Clinician Preferences Research Articles

Community Health Centers' Practices, Barriers, and Facilitators for Providing a 1-Year Supply of Oral Contraception on Site.

High-quality family planning services help women to achieve their preferred family size and birth spacing, which in turn leads to improved health outcomes and better quality of life. This study investigates whether women have access to a 1-year supply of oral contraceptives (OCs) on site when they receive care at community health centers and whether states require coverage for a 1-year supply. This study used a concurrent, mixed-methods approach, with a single phase of quantitative research (survey of health centers) and two phases of qualitative research (50-state policy environment scan and in-depth interviews). Only three states require coverage for a 1-year supply of OCs under all Medicaid and private insurance coverage mechanisms; the majority of states limit it through at least one mechanism. The survey found that 50.9% of health centers provided OCs on site, and of these, only 29.9% offered up to a 1-year supply at a time. An analysis of interviews revealed that clinician and pharmacist preferences and the organization's overall approach to family planning played a role in these practices. This study finds that that only a minority of health centers provide a 1-year supply on site and that a minority of states have rules requiring coverage for a 1-year supply of OCs. To remedy these gaps, change is needed at multiple levels, including health center practices, clinician knowledge and beliefs, federal agency guidance, and state-level insurance policy.

Clinical Practice Guideline for Physical Therapist Management of People With Rheumatoid Arthritis.

This guideline revises the 2008 Royal Dutch Society for Physical Therapy guideline for physical therapy for patients with rheumatoid arthritis (RA). This revised guideline was developed according to the Appraisal of Guidelines for Research and Evaluation tool and the Guidelines International Network standards. A multidisciplinary guideline panel formulated clinical questions based on perceived barriers in current care. For every clinical question, a narrative or systematic literature review was undertaken, where appropriate. The guideline panel formulated recommendations based on the results of the literature reviews, the values and preferences of patients and clinicians, and the acceptability, feasibility, and costs, as described in the Grading of Recommendations Assessment, Development and Evaluation evidence-to-decision framework. The eventual guideline describes a comprehensive assessment based on the International Classification of Functioning, Disability and Health Core Set for RA. It also includes a description of yellow and red flags to support direct access. Based on the assessment, 3 treatment profiles are distinguished: (1) education and exercise instructions with limited supervision, (2) education and short-term supervised exercise therapy, and (3) education and intensified supervised exercise therapy. Education includes RA-related information, advice, and self-management support. Exercises are based on recommendations concerning the desired frequency, intensity, type, and time-related characteristics of the exercises (FITT factors). Their interpretation is compliant with the individual patient's situation and with public health recommendations for health-enhancing physical activity. Recommended measurement instruments for monitoring and evaluation include the Patient-Specific Complaint instrument, Numeric Rating Scales for pain and fatigue, the Health Assessment Questionnaire Disability Index, and the 6-minute walk test. An evidence-based physical therapy guideline was delivered, providing ready-to-use recommendations on the assessment and treatment of patients with RA. An active implementation strategy to enhance its use in daily practice is advised. This evidence-based practice guideline guides the physical therapist in the treatment of patients with RA. The cornerstones of physical therapist treatment for patients with RA are active exercise therapy in combination with education. Passive interventions such as massage, electrotherapy, thermotherapy, low-level laser therapy, ultrasound, and medical taping play a subordinate role.

Differences in Preferences Between Clinicians and Patients for the Use and Dosing of Direct Oral Anticoagulants for Atrial Fibrillation

BackgroundDirect oral anticoagulants (DOACs) are effective in reducing the stroke risk for patients with nonvalvular atrial fibrillation if prescribed at the labeled dose, yet underdosing is frequent. Little is known about clinician knowledge and patient or clinician preferences for DOAC dosing.Methods and ResultsFrom April 2019 to March 2020, 240 clinicians and 343 patients with atrial fibrillation completed an assessment of anticoagulation knowledge/preferences. Clinician knowledge of DOAC dosing was tested with 4 hypothetical patient scenarios. Patients and clinicians were asked to grade the importance of 25 factors in anticoagulation decision making. Among clinicians, the median age was 55 years, and 23% were primary care clinicians. In scenarios of a patient indicated for full‐dose DOAC, 41.2% of clinicians underdosed apixaban and 17.6% underdosed rivaroxaban. In scenarios of a patient indicated for reduced‐dose DOAC, 64.6% and 71.7% of clinicians chose to use reduced‐dose apixaban and rivaroxaban, respectively. Only 35.0% of clinicians correctly answered all 4 scenarios with the label‐indicated dose; this knowledge gap was similar between clinicians who did and did not underdose. Among patients with atrial fibrillation, the median age was 65 years, and 89% were currently anticoagulated. Patients and clinicians ranked stroke prevention and avoiding severe bleeding as very important to anticoagulation decision making. Patients were more likely than clinicians to rank the ability to reduce anticoagulation dose if needed as very important (70.5% versus 43.6%; P<0.001).ConclusionsThere are considerable knowledge gaps regarding DOAC dosing in clinicians treating patients with atrial fibrillation, as well as significant differences in treatment dosing preferences between clinicians and patients.

Role of point-of-care tests in the management of febrile children: a qualitative study of hospital-based doctors and nurses in England

ObjectivesThe use of rapid point-of-care tests (POCTs) has been advocated for improving patient management and outcomes and for optimising antibiotic prescribing. However, few studies have explored healthcare workers’ views about...

P148. Virtual phone call or video consultations: Patient and clinician preference during COVID-19

In response to COVID-19 and social distancing guidelines, healthcare services have evolved. Telehealth has been a part of this change and many services have introduced virtual telephone clinics. The HSE recently approved a video conferencing tool, 'Attend Anywhere', and although available it is not widely used. We have received positive feedback from patients, but only a few studies provide information on patient and clinician satisfaction of virtual consultations. We aim to validate this by assessing preferences towards virtual telephone and video consultations.

An Assessment of Clinician and Patient Baseline Knowledge and Preferences Regarding Red Blood Cell Transfusions in Cardiac and Non-Cardiac Surgery

Purpose: To delineate the current knowledge of, and preference for perioperative red blood cell transfusion by clinician and patients. Methods: In this single center study, clinicians and patients were asked to complete a 21-item survey, and a 19-item survey, respectively. Results: On a 7-point category scale, clinicians felt more knowledgeable about when red blood cells should be transfused (5.5 vs 2.1; p&lt;0.0001), clinicians, in preparation for open heart surgery, were more interested in hearing about the risks and benefits of a blood transfusion (4.6 vs 2.6; p&lt;0.0001), and more clinicians felt it was important for them to be involved in deciding whether they should receive a blood transfusion (5.7 vs 5.0; p=0.015). The majority of clinicians chose hemoglobin triggers of either &lt;7.5 mg/dL for non-cardiac surgery or 7.5-8.9 mg/dL for cardiac surgery, while patients either felt they did not have enough information or did not know. Conclusion: Our results highlight important differences between clinicians and patients in the basic knowledge about, and preferences for perioperative red blood transfusion, and imply a clinician-driven decision model to transfuse RBCs, and supports future efforts to develop decision aids to facilitate patient involvement in the shared decision-making about perioperative transfusion.

Neuromuscular Clinician Preferences and Experience in the Management of Myasthenic Crisis (2662)

Neuromuscular Clinician Preferences and Experience in the Management of Myasthenic Crisis (2662)

Adaptive Control Improves Sclera Force Safety in Robot-Assisted Eye Surgery: A Clinical Study.

The integration of robotics into retinal microsurgery leads to a reduction in surgeon perception of tool-to-tissue interaction forces. This blunting of human tactile sensory input, which is due to the inflexible mass and large inertia of the robotic arm as compared to the milli-Newton scale of the interaction forces and fragile tissues during ophthalmic surgery, identifies a potential iatrogenic risk during robotic eye surgery. In this paper, we aim to evaluate two variants of an adaptive force control scheme implemented on the Steady-Hand Eye Robot (SHER) that are intended to mitigate the risk of unsafe scleral forces. The present study enrolled ten retina fellows and ophthalmology residents into a simulated procedure, which simply asked the trainees to follow retinal vessels in a model retina surgery environment. For this purpose, we have developed a force-sensing (equipped with Fiber Bragg Grating (FBG)) instrument to attach to the robot. A piezo-actuated linear stage for creating random lateral motions to the eyeball phantom has been provided to simulate disturbances during surgery. The SHER and all of its dependencies were set up in an operating room in the Wilmer Eye Institute at the Johns Hopkins Hospital. The clinicians conducted robot-assisted experiments with the adaptive controls incorporated as well as freehand manipulations. The results indicate that the Adaptive Norm Control (ANC) method, is able to maintain scleral forces at predetermined safe levels better than even freehand manipulations. Novice clinicians in robot training however, subjectively preferred freehand maneuvers over robotic manipulations. Clinician preferences once highly skilled with the robot is not assessed in this study.

Technology-Based Psychological Interventions for Young Adults With Early Psychosis and Cannabis Use Disorder: Qualitative Study of Patient and Clinician Perspectives.

BackgroundThe persistence of cannabis use disorder (CUD) in young adults with first-episode psychosis (FEP) is associated with poor clinical and functional outcomes. Face-to-face psychological interventions are effective in treating CUD. However, their use in early intervention services (EISs) for psychosis is inconsistent because of barriers, including high workload and heterogeneity in training of clinicians and lack of motivation for treatment among patients. Tailoring new technology-based psychological interventions (TBPIs) to overcome these barriers is necessary to ensure their optimal acceptability.ObjectiveThe aim of this study is twofold: to explore psychological intervention practices and intervention targets that are relevant for treating CUD in individuals with early psychosis and to explore factors related to the development and implementation of a technology-assisted psychological intervention.MethodsA total of 10 patients undergoing treatment for FEP and CUD in EISs participated in a focus group in June 2019. Semistructured individual interviews were conducted with 10 clinicians working in first-episode clinics in the province of Québec, Canada. A hybrid inductive-deductive approach was used to analyze data. For the deductive analysis, we used categories of promoting strategies found in the literature shown to increase adherence to web-based interventions for substance use (ie, tailoring, reminders, delivery strategies, social support, and incentives). For the inductive analysis, we identified new themes through an iterative process of reviewing the data multiple times by two independent reviewers.ResultsData were synthesized into five categories of factors that emerged from data collection, and a narrative synthesis of commonalities and differences between patient and clinician perspectives was produced. The categories included attitudes and beliefs related to psychological interventions (eg, behavioral stage of change), strategies for psychological interventions (eg, motivational interviewing, cognitive behavioral therapy, psychoeducation, stress management), incentives (eg, contingency management), general interest in TBPIs (eg, facilitators and barriers of TBPIs), and tailoring of TBPIs (eg, application needs and preferences, outcome measures of interest for clinicians).ConclusionsThis study provides a comprehensive portrait of the multifaceted needs and preferences of patients and clinicians related to TBPIs. Our results can inform the development of smartphone- or web-based psychological interventions for CUD in young adults with early psychosis.

AB033. SOH21AS156. Virtual phone call or video consultations: patient and clinician preference during COVID-19

Background: In response to COVID-19 and social distancing guidelines, healthcare services have evolved. Telehealth has been a part of this change and many services have introduced virtual telephone clinics. The HSE recently approved a video conferencing tool, ‘Attend Anywhere’, and although available it is not widely used. We have received positive feedback from patients, but only a few studies provide information on patient and clinician satisfaction of virtual consultations. We aim to validate this by assessing preferences towards virtual telephone and video consultations.

FACTORS ASSOCIATED WITH ANTIHYPERTENSIVE MONOTHERAPY AMONG US ADULTS WITH TREATED AND UNCONTROLLED BLOOD PRESSURE, NHANES 2005-2016

Abstract Objective: Combining antihypertensive medication classes more efficaciously lowers blood pressure (BP) than monotherapy. We sought to determine factors associated with antihypertensive monotherapy in US adults with uncontrolled BP. Design and method: This serial, cross-sectional study analyzed pooled data from the 2005–2008, 2009–2012, and 2013–2016 US National Health and Nutrition Examination Survey (NHANES) cycles. We included NHANES participants age 20 years or older with hypertension taking antihypertensive medication and with uncontrolled BP, defined as systolic BP of 140 mm Hg or greater or diastolic BP of 90 mm Hg or greater (N = 2,699). Antihypertensive medication use was obtained from a medication inventory of participants’ pill bottles. We calculated prevalence ratios (PRs) and 95% confidence intervals (CIs) for antihypertensive monotherapy versus taking more than one antihypertensive medication associated with each characteristic using multivariable adjusted Poisson regression models with robust standard errors. Results: The proportion of US adults with hypertension and uncontrolled BP taking monotherapy was 35.7%, 36.3%, and 37.9% in 2005–2008, 2009–2012, and 2013–2016, respectively. After multivariable-adjustment, monotherapy was more common among current smokers (PR 1.26, 95%CI 1.06–1.50) compared to never/former smokers. Monotherapy was less common among participants 75 years or older (PR 0.71, 95%CI 0.53–0.95) compared to participants younger than 40 years, females (PR 0.81, 95%CI 0.71–0.92) compared to males, non-Hispanic black adults (PR 0.76, 95%CI 0.65–0.89) compared to non-Hispanic white adults, and obese (PR 0.73, 95%CI 0.63–0.86) compared to normal/underweight participants. Monotherapy was also less common among participants with versus without diabetes (PR 0.80 95%CI 0.67–0.94), coronary heart disease (PR 0.73, 95%CI 0.54–0.98), chronic kidney disease (PR 0.80, 95%CI 0.68–0.94), and heart failure (PR 0.46, 95%CI 0.29–0.73). Conclusions: Among US adults with hypertension and uncontrolled BP, smoking was positively associated with monotherapy use while older age, female sex, and comorbidities of diabetes, coronary heart disease, chronic kidney disease, and heart failure were associated with a lower prevalence of monotherapy use. The extent to which other factors such as clinician or patient preferences, adverse medication effects, or therapeutic inertia influence monotherapy among those with uncontrolled BP need to be investigated.

Effect of Impression Technique and Operator Experience on Impression Time and Operator-Reported Outcomes.

To investigate the effect of impression technique (conventional preliminary alginate and digital scan) and operator experience in impression making (experienced in digital and conventional, experienced in conventional and inexperienced in digital, and inexperienced in conventional and digital) on impression time, satisfaction and stress levels, and the preference of the operators. One patient was assigned for each of the 60 operators, who were experienced in impression techniques at different levels (Group 1: experienced in conventional and digital, Group 2: experienced in conventional and inexperienced in digital, Group 3: inexperienced in conventional and digital). They made conventional impressions (irreversible hydrocolloid) and digital scans (Trios 3) from the same patient. The impression times were recorded at each step (patient registration, maxillary arch, mandibular arch, and bite registration) and in total. A visual analog scale (VAS) was used for the operator satisfaction for applicability, comfort, and hygiene; the State-Trait Anxiety Inventory form (STAI-TX1) was used for stress, and a questionnaire was completed to measure the operator's impression preference. The data were analyzed with a 2-way ANOVA and Chi-square test (α = 0.05). A significant interaction was found between the operator experience in impression making and the impression technique on time for maxillary and mandibular arch impressions and total time (p ≤ 0.002). Operator experience and impression technique interaction had a significant effect on comfort and average VAS scores (p ≤ 0.016). Whereas, no significant effect of this interaction was found on stress (p ≥ 0.195). Operator experience in impression making had a significant effect on applicability (p < 0.001), and the impression technique had a significant effect on hygiene VAS scores (p < 0.001). Operators in Group 1 and Group 3 preferred the digital scans, however, operators in Group 2 had no preference (p = 0.022). Operator experience in impression making and impression technique had varying effects on clinician's impression time, comfort, applicability, hygiene, and preference. Operators needed less time for the impressions they were experienced with. Operator stress level was not affected by the operator experience in impression making and the impression technique. Dental students and operators experienced in both techniques were satisfied with the digital scans and they preferred digital scans. Operators experienced with conventional impressions were satisfied with conventional impressions but didn't have a preference for the impression type.

Time dependent hazard ratio estimation using instrumental variables without conditioning on an omitted covariate

BackgroundEstimation that employs instrumental variables (IV) can reduce or eliminate bias due to confounding. In observational studies, instruments result from natural experiments such as the effect of clinician preference or geographic distance on treatment selection. In randomized studies the randomization indicator is typically a valid instrument, especially if the study is blinded, e.g. no placebo effect. Estimation via instruments is a highly developed field for linear models but the use of instruments in time-to-event analysis is far from established. Various IV-based estimators of the hazard ratio (HR) from Cox’s regression models have been proposed.MethodsWe extend IV based estimation of Cox’s model beyond proportionality of hazards, and address estimation of a log-linear time dependent hazard ratio and a piecewise constant HR. We estimate the marginal time-dependent hazard ratio unlike other approaches that estimate the hazard ratio conditional on the omitted covariates. We use estimating equations motivated by Martingale representations that resemble the partial likelihood score statistic. We conducted simulations that include the use of copulas to generate potential times-to-event that have a given marginal structural time dependent hazard ratio but are dependent on omitted covariates. We compare our approach to the partial likelihood estimator, and two other IV based approaches. We apply it to estimation of the time dependent hazard ratio for two vascular interventions.ResultsThe method performs well in simulations of a stepwise time-dependent hazard ratio, but illustrates some bias that increases as the hazard ratio moves away from unity (the value that typically underlies the null hypothesis). It compares well to other approaches when the hazard ratio is stepwise constant. It also performs well for estimation of a log-linear hazard ratio where no other instrumental variable approaches exist.ConclusionThe estimating equations we propose for estimating a time-dependent hazard ratio using an IV perform well in simulations. We encourage the use of our procedure for time-dependent hazard ratio estimation when unmeasured confounding is a concern and a suitable instrumental variable exists.

Exploring variation in the performance of planned birth: A mixed method study

Objective: Variation in practice in relation to indications and timing for both induction of labour (IOL) and planned caesarean section (CS) clearly exists. However, the extent of this variation, and how this variation is explained by clinicians remains unclear. The aim of this study was to map the variation in IOL and planned CS at eight Australian hospitals, and understand why variation occurs from the perspective of clinicians at these hospitals. Our ultimate aim was to identify opportunities for improvement as evidenced by hospital data, clinician experiences, and feedback.Design: A two-phased mixed method study using sequential explanatory study design. The first phase consisted of an analysis of routinely collected patient data to map variation between hospitals. The second phase consisted of focus groups with clinicians to gain their perspectives on the reasons for variation.Setting and Participants: Patient data consisted of routine data from 19,073 women giving birth at eight Sydney hospitals between November 2017 and October 2018. Focus groups were attended by a total of 61 medical staff and 121 midwives.Results: Hospital data analysis found substantial variation, before and after adjustment for case-mix, in rates of both IOL (adjusted rates 27.6%–42%) and planned CS (adjusted rate 15.4%–22.6%). Planned CS by gestation also showed variation, although after restricting analysis to term (≥37 weeks gestation) births, variation was reduced. At focus groups, five main themes explaining variation emerged: local guidelines, policies and procedures (inconsistency and ambiguity); uncertainty of the evidence/what is best practice (contradictory research and different interpretations of evidence); clinician preferences, beliefs and values; the culture of the unit; and organisational influences (access to specialised clinics, theatre time).Key conclusions: Considerable variation in IOL and planned CS, even after case-mix adjustment, was found in this sample of Australian hospitals. Engagement with hospital clinicians identified likely sources of this variation and enabled clinicians at each hospital to consider appropriate local responses to address variation, such as more detailed review of their planned birth cases.Implications for practice: At a macro level, measures to reduce unwarranted variation should initially focus on consistent national guidelines, while supporting equitable access to operating theatres for optimal CS timing, and shared decision-making training to reduce influence of clinician preference.

Digital health & low-value care

Digital health advances offer a multitude of possibilities to improve public health and individual wellbeing. Little attention has been paid, however, to digital health's potential to create low-value care - the reduction of which is increasingly appreciated as a policy priority. This commentary provides a framework to illustrate the potential for consumer-facing digital health to generate three distinct categories of low-value care; 1) ineffective care because it is underdeveloped, 2) inefficient care because it supplements rather than substitutes, or 3) unwanted care because it is not aligned with clinician and patient preferences. We offer specific policy recommendations to reduce each type of low-value care.

Clinical Outcomes and Medical Costs of Hydration Therapy with Hydroxyethyl Starch (130/0.4) or Acute Single Infarction

ObjectivesTo investigate the effects of hydration with or without Hydroxyethyl Starch (HES) 130/0.4 on neurological outcomes and medical costs during hospitalisation in patients with a single infarction (SI) in the posterior lenticulostriate artery (LSA) territory. Materials and methodsIn this retrospective, single-centre, non-blinded cohort study, SI in the posterior LSA was defined as an ischaemic lesion with a high-signal intensity area ≥20 mm. All patients received basic stroke care within 48 h of symptom onset between April 2015 and January 2019. Patients were divided into the following two groups by clinician's preference: 1) those administered HES 130/0.4 and 2) those receiving other infusion fluid. The relationships between hospital costs and hydration therapy type were examined. ResultsEighteen (31%) of 58 patients received HES 130/0.4. The HES group had a significantly lower total cost than the control group (3.6 vs. 6.4 million yen, p=0.006). Moreover, the HES group had a significantly shorter hospital stay duration (79.5 vs. 141.0 days) and lower National Institutes of Health Stroke Scale score on day 7. Multivariate analysis found that HES 130/0.4 administration was an independent factor associated with high costs. ConclusionsHydration therapy with HES 130/0.4 significantly decreased the total costs and hospitalisation duration of patients with SI in the posterior LSA territory.

Complications following equine sacroiliac region analgesia are uncommon: A study in 118 horses.

BackgroundDiagnosis of sacroiliac region pain is supported by a positive response to sacroiliac region analgesia (SIRA). Varying techniques have been described for SIRA; with clinician preference often dictating method. Potential complications following SIRA include ataxia and recumbency. No study has specifically evaluated the prevalence of complications.ObjectivesTo describe the complication prevalence following SIRA in a referral clinic.Study designRetrospective cohort study.MethodsReview of records from horses presented to two of the authors at Rossdales, Newmarket, between January 2014 and December 2018, that underwent SIRA. Injection was performed using a blind midline approach with 20 mL mepivacaine (Intra-Epicaine 20mg/ml; Dechra) infiltrated through a straight 18 gauge 8.9cm spinal needle subdivided into four sub-locations per block.Results118 horses were included, with 167 individual blocks. One horse showed a mild hindlimb gait abnormality following SIRA, which resolved uneventfully over 3 hours; complication rate 1/118 horses (0.85%; 95% CI: 0,2.5%), 1/167 joints (0.60%; 95% CI: 0,1.8%). SIRA subjectively improved lameness/performance in 132/167 (79%) joints. 49/118 (42%) received bilateral SIRA with 53/118 (45%) evaluated ridden following SIRA.Main limitationsSmall population numbers with low complication prevalence rate.ConclusionsSIRA, using the described technique, has a low (0.85%) prevalence of complications.

Preferences of patients and clinicians for treatment of Graves' disease: a discrete choice experiment.

Treatment options for Graves' disease (GD) consist of antithyroid drugs (ATD), radioactive iodine (RAI) and total thyroidectomy (TT). Guidelines recommend to discuss these options with patients, taking into account patients' preferences. This study aims to evaluate and compare patients' and clinicians' preferences and the trade-offs made in choosing treatment. A discrete choice experiment (DCE) was performed with GD patients with a first diagnosis or recurrence in the previous year, and with clinicians. Participants were offered hypothetical treatment options which differed in type of treatment, rates of remission, severe side effects, permanent voice changes and hypocalcemia. Preference heterogeneity was assessed by latent-class analysis. In this study, 286 (82%) patients and 61 (18%) clinicians participated in the DCE. All treatment characteristics had a significant effect on treatment choice (P < 0.05). Remission rate was the most important determinant and explained 37 and 35% of choices in patients and clinicians, respectively. Both patients and clinicians preferred ATD over surgery and RAI. A strong negative preference toward RAI treatment was observed in a subclass of patients, whereas clinicians preferred RAI over surgery. For both patients and clinicians, remission rate was the most important determinant of treatment choice and ATD was the most preferred treatment option. Patients had a negative preference toward RAI compared to alternatives, whereas clinicians preferred RAI over surgery. Clinicians should be aware that their personal attitude toward RAI differs from that of their patients. This study on patients' and clinicians' preferences can support shared decision making and thereby improve clinical treatment.

O005 / #486: INTUBATION PRACTICES FOR CHILDREN IN EMERGENCY DEPARTMENTS AND INTENSIVE CARE UNITS ACROSS AUSTRALIA AND NEW ZEALAND: A SURVEY OF MEDICAL STAFF

Aims & Objectives: Intubation of children in the emergency setting is a high risk, low incidence event. Standardisation of clinical practice has been hampered by a lack of high-quality evidence to support one technique over another. We aim to report clinician preference in intubation practice of children in emergency departments (EDs) and intensive care units (ICUs) in Australia and New Zealand as baseline information to allow targeted research focused on improving the safety of paediatric emergency airway management. Methods: A voluntary questionnaire was undertaken by medical staff in EDs and ICUs associated with the Paediatric Research in Emergency Departments International Collaborative (PREDICT) and Australia and New Zealand Intensive Care Society Paediatric Study Group (ANZICS PSG) research networks. Respondents reported on their individual intubation practices. Results: A total of 502 clinicians were invited to complete the survey between May and October 2018 with 336 (66.9%) responding. There was marked variation in practice between ED clinicians and ICU clinicians in the in the techniques used for pre-oxygenation, the frequency of use of apnoeic oxygenation, and the reported use of video laryngoscopy.Conclusions: This survey highlights the self-reported variations in clinical practice in the intubation of children in the emergency and intensive care settings in Australia and New Zealand. While there is unlikely to be a one-size-fits-all approach to paediatric airway management, there is a paucity of high-quality evidence to support clinicians in adopting a best practice approach. Targeted research into preoxygenation techniques, the role and method of apnoeic oxygenation, and the role of VL in paediatric intubation is warranted.

Radiotherapy for Post-Chemotherapy Residual Mass in Advanced Seminoma: A Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography-Based Risk-adapted Approach

AimsThere is a lack of consensus regarding the management of post-chemotherapy residual mass in classical seminoma. The use of fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET-CT) may aid the detection of residual masses harbouring viable disease and help to tailor therapy. The aim of this study was to evaluate if PET-CT could identify patients who will benefit from locoregional radiotherapy. Materials and MethodsThis ethics-approved study included patients with advanced classical seminoma primarily treated with standard platinum-based first-line chemotherapy. Patients were either observed or given adjuvant radiotherapy based on the clinician's preference and followed up. For this study, patients were stratified into two groups based on FDG PET-CT residual nodal maximum standardised uptake value (SUVmax): low risk (SUVmax <3) and high risk (SUVmax ≥3). Further subgroup analysis was carried out for patients with residual nodal size ≥3 cm and SUVmax ≥3, and this was considered as the very high risk group. The diagnostic accuracy of FDG PET-CT was assessed and survival was compared between the different groups. ResultsSixty-nine patients were included in the study: 48 patients were observed and 21 received radiotherapy. The low and high risk groups contained 50.7% and 49.3% of the patients, respectively. The very high risk subgroup had 24 patients. At a median follow-up of 44 months, locoregional failures in the radiotherapy and observation cohorts were 0% and 30% (P = 0.059) in the very high risk subgroup and 5.8% and 29.4% (P = 0.078) in the high risk group. The positive predictive value for the very high risk and high risk groups was 30% and 17.1%, respectively. The benefit of locoregional control failed to translate into overall survival benefit. ConclusionA tailored, FDG PET-based risk-adapted treatment approach can refine the management of post-chemotherapy residual masses in seminoma. In this study, with the largest cohort of advanced seminoma patients treated with radiotherapy reported to date, radiotherapy seems to benefit patients with post-chemotherapy residual mass SUVmax ≥3.