Contemporary Practice Patterns Research Articles

Contemporary Practice Patterns in the Treatment of Cervical Stenosis and Central Cord Syndrome: A Survey of the Cervical Spine Research Society.

Cross-sectional study. To evaluate for areas of consensus and divergence of opinion within the spine community regarding the management of cervical spondylotic conditions and acute traumatic central cord syndrome (ATCCS) and the influence of the patient's age, disease severity, and myelomalacia. There is ongoing disagreement regarding the indications for, and urgency of, operative intervention in patients with mild degenerative myelopathy, moderate to severe radiculopathy, isolated axial symptomatology with evidence of spinal cord compression, and ATCCS without myelomalacia. A survey request was sent to 330 attendees of the Cervical Spine Research Society (CSRS) 2021 Annual Meeting to assess practice patterns regarding the treatment of cervical stenosis, myelopathy, radiculopathy, and ATCCS in 16 unique clinical vignettes with associated MRIs. Operative versus nonoperative treatment consensus was defined by a management option selected by >80% of survey participants. Overall, 116 meeting attendees completed the survey. Consensus supported nonoperative management for elderly patients with axial neck pain and adults with axial neck pain without myelomalacia. Operative management was indicated for adult patients with mild myelopathy and myelomalacia, adult patients with severe radiculopathy, elderly patients with severe radiculopathy and myelomalacia, and elderly ATCCS patients with pre-existing myelopathic symptoms. Treatment discrepancy in favor of nonoperative management was found for adult patients with isolated axial symptomatology and myelomalacia. Treatment discrepancy favored operative management for elderly patients with mild myelopathy, adult patients with mild myelopathy without myelomalacia, elderly patients with severe radiculopathy without myelomalacia, and elderly ATCCS patients without preceding symptoms. Although there is uncertainty regarding the treatment of mild myelopathy, operative intervention was favored for nonelderly patients with evidence of myelomalacia or radiculopathy and for elderly patients with ATCCS, especially if pre-injury myelopathic symptoms were present. Level V.

Treatment patterns among HCPs and concordance with expert recommendations in HER2-negative early breast cancer: Analysis of an interactive online treatment decision support tool.

e13601 Background: Management of HER2- EBC continues to evolve with expansion of targeted therapies, including abemaciclib, olaparib, and pembrolizumab, in the adjuvant setting for eligible pts. We sought to identify contemporary practice patterns among HCPs for HER2- EBC and compare them with those of experts using an online interactive decision support tool. Methods: An online decision support tool was developed with input from 5 BC experts to provide tx recommendations for 19 unique pt case scenarios based on considerations including subtype, tx history, and recurrence risk. HCPs entered specific patient criteria along with their intended management for that case, and then were shown 5 expert recommendations. HCPs were asked if the recommendations impacted their intended approach. An analysis of expert recommendations and HCP-selected tx was performed. Results: Between Oct 2023 and Jan 2024, 83 HCPs entered 105 cases. Of the 97 cases where HCPs noted a definitive tx plan, recommendations were discordant from experts in 29%. The most commonly queried cases, expert recommendations, and discordance between HCPs and experts are outlined in the table. Discord with experts was similar among HCP tx plans for cases of TNBC (33%) and HR+/HER2- EBC (27%). HCPs predominantly sought guidance for pts with HR+/HER2- EBC, no g BRCAm, and high-risk disease per monarchE trial criteria (79%), with 22% discordance from expert recommendations. Regardless of BC subtype, the highest level of discord between HCPs and experts (67%) was observed in cases where pts had received neoadjuvant tx and had no residual disease following surgery, although this represents a small subset (n = 12). When asked if the expert recommendations changed their tx choice, 7 of 27 (26%) HCPs who responded indicated that expert recommendations changed their intended tx, whereas 15% noted that there were barriers to implementing those recommendations. Conclusions: These data suggest ongoing challenges with incorporating the newest targeted therapies for high-risk EBC management. Continued education and development of resources for HCPs, including online decision support tools, may be increasingly important as the treatment of EBC continues to evolve. [Table: see text]

Contemporary androgen deprivation therapy practice patterns in locally advanced prostate cancer treated with definitive radiotherapy: Prospective results from a statewide radiation oncology quality consortium.

307 Background: Androgen Deprivation Therapy (ADT) is a critical treatment component for men with locally advanced prostate cancer receiving definitive radiotherapy. National guidelines recommend 18-36 months of ADT for men with high-risk disease, along with androgen receptor signaling inhibitors (ARSI) for those with very high-risk and clinical node positive disease. However, minimal data exist regarding treatment intent in the real-world setting. Given the rapid rate of scientific advances with respect to ADT types and duration, we hypothesized significant practice pattern variation. Using prospectively collected data, we sought to characterize patterns of care within the Michigan Radiation Oncology Quality Consortium (MROQC). Methods: This analysis includes men enrolled in MROQC with intact, non-metastatic, high-risk, or clinical node-positive (cN1) disease. Patient, tumor, and treatment data were prospectively collected at baseline and follow-up using standardized data elements. Physicians prospectively documented intent, type, and duration of ADT. Our primary outcome was guideline-concordant intended use ADT of ≥18 months. Secondary analyses included ARSI use among patients meeting eligibility for STAMPEDE high-risk M0/N1. Univariable (UVA) and multivariable (MVA) analyses were conducted to determine associations with T/N category, grade group, prostate specific antigen (PSA) and practice-related factors. Results: Between 6/9/20 to 6/30/23, 234 men across 26 centers were identified, all of whom should receive ≥18 months of ADT per NCCN guidelines. Eight percent (18/234) had locally advanced T3/4 disease, and 8% (n=18/234) had cN1 disease. Most men had grade group 4 (48%, n=112/234) or 5 (24%, n=56) adenocarcinoma. Intended ADT duration was known for 88% (n=207). ADT use ≥18 months was planned for 56% (n=115/207), <18 months in 30% (n=63/207), and no ADT was intended for 14% (n=29/207) of men. On MVA, grade group 4-5 and PSA >40 were the strongest drivers of guideline-concordant intended ADT. There were no significant associations with comorbidities or race. STAMPEDE M0/cN1 criteria were met for 15% (n=36/234). Intended ARSI use in this subset was 19% (n=7/36), including 26% (n=6/23) of patients treated after publication of STAMPEDE M0/N1. Conclusions: Within a diverse state-wide consortium of academic and community practice, guideline concordant intended ADT use was 56% and was associated with higher risk tumor features. Fewer than 1 in 5 treated with curative intent radiotherapy met STAMPEDE high-risk M0/N1 criteria, and ARSI use among these men was less than 20%. Future work will evaluate patient and practice level drivers of the variation. [Table: see text]

Abstract 16304: Contemporary Practice Patterns and Opportunities to Improve Type 2 Diabetes (T2D) Therapy in Patients at Elevated Cardiovascular and/or Kidney Risk

Background: Evidence-based SGLT2 inhibitors (SGLT2i) and GLP-1 receptor agonists (GLP-1 RA) reduce cardiovascular (CV) events and improve kidney outcomes in patients with type 2 diabetes (T2D) who are at elevated cardiac or renal risk; however, prescription rates are low despite guidelines recommending their use. We aimed to evaluate the eligibility for, and utilization of, SGLT2i and GLP-1 RA in real-world practice in a large, integrated, multicenter health system. Aim: To determine the prevalence of CV and kidney comorbidities in patients with T2D and current medication use patterns within a large, urban healthcare system. Methods: In this cross-sectional analysis of the Mass General Brigham healthcare system from 2020-2023, we identified all patients with T2D meeting current guideline eligibility criteria for SGLT2i and/or GLP-1 RA. Indications for therapy included ASCVD, heart failure, kidney disease, or high risk for developing ASCVD - determined by EHR data. High risk for developing ASCVD and ASCVD were mutually exclusive, however other indications were reported as identified comorbidities by patient. Demographics, medications, laboratory values, and comorbidities were assessed. Results: There were 304,105 people with T2D and an HbA1c within 3 years: mean age 70 years, HbA1c 7.1%, 52% male, 30% non-white, 11% non-English language preferred. 186,885 (62%) patients had > 1 CV or kidney comorbidity: 82,245 (44%) high risk for developing ASCVD, 90,408 (48%) ASCVD, 29,766 (16%) HF, 46,801 (25%) kidney disease, and 50,825 (27%) with > 2 comorbidities. Of the 186,885 patients with an indication, 21,997 (12%) were prescribed an SGLT2i, 28,620 (15%) a GLP-1 RA, and 7,544 (4%) both ( Figure 1 .) Conclusion: Ongoing limited use of agents with proven CV and kidney benefit exists among commonly encountered patients with T2D despite guideline recommendations; novel strategies are needed to overcome the barriers that keep patients from improved outcomes.

Contemporary Multiple Myeloma Treatment Patterns Among HCPs and Concordance with Expert Recommendations: Analysis of an Interactive Online Decision Support Tool

Background: The management of multiple myeloma (MM) continues to evolve with the emergence of new classes of therapy, most recently including BCMA-targeted therapies. Considering the expanding MM treatment armamentarium, we sought to identify contemporary practice patterns among healthcare professionals (HCPs) for MM and compare them with those of experts using an online decision support tool. Methods: An online decision support tool was developed with input from 5 experts providing therapy recommendations for 192 unique patient case scenarios based on considerations including disease setting, treatment history, access to therapy, and specific comorbidities. HCP tool users entered specific patient criteria to define a case along with their intended management for that case. The tool then showed the 5 expert recommendations for that same case scenario, and users were asked if the recommendations impacted their intended approach. An analysis of expert recommendations and user-selected therapy was performed. Results: Between April 2023 and July 2023, 207 patient cases were entered by 144 participating HCPs. HCP and expert treatment recommendations were frequently discordant, regardless of treatment setting (Table). The highest concordance between HCP and expert recommendations (47%; P <.0001) was in the induction setting (n = 111). In this setting, experts were more likely to recommend quadruplet regimens compared with HCPs (62% vs 27%, respectively; P <.0001). Treatment selection concordance was lower in the maintenance (n = 17; 24%; P <.0001) and relapsed/refractory settings (n = 79; 20%; P <.0001). The lowest concordance (10%; P <.0001) between HCP and expert treatment recommendations was noted in the relapsed/refractory setting specifically among patients who were refractory to earlier lines of therapy (n = 41; P <.0001). For patients who are refractory to earlier lines of therapy, experts were more likely to recommend an anti-CD38-based combination regimen compared with HCPs (81% vs 32; P <.0001). When recommending treatment for patients with triple- or penta-refractory disease, experts were significantly more likely to recommend BCMA-targeted agents (83% vs 39%; P <.0001). For HCPs whose treatment plan did not match expert recommendations in these scenarios, 53% of respondents indicated that expert recommendations confirmed or changed their intended therapy, but 31% indicated that there were barriers to implementing those recommendations. Conclusions: These data suggest ongoing challenges with incorporating the newest therapies and combinations across the spectrum of MM into patient care, particularly multidrug regimens in the induction and maintenance settings and BCMA-targeted therapies in those with triple- or penta-refractory disease. Continued education and development of resources for HCPs, including online decision support tools, may be increasingly important as the treatment of MM continues to grow in complexity.

Contemporary transesophageal echocardiography practice patterns among paediatric cardiology centres in the United States and Canada.

To characterise transesophageal echocardiography practice patterns among paediatric cardiac surgical centres in the United States and Canada. A 42-question survey was sent to 80 echocardiography laboratory directors at paediatric cardiology centres with surgical programmes in the United States and Canada. Question domains included transesophageal echocardiography centre characteristics, performance and reporting, equipment use, trainee participation, and quality assurance. Fifty of the 80 centres (62.5%) responded to the survey. Most settings were academic (86.0%) with 42.0% of centres performing > 350 surgical cases/year. The median number of transesophageal echocardiograms performed/cardiologist/year was 50 (26, 73). Pre-operative transesophageal echocardiography was performed in most surgical cases by 91.7% of centres. Transesophageal echocardiography was always performed by most centres following Norwood, Glenn, and Fontan procedures and by < 10% of centres following coarctation repair. Many centres with a written guideline allowed transesophageal echocardiography transducer use at weights below manufacturer recommendations (50.0 and 61.1% for neonatal and paediatric transducers, respectively). Most centres (36/37, 97.3%) with categorical fellowships had rotations which included transesophageal echocardiography participation. Large surgical centres (>350 cases/year) had higher median number of transesophageal echocardiograms/cardiologist/year (75.5 [53, 86] versus 35 [20, 52], p < 0.001) and more frequently used anaesthesia for diagnostic transesophageal echocardiography ≥ 67% of time (100.0 versus 62.1%, p = 0.001). There is significant variability in transesophageal echocardiography practice patterns and training requirements among paediatric cardiology centres in the United States and Canada. Findings may help inform programmatic decisions regarding transesophageal echocardiography expectations, performance and reporting, equipment use, trainee involvement, and quality assurance.

Antimicrobial Prophylaxis for Percutaneous Nephrolithotomy: Contemporary Practice Patterns.

Background: Updated in 2019, the American Urological Association's (AUA) Best Practice Statement on Urologic Procedures and Antimicrobial Prophylaxis outlines prophylaxis for percutaneous nephrolithotomy (PCNL). Recent studies have challenged these recommendations. We hypothesized that endourologists do not routinely follow the AUA's statement on antibiotic use during PCNL and assessed their prescribing patterns. Methods: A 24-question survey was distributed to members of the Endourological Society. The primary outcome was adherence to the AUA's recommendations. Two multiple logistic regression analyses were performed with demographics and antibiotic preference as predictors of following the AUA. Results: A total of 51.4% of endourologists follow the AUA Best Practice Statement for antimicrobial prophylaxis of uncomplicated PCNL. No demographic data were predictive of following the AUA. 90.9% and 83.6% reported they have "never" used the first-line recommendation options of metronidazole and aztreonam, respectively. Preferred antibiotics were cephalosporins (uncomplicated 60%, complicated 52.6%), fluoroquinolones (13.3%, 7.2%), aminoglycosides (12.7%, 17.8%), penicillins (7.9%, 11.2%), carbapenems (0.6%, 0.7%), trimethoprim-sulfamethoxazole (2.4%, 5.9%), fosfomycin (0.6%, 0.7%), nitrofurantoin (2.4%, 2.6%), aztreonam (0%, 0.7%), and clindamycin (0%, 0.7%). For uncomplicated PCNL, 63.1% prescribe ≤24 hours of perioperative antibiotics. For complicated PCNL, 16.2% prescribe ≤24 hours of perioperative antibiotics, while 20.4% begin antibiotics 7 or more days prior. Conclusions: Nearly half of respondents do not follow the AUA's recommendations for antibiotic choice for PCNL. Few endourologists prescribe 7 days of preoperative antibiotics for complicated PCNL despite supporting data. Metronidazole and aztreonam are rarely used as a first-line antibiotic choice for PCNL and their roles needs to be further evaluated as first-line prophylaxis recommendations. Updates on antibiotic recommendations for PCNL are needed based on current literature, antimicrobial stewardship, and contemporary practice patterns.

TCT-447 Contemporary Practice Patterns and Outcomes for Patients With Mitral Regurgitation: Results From a Large Multicenter Real-World Database

TCT-447 Contemporary Practice Patterns and Outcomes for Patients With Mitral Regurgitation: Results From a Large Multicenter Real-World Database

Patterns and Longitudinal Changes in The Practice of Breast Cancer Radiotherapy in Korea: Korean Radiation Oncology Group 22-01

To analyze contemporary practice patterns in breast cancer radiotherapy (RT) and to assess longitudinal changes therein over 5 years in Korea. A nationwide survey was conducted among board-certified radiation oncologists in Korea by the Division for Breast Cancer of the Korean Radiation Oncology Group in March 2022. The survey consisted of 44 questions related to six domains: hypofractionated (HypoFx) whole breast RT, accelerated partial breast RT (APBI), regional nodal irradiation (RNI), RT for ductal carcinoma in situ (DCIS), postmastectomy RT (PMRT), and tumor bed boost. In total, 70 radiation oncologists from 61 of 101 (60%) institutions participated in the survey. HypoFx RT was used by 62 respondents (89%), which has significantly increased from 36% in 2017. The HypoFx RT was commonly administered at 40-42.5 Gy in 15-16 fractions. APBI was used by 12 respondents (17%), which has increased from 5% in 2017. The use of RNI did not change significantly: ≥ pN2 (6%), ≥ pN1 (33%), and ≥ pN1 with pathological risk factors (61%). However, the indications for use of internal mammary lymph node (IMN) irradiation have expanded. In particular, the rates of routine treatment of IMN (11% from 6% in 2017) and treatment in cases of ≥ pN2 (27% from 14% in 2017) have doubled; however, the rate of treatment for only IMN involvement, identified on imaging, has decreased to 31% from 47% in 2017. With regard to DCIS, the use of hypoFx RT increased to 75% from 25%, and the rate of omission on of RT after breast-conserving surgery decreased to 38% from 48% in 2017. The use of hypoFx RT for PMRT also increased to 36% from 8% in 2017. The adoption of HypoFx RT after breast-conserving surgery in invasive breast cancer and DCIS has increased significantly, whereas that for PMRT has increased moderately, compared to 2017. Further studies are required to determine the optimal use of RNI.

Volume distribution of primary shoulder arthroplasty among low- and high-volume surgeons

BackgroundCare from high-volume surgeons has been shown to improve patient outcomes and reduce revision rates, complications, and hospital stays. According to prior research, most shoulder arthroplasties are performed by lower volume surgeons. However, this research is limited as it does not account for the recent increase in case numbers and projected growth of shoulder arthroplasty, and was focused only to states with urban populations. The purpose of this study is to identify and compare contemporary shoulder arthroplasty practice patterns and volume distributions in the state of Iowa. MethodsThe Iowa Hospital Association Databank was queried using International Classification of Diseases (ICD)-10 procedure codes for primary total shoulder arthroplasty. Surgeon and hospital volume were stratified according to procedures performed yearly as: low-volume <15 arthroplasties yearly, medium-volume 15-49, and high-volume ≥50 arthroplasties yearly. The proportion of surgeon and hospital volume, and number of procedures performed by each group were assessed. Distance traveled by patients to visit high-volume vs. low-volume surgeons and hospitals was compared. ResultsIn 2019, 1847 primary shoulder arthroplasties were performed in the state of Iowa by 144 surgeons at 49 institutions. Seventy four percent (106/144) of these surgeons were considered low-volume, 20% (29/144) medium-volume, and only 6% (9/144) were high-volume. However, 43% (793/1847) of shoulder arthroplasties were performed by high-volume surgeons, and 18% (333/1847) by low-volume surgeons. Eighteen percent (9/49) of hospitals where shoulder arthroplasties were performed qualified as high-volume institutions, whereas 45% (22/49) were low-volume. Compared to previous results, 65% (1194/1847) of procedures were performed at high-volume institutions and 6% (118/1847) at low-volume institutions. There was a significant difference in median distance traveled for patients to access high vs. low-volume surgeons (34 vs. 14 miles, P < .0001), and high-volume vs. low-volume hospitals (30 vs. 14.5, P < .0001). DiscussionIn the state of Iowa, while only a small portion of surgeons are considered “high-volume”, almost half of primary shoulder arthroplasties are performed by high-volume surgeons. These findings differ from the previous literature regarding volume distribution in shoulder arthroplasty. Furthermore, the results from this study demonstrate a shift from former documented trends which in the past had indicated that most shoulder arthroplasties were performed by low-volume surgeons. Data from this current study provides a glimpse into the evolution in practice patterns for shoulder arthroplasty. As practice patterns continue to evolve, further investigation may demonstrate improved patient outcomes in patients undergoing shoulder arthroplasty at higher volume hospitals with high-volume surgeons.

Acceptance of Early Surgery for Treatment of Spinal Cord Cavernous Malformation in Contemporary Japan.

Spinal cord cavernous malformation (CM) is an intramedullary vascular lesion that may present with progressive symptoms. Surgery is recommended for symptomatic patients, but optimal timing of surgery is debatable. Some advocate waiting until plateau of neurological recovery and others support emergency surgery. There is no statistic on how commonly these strategies are utilized. We aimed to find contemporary practice pattern among neurosurgical spine centers in Japan. A database of intramedullary spinal cord tumors assembled by Neurospinal Society of Japan was surveyed and 160 patients with spinal cord CM were identified. Neurological function, disease duration, and number of days between presentation to hospitals and surgery were analyzed. Duration of disease before presentation to hospitals ranged from 0 to 336 months (median, 4 months). Number of days between patients' presentation and surgery ranged from 0 to 6,011 days (median, 32 days). Time from symptom onset to surgery ranged from 0 to 336.9 months (median, 6.6 months). Patients with severe preoperative neurological dysfunction had shorter duration of disease, fewer days between presentation and surgery, and shorter time between symptom onset and surgery. Patients with paraplegia or quadriplegia were more likely to improve when operated on within 3 months from onset. Timing of surgery for spinal cord CM in Japanese neurosurgical spine centers generally was early, with 50% of patients undergoing surgery within 32 days after presentation. Further study is needed to clarify optimal timing of surgery.

The Use of Salvage Chemotherapy for Patients with Relapsed Testicular Germ Cell Tumor (GCT) in Canada: A National Survey.

Although metastatic germ cell tumor (GCT) is highly curable with initial cisplatin-based chemotherapy (CT), 20-30% of patients relapse. Salvage CT options include conventional (CDCT) and high dose chemotherapy (HDCT), however definitive comparative data remain lacking. We aimed to characterize the contemporary practice patterns of salvage CT across Canada. We conducted a 30-question online survey for Canadian medical and hematological oncologists with experience in treating GCT, assessing treatment availability, patient selection, and management strategies used for relapsed GCT patients. There were 30 respondents from 18 cancer centers across eight provinces. The most common CDCT regimens used were TIP (64%) and VIP (25%). HDCT was available in 13 centers (70%). The HDCT regimen used included carboplatin and etoposide for two cycles (76% in 7 centers), three cycles (6% in 2 centers), and the TICE protocol (11%, in 2 centers). "Bridging" CDCT was used by 65% of respondents. Post-HDCT treatments considered include surgical resection for residual disease (87.5%), maintenance etoposide (6.3%), and surveillance only (6.3%). HDCT is the most commonly used GCT salvage strategy in Canada. Significant differences exist in the treatment availability, selection, and delivery of HDCT, highlighting the need for standardization of care for patients with relapsed testicular GCT.

Innovations in Endourologic Stone Surgery: Contemporary Practice Patterns from a Global Survey.

Objective: The purpose of this study is to evaluate the current availability of technology for urolithiasis treatment and ureteroscopy (URS). Perioperative practice patterns, availability of ureteroscopic technologies, pre- and poststenting practices, and methods to alleviate stent-related symptoms (SRS) were assessed via a survey of members of the Endourological Society. Methods: We distributed a 43-question survey online via the Qualtrics platform to members of the Endourological Society. The survey consisted of questions pertaining to the following topics: general (6), equipment (17), preoperative URS (9), intraoperative URS (2), and postoperative URS (9). Results: A total of 191 urologists responded to the survey and 126 completed all questions of the survey (66%). Fifty-one percent (65/127) of urologists were fellowship trained and dedicated an average of 58% of their practice to stone management. In terms of procedures, most urologists performed URS most commonly (68%), followed by percutaneous nephrolithotomy (23%) and extracorporeal shockwave lithotripsy (11%). Ninety percent (120/133) of respondent urologists purchased a new ureteroscope within the last 5 years (16% single-use scopes, 53% reusable, and 31% purchased both). Fifty-three percent (70/132) of the respondents stated that they would be interested in a ureteroscope that can sense intrarenal pressure, with an additional 28% (37/132) stating they would be interested depending on the cost. Seventy-four percent (98/133) of responders purchased a new laser within the last 5 years, and 59% (57/97) changed their lasering technique due to the new laser. Urologists are performing primary ureteroscopy for obstructing stones in 70% of cases, and prefer prestenting patients for subsequent URS in 30% (on average after 21 days). Seventy-one percent (90/126) of responders insert a ureteral stent after uncomplicated URS, which is removed, on average, after 8 days in uncomplicated cases and 21 days after complicated URS. Most urologists give analgesics, alpha-blockers, and anticholinergics for SRS and <10% prescribe opioids. Conclusion: Our survey revealed urologists' eagerness for the early adoption of novel technologies and adherence to conservative practice patterns focused on patient safety.

CI-452768-3 PREVALENCE, TREATMENT AND OUTCOMES OF LEAD-RELATED VENOUS OBSTRUCTION AMONG MEDICARE PATIENTS WITH CARDIOVASCULAR IMPLANTABLE ELECTRONIC DEVICES IN THE UNITED STATES

The incidence and clinical burden of lead-related venous obstruction (LRVO) remains poorly understood despite rising implant rates for cardiovascular implantable electronic devices (CIEDs). Determine the incidence and predictors of symptomatic LRVO after CIED implant in the US; describe contemporary practice patterns in CIED extraction and revascularization; quantify the burden of LRVO-related healthcare utilization, based on each type of intervention. LRVO status, comorbidities, and healthcare visits were defined in Medicare beneficiaries who received a CIED from October 1, 2015 to December 31, 2020. Cumulative incidence functions of LRVO development were estimated by Fine-Gray methods. Independent associations between patient factors and LRVO were identified using multivariable logistic regression. Incidence rates for LRVO-related healthcare utilization (i.e. hospitalizations, emergency department and clinic visits) were calculated with Poisson models. Among 649,524 Medicare beneficiaries who received their first transvenous CIED, 28,214 developed LRVO – generating a cumulative incidence of 5.0% (95% confidence interval [CI] 4.9%-5.1%) at a maximum follow-up time of 5.2 years after CIED implant. Patients with LRVO had a mean age of 77.6 years, with 41.5% females. Cardiovascular comorbidities were common and similarly distributed among patients with and without LRVO. Independent predictors of LRVO included having a CIEDs with >1 lead (adjusted odds ratio [AOR] 1.07, 95% CI 1.02-1.11), chronic kidney disease (AOR 1.13, 95% CI 1.10-1.16) and malignancies (AOR 1.24, 95% CI 1.20, 1.27). Among 28,214 patients with LRVO, most were managed conservatively (85.2%). Of the 14.8% (N=4,186) who received an invasive intervention, the majority consisted of CIED extraction (74%) followed by percutaneous revascularization (26%). Of the 3,111 patients who underwent extraction, 90% did not receive a second CIED, with low use (2.2%) of leadless pacemakers. In adjusted models, extraction was associated with a significant reduction in LRVO-related healthcare utilization compared to conservative management (adjusted rate ratio 0.58, 95% CI 0.52, 0.66). In a large nationwide sample, the incidence of LRVO was substantial, affecting 1 of every 20 patients with CIEDs. Most events occurred within 2 years of device placement. Among patients treated for LRVO, device extraction was most commonly used and allowed for the greatest long-term reduction in recurrent healthcare utilization.

Clinical Profiles, Outcomes, and Sex Differences of Patients With STEMI: Findings From the NORIN-STEMI Registry

BackgroundLow- and middle-income countries account for most of the global burden of coronary artery disease. There is a paucity of data regarding epidemiology and outcomes for ST-segment elevation myocardial infarction (STEMI) patients in these regions. ObjectivesThe authors studied the contemporary characteristics, practice patterns, outcomes, and sex differences in patients with STEMI in India. MethodsNORIN-STEMI (North India ST-Segment Elevation Myocardial Infarction Registry) is an investigator-initiated prospective cohort study of patients presenting with STEMI at tertiary medical centers in North India. ResultsOf 3,635 participants, 16% were female patients, one-third were <50 years of age, 53% had a history of smoking, 29% hypertension, and 24% diabetes. The median time from symptom onset to coronary angiography was 71 hours; the majority (93%) presented first to a non-percutaneous coronary intervention (PCI)-capable facility. Almost all received aspirin, statin, P2Y12 inhibitors, and heparin on presentation; 66% were treated with PCI (98% femoral access) and 13% received fibrinolytics. The left ventricular ejection fraction was <40% in 46% of patients. The 30-day and 1-year mortality rates were 9% and 11%, respectively. Compared with male patients, female patients were less likely to receive PCI (62% vs 73%; P < 0.0001) and had a more than 2-fold greater 1-year mortality (22% vs 9%; adjusted HR: 2.1; 95% CI: 1.7-2.7; P < 0.001). ConclusionsIn this contemporary registry of patients with STEMI in India, female patients were less likely to receive PCI after STEMI and had a higher 1-year mortality compared with male patients. These findings have important public health implications, and further efforts are required to reduce these gaps.

MP61-07 EARLY SECONDARY TREATMENT OF LYMPH NODE POSITIVE PROSTATE CANCER AFTER RADICAL PROSTATECTOMY IS ASSOCIATED WITH AGGRESSIVE TUMOR FEATURES AND DETECTABLE PROSTATE SPECIFIC ANTIGEN

You have accessJournal of UrologyCME1 Apr 2023MP61-07 EARLY SECONDARY TREATMENT OF LYMPH NODE POSITIVE PROSTATE CANCER AFTER RADICAL PROSTATECTOMY IS ASSOCIATED WITH AGGRESSIVE TUMOR FEATURES AND DETECTABLE PROSTATE SPECIFIC ANTIGEN Daniel Triner, Ji Qi, Udit Singhal, Michael Sessine, Kevin Ginsburg, Brian Lane, and Todd Morgan Daniel TrinerDaniel Triner More articles by this author , Ji QiJi Qi More articles by this author , Udit SinghalUdit Singhal More articles by this author , Michael SessineMichael Sessine More articles by this author , Kevin GinsburgKevin Ginsburg More articles by this author , Brian LaneBrian Lane More articles by this author , and Todd MorganTodd Morgan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003319.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Patients with lymph node positive (pN+) disease found at the time of radical prostatectomy (RP) and pelvic lymphadenectomy (PLND) are at high risk of disease recurrence and progression. There is ongoing debate with regards to optimal care of pN+patients. While data supports the use of adjuvant androgen deprivation therapy (ADT) with or without radiation (RT), most guidelines include observation as an alternative. We sought to understand contemporary practice patterns of patients with pN+prostate cancer (PCa) in a diverse, statewide quality collaborative. METHODS: Patients in the Michigan Urologic Surgery Improvement Collaborative (MUSIC) with PCa who underwent RP with PLND and pN+on final pathology and 12 months follow up between March 2012 and Feb 2021 were identified. Patients who received neoadjuvant therapy were excluded. The primary outcome was early post-RP treatment (ADT, RT, ADT+RT) within 12 months of diagnosis, which was categorized as either adjuvant (PSA<0.1 ng/ml) or salvage (PSA≥0.1 ng/ml). Time to any post-RP treatment and type of treatment were secondary outcomes. Multivariable logistic and Cox regression models were fit to identify factors associated with post-RP treatment. Kaplan-Meier analysis was performed to assess treatment-free survival. RESULTS: We identified 425 patients who had pN+disease at the time of RP, of which 280 (66%) underwent early post-RP treatment (86 adjuvant and 194 salvage) and 145 (34%) were observed. One year treatment-free survival for patients with first post-RP PSA≥0.1 was 18% (95% CI 14%-24%) compared to 58% (95% CI 51%-65%) for PSA<0.1 ng/ml (p<0.001). In the multivariable Cox model, pathologic grade group, tumor stage, margin status, first post-RP PSA, and race were associated with time to secondary treatment (p<0.05 for each). Of 145 patients on initial observation, 23% had post-RP PSA≥0.1. ADT was most common early adjuvant therapy (45.4%), followed by ADT+RT (36%), RT alone (17.4%), and other (1.2%) CONCLUSIONS: Most patients with pN+PCa in MUSIC received early post-RP treatment and men with a first post-RP PSA<0.1ng/mL had improved secondary treatment free survival. Early treatment, which was predominantly ADT±RT, is influenced by aggressive disease features and detectable post-RP PSA. Nearly one out of four patients with pN+cancer not receiving early post RP treatment had a detectable PSA, suggesting an opportunity for quality improvement by increasing use of postoperative therapy. Source of Funding: Blue Cross Blue Shield of Michigan © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e855 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel Triner More articles by this author Ji Qi More articles by this author Udit Singhal More articles by this author Michael Sessine More articles by this author Kevin Ginsburg More articles by this author Brian Lane More articles by this author Todd Morgan More articles by this author Expand All Advertisement PDF downloadLoading ...

Preventive medicine in pediatric cardiology practice.

The objective of the study was to assess contemporary practice patterns of pediatric cardiologists with respect to cholesterol disorders and smoking-related illness. We sent 2 anonymous surveys to the members of the American Academy of Pediatrics Section on Cardiology and Cardiac Surgery and the Pediheart online community. The surveys addressed training in and management of cholesterol disorders and smoking-related illness. There were 97 responses to the cholesterol disorders survey. A total of 51.6% reported little or no formal training on cholesterol disorders. A total of 56.4% underestimated the prevalence of familial hypercholesterolemia by at least twofold. A total of 54.7% were at least somewhat comfortable prescribing statins. In 5 clinical vignettes, respondents frequently gave clinical recommendations in line with the 2019 American Heart Association guidelines although both undertreatment and overtreatment were recommended. There were 90 responses to the survey on smoking-related illness. Little or no formal training in nicotine addiction (52.3%) or smoking cessation (60.5%) was reported by respondents. Respondents screened for tobacco use in less than a one-third of hospitalizations and less than two-thirds of outpatient clinic visits. Screening for exposure to secondhand smoke was even less common. Twenty-seven percent of respondents never recommend a household smoking ban for their patients. A total of 83.3% were uncomfortable prescribing medications for their patients for smoking cessation, and 65.5% rarely or never refer patients for smoking cessation assistance. Although positioned to address the childhood origins of adult heart disease, those cardiologists surveyed placed a limited emphasis on cholesterol disorders and smoking-related disease in their clinical practice.

Patterns and Longitudinal Changes in the Practice of Breast Cancer Radiotherapy in Korea: Korean Radiation Oncology Group 22-01.

We aimed to analyze contemporary practice patterns in breast cancer radiotherapy (RT) and assess longitudinal changes over five years in Korea. In 2022, a nationwide survey was conducted among board-certified radiation oncologists. The survey consisted of 44 questions related to six domains: hypofractionated (HypoFx) whole breast RT, accelerated partial breast RT (APBI), regional nodal irradiation (RNI), RT for ductal carcinoma in situ (DCIS), postmastectomy RT (PMRT), and tumor bed boost. Seventy radiation oncologists from 61 (out of 101; 60%) institutions participated in the survey. HypoFx RT was used by 62 respondents (89%), a significant increase from 36% in 2017. HypoFx RT is commonly administered at 40-42.5 Gy in 15-16 fractions. APBI was used by 12 respondents (17%), an increase from 5% in 2017. The use of RNI did not change significantly: ≥ pN2 (6%), ≥ pN1 (33%), and ≥ pN1 with pathological risk factors (61%). However, indications for internal mammary lymph node (IMN) irradiation have expanded. In particular, the rates of routine treatment of IMN (11% from 6% in 2017) and treatment in cases of ≥ pN2 (27% from 14% in 2017) have doubled; however, the rate of treatment for only IMN involvement, identified on imaging, has decreased from 47% in 2017 to 31%. For DCIS, the use of HypoFx RT increased from 25% in 2017 to 75%, and the rate of RT omissions after breast-conserving surgery (BCS) decreased from 48% in 2017 to 38%. The use of HypoFx RT for PMRT increased from 8% in 2017 to 36%. The adoption of HypoFx RT after BCS for invasive breast cancer and DCIS has increased significantly, whereas the use of HypoFx PMRT has increased moderately since 2017. However, further studies are required to determine the optimal use of RNI.

A Survey on the Choice of Spinal Cord Stimulation Parameters and Implantable Pulse Generators and on Reasons for Explantation.

Spinal Cord Stimulation (SCS) is a vital treatment for chronic intractable pain. In the last few years, the field has undergone dramatic changes in new waveform and frequency introduction as well as device miniaturization. It is important to understand contemporary practice patterns regarding these parameters. We surveyed the active membership of Spine Intervention Society (SIS), and American Society of Regional Anesthesia (ASRA) on their practices regarding various aspects of Spinal Cord Stimulation therapy. Here we report on SCS waveform usage, battery types, and causes of explant in this cohort of providers. There was similar degree of usage of tonic, burst, and 10 kHz usage at 71.5%, 74.1% and 61.7% respectively. Dorsal root ganglion stimulation was used by 32.6% and other modes of stimulation by 13.5%. Rechargeable systems were often or always used by 67.2% whereas 10% never used a rechargeable system. Most common cause of explant was loss of effectiveness, reported by 53.7%. There has been significant adoption of new waveforms in daily practice of spinal cord stimulation therapy and there is robust mixed usage of new waveforms and frequencies. Rechargeable systems are the most commonly used but primary cell is also used in significant numbers. Loss of efficacy remains the most common cause of explant for the majority of practitioners. This survey establishes practice patterns of SCS usage regarding these important variables against which future changes can be gauged.

National Collegiate Athletic Association athletic trainers’ response to the Arrington settlement: management, compliance, and practice patterns

ABSTRACT The primary purpose of this study was to assess Athletic Trainers’ (ATs) report of NCAA member institution compliance with the Arrington settlement, the concussion lawsuit vs. the NCAA, and to elucidate compliance predictors. A secondary purpose was to provide a contemporary concussion management clinical practice pattern description among NCAA collegiate athletic trainers. Head Athletic Trainers from NCAA Division I, II, and III completed an electronic questionnaire in August 2020 regarding their institution’s response to the Arrington Settlement and their current concussion management clinical practice patterns. The 37-item questionnaire included AT and institution demographics, current concussion management policies, and response to the Arrington settlement with a specific focus on the five settlement requirements. An overall compliance score on the five requirements, compliance on the individual requirements, and concussion management practices are reported with descriptives. Regression was used to identify specific predictors of both overall and individual settlement requirements. An ANOVA compared compliance by NCAA division level. Being pressured to be non-compliant was assessed between sexes by a chi-square. There were 223 respondents (21.8%), and overall compliance was high (4.1 ± 0.7) with the five required Arrington Settlement components. Settlement requirement 1, pre-season baseline testing, and requirement 5, presence of trained personnel at all contact sport practices, had the lowest compliance rates at 44.8% and 73.3%, respectively. The number of sports the institution offered was the only significant predictor of each requirement. There was no difference in compliance between NCAA divisions. Although the overall rate of being non-compliant pressure was low (13.8%), females were 3.28x more likely report being pressured than males. NCAA institutions are generally compliant with the Arrington settlement; however, lack of clarity in the requirements, particularly requirement 1, raises potential concerns. Concussion management practices continue to incorporate multifaceted approaches and are largely consistent with current best practices.