Recent randomized controlled trials (RCTs) challenge the routine practice of keeping patients NPO ("nil per os") after midnight before diagnostic cardiac catheterization. Shorter fasting durations improve patient experience without increasing risks; however, systematic uptake into routine practice remains limited. At a high-volume cardiac care centre, patients were still being required to fast from midnight, despite emerging evidence. To assess the feasibility of shifting long‑standing practice patterns, we established a >70% adherence target for uptake of a shortened fasting protocol. A structured quality improvement initiative using sequential Plan-Do-Study-Act (PDSA) cycles modified pre-procedural fasting protocols to permit a light meal up to 2 hours before cardiac catheterization and clear fluids until the procedure (i.e., intervention). Patient experience surveys were administered to intervention and control groups in 2 PDSA cycles, followed by a post-implementation intervention group. The primary outcome was adherence to shortened fasting protocols (>70% target). Secondary outcomes included patient comfort, satisfaction, safety events, and sustained uptake. Cycle 1 included 97 outpatients (37 control, 60 intervention), cycle 2 included 84 inpatients (40 control, 44 intervention), and 45 patients were in the post-implementation group. Target adherence was met (77% in cycle 1, 82% in cycle 2, and 79% at post-implementation). Patients in the intervention groups reported lower hunger (cycle 1 outpatients) and lower nausea (cycle 2 inpatients), while satisfaction scores remained consistently high across all groups. No aspiration, intubation, or escalation to higher-level care was observed. Shortening fasting requirements to 2 hours before cardiac catheterization was feasible to implement in a high‑volume cardiac centre.

Despite the frequent occurrence of thumb ulnar collateral ligament injury, evidence supporting current diagnostic and treatment recommendations remains limited. To identify areas where comparative research is needed to support future evidence-based guidelines and potential challenges to their subsequent implementation, this study aimed to characterize international practice patterns, identifying consensus and variation. A web-based international survey was distributed between May and December 2024 through professional societies for hand surgery and associated clinical networks. The questionnaire comprised twenty-five items covering clinician characteristics, diagnostic strategies, and treatment preferences. Responses were analyzed descriptively and stratified by geographic region and years of clinical experience. Of 293 returned questionnaires, 262 were eligible for analysis. Respondents had practiced for a median of thirteen years, and most were based in Europe. Physical examination was considered sufficient to diagnose a complete ligament tear by most respondents (78%), whereas far fewer regarded it sufficient to detect a Stener lesion (27%). Radiographs were routinely used by 69%, ultrasound by 51%, and MRI by 40%. There was consensus for operative treatment of Stener lesions (95%) and displaced avulsion fractures (79%). Considerable variation existed for complete tears without Stener lesion: 59% preferred surgery, 52% would also attempt nonoperative treatment, and 25% reported they would never consider conservative management for any full-thickness tear. These findings identify areas of variation in which comparative evidence may be most relevant, while also showing where existing practice patterns may influence future guideline implementation. Not applicable.

Prior research has utilised person-centred approaches to identify parent feeding profiles distinguished by controlling and structure-based practices, but less research has examined autonomy support-based practices, or how social and family contextual factors differ between feeding profiles. This study aimed to identify profiles of parents with similar patterns of feeding practices and to examine whether profiles differ on family contextual factors. In 2022, 989 UK parents of children aged 3-6 years (M=4.1 years) completed an online survey, which included the Comprehensive Feeding Practices Questionnaire (CFPQ), measuring parental feeding practices, and validated questionnaires capturing family contextual variables. Latent Profile Analysis (LPA) was conducted to identify parent feeding profiles using the CFPQ. A MANCOVA assessed differences in family contextual variables between profiles. LPA identified three profiles based on common model fit indices and theoretical considerations. Profile 1 'moderate control' (25.2%) showed moderate use of controlling practices and low use of structure-based and autonomy support-based practices. Profile 2 'structured and supportive' (29.6%) showed low use of controlling practices and high use of structure-based and autonomy support-based practices. Profile 3 'using everything' (45.2%) showed high use of all three types of feeding practices. Parents in the 'moderate control' profile had significantly lower parental wellbeing and reported more barriers of time and energy for meal planning compared to other profiles. In contrast, parents in the 'structured and supportive' profile had significantly lower household chaos and lower parental stress. Mothers had a higher proportion of membership to the 'structured and supportive' profile (33.9%) compared to other profiles, whereas fathers had a higher membership proportion to the 'using everything' profile (60.9%). Future interventions should be tailored to parent feeding practice profiles and associated family contextual factors.

Drug-coated balloons (DCBs) are increasingly used in femoropopliteal (FP) endovascular therapy (EVT) to limit permanent scaffold implantation. Although this paradigm shift has substantially altered treatment strategies, its effects on real-world clinical outcomes remain unclear. Temporal trends in device selection and clinical outcomes after FP EVT were evaluated in contemporary practice. This multicenter, retrospective study included patients who underwent EVT for de novo FP artery disease at six institutions between July 2017 and December 2023. Patients were stratified into three equal, chronological eras (early, middle, and late). Trends in device use were evaluated, and clinical outcomes, including primary patency and restenosis patterns, were compared. Overall, 2815 patients were included in the analysis. DCB use increased substantially across eras (24.5% vs. 50.6% vs. 70.4%, p < 0.0001). Although the proportion of patients with chronic limb-threatening ischemia increased over time, lesion complexity seemed to decrease, with lower rates of severe calcification and poor distal runoff in the later era. The 1-year primary patency rates were comparable across the three eras (83% vs. 81% vs. 81%, p = 0.2688). Conversely, the incidence of re-occlusion in restenotic lesions declined progressively over time (37% vs. 35% vs. 26%, p = 0.0002). Despite substantial temporal changes in FP EVT strategy, including increased DCB use and more selective scaffold implantation, 1-year outcomes remained stable. Restenosis patterns shifted toward fewer reocclusive failures, indicating qualitative improvement in treatment outcomes. Contemporary FP EVT therefore reflects a more strategy-driven approach that preserves durable outcomes while reducing unfavorable restenosis patterns in real-world practice.

Total knee arthroplasty (TKA) remains a highly successful and frequently performed procedure with variability in surgeon preferences regarding implant fixation and patellar resurfacing. This study aimed to characterize current practice patterns among members of the Knee Society and to identify key factors influencing implant fixation and patella resurfacing. A 23-question survey was distributed to 216 members of the Knee Society. The survey assessed demographic information, primary TKA volume, fixation technique preferences, patellar resurfacing practices, and the clinical rationale for these decisions. Responses were collected over a 4-week period in May 2025. Descriptive statistics were used to summarize the data. The response rate was 48.1% (104 surgeons), with 52 (50.0%) being in practice greater than 25 years and 39 (37.9%) performing 201 to 300 primary TKAs annually. Cemented fixation was dominant, with an average use rate of 72.9%; 67.3% (70 surgeons) used both cemented and cementless implants, with an average cementless use of 35.8% of cases. Age (70.0%) and bone quality (82.9%) were the most cited indications for cementless use. Conversely, 35.6% (37 surgeons) reported using cemented fixation in all patients. Patellar resurfacing practices varied widely, with 34.7% (33 surgeons) reporting always resurfacing and individual rates ranging from 0 to 100%. In total, 40.2% (41 surgeons) of respondents have said that their indications have changed in the past five years; resurfacing was most influenced by degree of arthritis (53.7%), patellar tracking (23.1%), and size/thickness (21.0 to 31.6%). Among surgeons performing cementless TKA, patellar resurfacing remained heterogeneous, and 40% (24 surgeons) still preferred cemented patellar components. Cemented fixation in primary TKA remains the standard among expert TKA surgeons, though cementless techniques are increasingly used in select patients. Patellar resurfacing practices remain highly variable, reflecting individualized decision-making. These findings highlight evolving trends and underscore the need for continued research and consensus in primary TKA.

In Japan, endoscopic submucosal dissection (ESD) is the standard treatment for superficial esophageal squamous cell carcinoma (ESCC). Although clinical guidelines outline indications, additional treatment, and stricture prevention, real-world practice patterns remain insufficiently characterized. The present nationwide survey aimed to clarify the current endoscopic management of ESCC in Japan. A web-based, 20-item multiple-choice questionnaire was distributed to endoscopists performing upper gastrointestinal endoscopy at least weekly. Invitations were disseminated through the mailing lists of the Japan Esophageal Society and the individual mailing lists of core study members. The survey assessed diagnostic strategies, endoscopic treatment selection, indications for additional therapy after ESD, and approaches to stricture prevention. Altogether, 303 endoscopists who had performed endoscopic treatment for ESCC within the preceding year were enrolled. Most respondents reported using ESD exclusively. For clinical muscularis mucosa (MM) or shallow submucosa (SM1) lesions, treatment selection depended on circumferential extent, with ESD performed on 95.0% of patients with lesions involving < 1/2 of the circumference and ESD, chemoradiotherapy, and surgery conducted at similar frequencies for circumferential lesions. Decisions regarding additional treatment post-ESD for pathological MM or SM1 lesions were strongly influenced by lymphovascular invasion. Stricture prevention strategies varied according to the extent of mucosal defect, with steroid injection preferred for defects involving ≥ 1/2 but < 3/4 of the circumference and combined local steroid injection and oral steroids for circumferential defects. Although most practices align with guideline recommendations, substantial variability persists in areas lacking explicit guidance, highlighting the need for stronger evidence to support standardized clinical decision-making.

Sirolimus is a mainstay medical therapy for vascular anomalies (VAs). However, there is limited guidance on managing sirolimus. We sought to characterize the practice patterns of clinicians who prescribe sirolimus to identify best practices or areas of disagreement warranting future investigation. We conducted standardized interviews with 92 US clinicians who prescribe sirolimus to patients with VAs. We performed descriptive statistics of clinicians' responses. We found wide variation in sirolimus practices. Clinicians reported numerous dosing strategies. The upper end of target goal troughs ranged from 6 to 15ng/mL, with some clinicians targeting as low as 4-6ng/mL and others as high as 10-15ng/mL. Clinicians were split on whether they always, sometimes, or never administered pneumocystis prophylaxis. They were similarly divided on how they administered live-attenuated vaccines, with some forgoing vaccination indefinitely, some administering with specific measures, and others administering without precautionary measures. Fever management also varied. While many encouraged primary care evaluation, nearly 20% mandated emergency department visits. A sizeable minority obtained blood cultures and administered empiric antibiotics to all patients with fevers. Lastly, peri-procedural management of sirolimus varied. Half of the clinicians held sirolimus for major procedures, and 14% held sirolimus for all procedures, including sclerotherapy. Despite more than 15years of data on the efficacy of sirolimus, we identified wide variation in how clinicians prescribe and manage sirolimus for patients with VAs. Future work is needed to generate data and develop evidence-based guidelines for the management of sirolimus to ensure safe and appropriate care.

Depth of anaesthesia (DoA) is often guided by standard dosing protocols and evaluated through clinical signs, assuming these signs reliably indicate unconsciousness. However, this assumption is problematic: patients respond differently to anaesthetic drugs, and physiological markers can misrepresent brain state. Nociceptive responses may persist despite apparent unconsciousness. Excessive DoA is associated with cardiovascular instability and post-operative cognitive dysfunction, whereas insufficient DoA increases the risk of intraoperative awareness. Processed electroencephalography (pEEG), such as the Bispectral Index (BIS), was introduced to address these limitations by enabling monitoring of frontal cortical brain activity during general anaesthesia. We aimed to investigate how pEEG, measured as BIS, reflects anaesthetic depth across patient subgroups and anaesthetic techniques. This large-scale prospective observational cohort study analysed electronic health records from patients who underwent general anaesthesia between 1 January 2017, and 31 December 2020. The study evaluated associations between BIS values and patient age, sex and health status measured by American Society of Anaesthesiologists (ASA) scores. Clinical data were extracted from 97,733 patients, of whom 26,650 underwent continuous BIS monitoring. BIS monitoring was more frequent in patients classified as ASA scores of 1 or 2 and those receiving total intravenous anaesthesia. Patients with higher ASA scores, increasing age and female patients showed deeper anaesthesia with significantly lower BIS values. In this large observational cohort, older patients, patients with higher ASA score and females exhibited lower BIS values during general anaesthesia compared with younger, healthier and male patients, even when anaesthetic dosing followed standard protocols. These observed associations may reflect practise patterns, unmeasured confounding or physiological differences, and should not be interpreted as causal. Further studies are warranted to explore more individualised anaesthetic strategies and tailored neuromonitoring approaches to optimise anaesthetic depth, particularly in vulnerable patient subgroups. Using a large database of cases with processed EEG (BIS) and anaesthesiological data, this study found that older patients and those with higher ASA-class had the deepest anaesthetic depth despite standard anaesthetic dosing protocols. These findings support the need for more individualised EEG-monitoring, especially in the elderly and frail, but also how these BIS indicators should guide management. It remains unresolved if deeper anaesthesia with presumed benefits of reducing the surgical stress, can be balanced by improving brain perfusion rather than reducing anaesthetic depth.

Objective: This study investigated current clinical practices, organizational barriers, and resource availability in managing dual diagnosis (co-occurring psychiatric and substance use disorders) among Italian psychiatrists in a healthcare system characterized by service fragmentation between mental health and addiction care. Methods: A structured, self-administered online questionnaire was distributed nationwide to Italian psychiatrists. The survey covered demographic characteristics; organizational aspects and service collaboration; pharmacological and nonpharmacological approaches; and perceived clinical challenges. Data were analyzed descriptively to identify practice patterns and priority intervention areas. Results: Seventy-nine psychiatrists participated from diverse settings (38% addiction services, 25% community mental health services, 14% hospitals, 15% other facilities). While 78% regularly treated dual diagnosis patients, only 38% reported structured protocols between mental health and addiction services. Collaboration was rated as only partially effective by 44%. Integrated treatment was preferred by 61%. The most commonly prescribed medications included mood stabilizers (94%), atypical antipsychotics (68%), anticraving agents (54%), and antidepressants (37%). For depression, trazodone (32%) and serotonergic antidepressants (25%) were used most. For psychosis, aripiprazole (47%) was predominant. Most clinicians (81%) combined pharmacotherapy with psychosocial interventions. Key barriers included insufficient training (67% highlighted need for specialized clinicians), poor service integration, and diagnostic uncertainty. Conclusions: Significant gaps persist in Italian dual diagnosis care despite clinical awareness. Urgent priorities include routine screening, clinician training, national guideline development, organizational reforms promoting service collaboration, and increased availability of structural resources, which was reported as insufficient by 61% of respondents. These improvements are essential for delivering timely, evidence-based, integrated care to this vulnerable population.

Roux-en-Y gastric bypass (RYGB) is a widely performed metabolic and bariatric surgery (MBS) procedure with proven efficacy. However, significant variability exists in its technical execution. This study aimed to evaluate global practice patterns among surgeons affiliated with the International Federation for the Surgery and Other Therapies for Obesity (IFSO), identifying key variations and factors influencing intraoperative decision-making. A cross-sectional survey was distributed between January and November 2025 to active IFSO members performing RYGB. The survey explored techniques related to the gastric pouch configuration, intestinal limb lengths, gastrojejunostomy, ring augmentation, and adjunct use. Responses from 245 surgeons across 47 countries were analyzed using descriptive statistics, subgroup comparisons, and multivariable logistic regression. Technical variability was widespread. Only 53.5% routinely measured gastric pouch length; 67.3% described their pouches as "short" or "small," with variable anatomical endpoints. Bougie sizes ranged from 28 to 46 Fr, with 36 Fr being most common (41.2%). Only 21.6% of respondents reported routinely measuring total bowel length. Ring-augmentation was used by 20.4%, with significant regional and experiential variation. Linear stapling was preferred for gastrojejunostomy (81.2%), but stoma size and suture materials varied. Routine closure of both Petersen's space and the jejunojejunal mesenteric defect was common (69%) yet non-uniform. High-volume surgeons had shorter hospital stays and longer follow-up, but technical patterns were similar. Global RYGB practice exhibits heterogeneity in several key operative steps. Improved reporting of intraoperative technical variables may help clarify which differences are most relevant to perioperative, long-term, and registry-based outcomes, and may support future consensus-building in areas where standardization is clinically justified.

Tibial access is associated with tibial intervention in claudicants.

This study examined national trends in the use of accelerated partial-breast irradiation (APBI) for ductal carcinoma in situ (DCIS) and evaluated how practice patterns changed after the 2017 updated American Society for Radiation Oncology (ASTRO) consensus, which broadened the criteria for considering APBI in DCIS. The 2017 update expanded the "suitable" patient group to include DCIS cases meeting specific criteria: age 50 years or older, screen-detected lesions, low to intermediate nuclear grade, tumor size 25 mm or smaller, and resection margins 3 mm or greater. A retrospective analysis of the National Cancer Database was performed including patients with DCIS diagnosed between 2011 and 2021. The study compared APBI utilization before (2011-2017) and after (2018-2021) the guideline update. Overall APBI utilization increased from 7.2% (2011-2017) to 13.0% (2018-2021) after the consensus update. Among patients 50 years old or older with low- to intermediate-grade DCIS (≤25 mm), APBI use rose from 8.8% to 15.5%. After 2017, the strongest predictors of APBI use were age, facility type, tumor grade and size, and estrogen receptor (ER) status. Utilization was higher among patients 50 years old or older (13.6% vs 9.7%), those treated at academic centers (15.4% vs 12.0%), those with low-grade (15.8%) and intermediate-grade (13.5%) compared with high-grade (11.4%) disease, those with tumors 25 mm or smaller (13.7% vs 9.7%), and ER-positive cases (13.9% vs 10.7%). Since the updated guidelines in 2017, utilization of APBI for DCIS has increased. Key factors influencing APBI use align with the updated guidelines.

Current Practice Patterns for Treating Alcohol Use Disorder in US Emergency Departments.

Endourology has rapidly evolved, offering increasingly effective and minimally invasive treatments for urolithiasis. Despite evidence-based guidelines from the American Urological Association and European Association of Urology, adherence varies worldwide. This study evaluated international practice patterns and factors influencing treatment decisions. A 37-question online survey was distributed to Endourology Society members. The questionnaire included demographics, management of common clinical scenarios, technical preferences, and approaches to complex anatomical cases. Data from 300 respondents were analyzed using descriptive statistics and subgroup comparisons stratified by geography, fellowship training, and years in practice. Fisher's exact test defined significance (p < 0.05). Most respondents did not intervene on asymptomatic 4-6 mm renal stones, particularly in the lower pole. For 6-15 mm stones, retrograde intrarenal surgery (RIRS) was most frequently selected, though extracorporeal shockwave lithotripsy (ESWL) and percutaneous nephrolithotomy (PCNL) were also used depending on location and surgeon background. Stones 15-25 mm were most often managed with 17F PCNL, while stones >25 mm and staghorn calculi were primarily treated with 24-30F PCNL. Notably, a proportion of respondents selected RIRS even for staghorn calculi. U.S. urologists more often used RIRS and balloon dilators, whereas international respondents favored 17F PCNL and Amplatz dilators. Fellowship-trained surgeons reported lower reliance on ESWL and greater use of combined or advanced approaches. Surgeons with fewer than 5 years in practice more frequently chose RIRS, while those with over 15 years often performed PCNL, though they also reported increased RIRS use for 15-25 mm stones. This large international survey highlights substantial heterogeneity in stone management, shaped by geography, fellowship training, and years in practice. While PCNL remains the cornerstone for complex stones, technological advances are driving a measurable shift toward minimally invasive RIRS. These findings underscore the importance of adaptable, evidence-based guidelines to standardize global practice.

International practice patterns and perceptions of pressurised intraperitoneal aerosol chemotherapy for management of gastric cancer: A global clinician survey.

Cystic fibrosis (CF) is a rare, multisystem genetic disease requiring early diagnosis and lifelong multidisciplinary follow-up. In many middle-income countries, including Colombia, national CF registries are absent, and epidemiological information largely relies on administrative health data. Although such data do not reflect true clinical prevalence, they enable systematic monitoring of service-based prevalence and diagnostic practice patterns, offering critical insights for health system planning. We conducted a nationwide, observational study using the Colombian Individual Registry of Provision of Health Services (RIPS) from 2015 to 2024. Children and adolescents aged 0-19 years with CF diagnoses (ICD-10 E84.0-E84.9) were identified. Annual crude and age-standardized administrative prevalence rates were estimated using national population projections. Diagnostic test utilization (spirometry, chest CT, pancreatic elastase, genetic testing) was quantified per 100 encounters. Temporal trends were analyzed using LOESS smoothing with 95% confidence intervals. The age-standardized national administrative prevalence of CF-related healthcare encounters was 5.64 per 100,000. Administrative prevalence was highest in children aged 0-4 years and declined progressively with age. The contributory insurance regime showed the highest service-based prevalence, suggesting disparities in diagnostic access. Temporal patterns revealed a peak in 2018-2019 followed by a decline after 2020, coinciding with COVID-19-related disruptions in pediatric care. Diagnostic utilization was markedly low: spirometry was performed in fewer than 6 tests per 100 encounters annually, chest CT use was sporadic, and genetic testing was minimal before 2018, increasing slightly thereafter. Administrative prevalence of CF in Colombia has remained stable over a decade but is accompanied by underutilization of essential diagnostic procedures and inequities across insurance groups. Strengthening diagnostic capacity, standardizing monitoring practices, and improving early detection are urgent priorities. This study provides a scalable framework for CF surveillance in countries lacking national registries.

Axillary management in breast cancer has evolved toward de-escalation to reduce complications, particularly breast cancer-related lymphedema (BCRL). This study aimed to assess current practices and trends of axillary surgery and BCRL management in China. A nationwide survey was conducted across hospitals performing ≥ 200 breast cancer surgeries annually in 2022. The questionnaire evaluated institutional characteristics, clinical practices of axillary surgery and BCRL care. Data were compared with those from the 2017 national survey involving 110 hospitals to assess temporal changes in hospital-reported practice patterns. The 198 hospitals surveyed performed a total of 123,237 breast cancer surgeries in 2022. SLNB for cN0 patients was routine practice, with 59.6% of hospitals performing SLNB in > 90% of these cases, whereas the use of SLNB in patients with clinically suspicious axillary nodes and FNA-confirmed metastasis remained cautious. The omission of ALND for patients with limited SLN metastasis (1-2 positive SLNs) remained conservative, particularly for mastectomy cases. However, significant increases were observed compared with the 2017 survey (breast-conserving surgery: median 30.0% vs. 9.0%, P = 0.001; mastectomy: median 11.0% vs. 6.6%, P < 0.001). The timing of SLNB in patients receiving neoadjuvant chemotherapy (NAC) shifted toward the post-NAC setting compared with 2017 (54.0% vs. 45.5%). Comprehensive assessment after NAC, including targeted axillary dissection (TAD) with dual-tracer mapping, was underutilized (23.7%). Hospital-reported BCRL care teams had been established in 52.0% of hospitals, while surgical BCRL interventions remained rare (11.6%). Compared with the 2017 national survey, hospital-reported adoption of axillary de-escalation strategies in China was broader, although implementation remained cautious and uneven across clinical scenarios and institutional settings. As a hospital-level practice-mapping survey, this study describes implementation patterns rather than patient-level oncologic safety or efficacy. These findings suggest that tracer accessibility, evidence-based protocols, and multidisciplinary BCRL care may be important areas for future improvement.

To evaluate the impact of Ontario's public IVF funding program on intracytoplasmic sperm injection (ICSI) use and reproductive outcomes in non-male factor infertility (NMFI), and to compare insemination practices and cumulative live birth rates (cLBR) between funded and self-pay cycles. We conducted a population-based retrospective cohort study linking the CARTR Plus registry to the BORN dataset. All IVF cycles for NMFI in Ontario from 2013-2022 were included, excluding donor oocyte and embryo cycles, cycles with male factor infertility, split IVF/ICSI, or missing outcome data. Primary outcomes were temporal trends in ICSI use before (2013-2015) and after (2016-2022) implementation of the Ontario Fertility Program (OFP). The secondary outcome was cLBR within one year of retrieval. Comparisons were made between IVF vs ICSI and between OFP-funded and self-pay cycles. Among 47 562 NMFI cycles, ICSI accounted for 84% of inseminations overall. ICSI use increased after OFP implementation in both funded (82.9%) and self-pay (87.7%) cycles, despite exclusion of male factor cases. Conventional IVF decreased from 22% pre-OFP to 15% post-OFP (p < 0.001). cLBR remained stable over time and did not differ between IVF and ICSI in either funded (37.8% vs 39.6%) or self-pay cycles (38.7% vs 38.8%). Increased ICSI utilization was not associated with improved reproductive outcomes. In Ontario's NMFI population, ICSI is used far more frequently than conventional IVF, yet provides no cLBR benefit. The rise in ICSI following public funding reflects broader practice patterns rather than funding-driven behaviour. These findings highlight opportunities to optimize evidence-based, cost-effective IVF care.

Syncope is a common cause of emergency department visits and is associated with heterogeneous clinical practice and substantial hospital resource use. We primarily aimed to quantify the direct per-patient hospital costs of syncope. Secondary aims were to characterize patterns of resource utilization, determine the cost structure by care pathway and functional component, and identify determinants of total per-patient cost. Additionally, we estimated the potential emergency department cost savings resulting from adherence to the 2018 European Society of Cardiology syncope guidelines. We conducted an observational, retrospective cohort study at a private hospital in Lisbon, Portugal, from 1 January to 31 December 2023, including pediatric (< 18 years) and adult (≥ 18 years) patients with a principal emergency department diagnosis of syncope (ICD-9-CM 780.2/992.1). Direct costs were assessed by micro-costing (bottom-up approach) from the hospital perspective (base year 2023), with patient-level analysis. Total per-patient cost was modeled using a generalized linear model as a function of age, sex, etiology, and total number of comorbidities as predictors. Potential emergency department savings were estimated using a counterfactual simulation of guideline-concordant diagnostic testing. We analyzed 375 patients (mean age 49.4 ± 26.5 years; 60.3% female). Etiology was established in 41.1% of the cohort, with reflex syncope predominating (32.3%), whereas 58.1% remained unexplained. Aggregate total cost was €661,992.74, with a mean of €1,765.31 per patient. Costs ranged from €408 per patient for emergency department-only management to €13,048 for episodes requiring hospitalization. Diagnostic testing accounted for 63.3% of total cost. In multivariable analysis, age ≥ 80 years, male sex, higher comorbidity burden and cardiac etiology were associated with significantly higher hospital costs. Potential emergency department diagnostic-testing savings were €80,228.28, corresponding to €213.94 per patient. Syncope was associated with substantial hospital costs in a context of marked practice variation and intensive diagnostic testing. Structured, guideline-aligned care pathways may support more selective diagnostic evaluation and efficient use of healthcare resources. Not applicable.

External ventricular drains (EVDs) are critical for monitoring and managing intracranial pressure in acute traumatic brain injury patients. However, there is a lack of consensus on optimal EVD placement timing. Previous studies suggest benefits in early placement but are limited by smaller cohorts and lack of adjustment for illness severity. We sought to characterize EVD timing patterns and examine clinical characteristics and outcomes associated with early placement. We performed a retrospective study of patients in the National Trauma Data Bank (2018-2023) who received EVD placement for traumatic brain injury. Early EVD was defined as placement ≤24 hours from admission. Multivariable regression models evaluated associations between EVD timing, patient characteristics (demographics, comorbidities, and injury severity), and in-hospital outcomes including mortality, severe sepsis, extended hospitalization (>14 days), ventilator duration, and secondary EVD placement. Of 26 020 patients, 77.3% received early placement. Patients receiving early EVD were independently more likely to be younger and to have lower Glasgow Coma Scale. Placement was delayed in patients with comorbidities such as hypertension, diabetes, smoking, and dementia. Early EVD was associated with higher in-hospital mortality (adjusted odds ratio [aOR] 1.39), with lower mortality odds for each 24-hour delay (aOR 0.96). However, early EVD was also associated with lower odds of severe sepsis (aOR 0.60) and prolonged hospitalization (>14 days) (aOR 0.44). Secondary EVD placement occurred in 8.2% of patients with less frequent and more delayed placement after early first EVD (aOR 0.84). Early EVD placement often identifies severe neurological compromise and is associated with higher mortality. However, early placement was also associated with lower complication rates, shorter hospitalization, and fewer and later EVD revisions. These findings suggest early EVD to be both a marker of severe injury and practice pattern reflecting efficient care, underscoring the need for distinguishing procedural benefit from confounding by indication.