Tertiary Academic Medical Center Research Articles

Systemic lidocaine versus erector spinae plane block for improving quality of recovery after laparoscopic cholecystectomy: A randomized controlled trial

Study objectiveTo compare intravenous lidocaine, ultrasound-guided erector spinae plane block (ESPB), and placebo on the quality of recovery and analgesia after laparoscopic cholecystectomy. DesignA prospective, triple-arm, double-blind, randomized, placebo-controlled non-inferiority trial. SettingA single tertiary academic medical center. Patients126 adults aged 18–65 years undergoing elective laparoscopic cholecystectomy. InterventionsPatients were randomly allocated to one of three groups: intravenous lidocaine infusion (1.5 mg/kg bolus followed by 2 mg/kg/h) plus bilateral ESPB with saline (25 mL per side); bilateral ESPB with 0.25% ropivacaine (25 ml per side) plus placebo infusion; or bilateral ESPB with saline (25 ml per side) plus placebo infusion. MeasurementsThe primary outcome was the 24-h postoperative Quality of Recovery-15 (QoR-15) score. The non-inferiority of lidocaine versus ESPB was assessed with a margin of −6 points and 97.5% confidence interval (CI). Secondary outcomes included 24-h area under the curve (AUC) for pain scores, morphine consumption, and adverse events. Main results124 patients completed the study. Median (IQR) 24-h QoR-15 scores were 123 (117–127) for lidocaine, 124 (119–126) for ESPB, and 112 (108–117) for placebo. Lidocaine was non-inferior to ESPB (median difference –1, 97.5% CI: −4 to ∞). Both lidocaine (median difference 9, 95% CI: 6–12, P < 0.001) and ESPB (median difference 10, 95% CI: 7–13, P < 0.001) were superior to placebo. AUC for pain scores and morphine use were lower with lidocaine and ESPB versus placebo (P < 0.001 for all), with no significant differences between lidocaine and ESPB. One ESPB patient reported a transient metallic taste; no other block-related complications occurred. ConclusionsFor patients undergoing laparoscopic cholecystectomy, intravenous lidocaine provides a non-inferior quality of recovery compared to ESPB without requiring specialized regional anesthesia procedures. Lidocaine may offer a practical and accessible alternative within multimodal analgesia pathways.

The effects of a Teddybear Hospital project on prescool childrens' knowledge and medical students' professionalism: a prospective cohort study.

The Teddybear Hospital (TH) Project is an effort to increase children's knowledge and decrease their anxiety. It is also intended to improve medical students' pediatric communication skills. This study evaluated the educational effects on participating preschool children and medical students. Preschool children were offered to bring their stuffed toys to the TH at our tertiary academic medical center. Medical students who had completed the pediatric surgery rotation staffed the TH, performed examinations, and interacted with the children. The children's knowledge of anatomy, medical equipment, and healthy lifestyle, along with their level of anxiety towards hospitalization, was assessed using preinterventional and postinterventional validated survey tools. Preschool peers who did not participate in the TH served as controls. Participating medical students were tested on professionalism and pediatric surgical knowledge during, and 3 weeks after the intervention, and compared to their nonparticipating peers. A total of 131 children (63 intervention, 68 control) and 48 medical students (16 intervention, 32 control) participated in the study. Children's state anxiety decreased by 0.98 points (95% CI: -0.3 to -1.8, P <0.001), while knowledge increased significantly on 'healthy lifestyle' by 1.4 points (95% CI: 1.01-1.79, P <0.05), on 'medical equipment' by 4.5 points (95% CI: 3.8-5.2, P <0.0001), and on 'anatomy' by 5.05 points (95% CI: 4.73-5.73, P <0.01). No changes were detected in any of the outcome measures in the control group. Medical students' objective professionalism increased by 4.2 points (95% CI: 1.58-6.80, P <0.01) compared to nonparticipant medical students. The tests did not show an increase in the medical students' pediatric surgical knowledge. Preschool participation in a TH increased knowledge and decreased anxiety regarding hospitalization and medical personnel. It also helped medical students to playfully acquire medical professionalism.

Multiple Goals Theory and Communication Quality Analysis for Fellows Communication Training.

End-of-life communication skills are vital to high-quality critical care. Patients and families often report deficiencies in end-of-life communication by providers. However, formalized training is difficult to implement and study on a large scale. Furthermore, curricula are often designed with early-stage clinical trainees in mind and are not tailored to advanced clinician learners. The goal of this pilot study was to explore educational and practical implications of using Multiple Goals Theory (MGT), Communication Quality Analysis (CQA), and communication logs as a three-pronged, reflective communication curriculum for advanced trainees. We describe design and qualitative evaluation of a novel, pilot, longitudinal curricular intervention for pulmonary and critical care fellows and program directors at a tertiary academic medical center. The 2-year longitudinal communication curriculum incorporates 1) a theoretical framework from communication science (MGT), with 2) a novel training modality of analyzing audio-recorded intensive care unit family meetings (CQA), and 3) written communication logs after an intensive care unit family meeting. The sample included 13 pulmonary and critical care medicine fellows and two program directors. Qualitative thematic analysis was conducted on seven fellow interviews and on 23 communication logs completed. Four themes emerged from interviews: 1) fellows incorporated the skills into real-life practice and found the curriculum useful and valuable; 2) a key takeaway from MGT was the deemphasis of task goals; 3) CQA was an engaging opportunity for self-reflection and learning; and 4) written communication logs were perceived as helpful in theory but too burdensome in practice. Findings from analyses of the communication logs included that most fellows' writing was brief and without substantial reflection. Many scholars have argued that communication theory can impact practice, but few have recognized the potential of theory and methods, such as MGT and CQA, as educational tools. Our findings demonstrate that MGT is a feasible and useful theoretical framework for improving communication skills among advanced trainees, and CQA fosters meaningful self-reflection about practice. Communication logs were not feasible or useful training tools in this context, but CQA workshops helped fulfill the goals of narrative reflection. Next steps are to implement this curriculum in more programs and measure changes in behavior acquisition and clinical care.

Are renal stone protocol computed tomography reports giving us enough information?

Non-contrast computed tomography (CT) is the gold-standard diagnostic test for urolithiasis. Little is published regarding which information needs to be included in the report for it to be most useful to the healthcare team for efficient triage and high-quality patient care. This study aimed to assess the quality and variability of CT scan reporting at a single Canadian tertiary academic medical center. We completed a retrospective review of 100 consecutive renal colic CT scans. Descriptive statistics were used to report the frequency with which specific elements commonly used by urologists to triage and treat patients were included in radiology reports. Our sample had a mean age of 51.4±13.1 years. Stone size was universally reported for obstructing stones but was less frequently reported for non-obstructing stones (100% vs. 86.8%). A similar trend was observed for the exact stone number (100% vs. 93.4%). Non-obstructing stones were more likely than obstructing stones to be reported in one dimension (77.5% vs. 47%). Obstructing stones were reported in three dimensions 27% of the time. CT reports commonly include the presence or absence of hydronephrosis status (98%) but are less likely to include renal size (32%) and periureteral stranding (16%). Hounsfield units (HU) were reported in 3% of the reports, but skin-to-stone distance (SSD) and radiation dose were never reported. Reports routinely included assessments of stone size, location, and number (although not uniformly). HU, SSD, and radiation dose were rarely reported. This provides insight into opportunities for standardized reporting to optimize knowledge transfer that may result in clinical efficiency and improved quality of patient care.

Utilization trends for MR arthrography of the hip and shoulder: a retrospective cross-sectional analysis of 20-year data from a tertiary care academic medical center.

The purpose of this study is to analyze changes in the utilization of MRA of the hip and shoulder at a large tertiary care academic medical center during a period of significant technological advancements over the last 20 years. This retrospective cross-sectional analysis identified MRA of the hip and shoulder performed at our institution over a 20-year period (2/2003-2/2023) in relation to the total number of MR hip and shoulder examinations during the same period. Patient characteristics and referring provider demographic information were extracted. Descriptive statistics and trend analysis were performed. The total number of MRIs of the hip and shoulder increased overall, with small dips in 2020 and 2022. MRA of the hip increased significantly over the first 10 years of the study period (p = 0.0005), while MRA of the shoulder did not change significantly (p = 0.33). The proportion of both MRA of the hip and shoulder declined over the last 10 years (hip, p = 0.0056; shoulder, p = 0.0017). Over the same period, there was significant increase in the proportion of examinations performed at 3 Tesla versus 1.5 (p < 0.0001). Overall, there was a downward trend in MR shoulder and hip arthrogram utilization in the second half of this 20-year study period. However, utilization varied somewhat by referring specialties and credentials. These changes are likely reflective of both improvements in image quality and evolving practice recommendations. Awareness of such trends may be valuable in ensuring appropriate patient care, as well as for anticipating the needs of a musculoskeletal radiology practice.

Inpatient screening for social determinants of health: A quality improvement initiative.

Social determinants of health (SDOH) can contribute to disparities that negatively impact health outcomes and healthcare utilization. Comprehensive screening is frequently overlooked during inpatient clinical care. This pilot aimed to evaluate the capturability of a multi-domain SDOH screening tool during hospitalization, as well as correlation of SDOH needs to readmissions. The Protocol for Responding to and Assessing Patients' Assets, Risks and Experiences (PRAPARE) screening tool was implemented on admission with adult inpatients at an academic tertiary medical center in central Pennsylvania. A total of 80 patients were screened over an 8-week period using the PRAPARE tool. 43.7% of participants were identified as having at least one SDOH need and 21.2% were identified as having two or more needs. Of the participants identified as having at least one SDOH need through PRAPARE screening, 42.5% experienced a readmission within 30 days, compared to 15% readmissions among participants with no identified SDOH needs. For each additional SDOH need a patient had, the odds they experienced a readmission increased by 2.2 times. The study findings suggest that utilization of the PRAPARE screening tool has the ability to capture significant SDOH needs among hospitalized patients. This study also suggests that higher SDOH needs correlate to increased odds of experiencing a hospital readmission.

The Prevalence of Hip Dysplasia on Radiographs for Adolescent Idiopathic Scoliosis.

During radiographic assessment of adolescent idiopathic scoliosis (AIS), upright images frequently capture the hip. The purpose of this study was to assess the prevalence of radiographic hip dysplasia on postero-anterior (PA) scoliosis radiographs, as defined as a lateral center edge angle (LCEA) ≤25 degrees. All patients with upright PA scoliosis radiographs over a one-year study period at a single tertiary academic medical center (2020 to 2021) were included in the study. Radiographs containing the hip joints were annotated by 3 reviewers for left and right LCEA, and triradiate cartilage (TRC) status. Inter-rater reliability was determined among the 3 reviewers. Two hundred fifty patients {500 hips, 75.6% female, median age 14 [interquartile range (IQR)=3]} had PA scoliosis radiographs that captured the hip, which qualified for analysis. Seventy-four hips (14.8%) demonstrated evidence of dysplasia (LCEA ≤25 deg) in 55/250 patients (22%). The median LCEA was significantly lower in the dysplastic hip cohort (23.9 deg, IQR=4.8 deg), compared with those without dysplasia (33 deg IQR=7.3 deg; P =0.001). A higher percentage of dysplastic hip patients were female than male (72.7% vs. 27.3%). Patients with bilateral dysplasia had a similar LCEA ( 22.9 deg) [to those with unilateral dysplasia (22.9 deg left, 23.9 deg right, P =0.689)]. In a cohort of 250 AIS patients, 22% demonstrated evidence of hip dysplasia, as defined as an LCEA ≤2 degrees. The dysplastic patients were more likely to be female. Screening for hip symptomatology in AIS patients may be of benefit, considering the frequency of radiographic hip dysplasia in this population. III. Type of Evidence: diagnostic.

Validation of a new calculator for predicting success of vaginal birth after cesarean delivery

Race as a variable in a predictive model for a successful vaginal birth after cesarean delivery has been challenged as contributing to health inequity. In May 2022, the National Institute of Child Health and Development released a modified calculator that removed race as a variable. The aim of this study was to externally validate the revised calculator amongst a cohort at our institution.We reviewed all patients who underwent a trial of labor after cesarean delivery in 2018-2020 at a tertiary academic medical center and calculated the predicted probability of successful vaginal birth after cesarean delivery for each patient using both original and revised classification calculators and compared these to observed birth outcomes. The area under the receiver operating characteristic curve was calculated for each model.From the cohort of 225 patients that fit inclusion criteria, 37% (n=83) identified as African-American or Hispanic. The vaginal birth after cesarean delivery success rate was 75% for the entire population, and 76% among African-American and/or Hispanic patients. The area under the receiver operating characteristic curve of the original calculator was 0.71, compared to 0.74 for the new calculator. For African-American and/or Hispanic patients, the average predicted success rates between the models rose from 60 to 69%.Our review confirmed that African-American and Hispanic patients were calculated to have a lower prediction score for a successful vaginal birth after cesarean delivery based on the original calculator as compared to the revised calculator. Our results also suggest that race/ethnicity did not significantly contribute to classification ability of the calculator in our patient population.

Automatic Recognition of Auditory Brainstem Response Waveforms Using a Deep Learning-Based Framework.

Recognition of auditory brainstem response (ABR) waveforms may be challenging, particularly for older individuals or those with hearing loss. This study aimed to investigate deep learning frameworks to improve the automatic recognition of ABR waveforms in participants with varying ages and hearing levels. The research used a descriptive study design to collect and analyze pure tone audiometry and ABR data from 100 participants. The research was conducted at a tertiary academic medical center, specifically at the Clinical Audiology Center of Tsinghua Chang Gung Hospital (Beijing, China). Data from 100 participants were collected and categorized into four groups based on age and hearing level. Features from both time-domain and frequency-domain ABR signals were extracted and combined with demographic factors, such as age, sex, pure-tone thresholds, stimulus intensity, and original signal sequences to generate feature vectors. An enhanced Wide&Deep model was utilized, incorporating the Light-multi-layer perceptron (MLP) model to train the recognition of ABR waveforms. The recognition accuracy (ACC) of each model was calculated for the overall data set and each group. The ACC rates of the Light-MLP model were 97.8%, 97.2%, 93.8%, and 92.0% for Groups 1 to 4, respectively, with a weighted average ACC rate of 95.4%. For the Wide&Deep model, the ACC rates were 93.4%, 90.8%, 92.0%, and 88.3% for Groups 1 to 4, respectively, with a weighted average ACC rate of 91.0%. Both the Light-MLP model and the Wide&Deep model demonstrated excellent ACC in automatic recognition of ABR waveforms across participants with diverse ages and hearing levels. While the Wide&Deep model's performance was slightly poorer than that of the Light-MLP model, particularly due to the limited sample size, it is anticipated that with an expanded data set, the performance of Wide&Deep model may be further improved.

Focal motor weakness and recovery following chronic subdural hematoma evacuation.

The incidence of chronic subdural hematomas (cSDHs) is expected to climb precipitously in the coming decades because of the aging populous. Neurological weakness is one of the most common presenting neurological symptoms of cSDH. Yet, the recovery rates of motor strength recovery are seldom documented, as neurological outcomes have predominantly focused on broader functional assessment scores or mortality. In this study, the authors performed one of the first detailed analyses on functional motor weakness and recovery in patients who underwent cSDH evacuation. Patients who underwent evacuation of a cSDH at a tertiary academic medical center between November 2013 and December 2021 were retrospectively identified using ICD-9 and ICD-10 billing codes. The presence of focal motor weakness was subcategorized by location as upper extremity (UE) or lower extremity (LE). Postoperative improvement, worsening, or resolution of weakness was recorded at the time of discharge. Statistical analysis included univariate and backward stepwise multivariable logistic regression modeling. A total of 311 patients were included in the analysis. Patients were significantly more likely to experience UE weakness than LE weakness (29% vs 18%, p < 0.001). Forty-one percent (43/104) had both UE and LE weakness present. Risk factors for the development of focal motor weakness at the time of presentation were older age (OR 1.02, p = 0.03), increased cSDH size (OR 1.04, p = 0.02), and the presence of a unilateral cSDH (OR 2.32, p = 0.008). The majority of patients (68%, 71/104) experienced motor strength improvement following cSDH evacuation, with 58% (60/104) having complete resolution of weakness. Multivariable logistic regression analysis revealed that longer symptom duration was associated with lower rates of improvement (OR 0.96, p = 0.024). Older age was also associated with reduced resolution of weakness (OR 0.96, p = 0.02). This study represents one of the first in-depth analyses investigating the rates of motor strength weakness and recovery following cSDH evacuation. Nearly two-thirds of all patients had complete resolution of their weakness by the time of discharge, and more than three-quarters had partial improvement. Risk factors for impaired neurological recovery were longer symptom duration prior to treatment and older age.

Short-Term (90 Days) Clinical Outcomes Following the Day of Surgery Conversion of Inpatient to Same-Day Hip and Knee Arthroplasty

BackgroundThe incidence of total joint arthroplasty is increasing, with added emphasis on shifting care toward outpatient surgery. This has demonstrated improvements in costs and care; however, safety must be prioritized. Published assessment tools highlight candidates for outpatient surgery; however, they often do not define patients who have a worse prognosis. Limited healthcare resources occasionally force patients to convert to outpatient surgery or risk cancellation, creating a dilemma for both patients and surgeons. We evaluated the short-term (90-day) outcomes of patients converted from planned inpatient admission to same-day discharge on day of surgery outpatients and sought to identify any groups at risk, who may not be appropriate for this conversion. MethodsWe identified all patients undergoing planned inpatient total hip or knee arthroplasty at a tertiary academic medical center over a 2-year period. We included patients discharged the day of surgery for analysis, excluding revision procedures and those performed for fracture care. A manual chart review identified demographic factors and primary outcome measures; including reoperation, readmission, and emergency room visits within a 90-day postoperative period. ResultsWe identified a total of 80 patients who converted from inpatient to outpatient surgery over a 2-year interval. Over the first 90 days postoperatively 4 (5%) patients were readmitted: 2 (2.5%) for medical complications and 2 (2.5%) for reoperation. There were 2 (2.5%) reoperations; one (1.25%) for manipulation under anesthesia, and one (1.25%) for periprosthetic joint infection. There were 5 (6.3%) wound complications; however, only one (1.25%) required surgical intervention. A total of 5 (6.3%) patients returned to an emergency department, leading to a single (1.25%) hospital readmission. ConclusionsHospital and healthcare resources are occasionally limited to the extent that patients must convert to outpatient surgery or risk cancellation. At our institution, the same-day conversion of planned inpatient hip and knee arthroplasty patients to outpatient surgery was safe and did not increase short-term clinical outcomes or complications.

Association between modified frailty index and postoperative delirium in patients after cardiac surgery: A cohort study of 2080 older adults.

To evaluate the association between frailty and postoperative delirium (POD) in elderly cardiac surgery patients. A retrospective study was conducted of older patients admitted to the intensive care unit after cardiac surgery at a tertiary academic medical center in Boston from 2008 to 2019. Frailty was measured using the Modified Frailty Index (MFI), which categorized patients into frail (MFI ≥3) and non-frail (MFI = 0-2) groups. Delirium was identified using the confusion assessment method for the intensive care unit and nursing notes. Logistic regression models were used to examine the association between frailty and POD, and odds ratios (OR) with 95% confidence intervals (CI) were calculated. Of the 2080 patients included (median age approximately 74 years, 30.9% female), 614 were frail and 1466 were non-frail. The incidence of delirium was significantly higher in the frail group (29.2% vs. 16.4%, p < 0.05). After adjustment for age, sex, race, marital status, Acute Physiology Score III (APSIII), sequential organ failure assessment (SOFA), albumin, creatinine, hemoglobin, white blood cell count, type of surgery, alcohol use, smoking, cerebrovascular disease, use of benzodiazepines, and mechanical ventilation, multivariate logistic regression indicated a significantly increased risk of delirium in frail patients (adjusted OR: 1.61, 95% CI: 1.23-2.10, p < 0.001, E-value: 1.85). Frailty is an independent risk factor for POD in older patients after cardiac surgery. Further research should focus on frailty assessment and tailored interventions to improve outcomes.

Cochlear Implantation in Patients With Osteolytic Labyrinthitis: A Case Series.

To describe the rare process of osteolytic labyrinthitis, previously referred to as labyrinthine sequestrum, which involves progressive obliteration of the bony and membranous labyrinth with eventual supplantation with soft tissue and, in some cases, bony sequestrum. Three patients with diverse presentations of osteolytic labyrinthitis from two tertiary care academic medical centers. Case series report analyzing the relevant clinical, radiologic, pathologic, and surgical data on our patients with osteolytic labyrinthitis and comparing these index cases to the existing literature. We describe the varying image findings seen in osteolytic labyrinthitis on computed tomography and magnetic resonance imaging. Also, we report successful surgical intervention and hearing rehabilitation with cochlear implantation in patients with osteolytic labyrinthitis. Our three patients presented with profound sudden sensorineural hearing loss and vertigo consistent with labyrinthitis. None of the three patients had a history of chronic otitis media. Imaging workup revealed varying degrees of erosion to the otic capsule bone demonstrating the spectrum of disease seen in osteolytic labyrinthitis. Although two cases showed osteolytic changes to the semicircular canals and vestibule, the first case revealed frank bony sequestrum within the obliterated labyrinth. The three cases were taken for surgical debridement and cochlear implantation. We propose the new term, osteolytic labyrinthitis-previously referred to as labyrinthine sequestrum-to describe the rare spectrum of disease characterized by destruction of the osseous and membranous labyrinth and potential supplantation with bony sequestrum. Cochlear implantation is a viable option in selected patients with osteolytic labyrinthitis.

A reassessment of the clinical utility of 68Ga-DOTATATE PET/CT in patients with gastroenteropancreatic neuroendocrine tumors.

e16294 Background: Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are a rare and biologically diverse group of tumors that can be challenging to image. Gallium-68 (Ga-68) DOTATATE positron emission tomography/computed tomography (PET/CT) is the most sensitive imaging tool for these tumors and has now been in clinical practice for over a decade. While its use has increased over time, its clinical impact remains unclear for specific stages of disease and indications for imaging. We sought to investigate this to provide information to guide its future use in clinical management. Methods: This retrospective cohort study identified adults with pathologically confirmed GEP-NETs between 1/1/2020 and 9/1/2022 at a tertiary care academic medical center. The electronic medical record was reviewed for demographic, clinical, and radiographic data. The primary objective was to determine if the use of 68Ga-DOTATATE PET/CT was associated with a change in clinical management, medical or surgical. The secondary objective was to determine if 68Ga-DOTATATE PET/CT was more effective in identifying primary or metastatic lesions compared to traditional imaging such as CT or magnetic resonance imaging (MRI) performed less than 90 days of the PET/CT scan. Percentages are reported with 95% Confidence Intervals (CI). Results: Overall, 124 patients with pathologically confirmed GEP NETs underwent a total of 207 68Ga-DOTATATE PET/CT scans. The majority (92.7%) of GEP NETs were moderately/well differentiated and the primary sites included the small intestine (50%), pancreas (23.4%), appendix/colon (8.9%), gastric (8.1%), mesentery (2.4%), and unknown (7.3%). Following PET/CT scan, 51 patients (41.1%; 95% CI = 32.4-49.8) had a change in clinical management, with the proportion of patients who had a change being higher among those with metastatic disease (44.9% vs 14.5%). Of the 124, 72 patients had traditional imaging 90 days or less prior to PET/CT available for comparison. In this subgroup, 34 patients (47.2%; 95% CI = 35.7-58.7) had new lesions identified on PET/CT that were not identified using traditional imaging and of the 34 patients with new lesions identified, 79.4% (95% CI = 66-93) had a change in their clinical management. The majority of these patients had M1 disease (50% vs 15.4%). Conclusions: This study highlights the impact of 68Ga-DOTATATE PET/CT imaging in the clinical management of patients with gastroenteropancreatic neuroendocrine tumors (GEP NETs). Notably this imaging technique resulted in a change in clinical management for 41% of these patients, particularly benefiting those with metastatic (M1) disease, where the change in management was more pronounced (44.9% vs. 14.5%). Furthermore, 68Ga-DOTATATE PET/CT proved superior to traditional imaging revealing new lesions in 47.2% of the patients, with the majority being patients with metastatic disease.

Comparing Methods for Identifying Post-Market Patient Preferences at the Point of Decision-Making: Insights from Patients with Chronic Pain Considering a Spinal Cord Stimulator Device.

To compare three methods for identifying patient preferences (MIPPs) at the point of decision-making: analysis of video-recorded patient-clinician encounters, post-encounter interviews, and post-encounter surveys. For the decision of whether to use a spinal cord stimulator device (SCS), a video coding scheme, interview guide, and patient survey were iteratively developed with 30 SCS decision-making encounters in a tertiary academic medical center pain clinic. Burke's grammar of motives was used to classify the attributed source or justification for a potential preference for each preference block. To compare the MIPPs, 13 patients' encounters with their clinician were video recorded and subsequently analyzed by 4 coders using the final video coding scheme. Six of these patients were interviewed, and 7 surveyed, immediately following their encounters. For videos, an average of 66 (range 33-106) sets of utterances potentially indicating a patient preference (a preference block), surveys 33 (range 32-34), and interviews 25 (range 18-30) were identified. Thirty-eight unique themes (75 subthemes), each a preference topic, were identified from videos, surveys 19 themes (12 subthemes), and interviews 39 themes (54 subthemes). The proportion of preference blocks that were judged as expressing a preference that was clearly important to the patient or affected their decision was highest for interviews (72.8%), surveys (68.0%), and videos (27.0%). Videos mostly attributed preferences to the patient's situation (scene) (65%); interviews, the act of receiving or living with SCS (43%); surveys, the purpose of SCS (40%). MIPPs vary in the type of preferences identified and the clarity of expressed preferences in their data sets. The choice of which MIPP to use depends on projects' goals and resources, recognizing that the choice of MIPP may affect which preferences are found.

Hearing preservation outcomes using direct cranial nerve eight and auditory brainstem response neuromonitoring in the resection of vestibular schwannomas.

Advancements in microsurgical technique and technology continue to improve outcomes in patients with skull base tumor. The primary cranial nerve eight monitoring systems used in hearing preservation surgery for vestibular schwannomas (VSs) are direct cranial nerve eight monitoring (DCNEM) and auditory brainstem response (ABR), although current guidelines are unable to definitively recommend one over the other due to limited literature on the topic. Thus, further research is needed to determine the utility of DCNEM and ABR. The authors performed a retrospective cohort study and created an interactive model that compares hearing preservation outcomes based on tumor size in patients receiving ABR+DCNEM and ABR-only monitoring. Twenty-eight patients received ABR+DCNEM and 72 patients received ABR-only monitoring during VS hearing preservation surgery at a single tertiary academic medical center between January 2008 and November 2022. Inclusion criteria consisted of adult patients with a preoperative American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) hearing classification of A or B. Tumor size was measured as the maximal medial to lateral length, including the internal auditory canal component. Overall hearing preservation (word recognition score [WRS] > 0%) was achieved in 31 patients with ABR-only monitoring (43.1%) and in 18 patients with ABR+DCNEM (64.3%). Serviceable hearing preservation (AAO-HNS class A or B) was attained in 19 patients with ABR-only monitoring (26.4%) and in 11 patients with ABR+DCNEM (39.3%). There was no difference in overall hearing preservation between the two groups (p = 0.13). Change in tumor size was not associated with the odds of serviceable hearing preservation for the ABR-only group (p = 0.89); however, for ABR+DCNEM, there was some indication of an interaction between tumor size and the association of ABR+DCNEM versus ABR-only monitoring, with the odds of serviceable hearing preservation at p = 0.089. Furthermore, with ABR+DCNEM, every 0.5-cm increase in tumor size was associated with a decreased odds of serviceable hearing preservation on multivariable analysis (p = 0.05). For both overall and serviceable hearing preservation, a worse preoperative AAO-HNS classification was associated with a decreased odds of preservation (OR 0.43, 95% CI 0.19-0.97, p = 0.042; OR 0.17, 95% CI 0.053-0.55, p = 0.0031, respectively). The result of this interactive model study proposes that there may be a higher chance of hearing preservation when using ABR+DCNEM rather than ABR alone for smaller tumors, with that relationship reversing as tumor size increases.

Repeat tracheal aspirate cultures in pediatric intensive care patients: Frequency, resistance, and antimicrobial use.

To evaluate the clinical impact and features associated with repeat tracheal aspirate (TA) cultures in children admitted to the intensive care unit. Retrospective cohort study. A 338-bed freestanding, tertiary pediatric academic medical center with pediatric medical intensive care unit (PICU) and cardiac intensive care units (CICU). Children ≤18 years of age who were admitted to either the PICU or CICU who had ≥2 TA cultures in a single intensive care admission. Patients with ≥2 TA cultures between 2018 and 2019 were included in this study. The following information was collected: patient demographics, clinical data summarizing patient condition at the time of culture collection, number of TA cultures per patient, antibiotic usage, and microbiologic data. Descriptive statistics established the frequency of TA collection, time between culturing, clinical reasoning for collection, antibiotic exposure, and development of multidrug-resistant organisms (MDRO). Sixty-three patients had repeat TA cultures and accounted for 252 TA cultures during the study period. Most patients with repeat TA cultures were admitted to the PICU (71%) and were male (65%). A median of 3 TA cultures per patient were obtained with 50% of repeat cultures occurring within 7 days from the previous culture. Sixty-six percent of patients had the same organism cultured on ≥2 TA cultures. Most antibiotics were not modified or continued to treat the results of the TA culture. Repeat TA cultures frequently show the same pathogens, and results do not often influence antibiotic selection or usage. Repeat TA cultures did demonstrate the development of MDROs.

Reporting on Neurological Decline as Identified by Hourly Neuroassessments.

BACKGROUND: Hourly neurological examinations (neuro exam) have been widely used to monitor for a decline in neurological status, allowing for timely intervention. There are, however, limited data behind this common practice. The objective of this study was to identify how frequently neurological decline occurred across various diagnoses and whether that decline (1) was identified by a scheduled neurocheck and (2) altered management. METHODS: A cross-sectional survey was performed in a neurological intensive care unit at a tertiary care academic medical center. Clinical neuroscience nurses caring for patients with hourly neurological assessments completed a brief survey at 12-hour shift completion. RESULTS: Data were collected from 212 nurse's shifts. Neurological changes were identified by nurses in 14% (n = 30) of shifts. The neurological change was identified during a scheduled neurocheck 67% of the time, with the detection of changes more likely to occur during a scheduled neuro exam than at other times ( P < .05). There was no change to the care plan in 55% of the cases of neurological decline. Patients with subarachnoid hemorrhage were more likely to have a decline detected. CONCLUSION: Findings suggest that many patients undergo hourly neurological exams without ever identifying a neurological deterioration. In many instances of neurodeterioration, there was no change to the treatment plan pursued. Primary diagnoses and neurological changes may not be entirely independent, and therefore, hourly neuro exams may have greater yield in some diagnoses than others. Replication is warranted with a larger sample to evaluate the risks and benefits of neuroassessments.

Conventional clinical signs and symptoms are poor predictors of postoperative cerebrospinal fluid leak: A single-centre cohort perspective.

Postoperative cerebrospinal fluid (CSF) leak remains a concerning complication of the endoscopic endonasal approach (EEA) for skull base pathology. Signs and symptoms suggesting CSF leak often trigger additional workup during the postoperative course. We systematically evaluate associations between subjectively reported clinical signs/symptoms noted during the immediate postoperative period and incidence of postoperative CSF leaks. Retrospective chart review was conducted at a tertiary academic medical centre including 137 consecutive patients with intraoperative CSF leak during EEA with primary repair between July 2018 and August 2022. Postoperative CSF leak associations with clinical signs and symptoms were evaluated using positive (PPV) and negative predictive values (NPV), sensitivity, specificity and odds ratio (OR) via univariate logistic regression. Seventy-nine patients (57.7%) had high-flow leaks repaired and 5 (3.6%) developed CSF leaks postoperatively. Of reported symptoms, rhinorrhea was most common (n = 52, 38.0%; PPV [95% CI] = 7.6% [4.8%, 11.9%]), followed by severe headache (n = 47, 34.3%; 6.3% [3.1%, 12.5%]), dizziness (n = 43, 31.4%; 2.3% [0.4%, 12.1%]), salty or metallic taste (n = 20, 14.6%; 9.9% [3.3%, 25.8%]), and throat drainage (n = 10, 7.3%; 9.9% [1.7%, 41.4%]). Nausea or vomiting constituted the most reported sign concerning for CSF leak (n = 73, 53.3%; PPV [95% CI] = 4.1% [2.0%, 8.1%]). On univariate regression, no sign or symptom, including rhinorrhea (OR [95% CI] = 7.00 [0.76-64.44]), throat drainage (3.42 [0.35-33.86]), salty/metallic taste (4.22 [0.66-27.04]), severe headache (3.00 [0.48-18.62]), dizziness (0.54 [0.06-4.94]), fever (3.16 [0.50-19.99]), and nausea/vomiting (1.33 [0.22-8.21]), associated with postoperative CSF leak. A range of subjectively reported symptoms and signs failed to predict postoperative CSF leak. Further investigation is warranted to inform appropriate attention and response.

Automated segmentation for early detection of uveal melanoma

ObjectifLe mélanome de l'uvée est le cancer intraoculaire le plus fréquent chez l'adulte. À l'heure actuelle, les méthodes de dépistage et de triage des tumeurs choroïdiennes mélanotiques se butent à des obstacles intrinsèques, surtout dans les régions mal desservies par des oncologues oculaires spécialisés. La présente étude se penche sur le potentiel de l'apprentissage artificiel pour automatiser la segmentation tumorale. Nous avons créé et évalué un modèle d'apprentissage artificiel qui repose sur des photographies ultra-grand champ du fond d’œil pour réaliser la segmentation des lésions. MéthodeOn a procédé à un examen des dossiers médicaux de patients qui ont reçu un diagnostic de mélanome de l'uvée, de naevus choroïdien ou d'hypertrophie congénitale de l’épithélium pigmentaire rétinien dans un centre universitaire de soins tertiaires. On a réalisé une seule photographie ultra-grand champ (Optos PLC, Dunfermline, Fife, Écosse) du fond d’œil des patients retenus; la photographie était de qualité suffisante pour visualiser les lésions d'intérêt, comme l'a confirmé un oncologue oculaire unique. Ces images ont servi à créer et à tester un algorithme d'apprentissage artificiel en vue de la segmentation de lésions. RésultatsAu total, 396 images ont servi à créer un algorithme d'apprentissage artificiel en vue de la segmentation de lésions, et 90 images supplémentaires ont servi d'ensemble de données à tester parallèlement à des images de 30 sujets témoins en bonne santé. Parmi les images sur lesquelles le modèle d'apprentissage a réussi à identifier des lésions, la segmentation automatisée a donné un coefficient de similarité de Dice de 0,86, de 0,81 et de 0,85 pour le mélanome de l'uvée, le naevus choroïdien et l'hypertrophie congénitale de l’épithélium pigmentaire rétinien, respectivement. La sensibilité envers toute lésion décelée sur une image donnée se chiffrait à 1,00, à 0,90 et à 0,87, respectivement. La spécificité était de 0,93 dans les images sans lésion. ConclusionNotre étude a permis d'objectiver la capacité d'un nouvel algorithme d'apprentissage artificiel et d’évoquer son utilité clinique potentielle et sa grande accessibilité en tant que méthode de dépistage des tumeurs choroïdiennes. D'autres méthodes d’évaluation s'imposent pour améliorer davantage la précision du modèle en matière de classification des lésions et de détermination du diagnostic.