Institutional Practice Patterns Research Articles

Institution-level Patterns of Care for Early-stage Oropharynx Cancers in the United States.

The adoption of transoral robotic surgery and shifting epidemiology in oropharyngeal squamous cell cancer have stimulated debate over upfront and adjuvant treatment. Institutional variation in practice patterns can be obscured in patient-level analyses. We aimed to characterize institutional patterns of care as well as identify potential associations between patterns of care and survival. This was a retrospective cohort study of patients identified from 2004-2015 in the National Cancer Database. We analyzed 42,803 cases of oropharyngeal squamous cell cancer Stage cT1-2N0-2bM0 (AJCC 7th edition) treated with curative intent surgery and/or radiotherapy. We defined facility-4-year periods to account for changing institutional practice patterns. The 42,803 patients were treated within 2578 facility-4-year periods. We assessed institutional practice patterns, including the ratio of upfront surgery to definitive radiotherapy, case volumes, use of adjuvant therapies (radiotherapy or chemoradiotherapy), and margin positivity rates. Survival associations with institutional practice patterns were estimated with Cox regression. The ratio of upfront surgery to definitive radiotherapy ranged from 80-to-1 to 1-to-23. The institution-level median rate of adjuvant radiotherapy was 69% (IQR 50%-100%), adjuvant chemoradiotherapy was 44% (IQR 0%-67%), and margin-positive resection was 33% (IQR 0%-50%). On patient-level MVA, worse overall survival was not significantly associated with institutional case volume, adjuvant radiotherapy, or adjuvant chemoradiotherapy utilization. High rates of multimodal therapy and positive margins underscore the importance of multidisciplinary care and highlight variable patterns of care across institutions. Further work is warranted to explore indicators of high-quality care and to optimize adjuvant therapy in the HPV era.

Outpatient surgery benchmarks and practice variation patterns: Case controlled study.

Despite numerous potential benefits of outpatient surgery, there is currently a lack of national benchmarking data available for hospitals and surgeons to compare their own outcomes as they transition toward outpatient surgery. Patients who underwent 14 common general surgery operations from 2016-2020 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Operations were selected based on frequency and the ability to be performed both in- and outpatient. Postoperative complications and readmissions were compared between patients who underwent inpatient vs outpatient surgery. After adjusting for patient comorbidities, multivariable models assessed the effect of patient characteristics on the odds of experiencing postoperative complications. A separate multiinstitutional study of 21 affiliated hospitals assessed practice variation. In 13 of the 14 studied procedures, complications were lower for patients who were selected for outpatient surgery (all P<0.01); minimally invasive (MIS) adrenalectomy showed no difference (P=0.61). Multivariable analysis confirmed these findings; the odds of experiencing any adverse events were lower following outpatient surgery in all operations but MIS adrenalectomy (OR 0.97; 95% CI 0.47-2.02). Analysis of institutional practices demonstrated variation in the rate of outpatient surgery in certain breast, endocrine, and hernia repair operations. Institutional practice patterns may explain the national variation in the rate of outpatient surgery. While the present data does not support the adoption of outpatient surgery to less optimal candidates, addressing unexplained practice variations could result in improved utilization of outpatient surgery.

A survey of Asian Eye Institutions on perioperative antibiotic prophylaxis in cataract surgery

PurposeTo determine current institutional practice patterns for the use of perioperative antibiotics and other measures to prevent infection after cataract surgery in Asia.MethodsAn online survey-based study of leading eye institutions in China, Hong Kong, India, Indonesia, Japan, Malaysia, Pakistan, Philippines, Singapore, South Korea, Taiwan, Thailand and Vietnam was conducted. The survey was administered to 26 representative key opinion leaders from prominent tertiary eye institutions that are also national academic teaching institutions in Asia. Survey responses were collated and anonymized during analysis.ResultsAll surveyed institutions used povidone iodine for the preoperative antiseptic preparation of the eye, with notable variations in the concentration of povidone iodine used for conjunctival sac instillation. Preoperative topical antibiotics were prescribed by 61.5% and 69.2% of institutions in low-risk and high-risk cases, respectively. Regarding the use of intra-operative antibiotics, 60.0% and 66.7% of institutions administered intracameral antibiotics in low-risk and high-risk patients, respectively. Postoperative topical antibiotics use patterns were generally very similar in low-risk and high-risk patients. Over half of the institutions (52.2% and 68.0% in low-risk and high-risk patients, respectively) also indicated prolonged postoperative use of topical antibiotics (> 2 weeks). Not all surveyed institutions had established policies/protocols for perioperative antibiotic use in cataract surgery, endophthalmitis surveillance, and/or a monitoring program for emerging antimicrobial resistance.ConclusionThere are variations in antimicrobial prophylaxis approaches to preoperative, intra-operative and postoperative regimens in cataract surgery in Asia. More evidence-based research is needed to support the development of detailed guidelines for perioperative antibiotic prophylaxis to reduce postoperative infections.

Comparative Effectiveness of Percutaneous Microaxial Left Ventricular Assist Device vs Intra-Aortic Balloon Pump or No Mechanical Circulatory Support in Patients With Cardiogenic Shock

Recent studies have produced inconsistent findings regarding the outcomes of the percutaneous microaxial left ventricular assist device (LVAD) during acute myocardial infarction with cardiogenic shock (AMICS). To compare the percutaneous microaxial LVAD vs alternative treatments among patients presenting with AMICS using observational analyses of administrative data. This comparative effectiveness research study used Medicare fee-for-service claims of patients admitted with AMICS undergoing percutaneous coronary intervention from October 1, 2015, through December 31, 2019. Treatment strategies were compared using (1) inverse probability of treatment weighting to estimate the effect of different baseline treatments in the overall population; (2) instrumental variable analysis to determine the effectiveness of the percutaneous microaxial LVAD among patients whose treatment was influenced by cross-sectional institutional practice patterns; (3) an instrumented difference-in-differences analysis to determine the effectiveness of treatment among patients whose treatment was influenced by longitudinal changes in institutional practice patterns; and (4) a grace period approach to determine the effectiveness of initiating the percutaneous microaxial LVAD within 2 days of percutaneous coronary intervention. Analysis took place between March 2021 and December 2022. Percutaneous microaxial LVAD vs alternative treatments (including medical therapy and intra-aortic balloon pump). Thirty-day all-cause mortality and readmissions. Of 23 478 patients, 14 264 (60.8%) were male and the mean (SD) age was 73.9 (9.8) years. In the inverse probability of treatment weighting analysis and grace period approaches, treatment with percutaneous microaxial LVAD was associated with a higher risk-adjusted 30-day mortality (risk difference, 14.9%; 95% CI, 12.9%-17.0%). However, patients receiving the percutaneous microaxial LVAD had a higher frequency of factors associated with severe illness, suggesting possible confounding by measures of illness severity not available in the data. In the instrumental variable analysis, 30-day mortality was also higher with percutaneous microaxial LVAD, but patient and hospital characteristics differed across levels of the instrumental variable, suggesting possible confounding by unmeasured variables (risk difference, 13.5%; 95% CI, 3.9%-23.2%). In the instrumented difference-in-differences analysis, the association between the percutaneous microaxial LVAD and mortality was imprecise, and differences in trends in characteristics between hospitals with different percutaneous microaxial LVAD use suggested potential assumption violations. In observational analyses comparing the percutaneous microaxial LVAD to alternative treatments among patients with AMICS, the percutaneous microaxial LVAD was associated with worse outcomes in some analyses, while in other analyses, the association was too imprecise to draw meaningful conclusions. However, the distribution of patient and institutional characteristics between treatment groups or groups defined by institutional differences in treatment use, including changes in use over time, combined with clinical knowledge of illness severity factors not captured in the data, suggested violations of key assumptions that are needed for valid causal inference with different observational analyses. Randomized clinical trials of mechanical support devices will allow valid comparisons across candidate treatment strategies and help resolve ongoing controversies.

Calculating surgical readmission rates in gynecologic oncology: The impact of patient factors

ObjectiveTo determine the 30-day surgical readmission rate after major gynecologic oncology surgeries at a high-volume academic institution and correlated risk factors. MethodsRetrospective cohort study was conducted of surgical admissions from January 2016 – December 2019 at a single institution. Data were extracted from patient charts, including reason for readmission and length of stay. A readmission rate was calculated. Nested case control design was used to identify correlations between readmission and patient specific risk-factors. Multivariable logistic regression models were used to determine risk factors with readmission. ResultsA total of 2152 patients were included. The readmission rate was 3.5%, most commonly due to GI disturbance and surgical site infection. Average readmission length was 5 days. Prior to adjusting for covariates, insurance status, primary diagnosis, index admission length, and disposition at discharge differed between patients who were and were not readmitted. After adjusting for co-variates, younger patients, index admission >2 days, and higher Charlson co-morbidity index were associated with readmission. ConclusionsOur surgical readmission rate was lower than previously reported rates in gynecologic oncology patients. Patient factors associated with readmission included younger age, longer index hospital admission, and higher medical co-morbidity index scores. Provider factors and institutional practice patterns could contribute to the decreased readmission rate. These findings underscore the importance of standardizing how we calculate readmission rate and interpret these data. Varying readmission rates and institutional practice patterns deserve closer scrutiny to inform best practice and future policies.

Percutaneous vertebral augmentation for acute traumatic vertebral Fractures: A TQIP database study

Patients with vertebral fractures may be treated with percutaneous vertebroplasty (VP) and kyphoplasty (KP) for pain relief. Few studies examine the use of VP and KP in the setting of an acute trauma. In this study, we describe the current use of VP/KP in patients with acute traumatic vertebral fractures. All patients in the ACS Trauma Quality Improvement Program (TQIP) 2016 National Trauma Databank with severe spine injury (spine AIS ≥ 3) met inclusion criteria, including patients who underwent PVA. Logistic regression was used to assess patient and hospital factors associated with PVA; odds ratios and 95 % confidence intervals are reported. 20,769 patients met inclusion criteria and 406 patients received PVA. Patients aged 50 or older were up to 6.73 (2.45 – 27.88) times more likely to receive PVA compared to younger age groups and women compared to men (1.55 [1.23–1.95]). Hospitals with a Level II trauma center and with 401–600 beds were more likely to perform PVA (2.07 [1.51–2.83]) and (1.82 [1.04–3.34]) respectively. African American patients (0.41 [0.19–0.77]), isolated trauma (0.64 [0.42–0.96]), neurosurgeon group size > 6 (0.47 [0.30–0.74]), orthopedic group size > 10, and hospitals in the Northeastern and Western regions of the U.S. (0.33 [0.21–0.51] and 0.46 [0.32–0.64]) were less likely to be associated with PVA. Vertebroplasty and kyphoplasty use for acute traumatic vertebral fractures significantly varied across major trauma centers in the United States by multiple patient, hospital, and surgeon demographics. Regional and institutional practice patterns play an important role in the use of these procedures.

Surgeon Preference on Sending Routine Tonsillectomy Specimens for Pathological Evaluation.

Despite the presence of a growing body of literature suggesting cost-ineffectiveness of routine pathologic analysis of tonsillectomy specimens, little is known about common institutional policies and practice patterns of pediatric otolaryngologists. The objectives of this study were to determine the prevalence of routine pathological evaluation of tonsillectomy specimens for uncomplicated pediatric adenotonsillectomy procedures and to evaluate opinions regarding this controversy among board-certified pediatric otolaryngologists. This was a cross-sectional survey study sent to board-certified pediatric otolaryngologists currently practicing and registered with the American Society of Pediatric Otolaryngology (ASPO) assessing their institutions' or practices' current policies on sending routine tonsillectomy specimens for pathology, their experience with this practice, and their opinions on whether routine pathologic analysis should be employed. Basic statistical analysis was then conducted. Respondents mostly practiced in an academic setting (68.4%), with the next most common being academically affiliated private practice (21.8%), and private practice was the least common (9.8%). Most respondents (85.1%) did not agree with routine pathologic analysis of otherwise uncomplicated pediatric tonsillectomy specimens. Most pediatric otolaryngologists who responded to this survey do not support routine pathological analysis of otherwise uncomplicated pediatric tonsillectomy specimens. However, the results are likely biased and should be interpreted carefully, since only a small percentage of pediatric otolaryngologists responded to the survey. Potential cost savings could be seen by patients, payers, and hospital systems with judicious use of surgical pathology, specifically in cases with concurrent signs or symptoms suspicious for malignancy.

Low-Risk Papillary Thyroid Cancer: Treatment De-Escalation and Cost Implications.

The American Thyroid Association (ATA) updated consensus guidelines in 2015 for radioactive iodine (RAI) and resection for low-risk papillary thyroid cancer. The objective of this study was to describe the evolution of institutional practice patterns and estimate the cost implications of these trends. Patients with cT1-T2N0 papillary thyroid cancer were identified via an institutional tumor registry. Incidences of total thyroidectomy or RAI were tracked longitudinally using cumulative sum. Real-world costs for RAI and each surgical encounter were adjusted for inflation and standardized to national average costs from National Inpatient Sample cost data. Sixty-one patients met inclusion criteria between 2007 and 2018. Among these, 28 patients underwent total thyroidectomies and received RAI treatments based on criteria pre-dating the 2015 ATA guidelines. Cumulative sum revealed significant decreases in the rate of total thyroidectomy following May 2015 (15.8% versus 59.5%, P=0.002) and RAI following March 2013 (3.0% versus 32.1%, P=0.002). There were no locoregional recurrences in either period. The average cost savings attributable to these institutional practice changes was $1580 per patient. De-escalation in surgical and RAI utilization for low-risk papillary thyroid cancer according to 2015 ATA guidelines is associated with a substantial decrease in real-world costs.

RONC-05. Peri-transplant Radiation Therapy for Young Children Treated with High-Dose Chemotherapy for Primary Brain Tumors

PURPOSE: The role of peri-transplant radiation therapy (RT) in young children with primary brain tumors is unclear. We characterized our institutional practice patterns and patient outcomes. MATERIALS AND METHODS: The cohort included all patients treated with high-dose chemotherapy for primary brain tumors at our institution from 2011-2017. Rates of local control (LC), progression-free survival (PFS), overall survival (OS), and radiation-associated injury were assessed. RESULTS: Of 37 eligible patients, 29 (78%) received peri-transplant RT at a median age of 4 years. Patients treated with RT were more likely to have metastatic (p=0.0121) and incompletely resected (p=0.056) disease, and to have high-risk histologies including atypical teratoid rhabdoid tumor, nongerminomatous germ cell tumor, pineoblastoma, primitive neuro-ectodermal tumor, glioneuronal tumor and group 3 medulloblastoma. Of those treated with RT, 13 (45%) received craniospinal irradiation (CSI) and 16 (55%) received focal RT. The median CSI dose was 23.4 Gy (IQR: 18-36; boost median 54 Gy [IQR: 53.7-55.8]) and focal RT dose was 50.4 Gy (IQR: 50.4-54.5). Compared to the focal RT group, patients treated with CSI were older (p=0.0499) and more likely to have metastatic disease (p=0.0004). For the complete cohort, at a median follow-up of 3.8 years, the 2-year rate of LC was 82% (95% CI: 70-96%), PFS was 63% (95% CI: 49-81%), and OS was 65% (95% CI: 51-82%). These rates did not differ significantly between patients treated with and without peri-transplant RT. Two cases of fatal myelopathy were observed after spinal cord doses within the highest tertile (41.4 CGE and 36 Gy); both cases occurred in patients who received RT before high-dose chemotherapy. CONCLUSION: Peri-transplant RT was used for high-risk disease. Oncologic outcomes after RT were encouraging. However, 2 cases of grade 5 myelopathy were observed. If used cautiously, RT may contribute to durable remission in patients at high risk of relapse.

Routine repeat imaging of blunt splenic injuries identifies complications prior to clinical change

Background There are no definitive recommendations guiding repeat imaging, or its timing, in patients with blunt splenic injury managed non-operatively. This study examines delayed complications and interventions in patients with blunt splenic injuries who undergo repeat imaging. Imaging was prompted either by a clinical change (CC) or non-clinical change (NCC) including institutional recommendations and individual physician practice patterns. Methods A 3-year, retrospective, dual-institution study was conducted of adult patients with blunt splenic injuries. Patients who underwent repeat imaging were grouped based on the reason for scan: CC or NCC. The incidence of delayed complications and interventions was examined. Results Of 235 patients, 105 (45%) underwent repeat imaging [CC n = 67 (64%), NCC n = 38 (36%)]. Median time to repeat imaging was shorter in the NCC group [CC = 96 (IQR 48–192) hours, NCC = 48 (IQR 36–68) hours, p = .0005]. Delayed complications were found in 28 (42%) CC patients versus 18 (47%) NCC patients ( p = .683). Interventions for complications were performed in 6 (21%) CC versus 10 (56%) NCC ( p = .027). Discussion Nearly half of patients reimaged because of NCC were found to have complications, with more than half undergoing intervention. Complications were identified and treated earlier in the NCC group than the CC group. This suggests patients with blunt splenic injuries should undergo routine repeat imaging to allow for prompt identification and treatment of delayed complications.

Radiation Therapy for Young Children Treated With High-Dose Chemotherapy and Autologous Stem Cell Transplant for Primary Brain Tumors

Purpose: The role of peri-transplant radiation therapy (RT) in children with primary brain tumors is unclear. We characterized our institutional practice patterns and patient outcomes. Methods and MaterialsThe cohort included all patients treated with high-dose chemotherapy and autologous stem cell transplant for primary brain tumors at our institution from 2011 to 2017. Rates of local control, progression-free survival, overall survival, and radiation-associated injury were assessed. ResultsOf the 37 eligible patients, 29 (78%) received peri-transplant RT. Patients treated with RT were more likely to have metastatic (P = .0121) and incompletely resected (P = .056) disease. Of those treated with RT, 13 (45%) received craniospinal irradiation (CSI) and 16 (55%) received focal RT. The median CSI dose was 23.4 Gy (interquartile range [IQR], 18-36 Gy; boost: median, 54 Gy [IQR, 53.7-55.8 Gy]) and focal RT dose was 50.4 Gy [IQR, 50.4-54.5 Gy]). Compared with the focal RT group, patients treated with CSI were older (P = .0499) and more likely to have metastatic disease (P = .0004). For the complete cohort, 2-year local control was 82% (95% confidence interval [CI], 70%-96%), progression-free survival 63% (95% CI, 49%-81%), and overall survival 65% (95% CI, 51%-82%). These rates did not differ significantly between patients treated with and without peri-transplant RT. Two cases of fatal myelopathy were observed after spinal cord doses within the highest tertile (41.4 cobalt Gy equivalent and 36 Gy). ConclusionsPeri-transplant RT was used for high-risk disease. Oncologic outcomes after RT were encouraging. However, 2 cases of grade 5 myelopathy were observed. If used cautiously, RT may contribute to durable remission in patients at high risk of relapse.

Benign-appearing Incidental Adnexal Cysts at US, CT, and MRI: Putting the ACR, O-RADS, and SRU Guidelines All Together

Adnexal cysts are a common incidental finding at US, CT, and MRI but have historically caused a diagnostic dilemma for determining when to follow up and how to manage them. Characteristic imaging features of simple adnexal cysts include a simple fluid collection with smooth walls and no solid or vascular components. Day-to-day practice guidelines were recently updated to reflect the overwhelming evidence that incidental cystic adnexal masses are almost always benign. Three major consensus articles on adnexal cystic masses were published between 2019 and 2020: the Society of Radiologists in Ultrasound (SRU) consensus update on adnexal cysts, the Ovarian-Adnexal Reporting and Data System (O-RADS) US consensus guideline, and the American College of Radiology (ACR) white paper on the management for incidental adnexal findings at CT and MRI. All three standardize reporting terminology, are based on evidence-based data and institutional practice patterns, and apply to nonpregnant women of average risk for ovarian cancer. While there are small differences in follow-up recommendations based on size thresholds, the goal of each is the same-to limit unnecessary imaging follow-up and, by doing so, save the patient time, money, and anxiety. For the diagnostic radiologist to use these guidelines, it is essential that the entire mass is visualized well. Without adequate visualization, further characterization of the mass may be necessary. To put it all together, the SRU consensus guideline and ACR white paper are easily applied in day-to-day practice for masses that are O-RADS 2 and below. An invited commentary by Patel is available online.The online slide presentation from the RSNA Annual Meeting is available for this article.©RSNA, 2022.

Variations in Discharge Destination Following Severe Traumatic Brain Injury across the United States

Discharge destination after traumatic brain injury (TBI) may be influenced by non-patient factors such as regional or institutional practice patterns. We hypothesized that non-patient factors would be associated with discharge destination in severe TBI patients. All patients in the ACS Trauma Quality Improvement Program 2016 data set with severe TBI, defined as head Abbreviated Injury Scale ≥3, were categorized by discharge destination. Logistic regression was used to assess factors associated with each destination; odds ratios and 95% confidence level are reported. Regressions were adjusted for age, gender, race, insurance, GCS, ISS, polytrauma, mechanism, neurosurgical procedure, geographic region, teaching status, trauma center level, hospital size, and neurosurgeon group size. 75,690 patients met inclusion criteria. 51% were discharged to home, 16% to rehab, 14% to SNF, and 11% deceased. Mortality was similar across geographic region, teaching status, and hospital size. Southern patients were more likely to be discharged to home while Northeastern patients were more likely to be discharged to rehab. Treatment by groups of 3 or more neurosurgeons was associated with SNF discharge as was treatment at community or non-teaching hospitals. Patients treated at larger hospitals were less likely to be discharged to rehab and more likely to go to SNF. Geographic region, neurosurgeon group size, teaching status, and hospital size are significantly associated with variation in discharge destination following severe TBI. Regional and institutional variation in practice patterns may play important roles in recovery for some patients with severe TBI.

Institutional Variation in Gastrostomy Tube Placement After Duodenal Atresia Repair in Children With Trisomy 21.

To compare institutional practice patterns for gastrostomy tube placement in neonates with duodenal atresia (DA) and trisomy 21. A retrospective review of the Pediatric Health Information System (PHIS) from 2015 to 2018 identified infants <10 days old with ICD-10 diagnostic codes for DA and trisomy 21, in addition to procedure codes for an intestinal bypass or duodenoduodenostomy. This cohort was then queried for gastrostomy tube procedure codes and diagnostic codes for associated co-morbidities. Two hundred and nine infants were identified with DA, trisomy 21, and an intestinal bypass. Fifty-seven (27%) underwent gastrostomy placement. Baseline characteristics of those with and without gastrostomy tubes were similar. Patients from 16 hospitals that placed no gastrostomy tubes (No-G-tube-Hospitals) were compared to children from 30 hospitals that placed at least one gastrostomy tube (G-tube-Hospitals). Open atresia repairs occurred more frequently at G-tube-Hospitals, but patients were otherwise similar. There was no difference in readmission at 12 months for gastrostomy placement between children from No-G-tube-Hospitals and those from G-tube-Hospitals that did not undergo gastrostomy during their index admission. One-third of institutions in this study did not place gastrostomy tubes during index admissions for neonates with trisomy 21 and DA, yet this did not negatively impact the length of stay or incidence of subsequent gastrostomy placement as a result. Future research is needed to determine factors that predispose patients to failure without gastrostomy, as well as best practices for post-operative management in these patients to reduce unnecessary tube placement.

Abstract #992010: Practice Patterns and Cost Implications of Surgery and Radioactive Iodine for Papillary Thyroid Carcinoma

The American Thyroid Association (ATA) provided guidelines in 2015 for radioactive iodine (RAI) and extent of resection for low-risk papillary thyroid cancer. The objective of this study was to describe the evolution of institutional practice patterns over time and estimate the cost implications of these trends.

Management of Acute Central Retinal Artery Occlusion, a “Retinal Stroke”: An Institutional Series and Literature Review

ObjectivesAcute central retinal artery occlusion (CRAO) is an ophthalmologic emergency that often results in permanent vision loss. Over 25% are associated with acute cerebral ischemia. In the absence of existing Level I treatment options, this study aims to examine institutional practice patterns and review the literature to develop a formalized approach to the treatment of CRAO in the era of ischemic stroke protocols. Materials and methodsThis is a retrospective review of institutional practices in the workup and treatment of patients diagnosed with acute non-arteritic (NA) CRAO at a single center from January 2017 to August 2020. ResultsOf 91 patients managed for acute NA-CRAO, 62.6% were male and average age was 66.4 years. Only 20.9% of patients presented within 4 h of symptom onset. 12.1% of patients had evidence of acute stroke on MRI, and 27.5% had ipsilateral internal carotid artery stenosis >50%. Half (52.7%) did not receive any acute treatment for CRAO, excluding antiplatelet/anticoagulation. 48.5% of patients undergoing acute medical treatment had improved visual acuity compared to 29.4% without treatment (p=0.14). ConclusionsThere is a lack of clear protocol for the management of NA-CRAO. While not reaching statistical significance, our experience mirrors the literature with patients undergoing medical treatment demonstrating improved visual acuity over those without treatment. Given the presence of acute ischemic stroke, carotid disease, and/or stroke risk factors in over 25% of patients with CRAO, multidisciplinary involvement and modern stroke algorithms should be considered for this disease.

Benign Prostatic Hyperplasia: Clinical Manifestations, Imaging, and Patient Selection for Prostate Artery Embolization

Prostate artery embolization (PAE) has been shown to be safe and effective at treating lower urinary tract symptoms (LUTS), urinary retention, and hematuria caused by benign prostatic hyperplasia (BPH). To distinguish from other causes of these symptoms, a multidisciplinary evaluation by a urologist and interventional radiologist should include a complete history to screen for any nonprostate causes of LUTS. The International Prostate Symptom Score is a useful objective measure to quantify the patient's urinary complaints. A physical exam should be performed to evaluate a patient's candidacy for angiography, and baseline laboratory evaluation should ensure that the patient's coagulation and kidney function are adequate. In certain situations, patients may benefit from cystoscopy and urodynamic evaluation to ensure their symptoms are related to BPH. A review of the patient's imagining can be the most important component of the evaluation of a patient prior to PAE, because a patient's gland size is often a primary driver of what procedural options available are to him. Men with small glands (≤30 mL) can be treated with several of the available minimally invasive transurethral procedures, but larger glands (≥80-120 mL) may be limited to holmium laser enucleation of prostate, thulium laser enucleation of prostate, surgical prostatectomy, or PAE, depending on institutional practice patterns. Secondary considerations include medical comorbidities, the risks for sexual side effects, the risk for bleeding, and the possible adverse events associated with the procedure, which are all low for PAE. Most patients suffering from symptomatic BPH resulting in LUTS, retention, or hematuria will benefit from PAE.

Intra-aortic balloon pump placement in coronary artery bypass grafting patients by day of admission

IntroductionIntra-Aortic Balloon Pumps (IABPs) can be utilized to provide hemodynamic support in high risk patients awaiting coronary artery bypass grafting (CABG). There are many indications for IABP and institutional practice patterns regarding the placement of IABPs is variable. As a result, the preoperative placement of an IABP in a patient awaiting CABG is not standardized and may vary according to non-clinical factors. We hypothesize that the rate of IABP placement varies by day of the week.MethodsA retrospective cohort analysis of the Office of Statewide Health Planning and Development database from 2006 to 2010 was performed. All patients admitted for CABG were included. Patients who died within 24 h of admission and those who had absolute contraindications to IABP placement were excluded. The primary outcome was preoperative IABP placement versus non-placement. A multivariable logistic regression analysis to identify predictors of IABP placement was performed, adjusting for patient demographics, clinical factors, and system variables.ResultsA total of 46,347 patients underwent CABG, of which 7695 (16.60%) had an IABP placed preoperatively. On unadjusted analysis, IABP rates were significantly higher on weekends versus weekdays (20.83% vs. 15.70%, p < 0.001). On adjusted analysis, patients awaiting CABG were 1.30 times more likely to have an IABP placed on weekends than on weekdays (OR: 1.30, 95% CI 1.20–1.40, p < 0.001).ConclusionThe odds of preoperative IABP placement prior to CABG is significantly increased on weekends compared to weekdays, even when controlling for clinical factors. Further exploration of this phenomenon and its associations are warranted.

Resuscitative endovascular balloon occlusion of the aorta-Interest is widespread but need for training persists.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) was first described in the 1950s, but early attempts at REBOA faced several technical challenges. Subsequent advances in endovascular technologies led to renewed interest in employing REBOA for management of hemorrhagic shock. However, REBOA usage remains infrequent, and indications for REBOA implementation remain unclear. We evaluated current opinions of trauma surgeons toward the use of REBOA for control of trauma-related hemorrhage and other causes of hemorrhagic shock. We hypothesize, that despite heightened interest in REBOA, implementation remains limited. A 25-question survey was thus created to query institutional and surgeon-specific training and practice patterns related to REBOA usage. The anonymized survey was distributed via email to a national trauma surgeon database and responses were recorded online. 992 subjects were invited to participate, of whom 31% (n=311) responded. Of these, 89% reported to be a trauma or acute care surgeon at a Level I trauma center, 50% reported practicing for ≥20 years. Two-thirds (68%) reported REBOA use at their institution, and the majority (59%) employed REBOA at least once. However, most (78%) performed ≤5 REBOA placements last year. Respondents supported REBOA usage in non-trauma causes of shock including gastrointestinal bleeding (60%), post-partum hemorrhage (83%), and ruptured abdominal aortic aneurysm (69%). A significant minority (20.3%) reported either only slight confidence or no confidence in their ability to deploy REBOA, and thus 21% reported being 'very interested' in attending a REBOA skills course.We thus conclude that REBOA has gained wide interest among trauma surgeons. However, placement remains infrequent with most providers placing a few annually. Educational courses are needed to disseminate the necessary skills for REBOA utilization.

Survey of Current Institutional Practices in the Use of High-Flow Nasal Cannula for Pediatric Patients.

High-flow nasal cannula (HFNC) is an oxygen delivery device that provides heated humidified air with higher flow rates. The purpose of this survey is to look at institutional practice patterns of HFNC initiation, weaning, and disposition for pediatric patients across the United States. Survey was sent via electronic listservs to pediatric physicians in emergency medicine, hospital medicine, critical care, and urgent care. The questionnaire was divided into demographics and HFNC practices (initiation, management, and weaning). One response per institution was included in the analysis. Two hundred twenty-four responses were included in the analysis, composed of 40% pediatric emergency medicine physicians, 46% pediatric hospitalists, 13% pediatric intensive care unit (PICU) physicians, and 1% pediatric urgent care physicians. Ninety-eight percent of the participants have HFNC at their institution. Thirty-seven percent of the respondents had a formal guideline for HFNC initiation. Nearly all guideline and nonguideline institutions report HFNC use in bronchiolitis. Guideline cohort is more likely to have exclusion criteria for HFNC (42% in the guideline cohort vs 17% in the nonguideline cohort; P < 0.001) and less frequently mandates PICU admissions once on HFNC (11% in the guideline cohort vs 56% in the nonguideline cohort; P < 0.001). Forty-six percent of guideline cohort had an objective scoring system to help determine the need for HFNC, and 73% had a weaning guideline. Although there is general agreement to use HFNC in bronchiolitis, great practice variation remains in the initiation, management, and weaning of HFNC across the United States. There is also a discordance on PICU use when a patient is using HFNC.