Practice Patterns In Treatment Research Articles

Practice Patterns of Physician Treatment for Pediatric Chronic Myelogenous Leukemia

Chronic myelogenous leukemia (CML) is a rare disease in children for which pediatric evidence-based guidelines are lacking. We designed an anonymous survey for practicing pediatric oncologists and bone marrow transplantation (BMT) physicians to assess their willingness to recommend BMT for a patient with CML based on various clinical scenarios. A total of 274 physicians responded to the survey (13.4% response rate). Nearly all pediatric oncologists and BMT physicians recommended against BMT at time of diagnosis of CML in the chronic phase, with only 8.0% and 1.9% recommending BMT if a matched sibling donor (MSD) and a matched unrelated donor (MUD), respectively, was available. Similarly, after a first poor response to tyrosine kinase inhibitor (TKI) therapy or hematologic relapse, physicians continued to recommend against BMT (39.5% and 23.3% recommended BMT in patients with a matched sibling donor and matched unrelated donor, respectively). However, 81.7% and 69.8% of respondents would recommend BMT after 2 hematologic relapses on TKI therapy, if an MSD and an MUD, respectively, were available. In addition, there was great interest in developing a clinical trial evaluating the safety and efficacy of stopping TKIs in children with CML who achieve and maintain a deep molecular response, with 86.7% of respondents stating they would offer such a trial to their pediatric patients. This survey highlights the need for evidence-based, pediatric-specific guidelines for the management of children and adolescents with CML.

Preferences and Trends in Practices Caring Premature Infants for Retinopathy of Prematurity (ROP): A Web-based Survey

Objectives: To study preferences in treatment, follow-up and conclusion of examination in infants treated with and without bevacizumab (IVB) and/or laser photocoagulation for retinopathy of prematurity (ROP).Methods: A 22 question web survey was administered to physicians to understand practice patterns for treatment of type1 ROP, determine timeframe of conclusion of examinations with and without IVB/laser, and to approximate incidence of ROP recurrence post-treatment.Results: The survey revealed that 73% pediatric ophthalmologists reported not personally performing injections and 54.1% reported not performing laser. In infants with persistent avascular retina without pre-threshold disease, 54.2% continued examination > 50 weeks PMA, 23.3% discontinued at 50 weeks PMA, 3.2% preferred prophylactic laser and 5.1% fluorescein angiography and laser prior to concluding exams. 46.3% of physicians preferred IVB as primary monotherapy, 37.3% laser, and 16.4% both IVB and laser in type 1 ROP. Of those who preferred IVB, 20.4% concluded examination at ? 55 weeks PMA, whereas 79.6% continued evaluation >55 weeks PMA (60 to ? 80 weeks). Of those who preferred both IVB and laser, 50.6% concluded examination at ? 50 weeks PMA, whereas 49.4% continued > 50 weeks (60 to ? 80 weeks). 21.1 % of respondents reported recurrence with IVB and 8.8% with dual therapyConclusions: Treatment preferences and conclusion of examination in ROP varies considerably without and with treatment. Though a longer follow-up is recommended with IVB, this survey reveals extended examinations beyond 50 weeks PMA in infants with persistent avascular retina requiring no treatment and in the laser treated subgroup. The survey highlights low rates of performing treatments personally by pediatric ophthalmologists, and distinctlyvariable practice patterns in ROP care

Practice Patterns of Endophthalmitis Treatment: An International Survey of Retina Specialists

Practice Patterns of Endophthalmitis Treatment: An International Survey of Retina Specialists

National Norwegian Practice Patterns for Surgical Treatment of Kidney Cancer Tumors ≤7 cm: Adherence to Changes in Guidelines May Improve Overall Survival

BackgroundGuidelines on surgical treatment for kidney cancer (KC) have changed over the last 10 yr. We present population-based data for patients with KC tumors ≤7cm from 2008 to 2013 to investigate whether surgical practice in Norway has changed according to guidelines. ObjectiveTo assess the predictors of treatment and survival after KC surgery. Design, setting, and participantsWe identified all surgically treated KC patients with tumors ≤7cm without metastasis diagnosed during 2008–2013 (2420 patients) from the Cancer Registry of Norway. Outcome measurements and statistical analysisRelationships with outcomes were analyzed using joinpoint regression, multivariate logistic regression, Kaplan-Meier survival estimates, Cox regression, relative survival (RS), and competing-risk analyses. Results and limitationsThe mean follow-up was 5.2 yr. There was a 28% increase in the number of patients undergoing surgical treatment over the study period. Joinpoint regression revealed a significant annual increase in partial nephrectomy (PN) and a small reduction in radical nephrectomy (RN). PN increased from 43% to 66% for tumors ≤4cm and from 10% to 18% for tumors of 4.1–7cm. Minimally invasive (MI) RN increased from 53% to 72% and MI PN from 25% to 64%, of which 55% of procedures were performed with robotic assistance in 2013. The geographical distribution of treatment approaches differed significantly. Both PN and MI approaches were more frequent in high-volume hospitals. Cox regression analysis revealed that PN, age, and Fuhrman grade and stage were independent predictors of survival. There were no significant differences in cancer-specific survival (p=0.8). The 5-yr RS for T1a disease was higher after PN than after RN. ConclusionsThe rate of PN for tumors ≤7cm increased in the 6-yr study period. MI approaches increased for both RN and PN. This treatment shift coincides with the new guideline recommendations in 2010. The possible better survival for patients undergoing PN compared to RN indicates the importance of following evidence-based guidelines. Patient summaryThe use of partial nephrectomy and minimally invasive surgery for kidney cancer tumors increased in Norway from 2008 to 2013 according to population-based data, coinciding with guideline changes. The study illustrate that adherence to guidelines may improve patient outcomes.

PCN93 - Treatment Practice Patterns, Healthcare Resource Utilization (HRU), and Costs in Newly Diagnosed Patients with Therapy-Related Acute Myeloid Leukemia (TAML) or AML with Myelodysplasia-Related Changes (AML-MRC) in a United States (US) Commercially Insured Population

PCN93 - Treatment Practice Patterns, Healthcare Resource Utilization (HRU), and Costs in Newly Diagnosed Patients with Therapy-Related Acute Myeloid Leukemia (TAML) or AML with Myelodysplasia-Related Changes (AML-MRC) in a United States (US) Commercially Insured Population

Therapist's practice patterns for subsequent fall/osteoporotic fracture prevention for patients with a distal radius fracture

Study DesignCross-sectional survey. IntroductionMultifactorial risk factor screening and treatment is needed for subsequent falls/osteoporotic fractures prevention (SFOFP), given the elevated risk among patients with distal radius fracture (DRF). Purpose of the StudyThe primary objective was to describe hand therapists' knowledge and clinical practice patterns for assessment, treatment, referral, and education with respect to SFOFP for patients with DRF older than 45 years. Secondary objective was to explore therapist's preferences in content and delivery of knowledge translation tools that would support implementation of SFOFP. MethodsA cross-sectional multinational (Canada, the United States, and India) survey was conducted among 272 therapists from August to October 2014. Completed surveys were analyzed descriptively. ResultsSurveys were completed by 157 therapists. Most respondents were from the United States (59%), certified hand therapists (54%), and females (87%). Although 65%-90% believed that they had knowledge about SFOFP assessment, treatment, and referral options, 55% did not include it in their routine practice for patients with DRF. Most assessed medication history (82%) and never used a Fracture Risk Assessment Tool (90%) or lower extremity muscle strength testing (54%) to identify those at risk of secondary fractures. With respect to treatment, approximately 33% always used upper extremity muscle strengthening exercises. Most reported rarely (sometimes to never) using balance (79%), lower extremity muscle strengthening (85%), bone strengthening (54%), or community-based physical activity (72%) programs. Similarly, when surveyed about patient education, therapists rarely (sometimes to never) advised patients about web-based resources (94%), regular vision testing (92%), diet for good bone health (87%), bone density evaluation (86%), footwear correction (73%), and hazard identification (67%). Most hand therapists were interested to receive more information on SFOFP for patients with DRF. Nearly one-half preferred to have Web sites for patients, and two-fifth were in favor of pamphlets for patients. ConclusionCurrent practice patterns reveal care gaps and limited implementation with respect to SFOFP for patients with DRF. Future research should focus on web-based educational/knowledge translation strategies to promote implementation of multifactorial fall risk screening and hand therapist's engagement in SFOFP for patients with DRF.

Changes in Treatment Patterns and Overall Survival in Patients With Early-Stage Non-Small Cell Lung Cancer in the United States After the Incorporation of Stereotactic Ablative Radiation Therapy: A Population-based Analysis.

Technologic developments have made radiation therapy (RT) more effective and have introduced new treatment options, such as stereotactic ablative radiation therapy (SABR). This study sought to determine changes in practice patterns for treatment of stage IA non-small cell lung cancer (NSCLC) after the introduction of SABR into the United States. This population-based study also examined changes in survival during this time period for all patients and specifically for patients treated with RT, surgery, or observation. We included patients in the Surveillance, Epidemiology, and End Results database diagnosed with stage IA NSCLC diagnosed between 2004 and 2012. Changes in treatment patterns were assessed. Outcomes were compared across 2 time periods: 2004 to 2008 (pre-SABR) and 2009 to 2012 (post-SABR). Kaplan-Meier and Cox regression were performed to compare overall survival (OS) for patients treated with surgery, RT, or observation. A total of 32,249 patients met the specified criteria. Comparing patients diagnosed in 2004 to those diagnosed in 2012, RT use increased from 13% to 29% (P<0.001), surgery use decreased from 76% to 61% (P<0.001), and patients observed decreased from 11% to 10% (P=0.3). There was no significant OS improvement in all patients or those patients who were observed; there were significant improvements in OS for patients treated with RT (hazard ratio=0.768; 95% confidence interval, 0.711-0.829) and those patients treated with surgery (hazard ratio=0.9; 95% confidence interval, 0.855-0.962). There has been an increase in RT utilization and decrease in surgical utilization after the incorporation of SABR by radiation oncologists within the United States. In addition, there has been an improvement in OS for patients treated with definitive RT for early-stage NSCLC between 2004 and 2012 that may be associated with increased utilization of SABR.

A Web-based Survey on Clinical Practice Patterns of Korean Medicine Treatment for Traffic Injuries

The purpose of this study is to understand current status of Korean Medicine treatment practice patterns for traffic injuries by web-based survey.

Assessment of Radiation Trends in a Prospective Registry of Node Positive Patients With Triple Negative Breast Cancer

Our center is a mixed academic and community based practice, leading to significant variations in chemotherapy and radiation regimens. We sought to assess practice patterns for treatment of node positive triple negative breast cancer at our institution, utilizing a prospective registry. We were especially interested in the impact of the MA.20 trial (Whelan et al., NEJM, 2015) on practice patterns, as this trial has limited our interest in enrolling these patients on current national dose de-escalation trials, such as RTOG 1304. Stage I-IV triple negative breast cancer patients were enrolled on a prospective registry at academic and community practices within our institution over the past 7 years. Patients with non-metastatic breast cancer, with a biopsy proven positive node at diagnosis or at the time of surgery, were included for analysis. Data was collected on stage, surgery type, and timing of chemotherapy. Radiation plans were reviewed in detail, with information gathered on dose per fraction, total dose, use of boost, contouring of regional nodes, and dose to regional nodes. Statistical analysis was performed in SPSS version 24. Information regarding radiation treatment was available for 96 patients with node positive, triple negative breast cancer. All of the 22 patients undergoing lumpectomy received radiation. Only 75% of patients undergoing mastectomy received post-mastectomy radiation (PMRT). All clinical stage T3 or T4 patients received PMRT, as compared to 66% of T1 patients and 58% of T2 patients. There was no difference in 4 year survival for mastectomy versus lumpectomy (76.5% vs 78.9%). PMRT use was higher for patients receiving neoadjuvant chemotherapy, 79% versus 65%, but this was not statistically significant (p=0.19). There was significantly higher use of PMRT after publication of the MA.20 trial, (71% vs 100%, p=0.05). Similarly, use of regional nodal radiation for patients undergoing lumpectomy increased from 69% to 100% for this same time period, though this was not statistically significant. Reviewing individual plans, elective radiation to the internal mammary nodes (IMN) increased from 61% pre MA.20 to 74% afterwards. Recurrence rates for patients with IMN radiation were 20% vs 33% in patients without directed IMN radiation, however, this trend was not statistically significant. Publication of the MA.20 trial impacted radiation practice at our institution. With small patient numbers, significant reductions in recurrence were not evident. Further analysis and collaboration with other institutions is encouraged to further explore the impact of regional nodal radiation on patient outcomes for node positive, triple negative breast cancer.

Demographic, Clinical, and Immunologic Features of 389 Children with Opsoclonus-Myoclonus Syndrome: A Cross-sectional Study.

Pediatric-onset opsoclonus-myoclonus syndrome (OMS) is a devastating neuroinflammatory, often paraneoplastic, disorder. The objective was to characterize demographic, clinical, and immunologic aspects in the largest cohort reported to date. Cross-sectional data were collected on 389 children in an IRB-approved, observational study at the National Pediatric Myoclonus Center. Non-parametric statistical analysis was used. OMS manifested in major racial/ethnic groups, paralleling US population densities. Median onset age was 1.5 years (1.2–2 interquartile range), inclusive of infants (14%), toddlers (61%), and youngsters (25%). The higher female sex ratio of 1.2 was already evident in toddlers. Time to diagnosis was 1.2 months (0.7–3); to treatment, 1.4 months (0.4–4). Irritability/crying dominated prodromal symptomatology (60%); overt infections in <35%. Acute cerebellar ataxia was the most common misdiagnosis; staggering appeared earliest among 10 ranked neurological signs (P < 0.0001). Some untreated youngsters had no words (33%) or sentences (73%). Remote neuroblastic tumors were detected in 50%; resection was insufficient OMS treatment (58%). Age at tumor diagnosis related to tumor type (P = 0.004) and stage (P = 0.002). A novel observation was that paraneoplastic frequency varied with patient age—not a mere function of the frequency of neuroblastoma, which was lowest in the first 6 months of life, when that of neuroblastoma without OMS was highest. The cerebrospinal fluid (CSF) leukocyte count was minimally elevated in 14% (≤11/mm3) with normal differential, and commercially screened serum autoantibodies were negative, but CSF oligoclonal bands (OCB) and B cells frequency were positive (58 and 93%). Analysis of patients presenting on immunotherapy revealed a shift in physician treatment practice patterns from monotherapy toward multi-agent immunotherapy (P < 0.001); the number of agents/sequences varied. In sum, a major clinical challenge is to increase OMS recognition, prevent initial misdiagnosis, and shorten time to diagnosis/treatment. The index of suspicion for an underlying tumor must remain high despite symptoms of infection. The disparity in onset age of neuroblastoma frequency with that of neuroblastoma with OMS warrants further studies of potential host/tumor factors. OMS neuroinflammation is best diagnosed by CSF OCB and B cells, not by routine CSF or commercial antibody studies.

A Comparative Analysis of Resource Utilization Between Proximal Row Carpectomy and Partial Wrist Fusion: A Population Study

We conducted a population-level analysis comparing proximal row carpectomy (PRC) and partial wrist arthrodesis (PWA) for treatment of chronic wrist arthritis to (1) characterize national practice patterns, (2) determine the rate of conversion to total wrist arthrodesis (TWA), and (3) calculate the associated direct cost of care. Using the Truven MarketScan databases from 2009 to 2015, we identified patients 18 years or older with a diagnosis of wrist osteoarthritis who had a PRC or PWA and were followed for 18 months. We used Chi-square analysis and multivariable logistic regression to examine patient characteristics associated with conversion to a TWA. Rates of repeat PWA were also obtained, including the total number of procedures until completion and direct treatment cost. Of a total of 3,388 eligible patients, 1,305 had a PRC (39%) and 2,083 had a PWA (61%). In patients 54 years of age or younger, PWA was more commonly performed than PRC (49% vs 38%). The TWA rates were significantly higher for patients of all ages who underwent PWA (19.2%) versus PRC (4.9%). Those undergoing PWA required more total procedures than patients who received a PRC (average, 1.7 vs 1.1) resulting in a greater average direct cost perpatient ($10,842 vs $7,171). Conversion rates to a TWA are significantly higher with a PWA (19.2%) than with a PRC (4.9%) and have a greater associated direct cost. This includes younger patients, who in the past were considered better candidates for PWA. Our findings suggest that surgeons may need to reevaluate their indications for PWA and that there may need to be a paradigm shift in the current practice patterns for salvage treatment of wrist arthrosis, more often considering PRC for all age groups. Prognostic II.

Tobacco cessation in Vietnam: Exploring the role of village health workers

ABSTRACTThe purpose of this study was to explore current tobacco use treatment (TUT) practice patterns, and attitudes and beliefs among Village Health Workers (VHWs) about expanding their role to include delivering smoking cessation interventions and the perceived barriers. We conducted a survey of 449 VHWs from 26 communes in Thai Nguyen province, Vietnam. We assessed TUT practice patterns including asking about tobacco use, advising smokers to quit, offering assistance (3As) and attitudes, self-efficacy, and norms related to TUT. Seventy two per cent of VHWs reported asking patients if they use tobacco, 78.6% offered advice to quit, and 41.4% offered cessation assistance to few or more patients in the past month. Self-efficacy was low, with 53.2% agreeing that they did not have the skills to counsel patients about smoking cessation. The most commonly reported barriers to offering TUT were a lack of training and perceived lack of patient interest. Greater awareness of their commune health centre’s smoke-free policy and higher levels of self-efficacy were associated with screening and offering cessation assistance. VHWs support an expanded role in tobacco cessation, but require additional resources and training to increase their self-efficacy and skills to provide effective treatment.

Triple-NOTE (Triple Negative Outcome in ESME): Large recent real-world prognostic data on triple negative metastatic breast cancers (mTNBC).

e12592 Background: During last decade, therapeutic arsenal has expanded for metastatic breast cancer (mBC), but few data are available about mTNBC, a poor prognosis subtype. In 2014, UNICANCER (composed of 18 French Comprehensive Cancer Centers) launched the Epidemiological Strategy and Medical Economics (ESME) program to centralize real-world data. This base represents a great opportunity to update the outcomes and the treatment practice patterns of this population. Methods: The ESME-mBC database was built from information systems, treatment databases and patients’ electronic files including quality control processes. All pts who initiated treatment for mBC between 01-Jan-2008 and 31-Dec-2014 were selected. The primary objective of this study was to assess overall survival (OS) of mTNBC pts. TNBC status was defined as ER and PR &lt; 10% in both primary and metastatic disease, as well as the absence of overexpression or amplification of HER2. The secondary objectives were to describe the characteristics of this population, clinical management (duration and sequence of treatments) and to evaluate the prognostic value of several clinical factors (age, distant disease free interval, location and number of metastatic sites) Results: Among 16703 pts in the ESME-mBC database, 2368 (14%) had mTNBC. Median OS over this time period was 14.8 months (95% CI 14-15.6). Median age at diagnosis of mBC was 57 years. For the pts who relapsed, median metastasis free interval was 24 months, while 25.5% of the pts were de novo metastatic. 61% of the pts presented visceral metastasis and 12% had cerebral metastasis as first metastatic site. The pattern of metastatic involvement (visceral and cerebral) and a short metastasis free interval ( &lt; 24 months) were the most important prognostic factors in multivariate analysis. The description of treatment sequences (duration, prognostic value) will be presented. Conclusions: In this real-life setting database, mTNBC remain of poor prognosis despite a trend for a better OS than the historical data available (12-13 ms). This TNBC ESME cohort is one of the largest available and offers an updated assessment of the outcomes of this population.

Diagnosis and treatment patterns for patients with leptomeningeal metastasis from solid tumors across Europe.

Leptomeningeal metastases are a late manifestation of systemic cancer which affects up to 10% of patients with solid tumors. Prognosis is poor, and overall survival at 1year is only approximately 10%. Management depends mainly on general and neurological condition, primary tumor, and patterns of metastasis, notably absence or presence of concurrent systemic or solid brain metastases. Here we set out to characterize current practice patterns of diagnosis and treatment of patients with leptomeningeal metastasis in Europe. We prepared a web-based survey including 25 simple or multiple choices questions on best practice supplemented by eight case vignettes with various diagnosis and management options. The survey was sent to the membership of the European Association of Neuro-Oncology and the European Organisation for Research and Treatment of Cancer Brain Tumor Group. Between April 7, 2016 and August 8, 2016, 224 colleagues from 26 countries initiated the survey, 115 colleagues completed the whole survey. There were major differences both in the general diagnostic and therapeutic approach, e.g., regarding the use of cerebrospinal fluid (CSF) flow studies, intra-CSF chemotherapy, various types of radiotherapy, and even more so when selecting decisions on diagnostic and therapeutic measures for single case vignettes. Diagnosis and treatment decisions for patients with leptomeningeal metastasis from solid tumors vary widely across Europe. Standardization of diagnosis and evaluation tools as well as controlled studies to improve the level of evidence for all therapeutic approaches to LM are required.

A practice pattern assessment of members of the Society of Pediatric Urology for evaluation and treatment of urinary tract dilation

Over the last decade the literature, including a multidisciplinary consensus statement, has supported a paradigm shift in management of urinary tract dilation, yet the impact on practice patterns has not been well documented. This study aims to elucidate specific practice patterns for treatment of prenatal unilateral urinary tract dilation and to assess surgical intervention patterns for ureteropelvic junction obstruction. An online survey was distributed to 234 pediatric urologists through the Society of Pediatric Urology. The survey was composed of five clinical case scenarios addressing evaluation and management of unilateral urinary tract dilation. The response rate was 71% (n=168). Circumcision status, gender, and grade were significant factors in recommending prophylactic antibiotics for newborn urinary tract dilation. Prophylactic antibiotic use in the uncircumcised male and female was twice that of a circumcised male for grade 3 (Table). This difference was minimized for grade 4. Use of VCUG was high for circumcised males with grade 3 or 4 (Table). The choice of minimally invasive surgery for ureteropelvic junction repair increased with age from 19% for a 5-month-old, 49% for a 2-year-old, and 85% for a 10-year-old. Notably, 44% of respondents would observe a 10-year-old with intermittent obstruction. Retrograde pyelography was recommended in conjunction with repair in 65% of respondents. Antegrade stent placement was the most common choice (38-47%) for urinary diversion after pyeloplasty. Regarding postoperative imaging, only 5% opted for routine renal scan whereas most would perform renal ultrasound alone. Practice patterns seen for use of prophylactic antibiotics are in agreement with the literature, which promotes selective use in those at highest risk for urinary tract infections. Interestingly, use of aggressive screening was not concordant with this literature. Several studies have indicated an increased usage of robotic pyeloplasty; however, results indicate that minimally invasive surgery is not preferred in those younger than 6 months. Study limitations include use of clinical case scenarios as opposed to actual clinical practice. Practice patterns for prophylactic antibiotic use for neonatal urinary tract dilation are dependent on gender, circumcision status, and grade. The use of minimally invasive surgery for ureteropelvic junction repair increased with patient age, with 50% preferring this modality at 2 years.

Trends in diagnosis and management of idiopathic pulmonary fibrosis in Canada

ABSTRACTRATIONALE: Idiopathic pulmonary fibrosis (IPF) is a progressive lung disease with a poor prognosis. Physician practice patterns on the diagnosis and management of IPF in Canada have not been described.OBJECTIVE: To describe the practice patterns of Canadian respirologists on the diagnosis and management of IPF and to determine if these patterns reflect current guidelines.METHODS: We conducted surveys of Canadian physicians and fellows-in-training in 2009 and 2013. Questions addressed the diagnosis of IPF, screening for comorbidities, treatment of IPF, and acute exacerbations of IPF.MEASUREMENTS AND MAIN RESULTS: Response rates in the 2009 and 2013 surveys were 22% and 17%, respectively. Most respondents felt that high resolution CT scan can diagnose IPF in most cases, with lung biopsy rarely performed. The majority screened for hypoxemia, pulmonary hypertension, gastroesophageal reflux, and autoimmune disease. In 2013, more respondents used no pharmacologic therapy to treat IPF (2009, 36% vs. 2013, 56%, p < 0.01) and 34% used first-line pirfenidone. Fewer respondents used prednisone (2009, 61% vs. 2013, 7%, p < 0.001) or azathioprine (2009, 38% vs. 2013, 1%, p < 0.001), while many employed first-line N-acetylcysteine (2009, 47% vs. 2013, 42%, p = 0.47). In 2013, 20% had no access to multidisciplinary diagnosis discussion, 33% accessed specialty IPF clinics, and <1% accessed palliative care. Referral for lung transplantation was higher in 2013 than 2009 (26% vs. 13%, p = 0.01). Treatment of acute exacerbations changed, with more use of corticosteroids and antibiotics, and less additional immunosuppression in 2013.CONCLUSIONS: Practice patterns for diagnosis and treatment of IPF in Canada evolved in concordance with the publication of international guidelines in 2011. Access to palliative care, lung transplantation referral, multidisciplinary diagnosis discussion, and specialty IPF clinics were identified as gaps in IPF care in Canada.

Clinical features and practice patterns of treatment for adrenal crisis: a nationwide cross-sectional study in Japan.

Adrenal crisis is an endocrine emergency that requires prompt diagnosis and treatment. However, the clinical features and practice patterns of treatment for adrenal crisis are not completely understood. To investigate patient characteristics, comorbidities and treatments of adrenal crisis. We conducted a cross-sectional study of patients who received intravenous glucocorticoids for adrenal crisis at admission from 1 July 2007 to 31 March 2014, using a national inpatient database in Japan. Among approximately 34 million inpatients in the database, we identified 799 patients diagnosed with adrenal crisis and coexisting primary or secondary adrenal insufficiency at admission. The median (interquartile range) age was 58 (28-73) years, and the overall in-hospital mortality was 2.4% (19 of 799 patients). The most common comorbidity at admission was infections excluding pneumonia and gastroenteritis (15.0%). There were 68 (8.5%) patients with gastroenteritis, and no deaths occurred among these patients. The patients with secondary adrenal insufficiency showed significantly higher proportions of admission to ICU, extracellular fluid resuscitation, insulin therapy and catecholamine use than the patients with primary adrenal insufficiency. There were no significant between-group differences in mortality rate and variation in intravenous glucocorticoids (short-acting glucocorticoid, hydrocortisone; moderate-acting glucocorticoid, prednisolone or methylprednisolone; long-acting glucocorticoid, dexamethasone or betamethasone). Of the 19 dead patients, 15 were aged above 60 years, 12 had impaired consciousness at admission and 13 received insulin therapy. Clinicians should be aware that older patients with impaired consciousness and diabetes mellitus are at relatively high risk of death from adrenal crisis.

Prevalence of Atrial Fibrillation and Antithrombotic Therapy in Hemodialysis Patients: Cross-Sectional Results of the Vienna InVestigation of AtriaL Fibrillation and Thromboembolism in Patients on HemoDIalysis (VIVALDI).

BackgroundAtrial fibrillation (AF) adds significant risk of stroke and thromboembolism in patients on hemodialysis (HD). The aim of this study was to investigate the prevalence of AF in a population-based cohort of HD patients and practice patterns of antithrombotic therapy for stroke prevention in AF.MethodsThe Vienna InVestigation of AtriaL fibrillation and thromboembolism in patients on hemodialysis (VIVALDI), an ongoing prospective observational cohort study, investigates the prevalence of AF and the risk of thromboembolic events in HD patients in Vienna, Austria. We analyzed cross-sectional data of 626 patients (63.4% men, median age 66 years, approx. 73% of HD patients in Vienna), who provided informed consent. A structured interview with each patient was performed, recent and archived ECGs were viewed and medical histories were verified with electronic records.ResultsThe overall prevalence of AF was 26.5% (166 patients, 71.1% men, median age 72 years) of which 57.8% had paroxysmal AF, 3.0% persistent AF, 32.5% permanent AF, and 6.6% of patients had newly diagnosed AF. The median CHA2DS2-VASc Score was 4 [25th-75th percentile 3–5]. In multivariable analysis, AF was independently associated with age (odds ratio: 1.05 per year increase, 95% confidence interval: 1.03–1.07), male sex (1.7, 1.1–2.6), history of venous thromboembolism (2.0, 1.1–3.6), congestive heart failure (1.7, 1.1–2.5), history of or active cancer (1.5, 1.0–2.4) and time on HD (1.08 per year on HD, 1.03–1.13). Antithrombotic treatment was applied in 84.4% of AF patients (anticoagulant agents in 29.5%, antiplatelet agents in 33.7%, and both in 21.1%). In AF patients, vitamin-K-antagonists were used more often than low-molecular-weight heparins (30.1% and 19.9%).ConclusionsThe prevalence of AF is high amongst HD patients and is associated with age, sex, and distinct comorbidities. Practice patterns of antithrombotic treatment indicate a lack of consensus for stroke prevention in HD patients with AF.

Aneurysm treatment practice patterns for newly appointed dual-trained cerebrovascular/endovascular neurosurgeons: Comparison of open surgical to neuroendovascular procedures in the first 2 years of academic practice.

Background:The practice patterns of a hybrid open cerebrovascular/neuroendovascular (CVNV) neurosurgeon in early academic practice is unknown.Methods:We performed a multi-institutional retrospective cohort study of patients with cerebral aneurysms that were treated within the first 24 months of the neurosurgeon’s practice.Results:A total of 533 aneurysms were treated by the three senior authors within the first 24 months of their academic practice. Of these aneurysms, 172 were treated with microsurgical clipping, 191 with coiling, and 170 with flow diversion. Treatment in the setting of acute subarachnoid hemorrhage (SAH) occurred in 23% (122/533) of the aneurysms. Majority of the clipped aneurysms (70%, 121/172) were anterior cerebral artery (ACA), anterior communicating artery (ACOM), or middle cerebral artery (MCA) in location. In comparison, only 23% (82/361) of aneurysms treated with coiling or flow diversion therapy were ACA, ACOM, or MCA in location (P < 0.05). Additionally, majority of the flow diverted aneurysm (65%, 111/170) were cavernous or ophthalmic/paraophthalmic in location. During the second year of practice, there appeared to be a trend towards more aneurysms treated with neuroendovascular techniques (22% increase), particularly in flow diversion.Conclusion:Although the CVNV neurosurgeon treats cerebral aneurysms more commonly with neuroendovascular techniques, a third of the cerebral aneurysms are still selected for microsurgical clipping. Aneurysms located along the ACA/ACOM or MCA are the most frequent aneurysms reserved for microsurgical clipping. The CVNV neurosurgeon must be prepared to manage a high percentage of ACA/ACOM or MCA aneurysms microsurgically.

National Trends in Prostate Biopsy and Radical Prostatectomy Volumes Following the US Preventive Services Task Force Guidelines Against Prostate-Specific Antigen Screening

Studies demonstrate that use of prostate-specific antigen screening decreased significantly following the US Preventive Services Task Force (USPSTF) recommendation against prostate-specific antigen screening in 2012. To determine downstream effects on practice patterns in prostate cancer diagnosis and treatment following the 2012 USPSTF recommendation. Procedural volumes of certifying and recertifying urologists from 2009 through 2016 were evaluated for variation in prostate biopsy and radical prostatectomy (RP) volume. Trends were confirmed using the New York Statewide Planning and Research Cooperative System and Nationwide Inpatient Sample. The study included a representative sample of urologists across practice settings and nationally representative sample of all RP discharges. We obtained operative case logs from the American Board of Urology and identified urologists performing at least 1 prostate biopsy (n = 5173) or RP (n = 3748), respectively. The 2012 USPSTF recommendation against routine population-wide prostate-specific antigen screening. Change in median biopsy and RP volume per urologist and national procedural volume. Following the USPSTF recommendation, median biopsy volume per urologist decreased from 29 to 21 (interquartile range [IQR}, 12-34; P < .001). After adjusting for physician and practice characteristics, biopsy volume decreased by 28.7% following 2012 (parameter estimate, -0.25; SE, 0.03; P < .001). Similarly, following the USPSTF recommendation, median RP volume per urologist decreased from 7 (IQR, 3-15) to 6 (IQR, 2-12) (P < .001), and in adjusted analyses, RP volume decreased 16.2% (parameter estimate, -0.15; SE, 0.05; P = .003). Following the 2012 USPSTF recommendation, prostate biopsy and RP volumes decreased significantly. A panoramic vantage point is needed to evaluate the long-term consequences of the 2012 USPSTF recommendation.