Changes In Practice Patterns Research Articles

61. EVOLVING CLINICAL PRACTICE PATTERNS IN ABDOMINOPLASTY: A 16-YEAR ANALYSIS OF CONTINUOUS CERTIFICATION TRACER DATA FROM THE AMERICAN BOARD OF PLASTIC SURGERY

PURPOSE: This study evaluates changes in practice patterns in abdominoplasty based on a 16-year review of tracer data collected by the American Board of Plastic Surgery (ABPS) as part of the Continuous Certification process. METHODS: ABPS tracer data was reviewed from 2005 to 2020, comparing data between two timeframes with similar case numbers: 2005-2014 versus 2015-2020. Patient demographics, surgical techniques, and complication rates were compared using two-sample t-tests. RESULTS: Cumulative data included 4740 cases from 2005-2014 and 4250 cases from 2015-2020. Comparing patient selection practices, the latter group had significantly increased BMI; however, there was a decrease in pregnancies, previous intra-abdominal surgeries, body scars, and redundant skin over the umbilicus. Among procedure techniques, there has been a significant decline in the use of wide undermining, vertical plication of the abdomen, and surgical drains. Abdominoplasties are increasingly being performed in an outpatient setting (81%) and more surgeons are prescribing heparin instead of postoperative sequential compression devices. Liposuctioning the abdominal flap, hips, and flank is becoming more common while liposuctioning the thighs less common. More abdominoplasties are being performed with no complications (78%vs81%, p<0.001) and without the need for revisionary surgery (90%vs92%, p<0.001). CONCLUSION: Despite surgeons operating on higher BMI patients and performing more aggressive liposuction of the abdominoplasty flap, abdominoplasties are being performed with less complications and increasingly as an outpatient procedure.

Artificial Intelligence 12 Lead ECG Based Heart Age Estimation and 1-year Outcomes After Heart Transplantation

<h3>Purpose</h3> Donor-recipient age differences are known to play a role in post-transplant outcomes with donors >50 or recipients >60 resulting in more complications. Studies to date, however, have not utilized artificial intelligence (AI) based analysis to estimate heart-age in recipients after transplantation. We evaluated the impact of donor heart-age assessment by 12 lead ECG on predicting outcomes within the first year after transplantation with a validated AI model. <h3>Methods</h3> All heart transplant recipients from May 2018 to June 2020 at Mayo Clinic Florida were included. AI based ECG age analysis was performed at time of discharge and 12 months after transplantation. Change in AI ECG heart age was compared to donor and recipient age over time and analyzed for association with rejection or death within the first year after transplant. <h3>Results</h3> A total of 67 patients underwent heart transplantation during our review period. Two patients died prior to hospital discharge and were not included in the analysis. Of the remaining 65 recipients, 45 were male (69%). Median recipient age at transplant was 58 years (IQR 47-64) with a median donor age at transplant of 29 years (IQR 22 -37), p<0.01. Median donor age was 29 years younger than recipient at transplant. One-year survival was 95% with 11 patients treated for rejection during the first year after transplant. The median AI ECG predicted heart age at discharge was 50 years (IQR 41 - 60), which was associated with 1-year survival (p<0.001) and an AUC of .789. At 1 year follow up the AI ECG heart age found 33 patients age had increased to match the recipient age at transplant compared to 27 patients whose AI ECG heart age remained between the donor and recipient age (p = 0.012). Comparing younger (<60) to older recipients (>=60) at transplant correlated with younger AI ECG heart age between the two groups (46 vs 66, p < 0.01) on discharge and at 1 year (50 vs. 61, p<0.01). No significant difference in rejection (p=0.44) or death (p=0.31) between younger or older recipients at 1 year. <h3>Conclusion</h3> 12 lead ECG is a simple noninvasive procedure that can be done easily after transplantation. Our data suggests there may be a signal with AI ECG heart age and one-year endpoints. In an age of publicly reported outcomes, identification of higher risk patients may change practice patterns and improve survival. Larger studies are warranted to evaluate this finding.

32. EVOLUTION OF CLINICAL PRACTICE PATTERNS IN LIPOSUCTION: A SIXTEEN-YEAR REVIEW OF CONTINUOUS CERTIFICATION TRACER DATA FROM THE AMERICAN BOARD OF PLASTIC SURGERY

PURPOSE: A sixteen-year review of liposuction tracer data collected from diplomates of the American Board of Plastic Surgery (ABPS) as part of the Continuous Certification process was performed to evaluate for predominant practice patterns and changes in specific practice patterns over this time. METHODS: Liposuction tracer data were collected from 2005-2021, comparing tracer data from 2005-2014 to those from 2015-2021 using Fisher’s exact test and Student’s t-test. RESULTS: 2810 patients with an average age of 42 years were evaluated, of which 84% were female. In the later cohort (2015-2021), in-office procedures increased significantly. Concerning the body area of liposuction, abdomen, flank, and back have increased, while thighs and knees have decreased. Power-assisted lipectomy has grown in popularity, and significant increases were noted in the volume of wetting solution and lipoaspirate. Surgeons are performing procedures concomitantly with liposuction more often, and more mid-surgical position changes from prone to supine were noted. Perioperative heparin and low-molecular-weight heparin (LMWH) use have significantly increased. CONCLUSION: The present study is the first to objectively assess evolving trends in the clinical practice of liposuction over the last sixteen years. These data illustrate an increase in outpatient procedures, a shift in technique towards power-assisted liposuction, and greater surgical focus on the trunk (abdomen, flanks, and back).

Phase I study of trametinib in combination with whole brain radiation therapy for brain metastases

IntroductionTrametinib is a MEK inhibitor with intracranial activity indicated for BRAF-mutant metastatic malignancies. Yet, the safety of trametinib concurrent with whole brain radiation therapy (WBRT) is unknown. We performed a single-institution, prospective, 3 + 3, phase I clinical trial to determine the maximum tolerated dose (MTD) of trametinib with WBRT. Methods and MaterialsPatients with brain metastases (BM) received daily trametinib for 28 days, starting 7 days prior to and continuing through WBRT (37.5 Gy/15 fractions). Dose levels (DL)1–3 were 1.0, 1.5, and 2.0 mg. The MTD of trametinib plus WBRT, the max dose where ≤1 of 6 patients experienced a dose limiting toxicity (DLT), was the primary endpoint. Results10 patients were enrolled (median age-59 [47–64], BM-5 [1–10], 50% melanoma). Three and 7 patients were assigned to DL1 and 2. One DL2 patient withdrew. 89% of remaining patients completed therapy per protocol, but 1 DL2 patient with systemic progression discontinued therapy at 30 Gy. Thirteen grade (G)3–4 toxicities were observed, of which 12 occurred at DL2 (4/6 of patients). DLT was reached at DL2 (G4 thrombocytopenia and G3 diarrhea, 1 each). There were no G5 toxicities. Median overall survival was 2.2 months. During the study period, changing practice patterns favored utilization of stereotactic radiosurgery (SRS). Thus, the trial closed early prior to completion. ConclusionsIn a patient population representative of modern candidates for WBRT, trametinib plus WBRT is highly toxic with a MTD <1.5 mg. The safety of trametinib with SRS remains an important question for future study.

Intraoperative opioid and analgesic adjuvant administration practice patterns following implementation of an enhanced recovery after surgery protocol for laparoscopic donor nephrectomy

Study objectiveThe primary aim of this study is to understand how intraoperative medication administration patterns change in response to ERAS® protocol implementation for patients who underwent laparoscopic donor nephrectomy. DesignSingle-center, retrospective analysis of laparoscopic donor nephrectomy patients. SettingLarge tertiary academic medical center. PatientsWe divided all cases of laparoscopic donor nephrectomies (n = 929) over seven years into three approximately equal time periods: Pre-ERAS 1 (n = 317), Pre-ERAS 2 (n = 297) and Post-ERAS (n = 315). MeasurementsWe examined patient demographics, intraoperative opioid and non-opioid pain adjuvant administration, Post Anesthesia Recovery Unit (PACU) pain scores and opioid use as well as PACU and hospital lengths of stay (LOS). Main resultsSegmented regression analysis of interrupted time series was utilized to evaluate the association of ERAS protocol implementation with the amount of intraoperative opioid and non-opioid pain adjuvant use. In adherence to our institutional ERAS protocol, there was a significant reduction in intraoperative fentanyl use after ERAS protocol of −70.2μg (95% CI -106.0, −34.2, p < 0.001) and a significant increase in intraoperative hydromorphone use of 0.47 mg (95% CI 0.284, 0.655, p < 0.001). However, in contrary to our ERAS protocol, we found no significant change in odds of receiving IV acetaminophen OR 1.31 (95% CI 0.450, 3.76, p = 0.613) or IV ketorolac OR 1.65 (95% CI 0.804, 3.41, p = 0.172) after ERAS protocol implementation. We found a significant reduction in PACU opioid use of −9.68 Morphine Milligram Equivalents (MME) (95% CI -17.1, −2.31, p = 0.010) but no significant change in PACU initial pain score, PACU LOS and hospital LOS. ConclusionsWe examined intraoperative practice pattern changes by anesthesiologists in response to ERAS protocol implementation for laparoscopic donor nephrectomies. Our results suggest that there was a variable uptake of recommendations from ERAS protocol. While ERAS protocols are often studied as a bundle of best practice recommendations, understanding the variability of provider adherence represents an important future research direction for the ERAS initiative.

A hyperparameter-tuning approach to automated inverse planning.

In current practice, radiotherapy inverse planning often requires treatment planners to modify multiple parameters in the treatment planning system's objective function to produce clinically acceptable plans. Due to the manual steps in this process, plan quality can vary depending on the planning time available and the planner'sskills. This study investigates the feasibility of two hyperparameter-tuning methods for automated inverse planning. Because this framework does not train a model on previously optimized plans, it can be readily adapted to practice pattern changes, and the resulting plan quality is not limited by that of a trainingcohort. We retrospectively selected 10 patients who received lung stereotactic body radiation therapy using manually generated clinical plans. We implemented random sampling and Bayesian optimization to automatically tune objective function parameters using linear-quadratic utility functions based on 11 clinical goals. Normalizing all plans to deliver a minimum dose of 48 Gy to 95% of the planning target volume, we compared plan quality for the automatically generated plans to the manually generated plans. We also investigated the impact of iteration count on the automatically generated plans, comparing planning time and plan utility for randomized and Bayesian plans with and without stoppingcriteria. Without stopping criteria, the median planning time was 1.9 and 2.3 h for randomized and Bayesian plans, respectively. The organ-at-risk (OAR) doses in the randomized and Bayesian plans had a median percent difference (MPD) of 48.7% and 60.4% below clinical dose limits and an MPD of 2.8% and 3.3% below clinical plan doses. With stopping criteria, the utility decreased by an MPD of 5.3% and 3.9% for randomized and Bayesian plans, but the median planning time was reduced to 0.5 and 0.7 h, and the OAR doses still had an MPD of 42.9% and 49.7% below clinical dose limits and an MPD of 0.3% and 1.8% below clinical plandoses. This study demonstrates that hyperparameter-tuning approaches to automated inverse planning can reduce the treatment planner's active planning time with plan quality that is similar to or better than manually generated plans.

Non-negative matrix factorization temporal topic models and clinical text data identify COVID-19 pandemic effects on primary healthcare and community health in Toronto, Canada.

To demonstrate how non-negative matrix factorization can be used to learn a temporal topic model over a large collection of primary care clinical notes, characterizing diverse COVID-19 pandemic effects on the physical/mental/social health of residents of Toronto, Canada. The study employs a retrospective open cohort design, consisting of 382,666 primary care progress notes from 44,828 patients, 54 physicians, and 12 clinics collected 01/01/2017 through 31/12/2020. Non-negative matrix factorization uncovers a meaningful latent topical structure permeating the corpus of primary care notes. The learned latent topical basis is transformed into a multivariate time series data structure. Time series methods and plots showcase the evolution/dynamics of learned topics over the study period and allow the identification of COVID-19 pandemic effects. We perform several post-hoc checks of model robustness to increase trust that descriptive/unsupervised inferences are stable over hyper-parameter configurations and/or data perturbations. Temporal topic modelling uncovers a myriad of pandemic-related effects from the expressive clinical text data. In terms of direct effects on patient-health, topics encoding respiratory disease symptoms display altered dynamics during the pandemic year. Further, the pandemic was associated with a multitude of indirect patient-level effects on topical domains representing mental health, sleep, social and familial dynamics, measurement of vitals/labs, uptake of prevention/screening maneuvers, and referrals to medical specialists. Finally, topic models capture changes in primary care practice patterns resulting from the pandemic, including changes in EMR documentation strategies and the uptake of telemedicine. Temporal topic modelling applied to a large corpus of rich primary care clinical text data, can identify a meaningful topical/thematic summarization which can provide policymakers and public health stakeholders a passive, cost-effective, technology for understanding holistic impacts of the COVID-19 pandemic on the primary healthcare system and community/public-health.

Evolution of International Pediatric Endoscopic Practice Changes During the Coronavirus Disease 2019 Pandemic.

ABSTRACTObjectives:The coronavirus disease 2019 (COVID-19) pandemic has drastically altered endoscopic practices. We initially reported the international impact of COVID-19 on pediatric endoscopic practice. This follow-up study aimed to assess changes 7 months following the initial survey to delineate practice change patterns as the pandemic evolved.Methods:Pediatric gastroenterologists who responded to the initial survey were re-surveyed seven months later using Research Electronic Data Capture (REDCap). The survey recorded information on changes in pediatric endoscopic practice patterns, including COVID-19 screening and testing processes and personal protective equipment (PPE) utilization. Additionally, endoscopists’ risk tolerance of COVID-19 transmission was evaluated.Results:Seventy-five unique institutions from 21 countries completed surveys from the 145 initial responses (51.7% response rate). Procedural volumes increased at most institutions (70.7%) and most were performing previously postponed cases (90.7%). Ninety-seven percent of institutions were performing pre-endoscopy screening with 78.7% testing all patients. Many institutions (34.7%) have performed procedures on COVID-19 positive patients. There was significantly less PPE reuse (P < 0.05) and fewer institutions recommending full PPE for all endoscopies (43.2% vs 59.2%, P = 0.013). Overall, pediatric endoscopists’ risk tolerance of COVID-19 transmission is low.Conclusions:This is the first survey to highlight the evolution of pediatric endoscopic practices related to the COVID-19 pandemic, underscoring the need for ongoing pandemic-related guidance for pediatric endoscopic practice.

Use of Impella in Patients Listed for Heart Transplantation.

The new United Network for Organ Sharing (UNOS) policy has resulted in a significantly higher number of temporary mechanical circulatory support device usage such as extracorporeal membrane oxygenation, Impella, and intra-aortic balloon pump due to provision of higher priority with their use while on the waiting list. We aimed to identify Impella use in patients awaiting heart transplantation and temporal changes in its usage. The UNOS database was queried between years 2015 and 2019 for patients aged greater than or equal to 18 years, listed to undergo heart transplantation. A total of 378 patients had Impella support while listed for heart transplantation. Impella use skyrocketed from 2015 (1%) to 2019 (4%, p < 0.01). The most substantial increase in Impella use occurred after the UNOS policy change. The patients listed on Impella support after the policy change had significantly lower waiting time (median 12 days vs. 45 days, p < 0.01). More patients with Impella were directly transplanted (80% vs. 56%, p < 0.01) after the policy change, had significantly lower waitlist mortality (25% vs. 13%, p < 0.01) and fewer converted to a durable support (13% vs. 3%). The translatability (likelihood for receiving organs faster) was significantly improved after the policy change. A multivariable Cox regression model showed that post-transplant survival of Impella patients was not adversely affected after the policy change (hazard ratio = 0.9; p = 0.8). This increase in Impella use represents a substantial change in practice patterns of listing and managing patients on the heart transplant waiting list.

Abstract TMP102: Timing Of Withdrawal Of Antithrombotics And Impact On Stroke

Background: Antithrombotic medications (AT) are often withheld before procedures to reduce risk of bleeding. In 2005, members of our team reported that 5.2% of ischemic strokes were associated with the withdrawal of AT in the preceding 60 days. Subsequently, new medications, including DOACs, have become widely used. Given changing prescription and practice patterns we sought to compare rates of stroke in the setting of antithrombotic withdrawal in 2010 and 2015. Methods: The GCNKSS is a population-based stroke study from the Greater Cincinnati region. In 2005, 2010, and 2015, we captured all strokes in the Greater Cincinnati/Northern Kentucky 5 county area by screening ICD9 codes 430-436 and ICD10 (2015) codes I60-I68, and G45-46. Study nurses abstracted all cases and physicians adjudicated each event. Data regarding the withdrawal of AT and timing were captured. 2005 data was included as a reference. Fisher’s exact test was used to examine differences by years. Results: In 2010 and 2015, 4768 cases of ischemic stroke were identified. Across the study periods, those that were on AT at time of stroke versus those who stopped AT &lt;60 days prior to incident stroke were of similar median age, 73 and 74 years respectively, and of similar sex (55 vs 52%) and race (21 vs 18%) distribution. Atrial fibrillation (30 vs 52%) and median baseline NIHSS (3 vs 4) were higher in those who stopped AT &lt; 60 days prior to stroke than those on AT. Of the 4768, 228 (4.8%) occurred within 60 days of withdrawal of an antithrombotic medication. The proportion of strokes in the setting of warfarin being held is the only AT that had a significant change, decreasing in 2015 (Table). Conclusions: The withdrawal of AT is associated with 228 (4.8%) of ischemic strokes within 60 days in our study population. These rates remain consistent across our study periods. This highlights that despite new agents, stroke in the setting of AT withdrawal remains consistent and the decision to stop AT must be carefully considered.

Improving practice patterns in patients with newly diagnosed bladder masses treated with transurethral resection

Transurethral resection (TUR) is the mainstay for diagnosis, staging, and treatment of both high-grade and low-grade nonmuscle invasive bladder cancer (NMIBC). It is reported that 51% of initial transurethral resection of bladder tumors (iTURBT) does not contain muscle, which results in higher rates of clinical upstaging on repeat transurethral resection (reTUR) and worse oncologic outcomes. Presence of muscle on iTURBT specimen and performing reTUR within 6weeks in high-risk NMIBC aids in accurate staging and, therefore, guides proper treatment. This study aimed to assess and improve TURBT quality by making surgeons aware of their practice patterns and setting improvement goals. Patients who received TURBT for a newly diagnosed bladder mass were analyzed by retrospective chart review for 9months prior to quality improvement (QI) intervention. Data were collected pertaining to muscle presence/absence on biopsy, pathology of the tumor, risk stratification, whether reTUR was indicated, and time to reTUR. The primary endpoints were the presence of muscle on initial TURBT, whether a reTUR was performed when clinically indicated, and time to reTUR. Tumors requiring reTUR were defined as being HGT1 or HGTa >3cm. The QI intervention, physician education, was then implemented by presenting initial performance results to the physicians, and a second dataset was then collected by prospective analysis for another 9months to assess for changes in practice patterns. A total of 101 patients receiving TURBT were reviewed, including 52 patients prior to and 49 patients following QI intervention. Patients with a history of, or treatment for, bladder cancer were excluded, along withthose without assessment of muscle on pathological analysis. Fisher's exact test was utilized to determine differences in categorical data by comparing each of the following groups prior to and following QI intervention: percent of muscle presence on iTURBT, percent reTUR performed when indicated, and mean time to reTUR in days. A p<0.05 was considered statistically significant. After comparing the TURBT results before and after our QI intervention, we found a significant improvement in the number of patients receiving a reTUR when indicated, with 5/13 (38.5%) before compared to 15/19 (78.9%) after, p=0.03. The number of specimens on iTURBT with muscle present were not significantly different, with 38/52 (73.1%) before and 33/49 (67.3%) after, p=0.66. The average time to reTUR before (32.4days; n=5; range, 21-50days) and after (42.4days; n=15; range, 11-77days) QI intervention was also not significantly different, p=0.28. Our data suggest that critical analysis of physician practice patterns followed by education and setting improvement goals can significantly impact clinical practices and improve quality of care. Future studies will be performed to determine the impact that these changes have on oncologic outcomes.

Perceptions of changes in practice patterns and patient care among heart failure nurses during the COVID-19 pandemic

BackgroundThe Coronavirus (COVID-19) had a profound impact on the delivery of care in both hospital and outpatient settings across the United States. Patients with heart failure (HF) and healthcare providers had to abruptly adapt. ObjectiveTo describe how the COVID-19 pandemic affected practice patterns of HF nurses. MethodsPracticing HF nurses completed a cross-sectional, anonymous, web-based survey of perceptions of HF practice. Analyses involved descriptive and comparative statistics. ResultsOf 171 nurses who completed surveys, outpatient HF visits decreased and 63.2% added telehealth visits. Despite spending about 29 min educating patients during visits, 27.5% of nurses perceived that the pandemic decreased patients’ abilities to provide optimal self-care. Nurses reported decreased ability to collect objective data (62.4%; n = 78), although subjective assessment stayed the same (41.6%; n = 52). ConclusionNurses’ practice patterns provided insight into patient care changes made during COVID-19. Most core components of HF management were retained, but methods of delivery during the pandemic differed.

Practice Management Strategies Among Current Members of the American Association of Hip and Knee Surgeons

BackgroundA survey was conducted at the 2021 Annual Meeting of the American Association of Hip and Knee Surgeons (AAHKS) to evaluate current practice management strategies among AAHKS members. MethodsAn application was used by AAHKS members to answer both multiple-choice and yes or no questions. Specific questions were asked regarding the impact of COVID-19 pandemic on practice patterns. ResultsThere was a dramatic acceleration in same day total joint arthroplasty with 85% of AAHKS members performing same day total joint arthroplasty. More AAHKS members remain in private practice (46%) than other practice types, whereas fee for service (34%) and relative value units (26%) are the major form of compensation. At the present time, 93% of practices are experiencing staffing shortages, and these shortages are having an impact on surgical volume. ConclusionThis survey elucidates the current practice patterns of AAHKS members. The pandemic has had a significant impact on some aspects of practice activity. Future surveys need to monitor changes in practice patterns over time.

Endovascular aneurysm repair conversion is an increasingly common indication for open abdominal aortic aneurysm repair.

Although endovascular aneurysm repair (EVAR) reintervention is common, conversion to open repair (EVAR-c) occurs less frequently but can be associated with significant technical complexity and perioperative risk. There is a paucity of data highlighting the evolution of periprocedural results surrounding EVAR-c and change in practice patterns, especially for referral centers that increasingly manage EVAR failures. The purpose of this analysis was to perform a temporal analysis of our EVAR-c experience and describe changes in patient selection, operative details, and outcomes. A retrospective single-center review of all open abdominal aortic aneurysm repairs was performed (2002-2019), and EVAR-c procedures were subsequently analyzed. EVAR-c patients (n= 184) were categorized into two different eras (2002-2009, n= 21; 2010-2019, n= 163) for comparison. Logistic regression and Cox proportional hazards modeling were used for risk-adjusted comparisons. A significant increase in EVAR-c as an indication for any type of open aneurysm repair was detected (9% to 27%; P< .001). Among EVAR-c patients, no change in age or individual comorbidities was evident (mean age, 71± 9years); however, the proportion of female patients (P= .01) and American Society of Anesthesiologists classification >3 declined (P= .05). There was no difference in prevalence (50% vs 43%; P= .6) or number (median, 1.5 [interquartile range (IQR), 0-5]) of preadmission EVAR reinterventions; however, time to reintervention decreased (median, 23 [IQR, 6-34] months vs 0 [IQR, 0-22] months; P= .005). In contrast, time to EVAR-c significantly increased (median, 16 [IQR, 9-39] months vs 48 [IQR, 20-83] months; P= .008). No difference in frequency of nonelective presentation (mean, 52%; P= .9] or indication was identified, but a trend toward increasing mycotic EVAR-c was observed (5% vs 15%; P= .09). Use of retroperitoneal exposure (14% vs 77%; P< .0001), suprarenal cross-clamp application (6286%; P= .04), and visceral-ischemia time(median, 0 [IQR, 0-11] minutes vs 5 [IQR, 0-20] minutes; P= .05) all increased. In contrast, estimated blood loss (P trend= .03) and procedure time (P= .008) decreased. The unadjusted elective 30-day mortality rate improved but didnot reach statistical significance (elective, 10% vs 5%; P= .5) with no change for non-elective operations (18% vs 16%; P= .9). However, a significantly decreased risk of complications was evident (odds ratio, 0.88; 95% confidence interval, .8-.9; P= .01). One- and 3-year survival was similar over time. EVAR-c is now a common indication for open abdominal aortic aneurysm repair. Patients frequently present nonelectively and at increasingly later intervals after their index EVAR. Despite increasing technical complexity, decreased complication risk and comparable survival can be anticipated when patients are managed at a high-volume aortic referral center.

The Influence of an Online Platform (Hernia U) in Surgical Education and Patient Management.

Introduction:Hernia U was created with the objective to expand the educational landscape of abdominal wall surgery. It is an online platform where surgeons can register with no cost and subscribe for different courses. The aim of this study is to evaluate the impact of the platform on patient management and surgical education.Methods:A questionnaire regarding the influence of Hernia U in surgical education and patient management was emailed to professionals who had previously participated in any course of the Hernia U. Variables were shown with absolute and relative frequencies. Pearson’s χ2 and Fisher’s exact test were performed to analyze relationships between variables as appropriate.Results:Nine hundred three participants responded to the questionnaire. Seven hundred fifty-two (83.3%) were men; 248 (27.4%) participants were older than 50 years old; 240 (26.6%) were between 41 and 50 years old. Two hundred seventy-four (30.4%) participants had been in practice for more than 20 years, 242 (26.8%) between 11 and 20 years, and 161(17.8%) between 5 and 10 years. When analyzing the impact of time spent on the platform, spending over an hour per week was significantly associated with self-reported change in practice patterns compared to spending less than an hour per week (p < 0.0003). More experienced surgeons (10 or more years of practice) were less likely to change their practice patterns when compared to less experienced surgeons.Conclusion:Hernia U has allowed surgeons to change their daily practice and to boost their education. Surgeons spending more than one hour weekly in the platform are more likely to adopt changes.

Changing gender gap and practice patterns in reproductive endocrinology and infertility subspecialists in the United States: a Society for Reproductive Endocrinology and Infertility report

To identify changes in current practice patterns, salaries, and satisfaction by gender and by years in practice among board-certified reproductive endocrinology and infertility (REI) subspecialists in the United States. Cross-sectional web-based survey including 37 questions conducted by the Society for Reproductive Endocrinology and Infertility. Not applicable. None. None. The primary outcome measures were total compensation and practice patterns compared by gender and the type of practice. The secondary outcomes included demographics, the number of invitro fertilization cycles, surgeries performed, and the morale of survey respondents. There were 370 respondents (48.4% women and 51.4% men). Compared with a similar survey conducted 6 years earlier, a 27% increase in the number of female respondents was observed in this survey. There was a marginally significant trend toward lower compensation for female than male REI subspecialists (17% lower, $472,807 vs. $571,969). The gap was seen for responders with ≥10 years' experience, which is also when there was the largest gap between private and academic practice (mean $820,997 vs, $391,600). Most (77%) felt positively about the current state of the reproductive endocrinology field, and >90% would choose the subspecialty again. There has been a substantial increase in the number of recent female REI subspecialists showing less disparity in compensation, and the gap appears to be closing. There is an increasing gap in compensation between private and academic practices with ≥5 years of experience. Reproductive endocrinology and infertility remains a high morale specialty.

Implementation of Commission on Cancer Operative Standards: A Deceptively Complex Process.

Implementation of Commission on Cancer Operative Standards: A Deceptively Complex Process.

Changes in practice patterns of nephrolithiasis in the era of the coronavirus disease 2019 pandemic: a review.

Purpose of reviewThe coronavirus disease 2019 (COVID-19) pandemic led to a drastic change in healthcare priorities, availability of resources and accommodation of different needs and scenarios. We sought to review the effect of the pandemic on different aspects of nephrolithiasis.Recent findingsThe pandemic resulted in a significant impact on management of patients with nephrolithiasis around the world. A significant decrease in patient presentation and differences in strategies of management to truncate exposure and surgery time and expedite patient discharge deferring definitive management has been noted. Moreover, new safety measures such as COVID-19 PCR testing prior to surgery and limiting any intervention for COVID-19 positive patients to only life-saving scenarios has been implemented. Different emergency triaging proposals are being used, mainly including high risk patients with septic shock or complete obstruction/renal injury. Moreover, the emergence of telehealth has changed outpatient practice dramatically with a significant adoption to minimize exposure. Lastly, the effect of COVID-19 on renal physiology has been described with significant potential to cause morbidity from immediate or delayed acute kidney. No physiological effect on stone formation has yet been described, and transmission through urine is rare.SummaryThe COVID-19 pandemic has markedly shifted the treatment of nephrolithiasis in many ways, including emergency triage, outpatient care, and definitive management. Although various approaches and algorithms proposed are meant to optimize management in the time of the pandemic, further studies are required for validation.

Provider utilization of gestational diabetes screening methods – Have practices changed since the HAPO trial?

The 2008 Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study prompted an international change toward lowering the threshold for diagnosis and treatment of Gestational Diabetes Mellitus (GDM). However, it is unknown if this study changed practice patterns in the US. We assessed practice patterns in diagnosis and treatment of patients with GDM before and after the HAPO study.

Use of the Poisson Distribution Is a Helpful Tool That Is Underused in Nursing Practice.

The Poisson distribution is used to find the probability of an event occurring over an interval of time, distance, area, or volume. It is a helpful statistical tool, especially when evaluating rare events, and is underused in nursing practice. A single-group study design is used to demonstrate use of the Poisson distribution in determining whether a change in the number of discrete events is due to random variation or reflects a change in practice patterns and in determining the probability of seeing the number of observed events. Steps demonstrate how one can easily use the Poisson distribution to answer common questions. Use of the Poisson distribution can help nurses make better informed decisions about observed variations in care, especially when the data are not normally distributed, and can prevent undue concern when fluctuations in the number of events are associated with random fluctuations.