05 points (95% CI 4.73 to 5.73, P<0.01). No changes were detected in any of the outcome measures in the control group. Medical students' objective professionalism increased by 4.2 points (95% CI 1.58 to 6.80, P<0.01) compared to non-participant medical students. The tests did not show an increase in the medical students' pediatric surgical knowledge. Preschool participation in a TH increased knowledge and decreased anxiety regarding hospitalization and medical personnel. It also helped medical students to playfully acquire medical professionalism.

Multiple Goals Theory and Communication Quality Analysis for Fellows Communication Training.

End-of-life communication skills are vital to high-quality critical care. Patients and families often report deficiencies in end-of-life communication by providers. However, formalized training is difficult to implement and study on a large scale. Furthermore, curricula are often designed with early-stage clinical trainees in mind and are not tailored to advanced clinician learners. The goal of this pilot study was to explore educational and practical implications of using Multiple Goals Theory (MGT), Communication Quality Analysis (CQA), and communication logs as a three-pronged, reflective communication curriculum for advanced trainees. We describe design and qualitative evaluation of a novel, pilot, longitudinal curricular intervention for pulmonary and critical care fellows and program directors at a tertiary academic medical center. The 2-year longitudinal communication curriculum incorporates 1) a theoretical framework from communication science (MGT), with 2) a novel training modality of analyzing audio-recorded intensive care unit family meetings (CQA), and 3) written communication logs after an intensive care unit family meeting. The sample included 13 pulmonary and critical care medicine fellows and two program directors. Qualitative thematic analysis was conducted on seven fellow interviews and on 23 communication logs completed. Four themes emerged from interviews: 1) fellows incorporated the skills into real-life practice and found the curriculum useful and valuable; 2) a key takeaway from MGT was the deemphasis of task goals; 3) CQA was an engaging opportunity for self-reflection and learning; and 4) written communication logs were perceived as helpful in theory but too burdensome in practice. Findings from analyses of the communication logs included that most fellows' writing was brief and without substantial reflection. Many scholars have argued that communication theory can impact practice, but few have recognized the potential of theory and methods, such as MGT and CQA, as educational tools. Our findings demonstrate that MGT is a feasible and useful theoretical framework for improving communication skills among advanced trainees, and CQA fosters meaningful self-reflection about practice. Communication logs were not feasible or useful training tools in this context, but CQA workshops helped fulfill the goals of narrative reflection. Next steps are to implement this curriculum in more programs and measure changes in behavior acquisition and clinical care.

Are renal stone protocol computed tomography reports giving us enough information?

Non-contrast computed tomography (CT) is the gold-standard diagnostic test for urolithiasis. Little is published regarding which information needs to be included in the report for it to be most useful to the healthcare team for efficient triage and high-quality patient care. This study aimed to assess the quality and variability of CT scan reporting at a single Canadian tertiary academic medical center. We completed a retrospective review of 100 consecutive renal colic CT scans. Descriptive statistics were used to report the frequency with which specific elements commonly used by urologists to triage and treat patients were included in radiology reports. Our sample had a mean age of 51.4±13.1 years. Stone size was universally reported for obstructing stones but was less frequently reported for non-obstructing stones (100% vs. 86.8%). A similar trend was observed for the exact stone number (100% vs. 93.4%). Non-obstructing stones were more likely than obstructing stones to be reported in one dimension (77.5% vs. 47%). Obstructing stones were reported in three dimensions 27% of the time. CT reports commonly include the presence or absence of hydronephrosis status (98%) but are less likely to include renal size (32%) and periureteral stranding (16%). Hounsfield units (HU) were reported in 3% of the reports, but skin-to-stone distance (SSD) and radiation dose were never reported. Reports routinely included assessments of stone size, location, and number (although not uniformly). HU, SSD, and radiation dose were rarely reported. This provides insight into opportunities for standardized reporting to optimize knowledge transfer that may result in clinical efficiency and improved quality of patient care.

Utilization trends for MR arthrography of the hip and shoulder: a retrospective cross-sectional analysis of 20-year data from a tertiary care academic medical center.

The purpose of this study is to analyze changes in the utilization of MRA of the hip and shoulder at a large tertiary care academic medical center during a period of significant technological advancements over the last 20 years. This retrospective cross-sectional analysis identified MRA of the hip and shoulder performed at our institution over a 20-year period (2/2003-2/2023) in relation to the total number of MR hip and shoulder examinations during the same period. Patient characteristics and referring provider demographic information were extracted. Descriptive statistics and trend analysis were performed. The total number of MRIs of the hip and shoulder increased overall, with small dips in 2020 and 2022. MRA of the hip increased significantly over the first 10 years of the study period (p = 0.0005), while MRA of the shoulder did not change significantly (p = 0.33). The proportion of both MRA of the hip and shoulder declined over the last 10 years (hip, p = 0.0056; shoulder, p = 0.0017). Over the same period, there was significant increase in the proportion of examinations performed at 3 Tesla versus 1.5 (p < 0.0001). Overall, there was a downward trend in MR shoulder and hip arthrogram utilization in the second half of this 20-year study period. However, utilization varied somewhat by referring specialties and credentials. These changes are likely reflective of both improvements in image quality and evolving practice recommendations. Awareness of such trends may be valuable in ensuring appropriate patient care, as well as for anticipating the needs of a musculoskeletal radiology practice.

Reporting on Neurological Decline as Identified by Hourly Neuroassessments.

BACKGROUND: Hourly neurological examinations (neuro exam) have been widely used to monitor for a decline in neurological status, allowing for timely intervention. There are, however, limited data behind this common practice. The objective of this study was to identify how frequently neurological decline occurred across various diagnoses and whether that decline (1) was identified by a scheduled neurocheck and (2) altered management. METHODS: A cross-sectional survey was performed in a neurological intensive care unit at a tertiary care academic medical center. Clinical neuroscience nurses caring for patients with hourly neurological assessments completed a brief survey at 12-hour shift completion. RESULTS: Data were collected from 212 nurse's shifts. Neurological changes were identified by nurses in 14% (n = 30) of shifts. The neurological change was identified during a scheduled neurocheck 67% of the time, with the detection of changes more likely to occur during a scheduled neuro exam than at other times ( P < .05). There was no change to the care plan in 55% of the cases of neurological decline. Patients with subarachnoid hemorrhage were more likely to have a decline detected. CONCLUSION: Findings suggest that many patients undergo hourly neurological exams without ever identifying a neurological deterioration. In many instances of neurodeterioration, there was no change to the treatment plan pursued. Primary diagnoses and neurological changes may not be entirely independent, and therefore, hourly neuro exams may have greater yield in some diagnoses than others. Replication is warranted with a larger sample to evaluate the risks and benefits of neuroassessments.

The Prevalence of Hip Dysplasia on Radiographs for Adolescent Idiopathic Scoliosis.

During radiographic assessment of adolescent idiopathic scoliosis (AIS), upright images frequently capture the hip. The purpose of this study was to assess the prevalence of radiographic hip dysplasia on postero-anterior (PA) scoliosis radiographs, as defined as a lateral center edge angle (LCEA) ≤25 degrees. All patients with upright PA scoliosis radiographs over a one-year study period at a single tertiary academic medical center (2020 to 2021) were included in the study. Radiographs containing the hip joints were annotated by 3 reviewers for left and right LCEA, and triradiate cartilage (TRC) status. Inter-rater reliability was determined among the 3 reviewers. Two hundred fifty patients {500 hips, 75.6% female, median age 14 [interquartile range (IQR)=3]} had PA scoliosis radiographs that captured the hip, which qualified for analysis. Seventy-four hips (14.8%) demonstrated evidence of dysplasia (LCEA ≤25 deg) in 55/250 patients (22%). The median LCEA was significantly lower in the dysplastic hip cohort (23.9 deg, IQR=4.8 deg), compared with those without dysplasia (33 deg IQR=7.3 deg; P =0.001). A higher percentage of dysplastic hip patients were female than male (72.7% vs. 27.3%). Patients with bilateral dysplasia had a similar LCEA ( 22.9 deg) [to those with unilateral dysplasia (22.9 deg left, 23.9 deg right, P =0.689)]. In a cohort of 250 AIS patients, 22% demonstrated evidence of hip dysplasia, as defined as an LCEA ≤2 degrees. The dysplastic patients were more likely to be female. Screening for hip symptomatology in AIS patients may be of benefit, considering the frequency of radiographic hip dysplasia in this population. III. Type of Evidence: diagnostic.

Validation of a new calculator for predicting success of vaginal birth after cesarean delivery

Race as a variable in a predictive model for a successful vaginal birth after cesarean delivery has been challenged as contributing to health inequity. In May 2022, the National Institute of Child Health and Development released a modified calculator that removed race as a variable. The aim of this study was to externally validate the revised calculator amongst a cohort at our institution.We reviewed all patients who underwent a trial of labor after cesarean delivery in 2018-2020 at a tertiary academic medical center and calculated the predicted probability of successful vaginal birth after cesarean delivery for each patient using both original and revised classification calculators and compared these to observed birth outcomes. The area under the receiver operating characteristic curve was calculated for each model.From the cohort of 225 patients that fit inclusion criteria, 37% (n=83) identified as African-American or Hispanic. The vaginal birth after cesarean delivery success rate was 75% for the entire population, and 76% among African-American and/or Hispanic patients. The area under the receiver operating characteristic curve of the original calculator was 0.71, compared to 0.74 for the new calculator. For African-American and/or Hispanic patients, the average predicted success rates between the models rose from 60 to 69%.Our review confirmed that African-American and Hispanic patients were calculated to have a lower prediction score for a successful vaginal birth after cesarean delivery based on the original calculator as compared to the revised calculator. Our results also suggest that race/ethnicity did not significantly contribute to classification ability of the calculator in our patient population.

Automatic Recognition of Auditory Brainstem Response Waveforms Using a Deep Learning-Based Framework.

Recognition of auditory brainstem response (ABR) waveforms may be challenging, particularly for older individuals or those with hearing loss. This study aimed to investigate deep learning frameworks to improve the automatic recognition of ABR waveforms in participants with varying ages and hearing levels. The research used a descriptive study design to collect and analyze pure tone audiometry and ABR data from 100 participants. The research was conducted at a tertiary academic medical center, specifically at the Clinical Audiology Center of Tsinghua Chang Gung Hospital (Beijing, China). Data from 100 participants were collected and categorized into four groups based on age and hearing level. Features from both time-domain and frequency-domain ABR signals were extracted and combined with demographic factors, such as age, sex, pure-tone thresholds, stimulus intensity, and original signal sequences to generate feature vectors. An enhanced Wide&Deep model was utilized, incorporating the Light-multi-layer perceptron (MLP) model to train the recognition of ABR waveforms. The recognition accuracy (ACC) of each model was calculated for the overall data set and each group. The ACC rates of the Light-MLP model were 97.8%, 97.2%, 93.8%, and 92.0% for Groups 1 to 4, respectively, with a weighted average ACC rate of 95.4%. For the Wide&Deep model, the ACC rates were 93.4%, 90.8%, 92.0%, and 88.3% for Groups 1 to 4, respectively, with a weighted average ACC rate of 91.0%. Both the Light-MLP model and the Wide&Deep model demonstrated excellent ACC in automatic recognition of ABR waveforms across participants with diverse ages and hearing levels. While the Wide&Deep model's performance was slightly poorer than that of the Light-MLP model, particularly due to the limited sample size, it is anticipated that with an expanded data set, the performance of Wide&Deep model may be further improved.

Focal motor weakness and recovery following chronic subdural hematoma evacuation.

The incidence of chronic subdural hematomas (cSDHs) is expected to climb precipitously in the coming decades because of the aging populous. Neurological weakness is one of the most common presenting neurological symptoms of cSDH. Yet, the recovery rates of motor strength recovery are seldom documented, as neurological outcomes have predominantly focused on broader functional assessment scores or mortality. In this study, the authors performed one of the first detailed analyses on functional motor weakness and recovery in patients who underwent cSDH evacuation. Patients who underwent evacuation of a cSDH at a tertiary academic medical center between November 2013 and December 2021 were retrospectively identified using ICD-9 and ICD-10 billing codes. The presence of focal motor weakness was subcategorized by location as upper extremity (UE) or lower extremity (LE). Postoperative improvement, worsening, or resolution of weakness was recorded at the time of discharge. Statistical analysis included univariate and backward stepwise multivariable logistic regression modeling. A total of 311 patients were included in the analysis. Patients were significantly more likely to experience UE weakness than LE weakness (29% vs 18%, p < 0.001). Forty-one percent (43/104) had both UE and LE weakness present. Risk factors for the development of focal motor weakness at the time of presentation were older age (OR 1.02, p = 0.03), increased cSDH size (OR 1.04, p = 0.02), and the presence of a unilateral cSDH (OR 2.32, p = 0.008). The majority of patients (68%, 71/104) experienced motor strength improvement following cSDH evacuation, with 58% (60/104) having complete resolution of weakness. Multivariable logistic regression analysis revealed that longer symptom duration was associated with lower rates of improvement (OR 0.96, p = 0.024). Older age was also associated with reduced resolution of weakness (OR 0.96, p = 0.02). This study represents one of the first in-depth analyses investigating the rates of motor strength weakness and recovery following cSDH evacuation. Nearly two-thirds of all patients had complete resolution of their weakness by the time of discharge, and more than three-quarters had partial improvement. Risk factors for impaired neurological recovery were longer symptom duration prior to treatment and older age.