Low-volume Setting Research Articles

Structural and functional correlates of olfactory reward processing in behavioral variant frontotemporal dementia

The behavioral variant of frontotemporal dementia (bvFTD) includes symptoms that reflect altered pursuit of rewards, including food, alcohol, and money. Little is known, however, about how these reward changes relate to atrophy and functional connectivity within reward-related regions. The goal of this study was to examine the structural and functional correlates of valence perception for olfactory rewards in 24 patients with bvFTD. Regression analysis of resting-state brain functional connectivity indicated that more positive valence ratings of olfactory stimuli were predicted by ventral pallidum connectivity to other reward circuit regions, particularly functional connectivity between ventral pallidum and bilateral anterior cingulate cortex/ventromedial prefrontal cortex. Structural analysis showed that atrophy of the anterior cingulate cortex was also significantly associated with perceiving stimuli as more rewarding. Finally, there was a significant interaction between ventral pallidum connectivity and atrophy of the anterior cingulate cortex. More specifically, the ventral pallidum connectivity had a greater effect on the positive perception of olfactory stimuli in the setting of low anterior cingulate cortex volume. These findings indicate that atrophy and functional connectivity within reward-relevant regions exert independent and interacting effects on the perception of pleasantness in bvFTD, potentially due to changes in hedonic “liking” signals.

Achievement of international benchmark outcomes for robotic pancreaticoduodenectomy in a low volume country

BackgroundRecently, there has been an increase in the utilisation of the robotic platform to perform minimally invasive pancreaticoduodenectomy in high volume centres, with the goal of reducing morbidity and improving patient outcomes. This study reports the successful implementation of a robotic pancreaticoduodenectomy (RPD) programme in the relatively low volume setting of Australia, measured against established, internationally accepted benchmarks for low-risk open pancreaticoduodenectomy (OPD). MethodsRetrospective review of a prospectively maintained database for consecutive RPD at two Brisbane hospitals was performed, comparing data to internationally established benchmarks for low-risk OPD. A structured RPD programme was implemented by two surgeons across a study period spanning May 2017 to December 2023. ResultsOver the study period, seventy-two consecutive RPDs were performed, with 79 % for malignancy. Perioperative outcomes for transfusions, conversion rate, postoperative fistula rate, morbidity, mortality and oncological outcomes were all within established benchmark cutoffs for low-risk open pancreaticoduodenectomy (OPD), although operative time exceeded the benchmark value by 0.7hrs. ConclusionA carefully implemented RPD programme in the low volume Australian setting is feasible, with high quality outcomes achievable when compared to established benchmarks for low-risk OPD and to reported RPD series published by high volume pioneering centres.

BD SurePath Direct to Slide (DTS) cervical cytology: Migrating the benefits of liquid-based cytology to low-resource settings.

The benefits of liquid-based cytology (LBC) in routine cervical cancer screening are often associated with the availability of instrumented platforms and economic considerations. A low-cost alternative to LBC in low-volume settings remains an unmet need. A multisite evaluation of the BD SurePath (SurePath) LBC Direct to Slide (DTS) method was conducted. The DTS preparations were evaluated across 3 sites. Cytology features for DTS preparation included predetermined thresholds for total cellularity, cell distribution, cellular preservation, and stain quality. Rare event detection was evaluated using SiHa cells spiked into pools from negative cytology specimens. Concordance between Bethesda classification results was evaluated for SurePath LBC and DTS methods using routinely collected SurePath specimens in a split-sample study design. The DTS specimens met criteria for total cellularity, cell distribution, cellular preservation, and stain quality in more than 98% of all cases. Rare event detection was observed with an average detection of 5 SiHa cells per 2mL of specimen. Concordant cervical cytology classifications were observed between SurePath LBC and DTS methods. The results demonstrate that the DTS process is suitable for routine cervical cytology evaluation. The procedure is reproducible and detected abnormal cervical cells in concordance with standard SurePath LBC preparation.

The impact of transpancreatic precut sphincterotomy on the quality of ERCP in a low-volume setting

Background and aimsAlthough quality improvement is crucial for endoscopic retrograde cholangiopancreatography (ERCP), a low practice volume can pose challenges to achieving high-quality bile duct cannulation. Transpancreatic precut sphincterotomy (TPS) has been proven effective for advanced cannulation. However, existing data mainly come from skilled endoscopists in large medical centers. The impact of TPS on ERCP quality in a lower-volume setting deserves investigation. MethodsOur hospital performs approximately 200 ERCPs annually, with one expert performing approximately half of them and three nonexpert endoscopists sharing the remaining cases. TPS was started and became our predominant advanced cannulation technique in April 2016. We retrospectively reviewed ERCP cases three years before and after the introduction of TPS. The primary endpoints of the study were the differences in two ERCP quality indicators, the bile duct cannulation rate and the incidence of post-ERCP pancreatitis (PEP). ResultsA total of 701 ERCP cases with naïve papilla were analyzed, with 350 patients treated before the introduction of TPS and 351 patients treated afterward. The successful cannulation rate was significantly improved (before: 87.4%, after: 92.3%, P=0.032), while the incidence of PEP decreased, but not significantly (before: 4.0%, after: 2.8%, P=0.402). All endoscopists benefited from utilizing TPS, with nonexperts demonstrating a significantly higher improvement in the cannulation rate (before: 85.5%, after: 93.1%, P=0.019). ConclusionsTPS can effectively enhance the quality of ERCP irrespective of practice volume.

Microvascular surgery training in a low volume setting: a single healthcare center experience

Microvascular surgery training in a low volume setting: a single healthcare center experience

XPS™ Jensen lung as a low-cost, high-fidelity training adjunct to ex-vivo lung perfusion.

Ex vivo lung perfusion (EVLP) enables lung resuscitation before transplantation, and training is key, particularly in low-volume settings. To enable technique refinement and continuing education, we sought to demonstrate the value of a low-cost, high-fidelity EVLP simulator that would allow reproducible clinical scenarios. In partnership with our EVLP manufacturer, we utilized the XPS™ Jensen Lung with our clinical system. The Jensen Lung has two simulated lung bladders and an in-line polymethylpentene fiber oxygenator. It allows titration of ventilator support which aids in accurate clinical simulation. For simulations, blood gases (BGs) were obtained and compared with integrated in-line perfusate gas monitors (PGMs). PaO2 , PCO2 , and pH were measured and compared. The PGM and BG values were not significantly different throughout the range of FiO2 and sweep gas flow rates evaluated. The "delta" PaO2 was measured between LA and PA and did not show any change between approaches. The pH measurement between BG and PGM was not significantly different. The XPS™ Jensen Lung simulator allows for a high-fidelity simulator of clinical EVLP. The correlation of the PGM and the BG measurement of the PaO2 and pH allow for a low-cost simulation, as the PGMs are in line in the circuit, and enable real-time tracking of perfusate gas parameters with the PGM. Implementation of a standardized clinical EVLP training program allows the maintenance of technique and enables clinical simulation training without the need for costly animal perfusions and the use of multiple BG measurements.

Clinical characteristics and outcome of patients with brain arteriovenous malformations from a university hospital in Nepal

BackgroundClinical presentations, management strategies and outcomes of patients with brain arteriovenous malformations (bAVMs) are complex due to variable natural history and uncertainty in the optimal treatment modality. Data are scarce regarding patients with bAVMs from developing countries either due to low incidence or a low detection rate. The objective of this study is to describe the clinical characteristics, management strategies, and outcomes of patients with bAVMs treated microsurgically in a university hospital from Nepal. MethodsThe clinical records of patients confirmed to have bAVMs and microsurgically excised between July 2015 and March 2022 were retrospectively reviewed. Data on demographic and clinical characteristics, morphometric characteristics of bAVMs on imaging, management strategies, and the 6-month outcomes were abstracted and analyzed. ResultsOut of 43 bAVMs diagnosed, 23 were microsurgically excised during the study period. The mean age of the patients was 28 (7–57) years. Eighteen patients (78.2%) presented with hemorrhage whereas 5 (17.4%) had seizures. Eight (34.8&) patients had bAVMs on the motor cortex (6 on the right side and 2 on the left side). Only one patient had infratentorial bAVM. Seventeen (73.9%) out of 23 were in Spetzler-Martin grade II and III before surgery. One patient had flow-related two arterial aneurysms. A single-stage surgery was performed with angiographic confirmation of obliteration in all patients. The favorable outcome (mRS 0–2) was achieved in 22 (95.6%) patients. One patient died. ConclusionThe overall number of subjects diagnosed with bAVMs in our hospital is markedly lower than cerebral aneurysms. The resource limitation in the diagnosis due to the limited availability of computed tomography (CT), magnetic resonance imaging and angiography is the most likely cause of low detection. With an individualized and careful selection strategy, surgical results are excellent even in this low-volume setting.

Clinical decision making for abdominal stab wounds in high resourced but low volume centres require structured guidelines to be effective

The management of abdominal stab wounds (SW) has continued to evolve. The use of CT and laparoscopy has been advocated to reduce the rate of laparotomy. This study reviews our experience with SW in a high income, low volume setting. A retrospective study was undertaken from 2006 to 2020 at Waikato Hospital, New Zealand. All adult patients age > 16 years that were admitted following trauma were included. Seventy three cases of SW were included. Thirty two cases had indications for immediate laparotomy (peritonitis in 15, hemodynamic instability in 13, evisceration in 4). Twenty two underwent immediate laparotomy. Overall, 43 had a positive laparotomy. One had a negative laparotomy. Thirty seven cases had a CT. Laparoscopy was performed in 24 cases, with 23 demonstrating peritoneal breach. Subsequently 9 were converted to laparotomy whilst 15 had full laparoscopic exploration. The relative rarity of abdominal SW in our environment has resulted in a considerable degree of heterogeneity in our approach to this clinical dilemma. The simplified algorithm we have developed will hopefully facilitate clinical decision making in our institution.

Whipple's operation with a modified centralization concept: A model in low-volume Caribbean centers.

Conventional data suggest that complex operations, such as a pancreaticoduodenectomy (PD), should be limited to high volume centers. However, this is not practical in small, resource-poor countries in the Caribbean. In these settings, patients have no option but to have their PDs performed locally at low volumes, occasionally by general surgeons. In this paper, we review the evolution of the concept of the high-volume center and discuss the feasibility of applying this concept to low and middle-income nations. Specifically, we discuss a modification of this concept that may be considered when incorporating PD into low-volume and resource-poor countries, such as those in the Caribbean. This paper has two parts. First, we performed a literature review evaluating studies published on outcomes after PD in high volume centers. The data in the Caribbean is then examined and we discuss the incorporation of this operation into resource-poor hospitals with modifications of the centralization concept. In the authors’ opinions, most patients who require PD in the Caribbean do not have realistic opportunities to have surgery in high-volume centers in developed countries. In these settings, their only options are to have their operations in the resource-poor, low-volume settings in the Caribbean. However, post-operative outcomes may be improved, despite low-volumes, if a modified centralization concept is encouraged.

Trends and factors affecting approach choice to pulmonary resection.

The development of an advanced robotic platform in 2014 led to increased adoption of minimally invasive (MI) approaches in thoracic surgery. Due to dataset reporting lag, a comprehensive assessment of trends in thoracic approaches has not been analyzed to date. We queried the National Cancer Database (NCDB) for patients with Stage I-III who underwent lung resection from 2010 to 2018. Most published NCDB analyses on lung cancer using pre-2015 data. Overall treatment trends were analyzed, with geographic, institutional, and socioeconomic characteristics evaluated for approach. There were 162 335 lung resections, and 131 958 were anatomic. Robotic resection saw a steady increase through 2012 but plateaued in 2013-2014. From 2015 to 2018, another increase correlated with the release of a new platform. Video-assisted thoracoscopic surgery lung resection plateaued in 2014 and decreased in 2018. Open resection steadily decreased. Tumors requiring neoadjuvant radiation had an increase in MI approach with corresponding decreases in the open. On multivariable analysis, African-American race, low volume, Medicaid insurance, and nonacademic setting were associated with a lower likelihood of MI surgery. The open approach has decreased since 2010. More than 65% of anatomic resections are now performed inMI. As this trend will continue, it is important that all patients are afforded the opportunity of the least invasive approach.

A Rising Tide Lifts All Boats: Impact of Combined Volume of Complex Cancer Operations on Surgical Outcomes in a Low-Volume Setting.

Centralization for complex cancer surgery may not always be feasible owing to socioeconomic disparities, geographic constraints, or patient preference. The present study investigates how the combined volume of complex cancer operations impacts postoperative outcomes at hospitals that are low-volume for a specific high-risk cancer operation. Patients who underwent pneumonectomy, esophagectomy, gastrectomy, hepatectomy, pancreatectomy, or proctectomy were identified from the National Cancer Database (2004-2017). For every operation, 3 separate cohorts were created: low-volume hospitals (LVH) for both the individual cancer operation and the total number of those complex operations, mixed-volume hospital (MVH) with low volume for the individual cancer operation but high volume for total number of complex operations, and high-volume hospitals (HVH) for each specific operation. LVH was significantly (all p ≤ 0.01) predictive for 30-day mortality compared with HVH across all operations: pneumonectomy (9.5% vs 7.9%), esophagectomy (5.6% vs 3.2%), gastrectomy (6.8% vs 3.6%), hepatectomy (5.9% vs 3.2%), pancreatectomy (4.7% vs 2.3%), and proctectomy (2.4% vs 1.3%). Patients who underwent surgery at MVH and HVH demonstrated similar 30-day mortality: esophagectomy (3.2 vs 3.2%; p = 0.993), gastrectomy (3.2% vs 3.6%; p = 0.637), hepatectomy (3.8% vs 3.2%; p = 0.233), pancreatectomy (2.8% vs 2.3%; p = 0.293), and proctectomy (1.2% vs 1.3%; p = 0.843). Patients who underwent pneumonectomy at MVH demonstrated lower 30-day mortality compared with HVH (5.4% vs 7.9%; p = 0.045). Patients who underwent complex operations at MVH had similar postoperative outcomes to those at HVH. MVH provide a model for the centralization of complex cancer surgery for patients who do not receive their care at HVH.

Consensus statement on networks for high-quality rural anesthesia, surgery, and obstetric care in Canada

To describe the essential components of well-resourced and high-functioning multidisciplinary networks that support high-quality anesthesia, surgery, and maternity care for rural Canadians, delivered as close to home as possible. A volunteer Writers' Group was drawn from the Society of Obstetricians and Gynaecologists of Canada, the Society of Rural Physicians of Canada, the Royal College of Physicians and Surgeons of Canada, the Canadian Association of General Surgeons, the College of Family Physicians of Canada, and the Association of Canadian University Departments of Anesthesia. A collaborative effort over the past several years among the professional stakeholders has culminated in this consensus statement on networked care designed to integrate and support a specialist and non-specialist, urban and rural, anesthesia, surgery, and maternity work force into high-functioning networks based on the best available evidence. Surgical and maternity triage needs to be embedded within networks to address the tensions between sustainable regional programs and local access to care. Safety and quality must be demonstrated to be equivalent across similar patients and procedures, regardless of network site. Triage of patients across multiple sites is a quality outcome metric requiring continuous iterative scrutiny. Clinical coaching between rural and regional centres can be helpful in building and sustaining high-functioning networks. Maintenance of quality and the provision of continuing professional development in low-volume settings represent a mutual value proposition. The trusting relationships that are foundational to successful networks are built through clinical coaching, continuing professional development, and quality improvement. Currently, a collaborative effort in British Columbia is delivering a provincial program-Rural Surgical Obstetrical Networks-built on the principles and supporting evidence described in this consensus statement.

Defining a minimum hospital volume threshold for minimally invasive colon cancer resections

BackgroundLaparoscopic colectomy is considered the standard of care in colon cancer treatment when appropriate expertise is available. However, guidelines do not delineate what experience is required to implement this approach safely and effectively. This study aimed to establish a data-derived, hospital-level annual volume threshold for laparoscopic colectomy at which patient outcomes are optimized. MethodsThis evaluation included 44,157 stage I to III adenocarcinoma patients aged ≥40 years who underwent laparoscopic colon resection between 2010 and 2015 within the National Cancer Database. The primary outcome was overall survival, with 30- and 90-day mortality, duration of stay, days to receipt of chemotherapy, and number of lymph nodes examined as secondary. Segmented logistic and Cox regression models were used to identify volume thresholds which optimized these outcomes. ResultsIn hospitals performing ≥30 laparoscopic colectomies per year there were incremental improvements in overall survival for each additional resection beyond 30. Hospitals performing ≥30 procedures/year demonstrated improved 30-day mortality (1.3% vs 1.7%, P < .001), 90-day mortality (2.3% vs 2.9%, P < .001), and overall survival (84.3% vs 82.3%, P < .001). Those hospitals performing <30 procedures/year had no significant benefit in overall survival. Thresholds were not identified for any other outcomes. Results were comparable in colon cancer patients with stage IV or multiple cancers. ConclusionA high-volume hospital threshold of ≥30 cases/year for laparoscopic colectomies is associated with improved patient survival and outcomes. A minimum volume standard may help providers determine which approach is most suitable for their hospital’s practice as open procedures may yield better oncologic results in low volume settings.

Total robotic surgical volume influences outcomes of low-volume robotic-assisted partial nephrectomy over an extended duration

Introduction: The objective of this study was to examine the surgeon’s experience of low-volume robotic-assisted partial nephrectomy (RAPN) over an extended duration, and whether a high-volume fellowship-training influenced the outcomes.&#x0D; Methods: Data on all RAPN at a tertiary center performed by a uro-oncologist were retrospectively collected. The surgeon experience was assessed by examining perioperative outcomes among three groups of consecutive patients (first=14, second=14, third=15 patients, respectively).&#x0D; Results: Between February 2014 and February 2020, 45 RAPNs were performed out of a total of 200 robotic procedures. The median tumor size was 3 cm, and 28 (65%) patients had a R.E.N.A.L nephrometry score (RNS) ≥7. The median operative time and warm ischemia time (WIT) were 190 and 16 minutes, respectively. The median estimated blood loss (EBL) was 100 mL. Two (4%) patients had a positive surgical margin (PSM). Overall, five (12%) complications were recorded. All except one were minor (Clavien I–II). The median followup was 26.2 months. Trifecta and pentafecta were achieved in 40 (93%) and 27 (81.8%) patients, respectively. Increased surgeon experience was significantly associated with a shorter operative time and less EBL. Furthermore, there was an independent association between surgeon experience and operative time and EBL, and between RNS and operative time and WIT.&#x0D; Conclusions: With fellowship training and subsequent adequate total number of robotic procedures during practice, it is possible to perform RAPN with favorable perioperative outcomes in the setting of low-volume of cases over an extended duration.

A Failed Cardiac Surgery Program in an Underserved Minority Population County Reimagined: The Power of Partnership.

BackgroundPrince George's County Maryland, historically a medically underserved region, has a population of 909 327 and a high incidence of cardiometabolic syndrome and hypertension. Application of level I evidence practices in such areas requires the availability of highly advanced cardiovascular interventions. Donabedian principles of quality of care were applied to a failing cardiac surgery program. We hypothesized that a multidisciplinary application of this model supported by partnership with a university hospital system could result in improved quality care outcomes.Methods and ResultsA 6‐month assessment and planning process commenced in July 2014. Preoperative, intraoperative, and postoperative protocols were developed before program restart. Staff education and training was conducted via team simulation and rehearsal sessions. A total of 425 patients underwent cardiac surgical procedures. Quality tracking of key performance measures was conducted, and 323 isolated coronary artery bypass grafting procedures were performed from July 2014 to December 2019. Key risk factors in our patient demographic were higher than the Society of Thoracic Surgeons national mean. Risk‐adjusted outcome data yielded a mortality rate of 0.3% versus 2.2% nationally. The overall major complication rate was lower than expected at 7.1% compared with 11.5% nationally. Readmission rate was less than the Society of Thoracic Surgeons mean for isolated coronary artery bypass grafting (4.0% versus 10.1%, P<0.0001). Significant differences in 6 key performance outcomes were noted, leading to a 3‐star Society of Thoracic Surgeons designation in 7 of 8 tracking periods.ConclusionsExcellent outcomes in cardiac surgery are attainable following program renovation in an underserved region in the setting of low volume. The principles and processes applied have potential broad application for any quality improvement effort.

Low-Volume Sprint Interval Swimming Is Sufficient to Increase Blood Metabolic Biomarkers in Master Swimmers

ABSTRACT Purpose: Sprint interval exercise is a time-efficient way of inducing beneficial adaptations. However, little is known about its minimal effective volume, especially in swimming. The aim of the present study was to evaluate and compare the effects of two sprint interval swimming sets of different low volumes on blood biomarkers. Method: Twenty-one master swimmers [11 females aged 38.5 (8.5) years, 10 males aged 42.7 (5.7) years] completed two freestyle swimming sets of 4 × 50 m and 4 × 25 m at maximal intensity and a work-to-rest ratio of 1:1, on different days, in random and counterbalanced order. Blood samples were taken before, immediately after and one hour after exercise for determination of a number of biochemical parameters. Results: Swimming speed was higher in the 4 × 25-m set. Lactate, glucose, insulin, glucagon, cortisol, and reduced glutathione increased immediately post-exercise, while uric acid increased 1 h post-exercise (p < .05). All aforementioned biomarkers, excluding glucagon, increased more with the 4 × 50-m set, compared to the 4 × 25-m set (p < .05). Session rating of perceived exertion was higher after the 4 × 50-m set (p = .011). Conclusion: Both sprint interval swimming sets elicited increases in blood biomarkers in master swimmers. The set of higher volume elicited greater increases in most of the biochemical markers studied but also in subjective load. Thus, although the set of higher volume was more efficient in perturbing blood biomarkers, even the very low-volume set induced metabolic stress that may trigger adaptive mechanisms.

The Effect Of A Low Volume Trunk-stabilisation Exercise Protocol On Biomechanical Function And Compliance.

Sensorimotor control exercises (SCE) increase trunk stability by enhancing neuromuscular activity and strength, perhaps preventing low back pain (LBP). A trunk-specific intervention based on 4 exercises improved trunk stability, however a reduced set of 1 exercise may have similar effects and increase compliance concurrently. PURPOSE: To assess the response of a standard training (SG) and a low volume set of sensorimotor control exercises (EG) on trunk function and compliance. METHODS: 29 healthy subjects were randomly allocated to SG (n=15) or EG (n=14). A trunk-specific SCE protocol (3 weeks) was completed which differed in training volume (SG: 4 exercises; EG: 1 exercise). Training intensities were identical (1 familiarization session/ 6 home-based sessions; 3 sets; 10 repetitions). Pre-post intervention (M1; M2) isokinetic mean peak torque was measured for trunk extension (30°/s) and rightward rotation (30°/s) in concentric (CON), eccentric (ECC) and perturbed eccentric (PECC) mode. During testing neuromuscular activity of Mm. erector spinae, latissimus dorsi, external/internal obliquus and rectus abdominis were recorded by sEMG and summarized subsequently: dorso left (DL), dorso right (DR), ventral right (VR) and ventral left (VL). Mean peak torque was normalized to body weight (Nm/kg), EMG data was normalized to concentric MVC (%). Compliance was assessed using a training diary (sessions per week). Data was analysed descriptively (mean±SD) and by using a repeated measures ANOVA (α = .05). RESULTS: Mean peak torque in CON/ECC extension and rotation showed no group differences. During PECC rotation, SG (M1: 2.3±0.3, M2: 2.5±0.2) showed a significant larger increase of mean peak torque compared to EG (M1: 2.5±0.3, M2: 2.7±0.3) (p=.035). Both groups showed a significant increase in EMG activity of DR muscles for unperturbed ECC rotation (SG M1: 93±18, M2: 118±10; EG M1: 83±9, M2: 121±17) (p <.001). In SG, DL (M1: 95±13, M2: 113±16) (p=.011) and VR (M1: 83±14, M2: 110±29) (p=.010) muscle activity improved significantly during ECC rotation. Overall compliance was 7±3 (SG) and 7±2 (EG) sessions. CONCLUSION: Both protocols enhanced trunk function in terms of neuromuscular activity and mean peak torque in trunk rotation. LBP patients might benefit from a low volume approach due to improved time-efficiency.

Performance of a three-level triage scale in live triage encounters in an emergency department in Hong Kong

BackgroundDespite its continued use in many low-volume emergency departments (EDs), 3-level triage systems have not been extensively studied, especially on live triage cases. We have modified from the Australasian Triage Scale and developed a 3-level triage scale, and sought to evaluate its validity, reliability, and over- and under-triage rates in real patient encounters in our setting.MethodThis was a cross-sectional study in a single ED with 24,000 attendances per year. At triage, each patient was simultaneously assessed by a triage nurse, an adjudicator (the “criterion standard”), and a study nurse independently. Predictive validity was determined by comparing clinical outcomes, such as hospitalization, across triage levels. The discriminating performance of the triage tool in identifying patients requiring earlier medical attention was determined. Inter-observer reliability between the triage nurse and criterion standard, and across providers were determined using kappa statistics.ResultsIn total, 453 triage ratings of 151 triage cases, involving 17 ED triage nurses and 57 nurse pairs, were analysed. The proportion of hospital admission significantly increased with a higher triage rating. The performance of the scale in identifying patients requiring earlier medical attention was as follows: sensitivity, 68.2% (95% CI 45.1–86.1%); specificity, 99.2% (95% CI 95.8–100%); positive predictive value, 93.8% (95% CI 67.6–99.1%); and negative predictive value, 94.8% (95% CI 90.8–97.1%). The over-triage and under-triage rates were 0.7% and 4.6%, respectively. Agreement between the triage nurse and criterion standard was substantial (quadratic-weighted kappa = 0.76, 95% CI, 0.60–0.92, p < 0.001), so was the agreement across nurses (quadratic-weighted kappa = 0.81, 95% CI 0.65–0.97, p < 0.001).ConclusionsThe 3-level triage system appears to have good validity and reasonable reliability in a low-volume ED setting. Further studies comparing 3-level and prevailing 5-level triage scales in live triage encounters and different ED settings are warranted.

1003: Optimizing fetal aneuploidy screening in an austere military clinical environment: A cost of care analysis

Austere clinical settings within the military healthcare system pose unique challenges in screening for fetal aneuploidy. The objective of this study is to compare aneuploidy screening strategies in a military treatment facility with limited in-house perinatal resources. We identified Naval Hospital Guantanamo Bay as a surrogate for an austere prenatal clinical environment and performed a cost of care analysis to compare two aneuploidy screening strategies: the serum integrated and cell free DNA. The baseline screen opt-in rate was determined by reviewing all low risk subjects who presented for prenatal care < 20 weeks gestation over a six year period (2013-2018, n=48). Rates of diagnostic testing following a positive screen for trisomy 18/21 were derived from the literature. Test performance characteristics and costs were provided by the reference lab. Over the five year period, the screen opt-in rate was calculated at 90%. Screening using the serum integrated would cost $3,332.91 over six years versus $17,756.89 with cell free DNA. Traditional screening would result in 2.2 positive tests versus 0.2 using cell free DNA, leading to 0.87 versus 0.14 diagnostic testing procedures. The integrated screen will detect 90% and 88% of fetuses with Trisomy 18 and 21 respectively versus 98% and 99% for cell free DNA. As an initial screening strategy, cell free DNA for low risk women offers enhanced detection rates for Trisomy 18/21 with a lower false positive rate and need for confirmatory diagnostic testing but costs five times more than traditional screening. In a low volume setting with limited resources, the added cost may be justified given the implications of unrecognized aneuploidy.

Parathyroid surgery: an evidence-based volume-outcomes analysis : European Society of Endocrine Surgeons (ESES) positional statement.

The interest in correlation between hospital and surgeon practice volume and postoperative outcomes has grown considerably over the last decades; it has been suggested that surgery is likely to be associated with higher cure rates, lower morbidity and more favourable results in cost-effectiveness when performed in a high-volume setting. The aim of this paper is to undertake an evidence-based literature review of the relationship between surgical volume and clinical outcomes in parathyroidectomy for primary hyperparathyroidism. We used accepted quality markers to identify the relationship between volume and outcome with a view to defining a reproducible minimal surgical volume-related standard of care in parathyroid surgery. A peer review literature analysis of volume and outcomes in parathyroid surgery was carried out and assessed from an evidence-based perspective. Results were discussed at the 2019 Conference of the European Society of Endocrine Surgeons devoted to "Volumes, Outcomes and Quality Standards in Endocrine Surgery". Literature reports no prospective randomised studies; thus, a low level of evidence may be achieved. Parathyroid surgery is at increased risk of failures, morbidity and need for reoperations and cost when performed in low-volume settings; thus, it should be concentrated in dedicated settings, with adequate annual volume and expertise. Acceptable results may be achieved moving parathyroid surgery cases away from low-volume settings (< 15 parathyroidectomies/year). Challenging procedures (primary hyperparathyroidism without unequivocal preoperative localization, hereditary variants, paediatric patients, reoperations) should be confined to high-volume settings (> 40 parathyroidectomies/year).