Variation In Practice Patterns Research Articles

Analysis of Postoperative Distal Radius Fracture Outcomes in the Setting of Osteopenia and Osteoporosis for Patients with Comorbid Conditions

Distal radius fractures (DRFs) are among the most common orthopedic injuries, especially in the elderly. A wide variety of approaches have been advocated as successful treatment modalities; yet, there remains variability in practice patterns of DRF in patients with osteoporosis and osteopenia. Using large data set analysis, we sought to determine the risk profile of operative fixation of DRF in patients with low bone mineral density. A commercially available health care database, PearlDiver, was queried for all patients who underwent open reduction internal fixation of DRFs between 2010 and 2020. The study population was divided into groups based on the presence or absence of osteopenia or osteoporosis and was further classified by patients who were receiving bisphosphonate therapy. Complication rates were calculated, including rates of malunion, surgical site infection, osteomyelitis, hardware failure, and hardware removal. Five-year future fragility fractures were defined in hip, vertebrae, humerus, and wrist fractures. Chi-square analysis and logistic regression were performed to determine an association between these comorbidities and various postoperative complications. A total of 152,926 patients underwent open reduction internal fixation of a DRF during the study period. Chi-square analysis of major complications at 3 months showed a statistically significant increase in malunion in patients with osteopenia (P= .05) and patients with osteoporosis (P= .05) who underwent open reduction internal fixation. Logistic regression analysis at 12 months after surgery demonstrated that osteopenia was associated with an increased risk of hardware failure (P < .0001), hardware removal (P < .0001), surgical site infection (P < .0001), and malunion (P= .004). Osteoporosis was associated with a significantly increased risk of hardware failure (P= .01), surgical site infection (P < .0001), and malunion (P < .0001). We demonstrated, using large data set analysis, that DRF patients with osteopenia and osteoporosis are predicted to be at increased risk of multiple postoperative complications, and thus, bone density should be strongly considered in treatment planning for these patients. Prognostic III.

93 Inhalation Injury: Which Providers Can Assess the Need for Intubation?

Abstract Introduction Previous studies have suggested many burn patients undergo unnecessary intubation due to concern for inhalation injury. There is a lack of clear consensus guidelines for intubation and thus there is significant variation in practice pattern. In this study we hypothesized intubation rates would differ between Acute Care Surgeons with specialized burn training and those without. Methods A retrospective analysis of 388 patients admitted to an ABA verified level 1 burn center who presented emergently following burn injury from 7/2015 to 12/2021 was performed. Patients excluded include polytrauma patients, isolated friction burns, and patients intubated prior to hospital arrival. All providers performing initial evaluation are Acute Care Surgeons, with a subset having additional specialized fellowship training and/or extensive burn experience. Our primary outcome was intubation rates between burn and non-burn trained providers. The Chi-Square and Mann-Whitney U statistical tests were used to compare categorical and continuous variables, respectively. Results There were 465 major burn patients admitted through the trauma bay and screened during the study period with 388 patients meeting inclusion criteria. The population was 72% male, with mean age of 44 years +- 21, TBSA of 12%, and COHgb level of 2.9%. In total, 73 (19%) of patients underwent intubation. The patients in the two provider groups did not differ in terms of age, gender, race, TBSA, COHgb level, or airway exam findings. 240 (62%) patients were evaluated by a burn provider and 148 (38%) were evaluated by a non-burn provider. There was no significant difference in the rate of emergent intubation of patients treated by burn vs non-burn trained providers (RR 0.71, CI 0.47 - 1.07). Of the patients who were intubated, there was no significant difference between burn and non-burn providers in the diagnosis of inhalation injury on bronchoscopy (RR 1.3, CI 0.91-1.85). In both groups, objective evidence of inhalation injury was found in only 68% of patients undergoing routine bronchoscopy following emergent intubation. Conclusions There was no significant difference in intubation rates between burn and non-burn trained acute care surgeons. This demonstrates that following standard ATLS and ABLS principles provides appropriate training in the evaluation, diagnosis, and treatment of inhalation injury. Interestingly, 32% of all patients intubated did not have evidence of inhalational injury on bronchoscopy following intubation. This study suggests that further research is needed to determine objective criteria for intubation guidelines when inhalation injury is suspected in the acute burn patient population. Applicability of Research to Practice Applicable

717 Management of Gynecologic Involvement in Stevens-Johnson Syndrome (SJS)/ Toxic Epidermal Necrolysis Syndrome (TENS)

Abstract Introduction Stevens-Johnson Syndrome (SJS)/ Toxic Epidermal Necrolysis Syndrome (TENS) are rare and potentially life-threatening dermatologic conditions that require interdisciplinary management (Shanbhag et al., 2020). One of the most painful and traumatic is vaginal mucosal involvement. Gynecologic complications have been historically undermanaged, and lack of acute intervention can lead to dyspareunia, adhesion formation, and increased risk for vaginal cancers (Kaser et al., 2011). Unfortunately, treatment is variable but typically involves use of vaginal dilators, which can be painful, and often traumatic for both patient and provider. The purpose of this study was to analyze the utilization of these treatments and to observe any sequelae from gynecological involvement. Methods Retrospective chart review was completed for all female patients with a diagnosis of SJS/TENS who were admitted to a single center burn unit from 2015-2022. Trends in age, gynecologic involvement, wound care strategies, and outcomes were assessed. Results Twenty-nine patients met inclusion criteria. These patients ranged from 9-82 years of age with a mean of 43 (STD 21). Ten percent died in the hospital, 14% were transferred to another hospital, and the remaining patients were discharged to home or a rehabilitation facility. Of these 29 SJS/TENS patients, 59% had gynecologic involvement of which 52% received gynecologic interventions. Gynecologic interventions included use of vaginal dilators (67%), topical steroids (60%), antifungal ointment (33%), and menstrual suppression (13%). For pediatric populations, patient discomfort and family concerns limited pelvic exam and vaginal interventions. Accommodations for pediatric patients included completion of examination and treatment under anesthesia and education of parents about the treatment process. While 2 patients were confirmed to have no vaginal adhesions in follow up appointments, documentation of future vaginal complaints was not available for most patients. Conclusions Gynecologic management is an important part of SJS/TENS treatment with wide variability in practice patterns not only nationally but at a single setting institution. Outcomes from treatment versus non treatment with steroids +/- dilation is equivocal. Providers must be better at screening for symptoms in outpatient follow up. When forming new algorithms, special consideration among pediatric populations and invasive management needs to be considered. Applicability of Research to Practice There is wide practice variability on the gynecological management of SJS/TENS patients with variable outcomes. Longitudinal studies on outpatients would better help create algorithms for patient management.

Practice Pattern Variation in Adoption of New and Evolving Percutaneous Coronary Intervention Procedures.

Assess factors contributing to variation in the use of new and evolving diagnostic and interventional procedures for percutaneous coronary intervention (PCI). Evidence-based practices for PCI have the potential to improve outcomes but are variably adopted. Finding possible drivers of PCI procedure-use variability is key for efforts aimed at establishing more uniform practice. Veterans Affairs Clinical Assessment, Reporting, and Tracking Program data were used to estimate a proportion of variation attributable to hospital-, operator-, and patient-level factors across (a) radial arterial access, (b) intravascular imaging/optical coherence tomography, and (c) atherectomy for PCI. We used random-effects models with hospital, operator, and patient random effects. Overlap between levels generated cumulative variability estimates greater than 100%. A total of 445 operators performed 95,391 PCI procedures across 73 hospitals from 2011 to 2018. The rates of all procedures increased over this time. 24.45% of variability in the use of radial access was attributable to the hospital, 53.04% to the operator, and 57.83% to patient-level characteristics. 9.06% of the variability in intravascular imaging use was attributable to the hospital, 43.92% to the operator, and 21.20% to the patient. Lastly, 20.16% of the variability in use of atherectomy was attributed to the hospital, 34.63% to the operator, and 57.50% to the patient. The use of radial access, intracoronary imaging, and atherectomy is influenced by patient, operator, and hospital factors, but patient and operator-level effects predominate. Efforts to increase the use of evidence-based practices for PCI should consider interventions at these levels.

Practice patterns in extracorporeal life support in tertiary cardiac intensive care units in north america: a survey-based analysis from the critical care cardiology trials network

Abstract Funding Acknowledgements Type of funding sources: None. Background The use of veno-arterial (VA) and veno-venous (VV) extracorporeal membrane oxygenation (ECMO) has significantly increased in the last decade. However, there is substantial variability in practice patterns between institutions. To date, the optimal ECMO program model is unclear and possible differences between ECMO centers in staffing, organization and team structure have been poorly characterized. Purpose Our aim was to describe contemporary practices of care for patients undergoing ECMO in tertiary cardiac centers in North America. Methods An 11-question anonymous survey was sent to all participating sites in the Critical Care Cardiology Trials Network (CCCTN), a prospective registry of advanced cardiac intensive care units (CICUs) in North America, coordinated by the TIMI Study Group. The survey evaluated ECMO staffing models, decision-making processes, cannulation and longitudinal care. Results The response rate was 100% (39/39) across CCCTN centers. The decision to proceed with VA ECMO was made as a team in 79% of the cases and in 58.3% of the VV ECMO cases, rather than by an individual specialty. An ECMO consult service was used in 67% of the centers, and integrated with the cardiogenic shock team in 58%. The most common specialty participating in the ECMO service was cardiothoracic surgery (CTS) (73.1%), followed by heart failure specialists (38.5%), with critical care cardiology (CCC) in only 23.1% of the centers (Figure 1A). In the majority of centers, VA ECMO cannulation was performed by CTS alone (46.2%), Interventional cardiology (IC) and CTS (38.5%), and IC alone (7.7%, Figure 1B). Cannulation for VA ECMO was not performed by intensivists at any center. VV ECMO cannulations were performed by CTS in 51.3%, intensivists in 17.9% and IC in 2.6% of the centers. VA ECMO patients were admitted to the cardiovascular surgical intensive care unit in 64.1% of centers, with 20.5 % admitted to the CICU (Figure 1C). VV ECMO patients were admitted to the cardiovascular surgical intensive care unit in 36.8% of sites, and the medical intensive care unit in 34.2%. The most common ECMO specialist model was having a perfusionist at the bedside, followed by nurse specialist (Figure 1D). Specialty services consulted within 24-48 hours of cannulation included physical therapy in 48.7%, palliative care in 30.8%, and bioethics in only 2.6% of centers. Simulation-based ECMO training is performed in 59% of the centers. Half (51.3%) of the centers perform ECPR, while 17.9% reported plans of developing a program. Conclusions Although there is significant variability in ECMO cannulation, location of care, staffing practices in advanced CICUs in North America, a multidisciplinary team approach is common in ECMO centers, with early involvement of physical therapy and palliative care specialists. Further research to establish the optimal model for ECMO programs is of high importance.

213P Real-world clinical outcomes associated with first-line palbociclib and aromatase inhibitor therapy among patients with HR+/HER2- advanced breast cancer in Europe

Palbociclib (PB), a cyclin-dependent kinase 4/6 inhibitor, has become a standard of care in HR+/HER2- advanced/metastatic breast cancer (ABC) in Europe since EMA approval in 2016. This study examines clinical characteristics and outcomes in ABC patients treated with PB and an aromatase inhibitor (AI) in routine clinical practice in Europe. A multicenter retrospective medical record review collected data on adult patients with HR+/HER2- ABC in Europe who received first-line PB+AI between September 2016 and July 2020. Sites screened all patients who received PB+AI during the study time frame and abstracted data for patients who met all eligibility criteria. We report here results from Germany, Spain and the UK; data from 4 additional European countries will be reported when data collection is complete. Study measures were descriptively analyzed, with the Kaplan-Meier method used to estimate real-world progression-free survival (rwPFS). Data were abstracted and analyzed for 668 patients from 47 sites. Median age at ABC diagnosis was 64.4 years (33.8% ≥70 yo), 99.6% were female, 82.9% were white, and median follow-up was 32.7 months. Of females (665), 14.1% were premenopausal at first-line PB+AI initiation. 38.5% of patients had de novo disease. At ABC diagnosis, 24.9% had bone only disease and 46.7% had visceral disease (Table). Objective response and clinical benefit rate were 35.8% and 80.7%, respectively. The median rwPFS (95% CI) was estimated to be 31.8 (27.7-35.4) months (Table). Table: 213PN%Total number of patients668100.0Age (years) at ABC diagnosis<5010115.150-6934151.1≥7022633.8Clinical stage at initial BC diagnosisStage I–III (resectable)38056.9Stage III–unresectable182.7Stage IV23935.8Unknown314.6Disease-free intervalDe novo25738.5≤12 months15222.8>12 months22133.1Unknown385.7Performance status at first-line016124.1117626.3≥2588.7Not recorded27340.9Objective response rate23935.8rwPFS, Kaplan–Meier estimateMonths (95% CI)Median31.8 (27.7-35.4)rwPFS rate% (95% CI)12 months77.2(73.8-80.3)24 months59.5(55.5-63.2)36 months45.2(41.0-49.4) Open table in a new tab This real-world study affirms the favorable clinical outcomes demonstrated for first-line PB+AI in the previous clinical trials and supports its utilization as frontline treatment for this patient population. This study presents pooled analysis of 3 European countries and variability in practice patterns and disease management may exist among countries.

Characterizing the Use of Intrathecal Nicardipine for Post Traumatic Cerebral Vasospasm (P13-7.005)

<h3>Objective:</h3> Characterizing the use of intrathecal nicardipine for post traumatic cerebral vasospasm and treatment-related complications. <h3>Background:</h3> Post traumatic cerebral vasospasm (PTV) is a significant cause of secondary neurologic injury after traumatic brain injury (TBI) and is associated with worse outcomes. There is limited data to guide treatment of PTV. Intrathecal nicardipine (ITn) was shown to improve outcomes and reduce delayed cerebral ischemia in non-traumatic subarachnoid hemorrhage (SAH) patients, but traumatic mechanisms were not well studied. In this retrospective study, we characterize the use of ITn for PTV at a high-volume trauma center. <h3>Design/Methods:</h3> We reviewed all TBI admissions at a high-volume trauma center over a 10-year period. Patients ≥18 years of age requiring external ventricular drain (EVD) placement were included. We collected data regarding injury severity, length of stay, rationale, and timing for initiation of ITn, dosing, frequency and treatment-related complications. <h3>Results:</h3> Seven patients with severe TBI received ITn for radiographic vasospasm (VSP) on surveillance imaging. The average duration of treatment was 6 days. ITn was stopped given radiographic improvement (4), pre-defined decision for 48 hours of treatment (1), after DSA revealed no VSP (1) or identification of ventriculitis (1). Three patients had delayed cerebral ischemia on imaging; however, these were noted before the initiation of ITn. Two patients developed ventriculitis and one patient had brief, elevated intracranial pressure spikes with ITn. <h3>Conclusions:</h3> ITn is rarely used for PTV in this high-volume center. When ordered, it is done for radiographic VSP with variations in practice patterns for dosing, duration and weaning. Given the possible benefit of ITn in non-traumatic SAH patients and otherwise limited treatment options for PTV, understanding ITn use and outcomes in PTV is warranted. <b>Disclosure:</b> Dr. Sigman has nothing to disclose. Dr. Chester has nothing to disclose. Dr. Sciarretta has nothing to disclose. The institution of Dr. Ratcliff has received research support from Nico Corporation. The institution of Dr. Ratcliff has received research support from Sense . Ofer Sadan has received intellectual property interests from a discovery or technology relating to health care.

Radiotherapy for Mobile Spine and Sacral Chordoma: A Critical Review and Practical Guide from the Spine Tumor Academy.

Chordomas are rare tumors of the embryologic spinal cord remnant. They are locally aggressive and typically managed with surgery and either adjuvant or neoadjuvant radiation therapy. However, there is great variability in practice patterns including radiation type and fractionation regimen, and limited high-level data to drive decision making. The purpose of this manuscript was to summarize the current literature specific to radiotherapy in the management of spine and sacral chordoma and to provide practice recommendations on behalf of the Spine Tumor Academy. A systematic review of the literature was performed using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) approach. Medline and Embase databases were utilized. The primary outcome measure was the rate of local control. A detailed review and interpretation of eligible studies is provided in the manuscript tables and text. Recommendations were defined as follows: (1) consensus: approved by >75% of experts; (2) predominant: approved by >50% of experts; (3) controversial: not approved by a majority of experts. Expert consensus supports dose escalation as critical in optimizing local control following radiation therapy for chordoma. In addition, comprehensive target volumes including sites of potential microscopic involvement improve local control compared with focal targets. Level I and high-quality multi-institutional data comparing treatment modalities, sequencing of radiation and surgery, and dose/fractionation schedules are needed to optimize patient outcomes in this locally aggressive malignancy.

A215 EVALUATING THE COMPARABILITY OF CARE FOR PERSONS ADMITTED TO TORONTO AREA HOSPITALS WITH ACUTE SEVERE ULCERATIVE COLITIS

Abstract Background Approximately 20% of patients with ulcerative colitis will experience an acute severe exacerbation requiring hospitalization. Acute severe ulcerative colitis (ASUC) is a medical emergency associated with significant morbidity and a mortality rate of 1%. Timely initiation of treatment and assessment of clinical response is critical in the management of ASUC. With an aim to reduce treatment variability and improve outcomes, multiple gastrointestinal societies have published guidelines highlighting recommendations for optimal care in ASUC. It remains unclear how closely these guidelines are implemented in clinical practice. Measuring adherence to these recommended processes of care may act as a surrogate measure for quality of care and a way to indirectly evaluate outcomes in the management of patients with ASUC. Studies have shown that even amongst experienced providers practice pattern variability exists. Identifying significant variations in the management of patients with ASUC will highlight where improvement in guideline dissemination and greater adherence is required. Purpose We sought to evaluate how quality of care indicators varied across 7 hospital sites for patients admitted ASUC in the Greater Toronto Area. Method Using GEMINI, a research collaborative that collects and analyses data from inpatient admissions at 7 Toronto area hospitals, we identified patients admitted to hospital with ASUC from June 2016-December 2019. Hospital sites were further categorized into 3 hospital types; 1 IBD specialty centre (ISC), 3 other academic centres (AC) and 3 community centres (CC). Process measures assessed included proportion tested for C-reactive protein at baseline and following treatment initiation, duration of corticosteroid use, timing and initiation of biologic agents, rates of venous thromboembolism prophylaxis and opioid use. Outcome measures included hospital length of stay, rates of colectomy and mortality. Result(s) 765 hospitalizations were included in the study; 320 occurring at ISC, 308 at AC and 137 at CC. Corticosteroid use on admission were highest at the ISC at 78% compared to 64% at AC and 63% at CC (p &amp;lt;0.001). Among those who received steroids on admission, 47% of patients remained on intravenous corticosteroids for at least 5 days in the ISC compared to 39% in AC and 75% in CC (p&amp;lt; 0.001). Initiation of biologic rescue therapy was highest at the ISC occurring in 37% of hospitalizations compared to 22% in AC and 23% in CC (p&amp;lt;0.001). In addition, VTE prophylaxis rates were highest at the ISC at 83% followed by 60% in AC and 45% in CC (p&amp;lt;0.001). Rates of colectomy were highest at ISC (12% of hospitalizations vs. 7% in AC). Conclusion(s) Greater adherence to indicators of quality of care were seen at the ISC compared to ACs and CCs, although patient outcomes assessed were not clearly different between sites. Further strategies are required to improve adherence to markers of quality care for patients admitted with ASUC. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Recall patterns and risk of primary liver cancer for subcentimeter ultrasound liver observations: a multicenter study

Patients with cirrhosis and subcentimeter lesions on liver ultrasound are recommended to undergo short-interval follow-up ultrasound because of the presumed low risk of primary liver cancer (PLC). The aim of this study is to characterize recall patterns and risk of PLC in patients with subcentimeter liver lesions on ultrasound. We conducted a multicenter retrospective cohort study among patients with cirrhosis or chronic hepatitis B infection who had subcentimeter ultrasound lesions between January 2017 and December 2019. We excluded patients with a history of PLC or concomitant lesions ≥1cm in diameter. We used Kaplan Meier and multivariable Cox regression analyses to characterize time-to-PLC and factors associated with PLC, respectively. Of 746 eligible patients, most (66.0%) had a single observation, and the median diameter was 0.7cm (interquartile range: 0.5-0.8cm). Recall strategies varied, with only 27.8% of patients undergoing guideline-concordant ultrasound within 3-6 months. Over a median follow-up of 26 months, 42 patients developed PLC (39 HCC and 3 cholangiocarcinoma), yielding an incidence of 25.7 cases (95% CI, 6.2-47.0) per 1000 person-years, with 3.9% and 6.7% developing PLC at 2 and 3 years, respectively. Factors associated with time-to-PLC were baseline alpha-fetoprotein >10ng/mL (HR: 4.01, 95% CI, 1.85-8.71), platelet count ≤150 (HR: 4.90, 95% CI, 1.95-12.28), and Child-Pugh B cirrhosis (vs. Child-Pugh A: HR: 2.54, 95% CI, 1.27-5.08). Recall patterns for patients with subcentimeter liver lesions on ultrasound varied widely. The low risk of PLC in these patients supports short-interval ultrasound in 3-6 months, although diagnostic CT/MRI may be warranted for high-risk subgroups such as those with elevated alpha-fetoprotein levels.

Survey of Diagnostic and Management Practices in Small Bowel Obstruction: Individual and Generational Variation Despite Practice Guidelines.

Background: Small bowel obstruction (SBO) is a common disorder managed by surgeons. Despite extensive publications and management guidelines, there is no universally accepted approach to its diagnosis and management. We conducted a survey of acute care surgeons to elucidate their SBO practice patterns.Methods: A self-report survey of SBO diagnosis and management practices was designed and distributed by email to AAST surgeons who cared for adult SBO patients. Responses were analyzed with descriptive statistics and Chi-square test of independence at α = .05.Results: There were 201 useable surveys: 53% ≥ 50years, 77% male, 77% at level I trauma centers. Only 35.8% reported formal hospital SBO management guidelines. Computed tomography (CT) scan was the only diagnostic exam listed as "essential" by the majority of respondents (82.6%). Following NG decompression, 153 (76.1%) would "always/frequently" administer a water-soluble contrast challenge (GC). There were notable age differences in approach. Compared to those ≥50years, younger surgeons were less likely to deem plain abdominal films as "essential" (16.0% vs 40.2%; P < .01) but more likely to require CT scan (88.3% vs 77.6%; P = .045) for diagnosis and to "always/frequently" administer GC (84.0% vs 69.2%; P < .01). Younger surgeons used laparoscopy "frequently" more often than older surgeons (34.0% vs 21.5%, P = .05).Discussion: There is significant variation in diagnosis and management of SBO among respondents in this convenience sample, despite existing PMGs. Novel age differences in responses were observed, which prompts further evaluation. Additional research is needed to determine whether variation in practice patterns is widespread and affects outcomes.

ASO Visual Abstract: Practice Pattern Variability in the Management of Regional Lymph Node Metastasis in Extremity and Trunk Soft Tissue Sarcoma (ETSTS): A Survey of the Society of Surgical Oncology (SSO) and Musculoskeletal Tumor Society (MSTS) Membership.

ASO Visual Abstract: Practice Pattern Variability in the Management of Regional Lymph Node Metastasis in Extremity and Trunk Soft Tissue Sarcoma (ETSTS): A Survey of the Society of Surgical Oncology (SSO) and Musculoskeletal Tumor Society (MSTS) Membership.

Physician Approaches to Antithrombotic Therapies for Recently Symptomatic Carotid Stenosis.

Whereas the beneficial effect of antiplatelet therapy for recurrent stroke prevention has been well established, uncertainties remain regarding the optimal antithrombotic regimen for recently symptomatic carotid stenosis. We sought to explore the approaches of stroke physicians to antithrombotic management of patients with symptomatic carotid stenosis. We employed a qualitative descriptive methodology to explore the decision-making approaches and opinions of physicians regarding antithrombotic regimens for symptomatic carotid stenosis. We conducted semi-structured interviews with a purposive sample of 22 stroke physicians (11 neurologists, 3 geriatricians, 5 interventional-neuroradiologists, and 3 neurosurgeons) from 16 centers on four continents to discuss symptomatic carotid stenosis management. We then conducted thematic analysis on the transcripts. Important themes revealed from our analysis included limitations of existing clinical trial evidence, competing surgeon versus neurologist/internist preferences, and the choice of antiplatelet therapy while awaiting revascularization. There was a greater concern for adverse events while using multiple antiplatelet agents (e.g., dual-antiplatelet therapy (DAPT)) in patients undergoing carotid endarterectomy compared to carotid artery stenting. Regional variations included more frequent use of single antiplatelet agents among European participants. Areas of uncertainty included antithrombotic management if already on an antiplatelet agent, implications of nonstenotic features of carotid disease, the role of newer antiplatelet agents or anticoagulants, platelet aggregation testing, and timing of DAPT. Our qualitative findings can help physicians critically examine the rationale underlying their own antithrombotic approaches to symptomatic carotid stenosis. Future clinical trials may wish to accommodate identified variations in practice patterns and areas of uncertainty to better inform clinical practice.

Outcomes of elective peripheral endovascular interventions for peripheral arterial disease performed in hospital outpatient departments, ambulatory surgical centers and office-based labs

BackgroundA recent shift in the location where peripheral endovascular interventions (PVI) are performed has occurred, from traditional settings such as hospital outpatient departments (HOPD), to ambulatory surgical centers (ASC) and outpatient-based laboratories (OBL). Different settings may influence the safety and efficacy of the PVI, as well as how it is done. This study aims to compare the postprocedural outcomes and intraprocedural details between the three settings. MethodsThe Vascular Quality Initiative database was queried for all elective infrainguinal PVIs for occlusive peripheral arterial disease between January 2016 and December 2021. The primary outcomes were rates of postprocedural hospital admissions, postprocedural medical complications, and access site complications. Secondary outcomes included technical success and intraprocedural details, such as types and number of devices used, amount of contrast, and fluoroscopy time. The χ2 test, analysis of variance, and multivariate logistic regression were used to analyze the outcomes. ResultsA total of 66,101 PVI cases (HOPD, 57,062 [83.33%]; ASC, 4591 [6.95%]; OBL, 4448 [6.73%]) were included in the study. There were 445 cases requiring hospital admission (HOPD, 398 [0.70%]; ASC, 26 [0.57%]; OBL, 21 [0.47%]; P = .126). There were no significant differences in cardiac, pulmonary, or renal complications. Access site complications occurred in less than 1.7% of all cases and were significantly higher in OBLs when compared with ASCs (adjusted odds ratio [aOR], 3.70; 95% confidence interval [CI], 1.70-8.03; P = .001) and significantly lower in ASCs in comparison to HOPDs (aOR, 0.27; 95% CI, 0.18-0.41; P < .001). Technical success occurred in at least 92% of all cases, regardless of setting. There was a 16-fold increase in the use of atherectomy devices in an OBL vs HOPD setting (aOR, 16.79; 95% CI, 11.77-23.95; P < .001) and a five-fold increase in the use of atherectomy devices in an ASC vs HOPD setting (aOR, 5.37; 95% CI, 2.47-11.65; P < .001). There was a five-fold decrease in the use of special balloons in an OBL vs HOPD setting (aOR, 0.20; 95% CI, 0.10-0.39; P < .001) and a four-fold decrease when comparing ASCs with HOPDs (aOR, 0.25; 95% CI, 0.12-0.51; P < .001). ConclusionsElective PVIs performed in any outpatient setting proved to be safe and technically successful. However, there are significant differences in the way PVIs are performed in each setting, such as the greater use of atherectomy devices in OBLs and greater use of special balloons in HOPDs. Long-term studies are needed to evaluate the durability and reintervention outcomes and understand factors associated with practice pattern variability across these different settings.

Practice Pattern Variability in the Management of Regional Lymph Node Metastasis in Extremity and Trunk Soft Tissue Sarcoma: A Survey of the Society of Surgical Oncology and Musculoskeletal Tumor Society Membership.

Regional lymph node metastasis in extremity and trunk soft tissue sarcoma (ETSTS) is rare with no standardized management. We sought to determine management patterns for regional lymph node metastasis in ETSTS. A survey regarding the management of ETSTS lymph node metastasis was distributed to the membership of the Musculoskeletal Tumor Society (MSTS) and the Society of Surgical Oncology (SSO) in January 2022. The survey queried the type of training (surgical oncology, orthopedic oncology), details of their practice setting, and management decisions of hypothetical ETSTS scenarios that involved potential or confirmed lymph node metastasis. The survey was distributed to 349 MSTS members (open rate of 63%, completion rate 21%) and 3026 SSO members (open rate of 55%, completion rate 4.7%) and was completed by 214 respondents, of whom 73 (34.1%) and 141 (65.9%) were orthopedic oncology and surgical oncology fellowship-trained, respectively. The majority of respondents practiced in an academic setting (n=171, 79.9%) and treat >10 extremity sarcoma cases annually (n=138, 62.2%). In scenarios with confirmed nodal disease for clear cell and epithelioid sarcoma, surgical oncologists were inclined to perform lymphadenectomy, while orthopedic oncologists were inclined to offer targeted lymph node excision with adjuvant radiation (p<0.001). There was heterogeneity of responses regarding the management of nodal disease regardless of training background. Self-reported management of nodal disease in ETSTS was variable among respondent groups with differences and similarities based on training background. These data highlight the variability of practice for nodal disease management and the need for consensus-based guidelines.

Current Orthognathic Surgery Practice Patterns Among Academic OMS.

Currently there is variation in perioperative care of orthognathic surgery patients and limited clinical practice guidelines. The current orthognathic surgery practice patterns among US academic OMFS training centers have not been described. The purpose of this study is to describe the practice patterns among US academic OMFS training centers. The study design is cross-sectional. Data was collected through a survey of the sample. OMFS programs in the US. Academic OMFS. 573 surgeons were contacted and 85 responses were received. Descriptive and bivariate statistics were reported. Respondents were 87% male and worked in full-time academic (80%), part-time academic (19%), or military settings (1%). Thirty-one percent have practiced for 30 years or more and then 29% with 11-20 years, 18% with 21-30 years, 12% with 6-10 years and 11% with 1-5 years. Twenty-six percent of respondents perform 20-40 orthognathic surgeries a year, 22% perform less than 20 surgeries a year, 21% perform 40-60 surgeries per year, and 19% perform more than 100 surgeries per year. Intraoperatively, 48% of surgeons request a mean arterial pressure of 60-64 mmHg, 25% utilize tranexamic acid (TXA), 85% report a blood loss of less than 400 milliliters, and 93% report a blood transfusion rate of <1%. There are variations in orthognathic surgery practice patterns with limited clinical practice guidelines. Only 13 of the 32 survey questions had a single response holding a simple majority. This study demonstrates the need for further research and evidence-based protocols and decision making.

Variations in Practice Patterns for Peripheral Vascular Interventions Across Clinical Settings

Peripheral vascular interventions (PVI) for lower extremity peripheral artery disease (PAD) have been increasing, particularly in the office-based setting. Our goal was to evaluate practice patterns for PVI by site of service using a contemporary real world dataset. The Vascular Quality Initiative PVI registry was queried from 2010-2021. Site of service was classified as hospital/inpatient, hospital/outpatient, and ambulatory/office based center. Patient demographics, comorbidities, procedural details, and peri-procedural outcomes were analyzed. There were 54,897 hospital/inpatient (43.2%), 64,105 hospital/outpatient (50.4%), and 8179 ambulatory/office based center (6.4%) PVI. When comparing the two outpatient settings, ambulatory/office based center patients were older than hospital/outpatient (mean age 70.7 vs. 68.7 years), more often female sex (41.4% vs 39.1%), never smokers (27.5% vs. 18.5%), primary Medicare (61.6% vs. 55.9%), non-ambulatory (6.5% vs. 4.7%), and less often with coronary artery disease (30.2% vs. 34.1%), chronic obstructive pulmonary disease (18.1% vs. 26.9%), congestive heart failure (13% vs 17.2%), and obesity (30.9% vs. 33.6%), and less often on a statin (71.4% vs. 76.1%), (P<.001). Ambulatory/office based center procedures were more likely for claudication (60.1% vs. 55.8%), more often involved femoro-popliteal (73.1%) vs. 64.6%) and infrapopliteal (36.7% vs. 24.3%), and less often iliac interventions (24.1% vs. 33.6%) (P<.001).Overall, atherectomy was used in 14.2% of hospital/inpatient, 19.4% of hospital/outpatient, and 63.4% of ambulatory/office based center procedures. Stents were used in 41.8% of hospital/inpatient, 45.1% of hospital/outpatient, and 48.8% of ambulatory/office based center procedures. However, stent grafts were used 12.5% of hospital/inpatient, 8.8% of hospital/outpatient, and only 1.3% of ambulatory/office based center procedures. On multivariable analysis, compared with hospital/inpatient, atherectomy use was associated with ambulatory/office based center setting (OR 10.9, 95% CI 10.3 - 11.5, P<.001) and hospital/outpatient setting (OR 1.57, 95% CI 1.51 - 1.62, P<.001). Peri-procedure complications including hematoma requiring intervention (0.3%), any stenosis/occlusion (0.2%), and distal embolization (0.6%) were quite low across all settings. There are substantial variations in both patient populations, procedural indications, and types of interventions undertaken during PVI across different locations. Ambulatory/office-based procedures more commonly treat claudicants, use atherectomy, and less often use stent grafts. Further research is warranted to investigate long-term trends in practice patterns, as well as long-term outcomes, for PVI in the ever-expanding ambulatory/office-based setting.

Predictors of Intraoperative Echocardiography: Analysis of The Society of Thoracic Surgeons Database

BackgroundIntraoperative transesophageal echocardiography (TEE) is associated with improved outcomes after cardiac surgery, but unexplained practice pattern variation exists. This study aimed to identify and quantify the predictors of intraoperative TEE use among patients undergoing isolated coronary artery bypass graft surgery (CABG) or cardiac valve surgery. MethodsThis observational cohort study used The Society of Thoracic Surgeon (STS) Adult Cardiac Surgery Database data to identify and quantify the predictors of intraoperative TEE use among adult patients aged 18 years or more undergoing either isolated CABG or open cardiac valve repair or replacement surgery between January 1, 2011, and December 31, 2019. Generalized linear mixed models were used to measure the relationship between intraoperative TEE and patient characteristics, surgical volume, and geographic location, while accounting for clustering within hospitals (primary analysis) or surgeons (secondary analysis). ResultsOf 1,973,655 patients, 1,365,708 underwent isolated CABG and 607,947 underwent cardiac valve surgery. Overall, intraoperative TEE was used in 62% of surgeries. The primary hospital-level generalized linear mixed models analysis demonstrated that the strongest predictor of intraoperative TEE use was the hospital where the surgery occurred—with a median odds ratio for TEE of 10.13 in isolated CABG and 5.30 in cardiac valve surgery. The secondary surgeon-level generalized linear mixed models analysis demonstrated similar findings. ConclusionsIntraoperative TEE use (vs lack of use) during surgery was more strongly associated with hospital and surgeon practice patterns than with any patient-level factor, surgical volume, or geographic location.

Practice patterns for reporting digestive system neuroendocrine neoplasms: results from a large, comprehensive international survey.

Criteria for the interpretation of digestive system neuroendocrine neoplasms (NENs) continue to evolve. Although there are some literature recommendations regarding workup and diagnosis of these lesions, different practice patterns exist among pathologists when signing out these specimens. The aim of this study was to assess practice trends among pathologists worldwide when reporting these neoplasms. We created an online survey with multiple questions pertaining to digestive NENs. The results were analysed based on type of practice setting, years of sign-out experience, and practice location. Respondents included 384 practicing pathologists: 70% academic, 30% private practice; 63% gastrointestinal (GI) pathology-subspecialised, 37% not; 39% North American, 42% European, 19% others; 45% with ≤10 years in practice; 55% with >10 years. Some question responses were chosen by the majority (e.g. 85% use both mitotic count and Ki67 index for grading NENs, 82% complete a synoptic, and Ki67 stain even for small incidental appendiceal neuroendocrine tumours [NETs], and 96% utilize the diagnosis of grade 3 NET). However, some questions showed varying responses, including counting mitotic figures, Ki67 stain interpretation, and pancreatic grade 3 NEN workup. Pathologists also had some variability in interpreting regional metastatic foci of small bowel NETs and in choosing blocks for Ki67 staining in multifocal lesions. There existed scenarios wherein practice patterns varied despite recommendations in the literature, and there were also scenarios lacking clear guidelines wherein pathologists used varying judgement. This survey highlights current key grey areas in digestive system NEN evaluation, leading to variation in practice patterns.

Antibiotic Protocols for Endophthalmitis Prophylaxis Following Open-Globe Repair: A Survey of U.S. Residency Programs.

Purpose To assess the various approaches to endophthalmitis prevention following traumatic open-globe injury (OGI) repair. Methods A research electronic data capture (REDCap) questionnaire evaluating the usage of antibiotics and steroids in patients with OGI was distributed to program directors of all U.S. ophthalmology residency programs using the Association of University Professors of Ophthalmology program directors' listserv. Completed questionnaires were analyzed for treatment patterns. Results The REDCap questionnaire was distributed to 111 programs, with 32 residency programs responding. Two responses were excluded. Ninety percent (27/30) of included programs used perioperative intravenous (IV) antibiotics, with 78% (21/27) of those giving one dose only. At the time of surgery, 27% (8/30) of programs gave intravitreal antibiotics and 60% (18/30) gave subconjunctival antibiotics. Postoperatively, 100% (30/30) gave topical antibiotics and 97% (29/30) gave topical steroids. Only 53% of responders discharged patients on oral antibiotics. Of the three programs who did not use IV antibiotics, all three gave intravitreal therapy and one also discharged patients on oral antibiotics. Conclusion There is a large variation in practice patterns for endophthalmitis prophylaxis among residency programs. Further investigation is needed to compare rates of endophthalmitis between these protocols and establish a safe and minimally burdensome standard of care.