Contemporary Practice Patterns Research Articles

Cervical dilation at time of caesarean delivery in nulliparous women: a population-based cohort study.

Our objective was to describe contemporary practice patterns in the timing of caesarean delivery in relation to cervical dilation, overall and by indication for caesarean. Our secondary objective was to examine how commonly caesarean delivery was performed for labour dystocia at dilations below 4 cm or without the use of oxytocin, overall and between hospitals. Retrospective, population-based cohort study. Ontario, Alberta, and British Columbia, Canada, 2008-2012. Nulliparous women in labour who delivered term singletons in cephalic position. Histograms were used to examine the distribution of cervical dilation at time of caesarean delivery, overall and by indication for caesarean. Funnel plots were used to illustrate variation in hospital-level rates of caesarean deliveries for labour dystocia that were performed early (<4 cm dilation) or without the use of oxytocin. Cervical dilation (in centimetres) at time of caesarean delivery. The population-based cohort comprised 392 025 women, of whom 18.8% had a caesarean delivery. Of first-stage caesareans for labour dystocia in women who entered labour spontaneously, 13.6% (95% CI 12.9, 14.2) had dilations <4 cm [hospital-level inter-quartile range (IQR): 6.2% to 20.0%] and 29.5% (95% CI 28.6, 30.4) did not receive oxytocin to treat their dystocia (hospital-level IQR: 22.1-54.6%). The proportion of caesareans done before 4 cm dilation or without oxytocin varies substantially across hospitals and suggests the need for institutions to review their practices and ensure that management of labour practice guidelines are followed. Many caesareans for labour dystocia are performed early during labour (<4 cm dilation) or without oxytocin.

Contemporary practice patterns related to the risk of acute kidney injury in the catheterization laboratory: Results from a survey of Society of Cardiovascular Angiography and Intervention (SCAI) cardiologists.

The goal of the present study was to survey the Society of Cardiovascular Angiography and Intervention (SCAI) member cardiologists to evaluate contemporary practice patterns with regards to contrast use, acute kidney injury (AKI) risk assessment, and prevention in patients undergoing invasive angiography. We sought to compare the physician responses against guideline statements and evidence-based data from clinical studies. A 20-question online survey based on a modified Likert scale was sent out via email to the Society of Cardiovascular Angiography and Intervention (SCAI) member cardiologists. The survey questions focused on prophylaxis methods, medication management, risk assessment, contrast agent use, and postprocedure care. A scoring system was developed which examined the individual responses to analyze the 10 questions with the greatest strength of evidence in the literature and guidelines. The survey was completed by 506 individuals. Selected responses of note included the use of standardized volume expansion protocols: 64.8%, use of iso-osmolar contrast (iodixanol) in the majority of patients at risk of AKI: 55%, and 27% of individuals reported diluting contrast with saline for patients at risk of AKI during coronary angiography. For questions with support from guideline documents, 56.9% of the responses were scored as concordant with evidence-based data. Individuals who reported that the risk of AKI was often or always important in planning angiography for "at risk patients" were more likely to closely monitor renal function (76.7% vs. 40.0%, P = 0.003), obtain nephrology consultation (45.2% vs. 13.3%, P = 0.016) and use iso-osmolar contrast agents (56.0% vs. 26.7%, P = 0.033). The majority of cardiologists participating in this survey, reported practice patterns consistent with guideline and evidence-based recommendations. However, over 40% of responses to questions were inconsistent with these recommendations, suggesting continued opportunities for education and quality improvement concerning AKI prevention. © 2016 Wiley Periodicals, Inc.

Contemporary Attitudes and Practice Patterns of North American Urologists in Investigating Stone-Forming Patients-A Survey of Endourological Society Members.

Recent evidence would suggest a low rate of metabolic assessment in stone formers, even in those deemed as high risk. We wished to assess the attitudes and practice patterns of metabolic work up in North American members of the Endourological Society as part of the management of stone-forming patients. A 12-question online multiple-choice questionnaire (using Survey Monkey(®)) was distributed to all members of the Endourological Society through e-mail. Descriptive analyses were performed. A total of 124 North American members of the Endourological Society responded (90% endourologists, 65% fellowship trained). Ninety-seven percent perform metabolic assessments without referring to a consultant. Eighty-three percent use a commercial analysis company and 17% request serum or urine parameters individually. Ninety-seven percent believe that 24-48-hour urine collection is a better way of assessing patients for metabolic abnormalities than a "basic analysis." Many respondents (37%) would be more likely to metabolically assess if results were easier to interpret, and 35% would like assistance/advice in the interpretation of results. At initial investigation of a first-time stone former, 87% of respondents use serum chemistry, 48% use 24-hour urine, 26% use 48-hour urine (two consecutive 24-hour urine collections), 54% send stone for analysis, and 7% do not investigate. On recurrent stone formers, 69% use serum chemistry, 73% use 24/48-hour urine, and 23% send stone for analysis. On routine follow-up, 36% check serum chemistry, 55% use 24-hour urine, 2% use 48-hour urine, and 29% do not metabolically evaluate. The majority agree that pharmacologic therapy plays a strong role in preventing recurrence (90%). After initiating pharmacologic therapy, 59% reassess using serum chemistry and 84% and 7% use 24/48-hour urine collection, respectively. Physicians re-evaluate patients after 1 month (7%), 1-2 months (10%), 2-4 months (44%), 4-6 months (30%), or after 6-12 months (7%). This snapshot assessment of Endourological Society members' practices in the metabolic investigation of stone-forming patients demonstrates wide testing variations. Many physicians expressed interest in assistance/advice in the interpretation of the metabolic assessment results.

MP55-01 CONTEMPORARY PRACTICE PATTERNS IN VOIDING CYSTOURETHROGRAM (VCUG) USE: THE IMPACT OF EVIDENCE-BASED GUIDELINES

You have accessJournal of UrologyPediatrics: Urinary Tract Infection and Vesicoureteral Reflux1 Apr 2016MP55-01 CONTEMPORARY PRACTICE PATTERNS IN VOIDING CYSTOURETHROGRAM (VCUG) USE: THE IMPACT OF EVIDENCE-BASED GUIDELINES Linda Lee, Armando Lorenzo, Rakan Odeh, Paul Bowlin, Jeffrey Traubici, and Martin Koyle Linda LeeLinda Lee More articles by this author , Armando LorenzoArmando Lorenzo More articles by this author , Rakan OdehRakan Odeh More articles by this author , Paul BowlinPaul Bowlin More articles by this author , Jeffrey TraubiciJeffrey Traubici More articles by this author , and Martin KoyleMartin Koyle More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.592AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES While VCUG is a widely accepted test, it is invasive and associated with radiation exposure. Most cases of VUR are low-grade and unlikely to be associated with acquired renal scarring. In an effort to select patients at greatest risk, the American Academy of Pediatrics (AAP) published revised guidelines on urinary tract infections in children ages 2 to 24 months in 2011. In this project, we examine contemporary practice patterns and indications for VCUG, in the context of newer evidence-based guidelines. We hypothesize that the rate of VCUGs has declined over time, which may be geared towards detection of more clinically significant VUR. METHODS All VCUGs performed at our institution from 2008 to present were identified. Follow-up VCUGs were excluded. Further data collection was performed for patients whom had a VCUG in the first six months of 2009 and 2014, in order to obtain representative data before and after publication of the 2011 AAP guidelines. Medical records for these patients were retrospectively reviewed for baseline patient characteristics, indication for VCUG, type of ordering physician, prior history of febrile UTIs, renal and bladder ultrasound and renal scan findings. RESULTS From January 2008 to August 2014, a total of 8214 VCUGs were performed at our institution. The annual number of VCUGs has declined steadily over time. We then compared the 6-month periods from January to June (inclusive) in 2009 and 2014, which identified 634 and 292 VCUGs, respectively. There were no statistically significant differences in mean age or gender between both groups. Although there was a decline in VCUGs in 2014, the rate of VCUGs performed for UTIs remained the same (65% in 2009 and 64% in 2014, p=0.88). In both groups, pediatric urologists comprised the minority of ordering physicians (14% in 2009 and 16% in 2014, p=0.48). While there is no statistically significant difference in detection rate of VUR from 2009 to 2014 (31% vs. 37%, p=0.07), there has been a three-fold increase in diagnosis of high grade (IV-V) VUR in 2014, compared to 2009 (10.2% vs 3.2%, p=0.0001). CONCLUSIONS There has been an overall trend towards fewer VCUGS being performed at our institution, even prior to the 2011 AAP guidelines. While the majority of VUR cases detected remain low-grade, there has been a higher detection rate of high-grade (IV-V) VUR in 2014, compared to 2009. This may be a reflection of changing practice patterns of ordering physicians. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e735 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Linda Lee More articles by this author Armando Lorenzo More articles by this author Rakan Odeh More articles by this author Paul Bowlin More articles by this author Jeffrey Traubici More articles by this author Martin Koyle More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Intraoperative Lung-Protective Ventilation Trends and Practice Patterns: A Report from the Multicenter Perioperative Outcomes Group.

The use of an intraoperative lung-protective ventilation strategy through tidal volume (TV) size reduction and positive end-expiratory pressure (PEEP) has been increasingly investigated. In this article, we describe the current intraoperative lung-protective ventilation practice patterns and trends. By using the Multicenter Perioperative Outcomes Group database, we identified all general endotracheal anesthetics from January 2008 through December 2013 at 10 institutions. The following data were calculated: (1) percentage of patients receiving TV > 10 mL/kg predicted body weight (PBW); (2) median initial and overall TV in mL/kg PBW and; (3) percentage of patients receiving PEEP ≥ 5 cm H2O. The data were analyzed at 3-month intervals. Interinstitutional variability was assessed. A total of 330,823 patients met our inclusion criteria for this study. During the study period, the percentage of patients receiving TV > 10 mL/kg PBW was reduced for all patients (26% to 14%) and in the subpopulations of obese (41% to 25%), short stature (52% to 36%), and females (39% to 24%; all P values <0.001). There was a significant reduction in TV size (8.90-8.20 mL/kg PBW, P < 0.001). There was also a statistically significant but clinically irrelevant difference between initial and overall TV size (8.65 vs 8.63 mL/kg PBW, P < 0.001). Use of PEEP ≥ 5 cm H2O increased during the study period (25%-45%, P < 0.001). TV usage showed significant interinstitutional variability (P < 0.001). Although decreasing, a significant percentage of patients are ventilated with TV > 10 mL/kg PBW, especially if they are female, obese, or of short stature. The use of PEEP ≥ 5 cm H2O has increased significantly. Creating awareness of contemporary practice patterns and demonstrating the efficacy of lung-protective ventilation are still needed to optimize intraoperative ventilation.

CONTEMPORARY DIAGNOSIS OF CARDIAC SARCOIDOSIS

BACKGROUND: Patients with systemic sarcoidosis manifest symptomatic cardiac involvement in approximately 5% of cases. With the availability of advanced cardiac imaging, including cardiacMRI and FDG-PET, evidence of asymptomatic cardiac sarcoidosis (CS) has been detected in up to 50% of patients. Cardiac involvement in patients with sarcoidosis portends a poor prognosis. PURPOSE: To evaluate contemporary practice patterns for the diagnosis of CS compared to current 2014 HRS expert consensus recommendations. METHODS: Retrospective cohort study of patients from the St. Paul’s Hospital CS Clinic. Baseline characteristics, diagnostic imaging and pathology were reviewed for patients between January 2013 andMarch 2015. Patients were analyzed according to 2014 HRS guidelines. Group 1 (22 patients) consisted of patients with biopsy proven extra-cardiac sarcoidosis referred for cardiac screening. Group 2 (13 patients) included those under the age of 60, with unexplainedMobitz II or third degree heart block. Group 3 (12 patients) consisted of patients with unexplained VT and Group 4 (13 patients) included all others, particularly unexplained LV dysfunction. RESULTS: Of the 115 patients referred to theCS clinic, 25 remain incompletely evaluated, 12 refused further evaluation, and18were discharged after initial triage. Complete data was available for 60 patients. The median age was 57 years (IQR 18) and 58.3% were males. Overall, there were 27 (45.0%) patients with an ICD and 17 (28.3%)with a pacemaker. Themean LVEFwas 46.1% (95% CI 34.0-58.2). Endomyocardial biopsy was performed in 24 (40.0%) of patients, cardiacMRI in 39 (65.0%) andFDG-PET in 54 (90.0%). According to 2014 HRS recommendations, patients were considered to have probable cardiac involvement in 15 (68.2%), 10 (76.9%), and 11 (91.7%) cases inGroups 1, 2 and 3, respectively. Similarly, advanced imaging was performed, but not recommendedby current guidelines, in 6 (27.3%), 1 (7.7%) and4 (33.3%) patients for Groups 1, 2 and 3, respectively. FDG-PET was negative for CS in 7/9 (77.8%) Group 4 patients with LV dysfunction and an abnormal biopsy or cardiac MRI. We found FDG-PET to be positive in a pattern consistent with active CS in 3/8 (37.5%) of cases where ordering FDG-PET was not recommended by current guidelines. CONCLUSION: In our study, contemporary screening and diagnosis of CS would often be considered not recommended by current HRS expert consensus recommendations. More liberal use of FDG-PET in patients evaluated for CS may help stratify this high risk population. 548 CINE MRI-BASED 4D-STRAIN ANALYSIS OF THE LEFT VENTRICLE FOR THE EVALUATION OF MYOCARDIAL FIBROSIS IN PATIENTS WITH HYPERTROPHIC CARDIOMYOPATHY

Contemporary Practice Patterns of Flexible Ureteroscopy for Treating Renal Stones: Results of a Worldwide Survey.

Flexible ureteroscopy (fURS) is increasingly used in the treatment of renal stones. However, wide variations exist in technique, use, and indications. To better inform our knowledge about the contemporary state of fURS for treating renal stones, we conducted a survey of endourologists worldwide. An anonymous online questionnaire assessing fURS treatment of renal stones, consisting of 36 items, was sent to members of the Endourology Society in October 2014. Responses were collected through the SurveyMonkey system over a 3-month period. Questionnaires were answered by 414 surgeons from 44 countries (response rate 20.7%). U.S. surgeons accounted for 34.4% of all respondents. fURS was routinely performed in 80.0% of institutions, with 40.0% of surgeons performing >100 cases/year. Respondents considered fURS to be first-line therapy for patients with renal stones <2 cm and lower pole calculi. A substantial minority (11.3%) preferred fURS as a primary treatment modality for renal stones >2 cm. Basket displacement for lower pole stones was routinely performed by 55.8%. Ureteral access sheaths (UAS) were preferred for every case by 58.3%. Respondents frequently utilized high-power lasers and dusting techniques. Criteria for determining stone-free rate were defined as zero fragments or residual fragment (RF) <1, <2, <3, and <4 mm by 30.9%, 8.9%, 31.5%, 15.8%, and 11.2% of respondents, respectively. The overwhelming majority of endourologists surveyed consider fURS as a first-line treatment modality for renal stones, especially those <2 cm. Use of UAS, high-power holmium lasers, and dusting technique has become popular among practitioners. When defining stone free after fURS, the majority of endourologists used a zero fragment or RF <2 mm definition.

Contemporary Practice Patterns in the Management of Acute Obstructing Ureteral Stones

To elucidate current practice patterns among Endourological Society members for acutely obstructing ureteral stones necessitating intervention. A practice pattern survey was sent to members of the Endourological Society using Survey Monkey. The following question stem was given: "Patient presents to the ER with acute renal colic and intractable pain, no signs of infection, i.e. afebrile and no pyuria. Stone is obstructing, and causing intractable pain; thus observation or medical expulsive therapy is not appropriate." A follow-up stem was provided for specific scenarios: "Calculus measuring x mm at x location. What is your preferred management option?" The options given for immediate management included shockwave lithotripsy (SWL), ureteroscopy (URS), stent placement, or percutaneous management. Four hundred and sixteen complete responses of approximately 2000 were received. There was a significant difference in management choice based on stone location (P<0.001) and stone size (P<0.001). URS was the predominant modality used for urgent treatment of acute proximal ureteral stones from 5, 10, and 15 mm except for calculi of 20 mm, where the preference was for percutaneous management. Immediate URS was the preferred choice for all distal and midureteral stones, regardless of size. The use of stents vs percutaneous nephrostomy drainage was similar (18% vs 16%, respectively) for proximally obstructing calculi, while stent insertion was preferred over nephrostomy for mid and distal stones. Current practice patterns among endourologists indicate a strong preference for immediate URS management over stent placement or SWL for acutely obstructing ureteral calculi. Not surprisingly, 20-mm stones in the proximal ureter had percutaneous management.

Contemporary practice patterns associated with percutaneous nephrolithotomy among certifying urologists.

Percutaneous nephrolithotomy (PCNL) is the treatment of choice for patients with complex stone burdens. We performed a study to assess the effect of urologist-specific parameters on the use of PCNL-both the access component of the procedure as well as the stone removal. We also examined trends in PCNL utilization over time. We analyzed self-reported 6-month case logs submitted to The American Board of Urology (ABU) for urologists who certified or recertified between 2004 and 2013. Surgeons performing PCNL were identified by Current Procedural Terminology coding. Urologist-specific data, including fellowship training, practice type, and practice population, were used to further stratify this cohort. Trends were examined over the study period. A total of 7278 urologists submitted case logs to the ABU between 2004 and 2013. The median ages of the initial certification group, first recertification group, and second recertification group were 36.0, 43.7, and 53 years, respectively. A greater proportion of newly certified urologists performed PCNL (53%) compared with urologists in the first (41%) and second (29%) recertification groups; initially certified urologists were also more likely to be high volume (>10) PCNL surgeons. Urologists with fellowship training were more likely to use PCNL (66%) and be high-volume surgeons (26.4%). PCNL utilization increased significantly during the study period, with 1330 procedures performed in 2004 and 2888 procedures performed in 2012 (117% increase). Younger and fellowship-trained urologists are the primary users of PCNL; the majority of senior urologists do not perform this operation. Overall, the use of PCNL and urologist-directed access has increased in the previous decade.

Acute type B aortic dissection: insights from the International Registry of Acute Aortic Dissection.

Acute type B aortic dissection comprises approximately one-third of all aortic dissection cases. Although this catastrophic cardiovascular condition was first described in the medical literature over two centuries ago, data on the optimal diagnostic and treatment modalities for type B dissection was slow to evolve throughout the latter half of the twentieth century, even as newer diagnostic techniques and management strategies became commonplace. To further elucidate contemporary practice patterns and outcomes of aortic dissection, the International Registry of Acute Aortic Dissection (IRAD) was established in 1996. Over the past two decades, IRAD publications have steadily increased our knowledge and understanding about aortic dissection. Specifically in recent years, analyses of IRAD data have gone beyond simply characterizing the patient with acute type B aortic dissection and have attempted to identify the means by which the outcome of such a patient could be improved. Thus, we present herein three areas in which IRAD data has recently advanced our understanding of acute type B aortic dissection: temporal classification especially for the subacute time period, risk stratification for identifying complicated cases, and thoracic endovascular aortic repair (TEVAR).

PD7-07 CONTEMPORARY PRACTICE PATTERNS ASSOCIATED WITH PERCUTANEOUS NEPHROLITHOTOMY AMONG CERTIFYING UROLOGISTS

You have accessJournal of UrologyStone Disease: Therapy I1 Apr 2014PD7-07 CONTEMPORARY PRACTICE PATTERNS ASSOCIATED WITH PERCUTANEOUS NEPHROLITHOTOMY AMONG CERTIFYING UROLOGISTS Gautam Jayram and Brian R. Matlaga Gautam JayramGautam Jayram More articles by this author and Brian R. MatlagaBrian R. Matlaga More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.696AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Percutaneous nephrolithotomy (PNL) is a specialized surgical procedure utilized for patients with complex stone burdens. Our understanding of factors affecting the utilization of this procedure is limited. We studied the impact of urologist training and practice parameters on the utilization of PNL and urologist-directed access over time. METHODS We analyzed self-reported 6 month case logs submitted to The American Board of Urology (ABU) for urologists certifying or re-certifying between 2004 and 2013. Surgeons performing PNL were identified by CPT coding: 50080 and 50081; percutaneous access was identified by CPT 50395. Urologist-specific data, including fellowship training, practice type, and practice population, were used to further stratify the cohort performing these procedures. RESULTS A total of 7,278 urologists submitted case logs to the ABU between 2004-2013. The median ages of the initial certification group, first recertifying group and second recertifying group were 36.0, 43.7 and 53 years, respectively. A greater proportion of newly certified urologists performed PNL (53%) compared to urologists in the 1st (41%) and 2nd (29%) recertification groups; newly certified urologists were also more likely to be high volume (> 10) PNL surgeons. Urologists with fellowship training in stones were much more likely to utilize PNL (66%) and be high-volume surgeons (26.4%). Non-private and heavily populated (>1,000,000) practice settings also had significantly more high-volume PNL surgeons. PNL utilization increased significantly during the study period, with 1,330 procedures performed in 2004 and 2,888 procedures performed in 2012 (117% increase). Older urologists' utilization of PNL increased over time. Urologist access concordantly increased over time, with 14.5% of PNL cases utilizing urologist access in 2004 and 20.4% in 2012, a 29% increase (see figure 1). Certification status did not correlate with urologist access. CONCLUSIONS Younger and fellowship-trained urologists are the primary utilizers of PNL, and the majority of senior urologists do not perform this operation. Overall, the use of PNL and urologist-directed access has increased in the previous decade. Our findings can serve to inform future discussions on the regionalization of specialized urologic care. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e186 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Gautam Jayram More articles by this author Brian R. Matlaga More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Intra-Coronary Imaging Modalities

The use of intracoronary imaging modalities has seen a significant increase over the past decade, as both imaging quality and delivery systems have improved. Generally accepted best practice indications for using intracoronary imaging include assessment of lesion characteristics prior to stent placement, optimization of stent placement with respect to appropriate sizing, adequate apposition, and expansion and exclusion of edge dissection. Intracoronary imaging plays a particular role in the setting of contemporary left main and bifurcation stenting. Stent interrogation using intracoronary imaging to exclude mechanical causes in the management of in-stent thrombosis has also become conventional. Current clinical guideline recommendations, however, have lagged behind contemporary practice patterns and the use of intravascular ultrasound only carries a class IIa recommendation in the appropriate clinical setting. We discuss the currently available intracoronary imaging modalities and their applications, including intravascular ultrasound (IVUS) and optical coherence tomography (OCT), and review the data supporting their use.

United States Practice Patterns in the Use of Transesophageal Echocardiography During Adult Liver Transplantation

To characterize contemporary practice patterns in the use of transesophageal echocardiography during adult liver transplantation and to identify factors preventing more frequent use. Online questionnaire. Liver transplantation centers in the United States performing 12 or more adult liver transplants in 2011. One representative from each qualifying center: The transplant anesthesiology director, a transplant anesthesiologist personally known to the authors, or the department of anesthesiology chair. Three e-mail attempts were made to solicit participation in the study between June and August 2012. Of the 97 institutions identified, an anesthesiologist from each of 79 (81.4%) centers completed the questionnaire; 38.0% of centers reported routine use and 57.0% for special circumstances or rescue situations, yielding an overall use rate of 94.9%. This distribution was consistent regardless of operative volume, practice size, or academic affiliation. The sole factor predictive of routine transesophageal echocardiography use was an overlap between an institution's cardiac and transplant anesthesiology teams. In practices not routinely employing the technology, the most compelling reason was a sense that it was not necessary. Although 69.9% of transplant anesthesiologists reportedly were proficient in echocardiography, inadequate anesthesiologist training was also a strongly cited hindrance. Transesophageal echocardiography during adult liver transplantation in the United States has become widely prevalent, with notable growth in its use as a routine diagnostic and monitoring modality. Almost all institutions now use the technology at least occasionally, with the participation of cardiac anesthesiologists being predictive of a center's routine use.

Lowering Risk for Postcesarean Thromboembolism

Thromboembolism is one of the leading causes of maternal death in the U.S. To identify contemporary practice patterns for thromboembolism prophylaxis in cesarean deliveries, investigators used the Perspective database, which captures data from >600 acute-care hospitals and approximately 15% of all hospitalizations in the U.S. All patients who had cesarean deliveries between January 2003 and March 2010 were included. Of 1.25 million women, 76% received …

Underuse of Postcesarean Thromboembolism Prophylaxis

To characterize contemporary practice patterns for postcesarean thromboembolism prophylaxis and determine whether opportunities to substantially decrease maternal mortality and morbidity in this clinical setting are being missed. A commercial hospitalization database that includes procedure and diagnosis codes, health care provider and hospital information, and patient demographic data were used to analyze use of venous thromboembolism prophylaxis after cesarean delivery in the United States between 2003 and 2010. The analysis evaluated whether patients received pharmacologic prophylaxis, mechanical prophylaxis, combined prophylaxis, or no prophylaxis. Hospital-level factors and patient characteristics were included in multivariable regression models evaluating prophylaxis administration. We identified 1,263,205 women who underwent cesarean delivery. Within the cohort, 75.7% (n=955,787) received no thromboembolism prophylaxis, 22.1% (n=278,669) received mechanical prophylaxis alone, 1.3% (n=16,639) received pharmacologic prophylaxis, and 1.0% (n=12,110) received combination prophylaxis. The rate of prophylaxis increased from 8.4% in 2003 to 41.6% in 2010. Prophylaxis rates varied significantly by geographic region. Medical risk factors for thromboembolism were associated with only modest increases in prophylaxis. Although our findings demonstrated increased adoption of postcesarean venous thromboembolism prophylaxis, fewer than half of patients received recommended care as of 2010, and significant variation was present. Thromboembolism prophylaxis is underused and represents a major opportunity to reduce maternal morbidity and mortality. Risk assessment tools and thromboprophylaxis guidelines are needed to assure high-quality, uniform care. : III.

Perioperative Outcomes for Laparoscopic and Robotic Compared With Open Prostatectomy Using the National Surgical Quality Improvement Program (NSQIP) Database

To examine contemporary outcomes of minimally invasive radical prostatectomy (MIRP) compared with open prostatectomy, using a national, prospective perioperative database reflecting diverse practice settings. The National Surgical Quality Improvement Program database was queried from 2005 to 2010 for laparoscopic or robotic prostatectomy (Current Procedural Terminology code 55866) and open retropubic prostatectomy (Current Procedural Terminology codes 55840, 55842, 55845). Perioperative outcomes examined were surgical and total operation duration, transfusion rates, length of stay, major morbidity (cardiovascular, pulmonary, renal, and infectious), and mortality. The study identified 5319 radical prostatectomies: 4036 MIRP and 1283 open. Although operative time was significantly longer in the MIRP group, there were significantly fewer perioperative blood transfusions and shorter mean length of stay. Major postoperative morbidity and mortality were 5% in the MIRP group and 9% in the open group (P<.001). Age, body mass index, presence of medical comorbidities, and open surgical technique were all independently predictive of major complications and mortality on multivariate analysis. In a nationwide database of diverse medical centers, MIRP was associated with longer operative time, but a significantly decreased rate of blood transfusions, length of stay, perioperative complication rate, and mortality compared with open prostatectomy. The minimally invasive surgical approach was independently associated with significantly fewer complications and deaths on multivariate analysis. Compared with other administrative databases that capture only inpatient events, the National Surgical Quality Improvement Program identifies complications up to 30 days postoperatively, providing more detailed characterization of complications after prostatectomy. These data reflect contemporary practice patterns and suggest that MIRP can be performed with low perioperative morbidity.

Prostate Cancer Detection by Using Digital Rectal Examination: Contemporary Practice Patterns in the United States

BackgroundDigital rectal examination (DRE) may play an important role as a secondary method of prostate cancer detection if prostate-specific antigen (PSA) screening decreases. Current practice patterns in the use of DRE are not well defined, and potential variations in its use among different subgroups of men are unclear. Materials and MethodsThe Behavioral Risk Factor Surveillance System was examined for the year 2010. All men aged 40 years old or older were asked if they ever had a rectal examination to check their prostate and the date of their last examination. Men who reported having had a DRE within the past 12 months were considered up to date. The proportion of men who reported having had a DRE and independent demographic and socioeconomic predictors for having had a DRE were determined. ResultsA total of 110,661 respondents were included: 72.2% of respondents reported ever having had a DRE; 36.8% had had a DRE within the past year, and 49.7% within the past 2 years. On multivariate analysis for reporting having an up-to-date DRE, older men, those with higher body mass index, and those of black race were more likely to have an up-to-date DRE. Asian or Hispanic race, divorced or widowed marital status, lower education, lower income, and lack of health insurance were independently associated with being less likely to have an up-to-date DRE. ConclusionsOf American men, 36.8% reported having an up-to-date DRE within the past year and 49.7% of men within the past 2 years. Demographic and socioeconomic characteristics were strongly associated with the likelihood of having an up-to-date DRE.

151 PERIOPERATIVE OUTCOMES FOR LAPAROSCOPIC AND ROBOTIC PROSTATECTOMY USING THE NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM (NSQIP) DATABASE

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Practice Patterns, Cost Effectiveness (II)1 Apr 2013151 PERIOPERATIVE OUTCOMES FOR LAPAROSCOPIC AND ROBOTIC PROSTATECTOMY USING THE NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM (NSQIP) DATABASE Jen-Jane Liu, Bryan Maxwell, Seung Jeon, Perkilis Panousis, John Leppert, and Benjamin Chung Jen-Jane LiuJen-Jane Liu Stanford, CA More articles by this author , Bryan MaxwellBryan Maxwell Stanford, CA More articles by this author , Seung JeonSeung Jeon Seoul, Korea, Democratic People's Republic of More articles by this author , Perkilis PanousisPerkilis Panousis Stanford, CA More articles by this author , John LeppertJohn Leppert Stanford, CA More articles by this author , and Benjamin ChungBenjamin Chung Stanford, CA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.1531AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Laparoscopic and robotic prostatectomy have become the dominant approaches for extirpative prostate cancer surgery. We examined contemporary outcomes of laparoscopic or robotic compared to open prostatectomy using a national, prospective perioperative database reflecting diverse practice settings. METHODS The NSQIP database was queried from 2005-2010 for laparoscopic/robotic prostatectomy (CPT 55866) and open retropubic prostatectomy (CPT 55842, 55845). Perioperative outcomes examined were surgical and total operation duration, transfusion rates, length of stay, major morbidity (cardiovascular, pulmonary, renal, and infectious) and mortality. RESULTS 5,319 radical prostatectomies were identified: 4,036 laparoscopic/robotic (MIS) and 1,283 open. Baseline characteristics including age (62 years), race (82% Caucasian), BMI (30 kg/m2), and American Society of Anesthesia (ASA) status were similar between the two groups. Although operative time was significantly longer in the MIS group, they had significantly fewer perioperative blood transfusions and shorter mean length of stay (table). Major postoperative morbidity and mortality was 5% in the laparoscopic/robotic group and 9% in the open group (p<0.001, table). Age, BMI, presence of medical comorbidities, and open surgical technique were all independently predictive of major complications and death on multivariate analysis. CONCLUSIONS In a nationwide database of diverse medical centers, minimally invasive prostatectomy was associated with longer operative time, but a significantly decreased rate of blood transfusions, length of stay, perioperative complication rate, and mortality compared to open prostatectomy. The open surgical approach was independently associated with significantly more complications on multivariate analysis. Compared to other administrative databases that only capture inpatient complications, NSQIP identifies complications up to 30 days postoperatively, providing a more detailed characterization of post-prostatectomy complications. These data reflect contemporary practice patterns, and suggest that minimally invasive prostatectomy can be performed with low perioperative morbidity. VARIABLE ROBOTIC/LAPAROSCOPIC N = 4,036 (%) OPEN N = 1,283 (%) P-VALUE Surgical time 270 min 252 min < 0.001 Blood transfusion 1.34% 21.4% < 0.0001 Length of stay 1.81 d 3.36 d < 0.0001 COMPLICATION Cardiac (arrest, CVA, MI, death) 15 (0.37%) 14 (1.09%) 0.01 Respiratory (pneumonia, ventilator > 48 h, reintubation) 19 (0.47%) 12 (0.94%) 0.06 DVT/PE 33 (0.82%) 23 (1.79%) 0.003 Composite 201 (4.98%) 116 (9.04%) < 0.0001 Death 2 (0.05%) 5 (0.39%) 0.01 © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e62 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jen-Jane Liu Stanford, CA More articles by this author Bryan Maxwell Stanford, CA More articles by this author Seung Jeon Seoul, Korea, Democratic People's Republic of More articles by this author Perkilis Panousis Stanford, CA More articles by this author John Leppert Stanford, CA More articles by this author Benjamin Chung Stanford, CA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The Diagnosis and Management of Hyperthyroidism Consensus - Report of the Korean Thyroid Association

Hyperthyroidism is one of the causes of thyrotoxicosis and the most common cause of hyperthyroidism in Korea is Graves disease. The diagnosis and treatment of Graves disease are different according to geographical area. Recently, the American Thyroid Association and the American Association of Clinical Endocrinologists suggested new management guidelines for hyperthyroidism. However, these guidelines are different from clinical practice in Korea and are difficult to apply. Therefore, the Korean Thyroid Association (KTA) conducted a survey of KTA members regarding the diagnosis and treatment of hyperthyroidism, and reported the consensus on the management of hyperthyroidism. In this review, we summarized the KTA report on the contemporary practice patterns in the diagnosis and management of hyperthyroidism, and compared this report with guidelines from other countries.

The diagnosis and management of hyperthyroidism in Korea: consensus report of the korean thyroid association.

Hyperthyroidism is one of the causes of thyrotoxicosis and the most common cause of hyperthyroidism in Korea is Graves disease. The diagnosis and treatment of Graves disease are different according to geographical area. Recently, the American Thyroid Association and the American Association of Clinical Endocrinologists suggested new management guidelines for hyperthyroidism. However, these guidelines are different from clinical practice in Korea and are difficult to apply. Therefore, the Korean Thyroid Association (KTA) conducted a survey of KTA members regarding the diagnosis and treatment of hyperthyroidism, and reported the consensus on the management of hyperthyroidism. In this review, we summarized the KTA report on the contemporary practice patterns in the diagnosis and management of hyperthyroidism, and compared this report with guidelines from other countries.