Early Surgical Referral Research Articles

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy Is NOT a Last Resort: Rationale for Early Surgical Referral.

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy Is NOT a Last Resort: Rationale for Early Surgical Referral.

Effect of Delayed Parathyroidectomy on Risk of Future Cardiovascular and Nephrolithiasis Interventions in Adults with Primary Hyperparathyroidism [Original Study

To determine whether the timing of parathyroid surgery impacts the risk of renal stone retreatment and cardiovascular interventions. Long-term, untreated primary hyperparathyroidism is associated with significant morbidity including nephrolithiasis and cardiovascular disease. We conducted a Population-based Cohort study of New York and California state-wide data from 2000-2020. Adult patients who underwent renal stone treatment and subsequently diagnosed with primary hyperparathyroidism (pHPT) and underwent parathyroidectomy (PTX) were included. Patients were excluded if PTX was prior to index stone procedure, they underwent second stone treatment within 6 months, with stage V CKD, with secondary or tertiary hyperparathyroidism, with prior kidney transplant or hemodialysis, or with prior cancer diagnosis. Rate of renal stone retreatment and cardiovascular interventions after PTX in pHPT patients with nephrolithiasis who underwent parathyroid surgery at ≤ 2 years and >2 years after index stone procedure was measured. We identified 2,093 patients who underwent first-time stone treatment and subsequent PTX. The median time to PTX was 560 days (IQR 187-1477) and follow-up was 7.4 years (IQR 4.5-13.1). Delaying PTX for more than 2 years increased the risk of renal stone retreatment by 59% (HR 1.59; P<0.001), increased the risk of experiencing coronary disease or associated interventions by 118% (HR=2.18; P=0.01), and increased the risk of experiencing an overall cardiovascular event by 52% (HR 1.52; P<0.01). In symptomatic pHPT, delaying PTX significantly increases the risk of requiring future stone retreatment and cardiac/vascular surgical interventions. This highlights the importance of early surgical referral and multidisciplinary approaches to optimize outcomes and resource utilization in pHPT.

Predictors of surgical intervention in first episode primary spontaneous pneumothorax requiring chest drain insertion.

Primary spontaneous pneumothorax occurs in patients with no underlying lung disease and guidelines recommend chest tube drainage for the first episode, with surgical intervention reserved for recurrent episodes, persistent air leak or failure of lung re-expansion. Modern surgical management is associated with reduced length of hospital stay and superior freedom from recurrence compared with chest tube drainage alone. The objective of this study was to identify risk factors for failed chest tube drainage in patients who present with first episode primary spontaneous pneumothorax. A retrospective analysis of patients who presented to Royal Prince Alfred Hospital, Australia with first episode PSP and underwent chest tube insertion was performed. Patient demographics and size of pneumothorax were examined in relation to the primary outcome, a composite of failed chest tube drainage and recurrent ipsilateral pneumothorax. Fifty-five patients underwent chest tube drainage for first episode primary spontaneous pneumothorax between 1st January 2017 and 31st December 2020. Complete lung collapse on admission chest x-ray was associated with an increased risk of the primary outcome (63% versus 19%, OR 7.3 [96% CI 2.0-27.4), P = 0.004). This small retrospective study found that patients that undergo chest drain insertion for first episode primary spontaneous pneumothorax who present with complete lung collapse on admission are at high risk of requiring pleurodesis and therefore may benefit from early surgical referral.

Management of Fournier's gangrene: a practical guide for clinicians.

Fournier's gangrene is a localised form of necrotising fasciitis affecting the external genitalia, perineal and perianal regions. Although rare, it is associated with high rates of morbidity and mortality, so clinician awareness is essential for prompt treatment. Risk factors include diabetes mellitus, hypertension, chronic alcoholism and immunosuppression. Perineal pain in patients with sepsis should be treated with a high level of suspicion and early surgical referral is required as prompt debridement can improve outcomes. Repeated surgical intervention and antimicrobial therapy are often needed and recovery can take a long time, with a long-term impact on quality of life. This article discusses the natural history of Fournier's gangrene, aetiology, risk factors, investigations and treatments with an algorithm to support clinical practice.

179 Postpartum Uterus Causing Mechanical Bowel Obstruction

Abstract Background Intestinal obstruction is a common surgical emergency. Common causes of mechanical large bowel obstruction include malignancy, sigmoid volvulus, and diverticular disease. Due to the risk of bowel ischaemia and perforation, large bowel obstruction requires urgent recognition and treatment to prevent morbidity and mortality. Case Presentation 35-year-old female developed nausea, vomiting and abdominal pain two days post emergency cesarian section at 39+5 weeks gestation. An abdominal X-Ray showed distended loops of large bowel and mechanical large bowel obstruction with a sigmoid transition point was diagnosed on CT. She was referred to the surgical team for further management and a flexible sigmoidoscopy under general anaesthetic was performed for decompression. Results The patient was reviewed the following day. She was asymptomatic and had opened her bowels. She was discharged from surgical follow-up at this stage following successful treatment and was able to return home with a healthy baby. Conclusions Mechanical compression from a postpartum uterus is a rare cause of mechanical large bowel obstruction, with just one previous case documented in the literature. Acute colonic pseudo-obstruction (Ogilvie syndrome) is a recognised postpartum complication, more common after cesarian section and an important differential with similar treatment options. The recommend diagnostic imagining includes abdominal x-ray and/or CT scan with early surgical referral for consideration of interventional or surgical management in patients presenting with symptoms of bowel obstruction in the postpartum period. Conservative management should include lateral decubitus position.

Midterm outcomes of isolated tricuspid valve surgery with a mini-thoracotomy and beating heart strategy.

Isolated tricuspid valve (TV) operation is considered high-risk surgery; thus, early surgical referral is frequently discouraged. Our study aims to evaluate the outcomes of isolated TV surgery with a mini-thoracotomy and beating heart strategy. We retrospectively reviewed 25 patients [median age, 65.0 years (Q1-Q3, 59.0-72.0 years)] who had undergone mini-thoracotomy beating heart isolated TV surgery from January 2017 to May 2021. TV repair was performed in 16 patients (64.0%), and TV replacement in 9 patients (36.0%). Among them, 18 patients (72.0%) had previous cardiac surgery, including TV replacement (n=4, 16.0%) and TV repair (n=4, 16.0%). The median cardiopulmonary bypass time was 75.0 minutes (Q1-Q3, 61.0-98.0 minutes). There was 1 early mortality (4.0%) due to low cardiac output syndrome. Acute kidney injury requiring dialysis occurred in 3 patients (12.0%), and a permanent pacemaker was required in 1 patient (4.0%). The median lengths of stay in the intensive care unit and hospital were 1.0 day (Q1-Q3, 1.0-2.0) and 9.0 days (Q1-Q3, 6.0-18.0), respectively. The median follow-up duration was 30.3 months (Q1-Q3, 19.2-43.8). Freedoms from overall mortality, severe tricuspid regurgitation (TR), and significant tricuspid stenosis [i.e., trans-tricuspid pressure gradient (TTPG) ≥5 mmHg] at 4 years were 89.1%, 94.4%, and 83.3%, respectively. There was no TV reoperation. Mini-thoracotomy beating heart strategy for isolated TV surgery showed favorable early and midterm outcomes. This strategy may be a valuable option for isolated TV operations.

Risk Factors for Urgent or Emergent Cholecystectomy Mid-workup for Symptomatic Cholelithiasis.

Patients who undergo cholecystectomy often do so for diagnoses related to the sequelae of gallstones. Many patients present acutely, requiring urgent removal due to complications of cholelithiasis. This study aims to characterize the patient population likely to present acutely during ongoing workup for cholelithiasis to better identify those who may benefit from expedited care. Medical records of all adult patients who underwent cholecystectomy for indications related to cholelithiasis between 2015 and 2016 were reviewed retrospectively. Qualitative data was analyzed using Chi square test and quantitative data was analyzed using independent t-tests. One hundred and seventy-four cholecystectomies were performed. Overall, 74.2% of the procedures were done electively while 25.8% were done urgently. And 42.2% of patients who underwent acute surgical intervention had evidence of prior workup. Patients requiring urgent intervention during ongoing diagnostic evaluation were more likely to have initially presented to an emergency department (ED) than another provider (68.4% vs 31.3%, P < .001) and had an odds ratio of 4.7 for undergoing acute intervention if they initially presented to the ED. They also tended to be more temporally remote from their initial diagnosis (119 ± 142 vs 74.6 ± 68.2days, P < .19) relative to those who underwent elective operations. Patients who require urgent intervention during ongoing workup for cholelithiasis have prolonged courses of care and present to the ED more often for initial evaluation when compared to those who undergo elective intervention. These findings suggest that an emphasis on expedited workup of cholelithiasis and early surgical referral may be warranted, especially for those who initially present in the ED.

A Review of Necrotizing Fasciitis and the Utility of the Laboratory Risk Indicator for Necrotizing Fasciitis Score in its Early Diagnosis at a Rural Australian Hospital

Background: Necrotizing fasciitis is a life-threatening orthopaedic emergency. This paper is a retrospective review of confirmed cases of necrotizing fasciitis (NF) in a rural centre. The primary aim was to define the trends in incidence, microbiological profile, management and mortality. The secondary aim was to assess the accuracy of the LRINEC score as a tool to diagnose and distinguish NF from cellulitis and other non-necrotizing soft tissue infections (NNSTIs). Methods: A retrospective paper based, and computerized search of the medical records was undertaken to identify adult patients diagnosed with NF between January 2009 and January 2018 was conducted. An age matched control group was generated from a randomized sample of patients diagnosed with cellulitis over the same timeframe. LRINEC scores of the NF and control group were calculated and compared. Results: Forty-five patients with NF were identified. A decreasing trend in incidence was noted from 2011 (5.43 per 100000 per year) to 2016 (3.81 per 100000 per year), however 13 cases of necrotizing fasciitis presented in 2017 with an estimated incidence of 13.7 per 100000. The overall mortality of patients with NF was 15.6%. The genus Streptococcus was the most common isolate (47%) with Staphylococcus a close second (32.4%). The LRINEC score had a sensitivity of 61% and a specificity of 79% at a score of ≥ 6. Conclusion: LRINEC scores in isolation cannot be reliably used to distinguish between NF and NNSTIs. A high index of clinical suspicion and early surgical referral for surgical cut-down diagnosis is recommended.

The need for early Kasai portoenterostomy: a Western Pediatric Surgery Research Consortium study.

The purpose of this study was to investigate factors impacting transplant-free survival among infants with biliary atresia. A multi-institutional, retrospective cohort study was performed at nine tertiary-level children's hospitals in the United States. Infants who underwent Kasai portoenterostomy (KP) from January 2009 to May 2017 were identified. Clinical characteristics included age at time of KP, steroid use, surgical approach, liver pathology, and surgeon experience. Likelihood of transplant-free survival (TFS) was evaluated using logistic regression, adjusting for patient and surgeon-level factors. Secondary outcomes at 1 year included readmission, cholangitis, reoperation, mortality, and biliary clearance. Overall, 223 infants underwent KP, and 91 (40.8%) survived with their native liver. Mean age at surgery was 63.9 days (± 24.7 days). At 1 year, 78.5% experienced readmission, 56.9% developed cholangitis, 3.8% had a surgical revision, and 5 died. Biliary clearance at 3months was achieved in 76.6%. Controlling for patient and surgeon-level factors, each additional day of age toward operation was associated with a 2% decrease in likelihood of TFS (OR 0.98, 95% CI 0.97-0.99). Earlier surgical intervention by Kasai portoenterostomy at tertiary-level centers significantly increases likelihood for TFS. Policy-level interventions to facilitate early screening and surgical referral for infants with biliary atresia are warranted to improve outcomes.

Complicated postoperative course in isolated tricuspid valve surgery: Looking for predictors.

This study aims at better defining the profile of patients with a complicated versus noncomplicated postoperative course following isolated tricuspid valve (TV) surgery to identify predictors of a favorable/unfavorable hospital outcome. All patients treated with isolated tricuspid surgery from March 1997 to January 2020 at our institution were retrospectively reviewed. Considering the complexity of most of these patients, a regular postoperative course was arbitrarily defined as a length-of-stay in intensive care unit less than 4 days and/or postoperative length-of-stay less than 10days. Patients were therefore divided accordingly in two groups. One hundred and seventy-two patients were considered, among whom 97 (56.3%) had a regular (REG) and 75 (43.6%) a non-regular (NEG) postoperative course. The latter had worse baseline clinical and echocardiographic characteristics, with higher rate of renal insufficiency, previous heart failure hospitalizations, cardiac operations, and right ventricular dysfunction. NEG patients more frequently needed tricuspid replacement and experienced a greater number of complications (p < .001) and higher in-hospital mortality (13% vs. 0%, p < .001). The majority of these complications were related to more advanced stage of the tricuspid disease. Among most important predictors of a negative outcome univariate analysis identified chronic kidney disease, ascites, previous right heart failure hospitalizations, right ventricular dysfunction, previous cardiac surgeries, TV replacement and higher MELD scores. At multivariate analysis, liver enzymes and diuretics' dose were predictors of complicated postoperative course. In isolated TV surgery a complicated postoperative course is observed in patients with more advanced right heart failure and organ damage. Earlier surgical referral is associated to excellent outcomes and should be recommended.

Surgical therapy of infective endocarditis following interventional or surgical pulmonary valve replacement.

Percutaneous pulmonary valve prostheses and right ventricle-to-pulmonary artery conduits are at risk for infective endocarditis (IE). In children and adults with a congenital heart disease, a pulmonary valve implant is frequently necessary. Prosthetic valve endocarditis is a conservatively barely manageable, serious life-threatening condition. We investigated the results of surgical pulmonary valve replacements in patients with IE. A total of 20 patients with congenital heart disease with the definite diagnosis of IE between March 2013 and July 2020 were included in this single institutional, retrospective review. Infected conduits were 11 Melody, 5 Contegra, 3 homografts and 1 Matrix P Plus. All of the infected prosthetic material was removed from the right ventricular outflow tract up to the pulmonary bifurcation. Pulmonary homografts were implanted after pulmonary root resection as right ventricle-to-pulmonary artery conduits. All patients survived and were discharged infection-free. The mean time from the conduit implant to the operation for IE was 4.9 years [95% confidence interval (CI), 3.0-6.9]. The median intensive care unit stay was 3.0 days (95% CI, 2.0-4.7), and the median hospital time was 25.0 days (95% CI, 19.2-42.0). Median follow-up time was 204.5 days (range 30 days to 5 years) without death or recurrent endocarditis. The surgical treatment of IE of percutaneous pulmonary valve prostheses and right ventricle-to-pulmonary artery conduits is a safe and effective therapeutic concept. Early surgical referral of patients with suspicion of IE should be pursued to avoid sequelae such as right ventricular failure, septic emboli, intracardiac expansion and antibiotic resistance.

VISCERAL FAT INDEX INFORMS RISK OF MEDICALLY REFRACTORY IBD AND NEED FOR SURGERY IN PATIENTS STARTING ANTI-TUMOR NECROSIS FACTOR (TNF) THERAPY

Abstract Background Increased visceral adipose tissue (VAT) is associated with systemic inflammation through amplified production of pro-inflammatory cytokines like TNF-α and interleukin-6. Higher visceral fat index (VFI), which is the ratio of VAT to subcutaneous adipose tissue (SAT) and reflects the degree of excess VAT in relation to SAT, is associated with complex IBD. However, its relevance to treatment response is unclear. We aim to evaluate the effect of VFI on treatment response and risk of surgery in IBD patients starting anti-TNF therapy. Methods IBD patients starting anti-TNF agents between 1/1/2009 to 7/31/2019 at two academic medical centers were included. Three dimensional VAT and SAT volumes were measured from CT scans with Aquarius (iNtuition, Foster City, CA). VFI was calculated with the ratio of VAT:SAT. Patients were categorized by predefined VFI cutoffs: &amp;lt;0.33, 0.33–0.66, &amp;gt;0.67. Primary outcomes included composite endpoint of corticosteroid-free response (CFR) at 6 and 12 months defined by meeting one of the following: a) clinical response based on Harvey Bradshaw Index for Crohn’s disease (CD) or Lichtiger score for ulcerative colitis (UC), b) endoscopic improvement based on ulcer healing for CD and Mayo score for UC compared to baseline, or c) 50% improvement or normalization of CRP or fecal calprotectin. Secondary outcomes included IBD-related surgery at 6 and 12 months. We performed a multivariable logistic regression on CFR and surgery, adjusting for age, gender, IBD diagnosis, disease duration, active tobacco use, and immunomodulator exposure, to calculate adjusted odds ratio (aOR) and 95% confidence interval (CI). Results We included 181 patients. Table 1 summarizes differences in baseline characteristics. There were no differences in disease severity or activity. There were no differences in CFR at 6 and 12 months (Figure 1a and b). With respect to surgery within 6 months, patients with VFI &amp;gt;0.67 were significantly more likely to undergo surgery (aOR: 41.92 [95%CI 5.09–345.59]), but no difference in patients with VFI 0.33–0.66 was observed when compared to patients with VFI &amp;lt;0.33 (aOR: 2.23 [95%CI 0.48–11.21]). Similarly at 12 months, patients with VFI &amp;gt;0.67 were more likely to undergo surgery (aOR: 15.55 [95%CI 2.85–80.56]) but no difference was observed in patients with VFI 0.33–0.66 compared to patients with VFI &amp;lt;0.33 (aOR: 1.38 [95%CI 0.36–5.29]). Conclusion In this retrospective, multicenter, cohort study, we found higher VFI is associated with increased odds of surgery in IBD patients starting anti-TNF therapy. If confirmed by future prospective studies, VFI may be employed as a biomarker to help identify IBD patients at risk for medically refractory disease and would benefit from an early surgical referral, especially considering the growing application of artificial intelligence in medical imaging.

Sudden Unexpected Death in Epilepsy (SUDEP) — What Pediatricians Need to Know

Sudden unexpected death in epilepsy (SUDEP) is a devastating complication in children with epilepsy. Children with generalized tonic-clonic convulsions, nocturnal seizures, and co-morbid developmental delay/intellectual disability are at higher risk of SUDEP. The pathogenic mechanisms are incompletely understood and involve cardiac, respiratory, autonomic and cerebral dysfunction. Prone positioning is also significantly associated with SUDEP and may be a target for SUDEP prevention. Good epilepsy control also attenuates the risk; hence, it is important to provide adequate antiepileptic drug therapy with stress on drug compliance as well as early surgical referral for seizure control, wherever necessary. It is recommended that parents of children with epilepsy be counseled about the risk factors for SUDEP and potential measures of SUDEP prevention. We herein provide a pediatric perspective of the problem and guidance about parental counselling for its prevention.

The impact of sleeve gastrectomy on renal function in patients with chronic kidney disease varies with severity of renal insufficiency.

Although laparoscopic sleeve gastrectomy is known, in general, to improve renal function in patients with obesity and chronic kidney disease (CKD), its effect on estimated glomerular filtration rate (eGFR) stratified by the stage of CKD is less clear. We aimed to evaluate the impact of sleeve gastrectomy on renal function in a stratified cohort of patients with CKD. University Hospital. We performed a retrospective review of 1932 patients who met National Institutes of Health's guidelines for metabolic surgery and underwent laparoscopic sleeve gastrectomy performed by 1 of 3 surgeons. One hundred sixty-four patients with CKD stages 1 through 4 were identified. Mean follow-up period was 1.57 ± 1.0 years. Mean age was 56.4 ± 9.9 years with a preoperative body mass index of 47 ± 9 kg/m2, which decreased to 38.9 ± 8.7 kg/m2 at most recent follow-up (P < .001). In the cohort of patients with diabetes, significant decreases were observed in mean glycated hemoglobin level, daily number of oral hypoglycemics, and daily long acting insulin use (P < .001 each). Of 67 patients with diabetes, 34.3% (n = 24) achieved complete remission. In patients with hypertension, average daily number of antihypertensives decreased (P < .001) and 22.3% (n = 31) of 133 patients with hypertension discontinued all antihypertensives. Patients with CKD stages 2, 3a, and 3b showed significant improvement in eGFR. Reinforcing this evidence of improvement, patients with CKD 3a and 3b were more likely to downstage disease compared with those with CKD 4 (58.1% versus 73.1% versus 22.7%, respectively) (P < .001). Renal function, as measured by eGFR, in patients with stages 1 and 4 CKD did not improve after laparoscopic sleeve gastrectomy; in contrast, eGFR in patients with CKD stages 2and 3 significantly improved. Early surgical referral and intervention may be important in achieving the greatest improvement in eGFR and possibly delaying or reversing progression to end-stage renaldisease.

Patterns of anti-seizure medication (ASM) use in pediatric patients with surgically managed epilepsy: A retrospective review of data from Boston Children’s Hospital

ObjectUp to 30 % of patients with epilepsy are medically intractable, defined as persistent seizures despite 2 or more appropriate anti-seizure medications (ASMs) at therapeutic doses. Such patients require non-pharmacologic management that often includes epilepsy surgery. This paper aims to assess the pre-operative ASM use patterns of patients who were surgically managed. MethodsRetrospective review of children who underwent surgery for epilepsy at Boston Children’s Hospital between January 2010 and December 2014 were performed. Patient demographics, covariates, etiology, surgery type and ASM use patterns were assessed. Patient characteristics were displayed using descriptive statistics, correlation between ASM use and patient covariates were calculated with the Spearman coefficient, and univariate analysis was performed with Cox regression analysis. Results141 consecutive records of children were reviewed. All underwent one of four surgical procedures: focal resection, hemispherectomy, corpus callosotomy, or magnetic resonance-guided laser interstitial thermal therapy (MRgLITT). In this cohort, at the time of surgical evaluation the average number of pre-operative ASMs trialed was 5.2 and the average number of current ASMs was 2.6. The mean age of seizure onset was 4.4 years, the mean age at the time of surgery was 11.1 years, and the average time from seizure onset to surgery was 6.7 years. The number of total pre-operative ASMs was significantly related to longer time to surgery. Focal resection was associated with decreased ASM use and corpus callosotomy was associated with increased ASM use. Patients with radiographic findings that confer better surgical candidacy did not use fewer pre-operative ASMs or undergo earlier surgical referral. ConclusionsDespite guidelines that encourage early surgical referral and evaluation for drug-resistant epilepsy, a delay in surgical referral was seen in clinical practice, as evidenced by an average trial of 5.2 ASMs prior to referral, and an average lag of 6.7 years between time of seizure onset and surgery. Increased medication trials was directly correlated with increased time to definitive surgery. Improved education amongst neurologists for earlier surgical referral is required, especially for pathologies associated with good surgical outcome.

Surgical management of Melioidosis: 10-year retrospective data from a tertiary hospital in India

Introduction: Melioidosis is endemic in Southeast Asia. Burkholderia pseudomallei is the causative agent. Abscess formation is the commonest surgical presentation. This usually occurs in the skin and subcutaneous tissues but it has also been reported at unusual sites such as the liver, spleen, lung, brain, prostate, bone and joints, lymph nodes, muscles, and eyes. The mortality of those diagnosed with Melioidosis ranges from 10-25%. Early diagnosis and initiation of early surgical and medical treatment can decrease mortality. Methods: Data were collected over 10 years (2007-2017), from culture-proven patients who were admitted into the emergency department or in the wards. Results: There were 153 patients recruited. 21 % of patients were farmers or agricultural workers. The most common risk factor was type 2 Diabetes Mellitus. Patients presented with spleen as the most common organ involved (39%). 10 % of those with intra-abdominal abscesses have the involvement of lungs as well. Various interventional radiological procedures such as abscess drainage by ultrasound-guided pig tailing and aspirations are common. Peripheral soft tissue abscess drainage was common and easy to perform. Splenectomy was the least common procedure performed for an abscess. The mortality is 14.7 % and is significantly associated with those presenting with bacteremia and sepsis. The surgical intervention had resulted in 92 % of patients discharged alive. Conclusions: Early surgical referral and intervention can decrease mortality and morbidity. Further imaging of the abdomen and thorax could decrease the mortality among those with bacteremia and sepsis.

Improving Wait Times and Patient Experience Through Implementation of a Provincial Expedited Diagnostic Pathway for BI-RADS 5 Breast Lesions.

Long diagnostic intervals following abnormal breast imaging (DI) cause patient anxiety and possibly poorer prognosis. This study evaluates the effect of a provincial diagnostic pathway for BI-RADS 5 lesions on wait times and the patient-reported experience (PRE). With multidisciplinary input, we developed a pathway for BI-RADS 5 lesions featuring expedited biopsy, early surgical referral, and nurse (RN) navigator support. Key diagnostic intervals were captured prospectively and compared with a prepathway control cohort. PRE data were obtained from a voluntary survey. 1205 patients were managed on the BI-RADS 5 pathway with 797 primary care physicians, 57 imaging centers, and 2 regional breast programs participating. Median duration from DI to biopsy was 6days, from biopsy to pathology report was 5days, DI to surgical referral was 6days, and DI to surgical consult was 21days. Compared with 128 prepathway controls, median intervals from DI to surgical referral and consult were significantly improved (15 vs. 6days, 26 vs. 21days, p < 0.001). Amongst 294 women who completed the survey, 92% experienced ≥ 1 anxiety complaint during assessment; prompt surgical consultation and multiple features of RN support reduced anxiety, and wait time satisfaction was high (70%). Patient preferences varied for receiving biopsy results from a surgeon (57%) vs. another provider (43%). A diagnostic pathway for BI-RADS 5 lesions reduced wait times and improved the patient experience through prompt surgical referral and RN navigator support. Differing preferences for receiving biopsy results emerged, and future iterations should incorporate individualized patient wishes.

Early Surgical Referral for Penetrating Aortic Ulcer Leads to Improved Outcome and Overall Survival

The natural history of penetrating aortic ulcer (PAU) has been variably described and clear guidelines are lacking. We reviewed our experience with PAUs in a tertiary referral center. Imaging reports from January 2010 to December 2017 were retrospectively searched for the diagnosis of "penetrating aortic ulcer." Diagnosis was confirmed by review of imaging studies. Patient demographics, presenting symptoms, and anatomic characteristics were collected and analyzed for associations with need for surgical intervention, aortic complication, and overall survival. One hundred six patients with PAU were identified. Locations included 57 (53.8%) aortic arch, 24 (22.6%) descending thoracic, and 25 (23.5%) abdominal aorta. Dissection was present in 12 (11.4%) and acute rupture in 4 (3.8%) cases. At presentation, 57 (53.8%) patients were symptomatic. Forty-six (43.8%) patients were evaluated by cardiothoracic or vascular surgeons. Thirteen (12.3%) underwent surgical or endovascular repair and 10 (10.4%) had a change in medical management. Long-term follow-up (LTFU) was available in 30 patients for a mean of 36.5±29.2months. Twenty-one (70%, 21/30) demonstrated disease stability or resolution and 9 (30%, 9/30) worsened with 3 undergoing surgery. No PAU ruptured during follow-up. Patient demographics, presenting symptoms, and PAU morphology did not predict disease progression. Referral to a cardiovascular surgeon at initial presentation was associated with a 40% decreased likelihood of disease progression (P=0.046) and a 60% survival advantage at LTFU (P=0.037). PAU disease progression occurs in 30% of patients at LTFU of 36.5±29.2months. All patients identified with PAU on diagnostic imaging should be referred for a surgical evaluation and follow-up, as referral to cardiovascular surgeon is associated with improved disease course.

Early Surgical Referral for Penetrating Aortic Ulcer Leads to Improved Outcome and Overall Survival

Early Surgical Referral for Penetrating Aortic Ulcer Leads to Improved Outcome and Overall Survival

Evaluation and Management of Rotator Cuff Tears: a Primary Care Perspective.

To provide a primary care perspective regarding the evaluation and management of shoulder pain and rotator cuff tears. In the primary care setting, rotator cuff pathology is commonly encountered. Information regarding the risks of oral medications for the management of the associated pain keeps mounting. Partial-thickness rotator cuff tears remain difficult to diagnose with a single imaging modality. Musculoskeletal education in medical schools and non-orthopaedic residency and fellowship training programs continues to be an area for additional improvement. In the primary care office, the initial evaluation of shoulder pain should include a thorough musculoskeletal evaluation in order to identify the source of the pain (e.g., shoulder, cervical spine, chest wall), as well as the development of an initial treatment plan. Access to imaging modalities such as ultrasound and MRI can vary depending on the resources available in the primary care setting. The identification of patients who may benefit from early surgical referral is imperative for optimizing outcomes.