Large Center Research Articles

Comparative Influences of Beta blockers and Verapamil on Cardiac Outcomes in Hypertrophic Cardiomyopathy

Guidelines recommend β blockers (BBs) as first-line therapy in symptomatic patients with hypertrophic cardiomyopathy (HCM) and nondihydropyridine calcium channel blockers, particularly, verapamil, as the second-line therapy, despite the absence of comparison trials between those 2 drugs. Because deleterious effects of verapamil have been reported in this setting, the present analysis aimed to evaluate the prognostic impact of BBs and verapamil in a cohort of patients with HCM. From a nationwide cohort of 1,434 patients with a diagnosis of HCM included in the French prospective observational REgistry of hypertrophic cardioMYopathy (REMY), we retrospectively analyzed patients with sarcomeric HCM included in the 3 largest centers and treated either with BBs or verapamil. Patients with a cardiac defibrillator or a pacemaker or who underwent a procedure of atrial fibrillation or septal ablation were excluded. The primary end point was the composite of cardiovascular death, hospitalization for heart failure, and hospitalization for atrial fibrillation. Of 600 patients with HCM, 544 (91%) were treated with BBs and 56 (9%) with verapamil. At inclusion, the 2 groups were comparable concerning the presence/amplitude of obstruction and sudden cardiac death risk factors. At up to 8 years of follow-up (median 3.9 years, interquartile range 2.1 to 5.8), no significant differences were observed in the primary end point (132 [24%] vs 10 [18%] under BBs or verapamil, respectively, hazard ratio 1.84, 95% confidence interval 0.94 to 3.63). In conclusion, in a real-world cohort of low-risk patients with HCM, verapamil therapy was not associated with a higher incidence of adverse events than β-blocker therapy.

Predictive MINT Pathologic Risk Score for Adjuvant Chemotherapy in Resected Cholangiocarcinoma: A Propensity Score-Matched Multicenter Study in Thailand.

This study aims to clarify the benefit of adjuvant chemotherapy (AC) in resectable cholangiocarcinoma (CCA) and develop a predictive risk score for treatment selection. Patients with resected CCA undergoing curative surgery, with or without AC, were identified from three centers in Thailand. Patients with R2 resection and 30 days postoperative death were excluded. Using the largest center as the discovery cohort, we generated propensity score matching (PSM). A predictive model for overall survival (OS) was identified, and a predictive risk score was developed from the PSM discovery cohort, classifying patients into high- and low-risk groups. The proposed risk score was validated in the other two centers. In the discovery cohort, 493 patients were identified. After PSM, 328 patients were categorized into surgery (n = 164) and surgery + AC (n = 164) groups. The baseline characteristics in the PSM discovery cohort were well-balanced. In the validation cohort (n = 83), patients with positive lymph node 1 received AC more frequently than those under observation (47% v 18%; P = .02). A MINT pathologic risk score was developed from multivariate analysis for OS. The score includes margin, perineural invasion, pathologic nodal status, and pathologic tumor size. In the PSM discovery cohort, for the low-risk score group, the surgery group had significantly longer OS compared with the surgery + AC group (49.4 v 31.5 months; hazard ratio [HR], 1.78 [95% CI, 1.11 to 2.86]; P = .016). Conversely, for the high-risk score group, the surgery + AC group had better OS than the surgery group (18.8 v 8 months; HR, 0.60 [95% CI, 0.46 to 0.79]; P < .001). The results were comparable in the validation cohort. Patients with resected CCA with a high-risk MINT pathologic risk score were likely to benefit from AC, whereas those with a low-risk score were not. Further validation in a larger prospective cohort is warranted.

Revolutionizing Liver Transplantation: Transitioning to an Elective Procedure Through Ex Situ Normothermic Machine Perfusion - A Benefit Analysis.

To assess the impact of normothermic machine perfusion (NMP) on patients, medical teams, and costs by gathering global insights and exploring current limitations. NMP for ex situ liver graft perfusion is gaining increasing attention for its capability to extend graft preservation. It has the potential to transform liver transplantation (LT) from an urgent to a purely elective procedure, which could revolutionize LT logistics, reduce burden on patients and health care providers, and decrease costs. A 31-item survey was sent to international transplant directors to gather their NMP experiences and vision. In addition, we performed a systematic review on cost-analysis in LT and assessed studies on cost-benefit in converting urgent-to-elective procedures. We compared the costs of available NMPs and conducted a sensitivity analysis of NMP's cost benefits. Of 120 transplant programs contacted, 64 (53%) responded, spanning North America (31%), Europe (42%), Asia (22%), and South America (5%). Of the total, 60% had adopted NMP, with larger centers (>100 transplants/year) in North America and Europe more likely to use it. The main NMP systems were OrganOx-metra (39%), XVIVO (36%), and TransMedics-OCS (15%). Despite NMP adoption, 41% of centers still perform >50% of LTs at nights/weekends. Centers recognized NMP's benefits, including improved work satisfaction and patient outcomes, but faced challenges like high costs and machine complexity. 16% would invest $100,000 to 500'000, 33% would invest $50,000 to 100'000, 38% would invest $10,000 to 50'000, and 14% would invest <$10,000 in NMP. These results were strengthened by a cost analysis for NMP in emergency-to-elective LT transition. Accordingly, while liver perfusions with disposables up to $10,000 resulted in overall positive net balances, this effect was lost when disposables' cost amounted to >$40,000/organ. The adoption of NMP is hindered by high costs and operational complexity. Making LT elective through NMP could reduce costs and improve outcomes, but overcoming barriers requires national reimbursements and simplified, automated NMP systems for multiday preservation.

Incidence of Endoscopic Retrograde Cholangiography after Subtotal Fenestrating and Reconstituting Cholecystectomy.

Laparoscopic subtotal cholecystectomy (SC) is used for the difficult cholecystectomy, but published experience with resource use for SC is limited. We hypothesized that the need for advanced resources are common after SC. This was a retrospective review of laparoscopic cholecystectomies between 2017 and 2021 at a large center. SC cases were identified using a medical record tool. Baseline characteristics were assessed with Student's t -test and chi-square test. Primary outcome was endoscopic retrograde cholangiography (ERC) within 60 days. Secondary outcomes were reconstituted SC on postoperative ERC and length of stay (LOS). Uni- and multivariable logistic regression were used for binary outcomes. Multiple linear regression was used for LOS. Covariates included were age, sex, BMI, and American Society of Anesthesiology class. A total of 1,222 laparoscopic cholecystectomies were performed between 2017 and 2021. Of these, 87 (7%) were SC. Male (p < 0.001) and older (p < 0.001) patients were more likely to undergo SC. Odds of postoperative ERC were higher in the SC group (odds ratio 9.79, 95% CI 5.90 to16.23, p < 0.001). There was no difference in preoperative ERC (17% vs 21%, p = 0.38). Reconstituting SC had lower odds of postoperative ERC (odds ratio 0.12, 95% CI 0.023 to 0.58, p = 0.009). LOS was 1.81 times higher in the SC group (p ≤ 0.001). Postoperative ERC was not associated with LOS (p = 0.24). We present one of the largest single-center series of SC. Patients who underwent SC are more likely to be male, older, have higher American Society of Anesthesiology class, and have increased LOS. SC should be performed when access to ERC and interventional radiology is available. In the absence of these adjuncts, reconstituting SC decreases the need for early ERC, but long-term outcomes are unknown.

Maternal perception of decreased fetal movements is independent of infant size.

Fetal movements are often used as a surrogate for fetal wellbeing. Previous research suggests a link between maternal perception of decreased fetal movements (DFM) and small for gestational age (SGA) infants. The aim of this study was to investigate the association between maternal presentation with DFM and birthweight centile categories at a large Australian perinatal center. This was a 5-year cohort study (January 2016 to October 2020) of non-anomalous singleton infants born at the Mater Mothers' Hospital in Brisbane, Australia at 28+0 weeks gestation or later. The primary outcome for this study was the rate of DFM by birthweight centile categories. Maternal demographics included age, body mass index, ethnicity, parity, medical conditions, and previous stillbirths. The effect of decreased fetal movements on birthweight centile was evaluated with adjusted multinomial regression models. Adjusted logistic regression models were then used to evaluate whether decreased fetal movements resulted in birthweight centiles <5 and <10. Robust standard errors were used to account for clustering at the patient level. Wald tests, Hosmer and Lemeshow's goodness of fit tests, Akaike's and Bayesian Information Criteria were used to evaluate models. Over the 5-year study period, 45042 women met the inclusion criteria. Of these, 6690 (14.9%) women presented with DFM. Of the DFM cohort, 80.9% (5411/6690) had only one presentation with DFM, whilst 19.1% (1279/6690) had >2 presentations. The overall stillbirth rate was similar in women with DFM (0.1%, 8/6690) and without DFM (0.1%, 50/38352). There was no difference in rates of DFM (either single or multiple) vs. no DFM and infant birthweight centile categories. There was no association between DFM (either single or multiple) and infant birth weight centile. The results of this study suggest that presentation with DFM is not associated with infant size. Clinicians should consider additional risk factors and the overall clinical context in deciding appropriate management. DFM is not necessarily an indication for an immediate or urgent ultrasound scan to assess fetal size. This article is protected by copyright. All rights reserved.

Survey of Continuous EEG Monitoring Practices in the United States.

Continuous EEG (cEEG) practice has markedly changed over the last decade given its utility in improving critical care outcomes. However, there are limited data describing the current cEEG infrastructure in US hospitals. A web-based cEEG practice survey was sent to neurophysiologists at 123 ACGME-accredited epilepsy or clinical neurophysiology programs. Neurophysiologists from 100 (81.3%) institutions completed the survey. Most institutions had 3 to 10 EEG faculty (80.0%), 1 to 5 fellows (74.8%), ≥6 technologists (84.9%), and provided coverage to neurology ICUs with >10 patients (71.0%) at a time. Round-the-clock EEG technologist coverage was available at most (90.0%) institutions with technologists mostly being in-house (68.0%). Most institutions without after-hours coverage (8 of 10) attributed this to insufficient technologists. The typical monitoring duration was 24 to 48 hours (23.0 and 40.0%), most commonly for subclinical seizures (68.4%) and spell characterization (11.2%). Larger neurology ICUs had more EEG technologists ( p = 0.02), fellows ( p = 0.001), and quantitative EEG use ( p = 0.001). This survey explores current cEEG practice patterns in the United States. Larger centers had more technologists and fellows. Overall technologist numbers are stable over time, but with a move toward more in-hospital compared with home-based coverage. Reduced availability of EEG technologists was a major factor limiting cEEG availability at some centers.

EPEN-13. PRE-IRRADIATION CHEMOTHERAPY EXPERIENCE FOR PEDIATRIC EPENDYMOMA POLISH PROTOCOL

Abstract BACKGROUND Pediatric ependymomas are aggressive central nervous system malignancies arising from the ependymal linings of ventricles and spinal canal. Despite better understanding of tumor biology ependymomas remain therapeutic challenge in pediatric neurooncology. The role of chemotherapy remains controversial. Herein, we describe the outcomes of patients treated at the largest center in Poland who underwent surgery, pre-irradiation chemotherapy and irradiation regardless of extent of surgical resection. METHODS This retrospective review includes pediatric patients with ependymoma treated according to national protocol at the Children’s Memorial Health Institute. We reviewed histology, disease extent, treatment, and report on overall survival (OS) and progression free survival rates (PFS). Descriptive statistics were analyzed using SPSS software. RESULTS Forty-nine patients were included (median age: 84 months). Most patients (96%) had cranial ependymomas (43% supratentorial and 57% posterior fossa lesions). Disseminated disease was found in 16% of cases. Complete resection was achieved in 43%. All patients received pre-irradiation chemotherapy; 6.1% had progressive disease and 41% achieved complete response (CR). All patients, except one, underwent irradiation (67% focal, 2% focal/ventricular, 29% craniospinal, and 2% whole brain). Thirty-five percent of patients relapsed. Five-year PFS and OS were 69% and 80% respectively. Comparing posterior fossa to supratentorial lesions, there was no difference in response after surgery and pre-irradiation chemotherapy (CR 37% versus 50% (p=0.51)) or irradiation (CR 42% versus 55% (p=0.37)). However, relapse was more likely in posterior fossa ependymomas (OR 0.30 IQR (0.70, 1.29), p=0.03) with lower 5-year PFS (56% versus 85%, p=0.03) and 10-year PFS (52% versus 85%, p=0.02). The benefit of chemotherapy was marked in patients with Grade 3 (5-year OS 82% versus 69%) CONCLUSIONS We describe a large cohort of pediatric ependymoma patients who received pre-irradiation chemotherapy. This strategy did not negatively impact the incidence of progression before irradiation.

Survival trends of extracorporeal membrane oxygenation support for pediatric emergency patients in regional and metropolitan areas in Japan

BackgroundTo assess the performance of pediatric extracorporeal membrane oxygenation (ECMO) centers, outcomes were compared between metropolitan and other areas. MethodsA retrospective cohort study was conducted at three regional centers on Kyushu Island and the largest center in the Tokyo metropolitan area of Japan. The clinical outcomes of patients of ≤15 years of age who received ECMO during 2010–2019 were investigated, targeting the survival and performance at discharge from intensive care units (ICUs), using medical charts. ResultsOne hundred and fifty-five patients were analyzed (regional, n = 70; metropolitan, n = 85). Survival rates at ICU discharge were similar between the two areas (64%). In regional centers, deterioration of Pediatric Cerebral Performance Category (PCPC) scores were more frequent (65.7% vs. 49.4%; p = 0.042), but survival rates and ΔPCPC scores (PCPC at ICU discharge–PCPC before admission) improved in the second half of the study period (p = 0.005 and p = 0.046, respectively). Veno-arterial ECMO (odds ratio [OR], 3.00; p < 0.03), extracorporeal cardiopulmonary resuscitation (OR, 8.98; p < 0.01), and absence of myocarditis (OR, 5.47; p < 0.01) were independent risk factors for deterioration of the PCPC score. A sub-analysis of patients with acute myocarditis (n = 51), the main indicator for ECMO, revealed a significantly higher proportion of cases with deteriorated PCPC scores in regional centers (51.9% vs. 25.0%; p = 0.049). ConclusionsThe survival rates of pediatric patients supported by ECMO in regional centers were similar to those in a metropolitan center. However, neurological outcomes must be improved, particularly in patients with acute myocarditis.

The Device for Intraventricular Entry guide: a novel solution to a perpetual problem.

The authors designed a low-profile device for reliable ventricular access and prospectively studied its safety, efficacy, and accuracy at a large academic center. A novel device for ventricular entry, the Device for Intraventricular Entry (DIVE) guide, was designed and created by the first and senior authors. Fifty patients undergoing external ventricular drainage (EVD) or shunt placement were prospectively enrolled for DIVE-assisted catheter placement at a single academic center. The primary outcome was the catheter tip location on postprocedural CT. Secondary outcomes included number of catheter passes, clinically significant hemorrhages, and procedure-related infections. Fifty patients were enrolled. Indications included subarachnoid hemorrhage, intraventricular hemorrhage, traumatic brain injury, hydrocephalus, pseudotumor, and postsurgical wound drainage. In total, 76% (38/50) of patients underwent right-sided placement and 24% (12/50) underwent left-sided placement. All 100% (50/50) of patients had successful cannulation with an average of 1.06 passes. Postprocedural head CT confirmed ipsilateral frontal horn or third ventricle placement (Kakarla grade 1) in 92% (46/50) of patients and placement in the contralateral lateral ventricle in 8% (4/50) (Kakarla grade 2). There were no clinically significant track hemorrhages or procedural infections. This single-center prospective study investigated the safety and efficacy of DIVE-assisted ventricular access. In total, 100% of procedures had successful ventricular cannulation, with 92% achieving Kakarla grade 1, with an average of 1.06 passes without any clinical complications.

Middle meningeal artery embolization associated with reduced chronic subdural hematoma volume and midline shift in the acute postoperative period

BackgroundMiddle meningeal artery (MMA) embolization for endovascular treatment of chronic subdural hematoma (cSDH) is growing in popularity. cSDH volume and midline shift were analyzed in the immediate postoperative window after...

Prevalence of HIV Drug Resistance Mutations among Treatment-Naive People Living with HIV in a Tertiary Care Center in India.

India has the third-largest number of people living with HIV (PLHIV) in the world. A national program provides free access to standard uniform antiretroviral therapy. However, the program is not monitored by comprehensive drug resistance surveys. The aim of this study was to determine the prevalence of HIV drug resistance mutations (DRMs) among treatment-naive PLHIV in a large antiretroviral treatment center of the national program. This cross-sectional study was done in 2017 and involved 200 consecutive treatment-naive PLHIV. A target fragment of 1,306 bp in the reverse transcriptase and protease regions was amplified. Identification of mutations and drug resistance interpretation was done by HIV Genotypic Resistance Interpretation and International Antiviral Society-USA list. Sequencing was successful in 177 samples. The majority (98.8%; 175/177) belonged to subtype C. Nineteen of 177 patients (10.7%; 95% CI: 6.2%-15.3%) had at least one major DRM. The prevalence of non-nucleoside reverse transcriptase inhibitor (NNRTI) mutations was 10.2% (18/177). The most frequent mutations were E138A/K, A98G, K103N, V179D, and K101H/E. The prevalence of nucleoside reverse transcriptase inhibitor (NRTI) mutations was 1.1% (2/177). None of the samples had major protease inhibitor resistance mutations. The prevalence of NNRTI mutations in this study was >10%, crossing the threshold recommended by the WHO to change the NNRTI-based first-line regimen to non-NNRTI based. In 2021, the national program replaced efavirenz with dolutegravir in the first-line regimen of tenofovir, lamivudine, and efavirenz. As the majority (64%) of PLHIV in India are accessing free ART from the national program, this study highlights the need for regular nationally representative drug resistance surveys for optimizing antiretroviral regimens in the program.

Cervical Cancer and a History of Incarceration: Examining a Social Determinant of Health.

Females who are incarcerated are disproportionately burdened by cancer, particularly cervical cancer. We measured the odds of cervical cancer compared with nonscreenable cancers for females who were incarcerated before diagnosis. By comparing a cancer for which screening and vaccination are available with cancers for which neither are available, we aimed to assess the relationship of incarceration with diseases for which preventive care mitigates risk. We created a novel data set combining cancer data from a large cancer center with incarceration data from the state department of corrections. We then estimated the odds of cervical cancer relative to nonscreenable cancers for those with and without a history of incarceration. Females with a history of incarceration had greater odds of being diagnosed with cervical cancer compared with nonscreenable cancers (odds ratio = 7.04; 95% confidence interval [CI]: 4.4-11.0) relative to those who had not been incarcerated. Adjusting for race and age, the odds of cervical cancer remained significantly greater for those with a history of incarceration (adjusted odds ratio = 3.86; 95% CI: 2.3-6.3). Our findings support the need for expanded cervical cancer screening and vaccination opportunities for incarcerated females and increased access to preventive health care after release.

Impact of pharmacist-driven referral to increase specialty pharmacy prescription capture.

To assess the impact of a clinical pharmacy specialist (CPS) embedded within a rheumatology clinic at a large academic medical center on the prescription capture rate at the health-system specialty pharmacy. Initially low prescription capture rates for the health-system specialty pharmacy led to the integration of a CPS in the main campus rheumatology clinic. Benchmarking was completed by assessing the prior prescription capture rate using electronic medical record analytics and Loopback Analytics (a database of prescription capture for the health-system specialty pharmacy). The existing workflows for both the rheumatology clinic and specialty pharmacy were observed with regard to biologic medication ordering and processing. Strategies for an updated workflow for biologic ordering with the incorporation of an embedded CPS in the rheumatology clinic were designed. This new workflow was established with key stakeholders, including the CPS, rheumatology providers, clinic staff, and pharmacy technicians. Once the workflow was established, all parties were educated and updated, including rheumatology providers, nursing staff, and specialty pharmacy staff. Prescription capture rate was monitored on a monthly basis. Prescription capture increased from 13.16% before pharmacist implementation (October to December 2021) to 35.42% after pharmacist implementation (October to December 2022) (P = 0.019). During the same periods, the revenue generated increased from $43,222.89 to $135,198.70 (P = 0.224) and the proportion of prescriptions initially sent to the health-system specialty pharmacy compared to other specialty pharmacies increased from 37% to 79% (P < 0.001) with CPS implementation. Expansion and implementation of pharmacy services by integrating a CPS in a rheumatology ambulatory clinic increased prescription capture and pharmacy revenue while optimizing patient care. We hope to expand similar CPS services to other clinics within the health system.

Patient and Parent Experience with Pediatric Care Providers During the COVID-19 Pandemic: A Comparison of Press Ganey Survey Scores for Telehealth and In-Person Encounters.

Background: Prior research suggests that pediatric patients and their parents/guardians are generally satisfied with care provided through telehealth. The objective of this study was to compare Press Ganey provider-oriented experience survey scores between telehealth and in-person patient encounters among a variety of pediatric clinical specialties at a large academic medical center. Methods: We analyzed Press Ganey survey data from pediatric patient encounters from UC Davis Health, collected between August 2020 and February 2022. Survey results analyzed respondents' satisfaction with care providers, including satisfaction with explanations given, discussions led, concern showed, and inclusion by providers; and the likelihood the survey respondent would recommend the provider to others. We used logistic regression models, which included case mix variables and clinical specialty to compare the odds of scoring the highest possible survey response ("top box" score). Results: Of the 6,093 survey responses that met inclusion criteria, 1,157 (19%) were associated with telehealth encounters and 4,936 (81%) were associated with in-person encounters. We found no significant difference in the odds of respondents giving a top box score to rate their satisfaction with their care provider between telehealth and in-person encounters. When respondents were asked whether they would recommend the care provider to others, the odds of giving a top box score following a telehealth encounter relative to an in-person encounter was 1.22 (95% confidence interval [0.97-1.52]; p-value = 0.09). Discussion: We found that survey respondents' experiences with their care provider are high and comparable for telehealth and in-person encounters in a pediatric population.

Cost-Effectiveness of Parathyroid Cryopreservation and Autotransplantation

Delayed autotransplantation of cryopreserved parathyroid tissue (DACP) is the only surgical treatment for permanent postoperative hypoparathyroidism. Studies suggest that only a small minority of cryopreserved samples are ultimately autotransplanted with highly variable outcomes. For these reasons, many have questioned the economic utility of the process, although, to the authors' knowledge, this has never been formally studied. To report the clinical outcomes of parathyroid cryopreservation and DACP at a large academic institution and to determine the cost-effectiveness of this treatment. An institutional review board-approved, retrospective review of patients at a single institution who underwent DACP over a 17-year period was conducted with a median follow-up of 48.2 months. A forward-looking cost-utility analysis was then performed to determine the economic utility of cryopreservation/DACP vs usual care (monitoring and supplementation). Patients who had parathyroid tissue in cryopreserved storage between August 2005 to September 2022 at a single-center, academic, quaternary care center were identified. Parathyroid cryopreservation and DACP. Graft functionality, clinical outcomes, and cost utility using a willingness-to-pay threshold of $100 000 per quality-adjusted life-year (QALY). A total of 591 patients underwent cryopreservation. Of these, 10 patients (1.7%; mean [SD] age, 45.6 [17.9] years; 6 male [60%]) underwent DACP. A minority of autografts (2 [20%]) were subsequently fully functional, one-half (5 [50%]) were partially functional, and 3 (30%) were not functional. The cost-utility model estimated that at a large academic center over 10 years, the additional cost of 591 patients undergoing cryopreservation and 10 patients undergoing autotransplantation would be $618 791.64 (2022 dollars) and would add 8.75 QALYs, resulting in a cost per marginal QALY of $70 719.04, which is less than the common willingness-to-pay threshold of $100 000/QALY. The reimplantation rate of cryopreserved tissue was low (<2%), but when implanted, autografts were at least partially functional 70% of the time. In the first-ever, to the authors' knowledge, formal cost analysis for this treatment, results of the current model suggest that cryopreservation and autotransplantation were cost-effective compared with the usual care for hypoparathyroidism at a large, academic institution. It is recommended that each surgical center consider whether the economic and logistical commitments necessary for cryopreservation are worthwhile for their individual needs.

Ophthalmology Census 2021: A Demographic Characterisation of Ophthalmologists in Portugal.

Human resources in ophthalmology have recently received particular attention, and it has been questioned whether there is a sufficient number of workers. The aim of this study was to analyze and characterize Portugal's ophthalmologist population. In this descriptive, cross-sectional study, an online questionnaire was sent to all ophthalmologists registered with the Portuguese College of Ophthalmology in December 2021. Information on the following variables was collected and analyzed: demographic factors, professional qualifications, professional activity, weekly professional activity and medium-term plans. Among the 910 registered ophthalmologists, a response rate of 64.7% was achieved. There were 0.9 ophthalmologists for every 10 000 inhabitants, 0.45:10 000 working in the public sector (0.35:10 000 full-time equivalent). Among the respondents, 57.6% were over 50 years old (59.6% male), 97.3% were Portuguese, 46.7% completed their residency in the Lisbon region, 27.3% complemented their programme with additional training, 9.5% had a PhD and approximately 58% lived and worked in large urban centres. Regarding professional activity, 58.5% of the respondents worked in the public sector (4.2% exclusively), while 67.9% worked in different economic sectors. The median number of weekly working hours reported was 45 hours, with those in the public sector reporting 35 hours. Private/social sector work and public sector work accounted for 12 926 hours/week and 10 808 hours/week, respectively. It was found that 31.4% of the respondents provided emergency medical services and that 52.8% performed surgical procedures more than once a week. Looking ahead, 38.7% of the ophthalmologists intended to reduce their workload within the next five years due to family reasons, fatigue and demotivation. The projected rate of retirement or cessation of activity in the next five years was estimated to be 1.7%, while an average of 20 new ophthalmologists are expected to enter the profession annually, resulting in a generational balance of 0.8%. While the number of ophthalmologists in Portugal meets the international recommendations, there is a shortage in the public sector and most ophthalmologists work in large urban centres. The number of ophthalmologists in Portugal is expected to be stable for the next five years.

Group B Streptococcus Infection and Obstetric Hemorrhage Risk.

To elucidate the association between GBS infection and maternal risk for obstetric hemorrhage (OBH) and OBH-related morbidities (OBH-M). This was a retrospective cohort study of all deliveries with a documented GBS status at a single large academic medical center from 2018 to 2019. GBS status was determined by either urine culture or rectovaginal culture collected during the antepartum period. The primary outcomes were quantitative blood loss (QBL), OBH, and a composite of OBH-M. Secondary outcomes were individual components of the OBH-M composite and frequency of hemorrhage-related interventions utilized intrapartum and postpartum. A stratified analysis was conducted examining only patients who were diagnosed intrapartum with an intrapartum intraamniotic infection (III). Of 4679 pregnant individuals who delivered a live infant between January 1, 2018 and January 1,2019 with a documented GBS status, 1,487 were identified as GBS positive (+) and 3192 were identified as GBS negative (-). The GBS + group did not have significantly higher QBL (p = 0.29) or rate of OBH (p = 0.35). There were no significant differences by GBS status in OBH morbidity (p = 0.79) or its individual components or frequency of individual pharmacologic or non-pharmacologic OBHrelated interventions. There were also no significant differences by GBS status among patients with an III. GBS infection at the time of delivery was not associated with increased risk for OBH or OBH-M. Further research is needed to further explore the relationship between peripartum infections and OBH risk.

Development of optimized adult epidural infusion preparations to reduce waste and improve operational efficiency.

Despite national recommendations to standardize infusion concentrations, there is minimal guidance on institution-specific strategies and outcomes related to epidural infusion concentration standardization and optimization. The purpose of this project is to identify the optimal compounded preparation for use in select adult epidural infusions and assess the impact on drug and fluid utilization and cost savings if the designated preparation is adopted. A previously validated tool, the VERB (vial, exchange, rate, and bag) analysis, was applied to epidural infusion pump administration data to identify preparations optimized for efficient supply and resource utilization at a large academic medical center. Weighing all components of the VERB analysis, the preferred preparation of hydromorphone and bupivacaine for the hospital site was hydromorphone (10 µg/mL) and bupivacaine (0.125%) in 50 mL of 0.9% sodium chloride injection (2,500 µg of hydromorphone per epidural). The preferred preparation of fentanyl and bupivacaine was fentanyl (2 µg/mL) and bupivacaine (0.0625%) in 50 mL of 0.9% sodium chloride injection (100 µg of fentanyl per epidural). Both recommendations are different from the currently utilized preparations at the study site. Analyzing historic drug administration data using the novel 4-step VERB analysis identified optimized drug preparations and fluid bag sizes for the most-prescribed epidural drug combinations at the hospital study site.

Ultrasound-guided deployment of ProGlide™ device in transfemoral transcatheter aortic valve implantation and risk reduction of vascular complications: A propensity-matched cohort study.

ProGlide is a percutaneous suture-mediated closure device used in arterial and venous closure following percutaneous intervention. Risk of vascular complications from use, particularly related to failure in hemostasis, or acute vessel closure, remains significant and often related to improper suture deployment. We describe a technique of ultrasound-guided ProGlide deployment in transfemoral transcatheter aortic valve implantation (TF-TAVI). The aim of this study is to assess vascular outcomes for ultrasound-guided deployment of ProGlide vascular closure devices in patients undergoing TF-TAVI. We collected relevant clinical data of patients undergoing TAVI in a large volume centre. main access Valve Academic Research Consortium 3 (VARC-3) major vascular complication. any major/minor VARC-3 vascular complication, its type (bleed or ischemia), and treatment required (medical, percutaneous, or surgical). We performed inverse weighting propensity score analysis to compare the population undergoing ultrasound-guided versus conventional ProGlide deployment for main TAVI access. Ultrasound technique for ProGlide insertion was performed as described below. Five hundred and seventeen patients undergoing TF-TAVI were included. In 126 (ultrasound-guided) and 391 (conventional ProGlide insertion), 0% versus 1.8% (p < 0.001) had a major VARC-3 vascular complication, respectively. 0.8% (one minor VARC-3 bleed) vs 4.1% (13 bleeds and three occlusions) had any VARC-3 vascular complication (major and minor) (p < 0.001). Surgical treatment of vascular complication was required in 0.8% versus 1.3% (p = NS). Ultrasound-guided deployment of ProGlide for vascular closure reduced the risk of major vascular complications in a large population undergoing TAVI.

Postoperative pain trajectories in total hip arthroplasty.

Total hip arthroplasty (THA) is a common procedure to address pain and enhance function in hip disorders such as osteoarthritis. Despite its success, postoperative patient recovery exhibits considerable heterogeneity. This study aimed to investigate whether patients follow distinct pain trajectories following THA and identify the patient characteristics linked to suboptimal trajectories. This retrospective cohort study analyzed THA patients at a large academic centre (NYU Langone Orthopedic Hospital, New York, USA) from January 2018 to January 2023, who completed the Patient-Reported Outcomes Measurement Information System (PROMIS) pain intensity questionnaires, collected preoperatively at one-, three-, six-, 12-, and 24-month follow-up times. Growth mixture modelling (GMM) was used to model the trajectories. Optimal model fit was determined by Bayesian information criterion (BIC), Vuong-Lo-Mendell-Rubin likelihood ratio test (VLMR-LRT), posterior probabilities, and entropy values. Association between trajectory groups and patient characteristics were measured by multinomial logistic regression using the three-step approach. Among the 1,249 patients, a piecewise GMM model revealed three distinct pain trajectory groups: 56 patients (4.5%) in group 1; 1,144 patients (91.6%) in group 2; and 49 patients (3.9%) in group 3. Patients in group 2 experienced swift recovery post-THA and minimal preoperative pain. In contrast, groups 1 and 3 initiated with pronounced preoperative pain; however, only group 3 exhibited persistent long-term pain. Multinomial regression indicated African Americans were exceedingly likely to follow trajectory groups 1 (odds ratio (OR) 2.73) and 3 (OR 3.18). Additionally, odds of membership to group 3 increased by 12% for each BMI unit rise, by 19% for each added postoperative day, and by over four if discharged to rehabilitation services (OR 4.07). This study identified three distinct pain trajectories following THA, highlighting the role of individual patient factors in postoperative recovery. This emphasizes the importance of preoperatively addressing modifiable risk factors associated with suboptimal pain trajectories, particularly in at-risk patients.