Private Practice Institutions Research Articles

Anterior segment optical coherence tomography-guided transepithelial phototherapeutic keratectomy for scarring of the central cornea following pterygium excision.

To report the outcomes of patients undergoing anterior segment optical coherence tomography-guided transepithelial phototherapeutic keratectomy (ASOCT T-PTK) for central corneal scarring after pterygium excision. The charts of 11 eyes of 10 patients that underwent ASOCT T-PTK following excision of visual axis-involving pterygia were retrospectively reviewed from a single private practice institution. The visual outcomes and corneal topographic findings were evaluated 4±1mo after pterygium excision and 6±2mo after transepithelial phototherapeutic keratectomy (T-PTK). All 11 eyes tolerated both the pterygium excision and T-PTK procedure well without any significant intraoperative or postoperative complications. Uncorrected distance visual acuity (UDVA) and manifest refraction corrected distance visual acuity (CDVA) improved after pterygium excision (P=0.03 and P=0.05, respectively). The UDVA and CDVA improved further after T-PTK (P=0.004 and P=0.002, respectively). The topographic surface asymmetry index, topographic surface regularity index, and topographic projected visual acuity significantly improved after T-PTK (P=0.0092, P=0.0022, and P=0.0002, respectively). None of the subjects lost any lines of CDVA, developed recurrence of pterygia or required keratoplasty during the postoperative period. ASOCT T-PTK can provide excellent visual and anatomic outcomes in patients with central corneal scarring after excision of visual axis-involving pterygia.

Epiretinal Membrane Formation after Treatment of Retinal Breaks: Cryoretinopexy versus Laser Retinopexy

The purpose of the study was to study the prevalence of macular epiretinal membrane (ERM) formation for retinal tears treated with laser retinopexy and cryoretinopexy. The study sought to identify whether there is a difference in ERM formation prevalence between these 2 treatments. Retrospective, single-center, chart review study. Patients seeking treatment at a private practice institution (The Retina Institute, St. Louis, Missouri) over a 10-year period between 2006 and 2016 for the evaluation and treatment of a retinal tear. A chart review was conducted comprising all patients undergoing procedures for Current Procedural Terminology codes 67141 (prophylaxis of retinal detachment, cryotherapy) and 67145 (prophylaxis of retinal detachment, photocoagulation) and patients with an International Classification of Diseases, Ninth Edition, Clinical Modification, diagnosis code of 362.56 (macular puckering), who underwent procedures identified with Current Procedural Terminology codes 67141 and67145. Epiretinal membrane development, time between treatment and ERM development, and surgical intervention for ERM progression. A total of 2257 eyes underwent treatment for retinal breaks with 1655 eyes treated by laser retinopexy and 602 eyes treated by cryoretinopexy. The mean age of the cryoretinopexy group was 59.4±1.5 years and in the laser retinopexy group was 61.4±0.8 years. A total of 74 patients (3.2%) demonstrated an ERM after treatment for a retinal tear during an 11-year period (2006-2016). A total of 26 cryoretinopexy eyes (4.32%) and 48 laser retinopexy eyes (2.90%) demonstrated an ERM after treatment of retinal breaks (P= 0.094). The average time to ERM development was 11.5 months for the cryoretinopexy group and 12 months in the laser retinopexy group (P= 0.878). Seven ERMs progressed to requiring surgical intervention: 2 in the cryoretinopexy group and 5 in the laser retinopexy group. There was no statistically significant difference between the groups with regard to ERM progression resulting in surgical intervention (P= 0.707). Treatment of retinal breaks with either cryoretinopexy or laser retinopexy showed no statistically significant difference in the incidence, timing, or severity of ERM formation between these treatment methods.

Optical Coherence Tomography-Guided Transepithelial Phototherapeutic Keratectomy for Central Corneal Opacity in the Pediatric Population.

Purpose To report the outcomes of optical coherence tomography- (OCT-) guided transepithelial phototherapeutic keratectomy (PTK) for central corneal opacity in the pediatric population. Methods The charts of 10 eyes of 8 children aged 9 to 17 with central corneal opacity from various pathologies who underwent a standardized OCT-guided transepithelial PTK technique at a single private practice institution were retrospectively reviewed. The corneal topographic findings, OCT measurements, and visual results with refractive outcomes were analyzed 6 months after the PTK treatment. Results All 10 eyes tolerated the procedure well without any significant intraoperative or postoperative complications. Uncorrected and best spectacle-corrected visual acuity (BSCVA) significantly improved postoperatively (p < 0.0001 and p=0.0045, respectively). The absolute value of spherical equivalent on cycloplegic refraction significantly improved postoperatively as well (p=0.0014), but there were no significant changes in topographic measurements. Seven out of the 10 eyes had complete resolution of the central corneal opacity on OCT imaging. None of the subjects lost any lines of BSCVA and developed recurrence of the corneal opacity from the primary disease condition or required keratoplasty during the follow-up period. Conclusions OCT-guided transepithelial PTK can provide excellent visual outcomes in pediatric patients with central corneal opacities.

Postoperative Opioid Use in Sinonasal Surgery.

To survey patients following sinonasal surgery regarding postoperative pain and opioid use. Patients were surveyed for 4 days following sinus and/or nasal surgery regarding their pain level and use of prescribed opioids. Four academic medical centers and 1 private practice institution. Consecutive adult patients undergoing sinonasal surgery. A total of 219 subjects met criteria and were included for analysis; 134 patients (61%) took 5 or fewer combination oxycodone (5-mg) and acetaminophen (325-mg) tablets in the first 3 postoperative days, and 196 patients (89.5%) took fewer than 15. Fifty-one patients (23%) consumed no opioid pain medication. Opioid consumption was positively correlated with postoperative pain ( R2 = 0.2, P < .01) but was not correlated with the use of acetaminophen ( R2 = 0.002, P = .48). No significant difference in postoperative pain or opioid consumption was seen with respect to age, sex, specific procedures performed, postoperative steroids, or smoking history. Current smokers reported higher average pain than nonsmokers ( P < .001) and also required more postoperative opioids ( P = .02). An evidence-based approach to postoperative pain control following sinonasal surgery that reduces the number of unused and potentially diverted opioids is needed. The current study suggests that 15 combination oxycodone (5-mg) and acetaminophen (325-mg) tablets provide sufficient pain control for 90% of patients in the immediate postoperative period following sinonasal surgery, irrespective of the specific procedures performed, use of acetaminophen, or use of systemic steroids. Smoking status may help surgeons predict which patients will require larger opioid prescriptions.

Weight Loss and Nutritional Outcomes 10 Years after Biliopancreatic Diversion with Duodenal Switch.

Biliopancreatic diversion with duodenal switch (BPD/DS) is the most effective bariatric surgical procedure, but major concerns exist about the nutritional consequences. The study reported weight loss and nutritional outcomes of 80 patients with a follow-up of at least 10years. The follow-up was conducted at a university hospital as well as in a private practice institution in France. Eighty patients operated on between February 2002 and May 2006 were reviewed. Weight outcomes were analyzed as well as complete biological status. Revisions were reported as well as the number of patients taking vitamin supplementation. A follow-up of 141±16months was available for 87.7% of the patients at least 10years from surgery. Preoperative BMI decreased from 48.9±7.3 to 31.2±6.2kg/m2 with an EWL of 73.4±26.7% and a TWL of 35.9%±17.7%. Despite weight regain ≥10% of the weight loss in 61% of the cases, 78% of the patients maintained a BMI <35. Fourteen percent of the patients had a revision. Normal vitamin D levels were found in 35.4%. The overall PTH level was 91.9±79.5ng/mL, and 62% of the patients had hyperparathyroidism. Other deficiencies were less frequent but fat-soluble deficiencies as well as a PTH >100ng/mL were significantly associated with the absence of vitamin supplementation. BPD/DS maintains a significant weight loss, but remains associated with side effects leading to revision and multiple vitamin deficiencies. The most severe deficiencies are related to the lack of supplementation compliance.

National trends and complication rates for invasive extraoperative electrocorticography in the USA

Invasive electrocorticography (ECoG) is used in patients when it is difficult to localize epileptogenic foci for potential surgical resection. As MR neuroimaging has improved over the past decade, we hypothesized the utilization of ECoG diminishing over time. Using the USA Nationwide Inpatient Sample, we collected demographic and complication data on patients receiving ECoG over the years 1988–2008 and compared this to patients with medically refractory epilepsy during the same time period. A total of 695 cases using extraoperative ECoG were identified, corresponding to 3528 cases nationwide and accounting for 1.1% of patients with refractory epilepsy from 1988–2008. African Americans were less likely to receive ECoG than whites, as were patients with government insurance in comparison to those with private insurance. Large, urban, and academic hospitals were significantly more likely to perform ECoG than smaller, rural, and private practice institutions. The most frequent complication was cerebrospinal fluid leak (11.7%) and only one death was reported from the entire cohort, corresponding to an estimated six patients nationally. Invasive ECoG is a relatively safe procedure offered to a growing number of patients with refractory epilepsy each year. However, these data suggest the presence of demographic disparities in those patients receiving ECoG, possibly reflecting barriers due to race and socioeconomic status. Among patients with nonlocalized seizures, ECoG often represents their only hope for surgical treatment. We therefore must further examine the indications and efficacy of ECoG, and more work must be done to understand if and why ECoG is preferentially performed in select socioeconomic groups.

Emergency Medicine Resident Anesthesia Training in a Private vs. Academic Setting

BackgroundAirway management is an essential part of any Emergency Medicine (EM) training program. Academic centers typically provide training to many learners at various training levels in a number of medical specialties during anesthesiology rotations. This potentially creates competition for intubation procedures that may negatively impact individual experiences. ObjectivesWe hypothesized that residents would report higher numbers of intubations and improved educational value in a private practice, rather than an academic, anesthesiology rotation. MethodsEM residents’ anesthesiology training was evaluated pre and post a change in training setting from an academic institution to a private practice institution. Outcome measures included the number of self-reported intubations, resident ratings of the rotation, and the number of positive comments. Residents’ evaluation was measured with: a 14-item evaluation; subjective comments, which two blinded reviewers rated as positive, negative, or neutral; and transcripts from structured interviews to identify themes related to training settings. ResultsThe number of intubations increased significantly in the private practice setting (4.6 intubations/day vs. 1.5 intubations/day, p < 0.001). Resident evaluations improved significantly with the private practice experience (mean scores of 3.83 vs. 2.23, p-values <0.05). Residents’ impressions were also significantly higher for the private practice setting with respect to increased educational value, greater use of adjunct airway devices, and directed teaching. ConclusionsNumber of intubations performed and residents’ rating of the educational value were more favorable for a private practice anesthesiology rotation. Alternative settings may provide benefit for training in areas that have competition among trainees.

Informed consent for labor epidurals: a survey of Society for Obstetric Anesthesia and Perinatology anesthesiologists from the United States

Ethicists agree that informed consent is a process rather than just simply the signing of a form. It should provide the patient with needed information and understanding to authorize a procedure. Essential elements of informed consent for women requesting labor epidurals include a description of the procedure, the risks and benefits, and alternative treatments for analgesia including the associated risks and benefits. The purpose of this pilot study was to determine practices and opinions of obstetric anesthesiologists regarding informed consent for parturients. Questionnaires were sent to 885 anesthesiologists who were members of the Society of Obstetric Anesthesia and Perinatology based in United States institutions in 2002. Of the 885 questionnaires sent, 448 (51%) were returned with 47% from academic and 47% from private practice institutions. Forty-six percent worked as part of an obstetric anesthesia team; 51% worked in centers where there were >3000 deliveries/year. Sixty-eight percent suggested that "parturients in active labor are able to give informed consent for labor epidural analgesia." Thirteen percent recommend antenatal anesthesia consults for parturients inquiring about labor epidurals and 41% participated in childbirth classes. Responses did not differ significantly between physicians in academic vs. private practice. More obstetric team practices than non-team practices participated in childbirth education (54% vs. 30%, P < 0.0001). Despite the painful, stressful circumstances confronted by parturients, many respondents (76% in academic, 64% in private practice) thought that women in active labor are able to give informed consent.

A survey on partial left ventriculectomy in the Asia–Pacific region

Background. There has been increasing interest in partial left ventriculectomy as a new therapy for end-stage heart failure. Because the most significant impact of this development is likely to be in regions where heart transplantation is largely unavailable, we conducted a survey among a group of cardiac surgeons based in the Asia–Pacific region to evaluate their overall views on partial left ventriculectomy procedures. Methods. A questionnaire was sent to surgeons from 65 major institutions in 17 countries and regions in the Asia–Pacific. Questions examined current demographics and opinions regarding potential application and future prospects of this operation. Results. Surveyed surgeons were based in equal proportions in academic, government, and private practice institutions. One third of respondents have already performed partial left ventriculectomy operations, largely in small numbers. In total, 86 procedures were performed with 75% hospital survival rate. Failures were thought to be caused by limited knowledge about patient selection criteria and lack of experience with operative technique and perioperative care. The majority of respondents believe that partial left ventriculectomy is potentially a valuable intervention and intend to perform more cases. Nevertheless, most surgeons identified the need to have larger clinical experience, to perform randomized trials against other therapeutic modalities, and to improve perioperative care. Conclusions. Although all surgeons recognize that more knowledge is needed before partial left ventriculectomy becomes a standard procedure, it is clear from this survey that the procedure has rapidly gained interest, with more surgeons seeking to learn it.

Pre or post-operative medical treatment with nafarelin in stage III–IV endometriosis: a French multicenter study

Objectives: To determine the effectiveness of a 6-month course of nafarelin in the treatment of stage III–IV endometriosis and to determine if pre-operative use of nafarelin facilitates surgery. Design: Prospective, multicenter, clinical trial. Setting: Eight university hospitals and two private practice institutions in France. Patients: Fifty-five patients with stage III and IV endometriosis. Two were excluded. Interventions: The severity of endometriosis was assessed at the time of laparoscopy and patients were randomized to have either laparosopic surgery at that time following 6 months of nafarelin therapy (n=28), or laparoscopic surgery following 6 months of nafarelin therapy (n=25). All had 200 μg intranasal nafarelin twice a day for 6 months and a second look laparoscopy. Main outcome measure: Clinical efficacy, tolerance to the treatment. Results: Efficacy and tolerance to the treatment were the same in both groups. AFS scores compared on both laparoscopies were significantly better if nafarelin was given prior to surgery (P=0.007). Conclusions: This preliminary study shows that in cases of combined medico-surgical treatment for stage III–IV endometriosis, preoperative medical treatment with GnRH-a gives a better AFS score improvement, but no conclusion was possible whether preoperative treatment facilitates surgery.