Variation In Management Of Patients Research Articles

Non-receipt of targeted and immunotherapies in diverse patients with metastatic cancers.

93 Background: The rapid evolution of molecularly targeted kinase inhibitors (TKIs) and immune checkpoint inhibitors (ICIs) in the treatment of metastatic cancer, coupled with high drug costs, raises potential for unwarranted variation in patient management. We evaluated correlates of non-receipt of TKIs and ICIs in a diverse, population-based sample of patients with metastatic non-small cell lung cancer (NSCLC), kidney and bladder (GU) cancer, and melanoma. Methods: We identified 2240 patients diagnosed in 2019 with metastatic NSCLC, GU cancer, or melanoma and reported to the Georgia or Los Angeles SEER registries. Using SEER registry data, we linked all patients to a managing oncology physician. We collected data from the managing physician regarding receipt of TKIs and ICIs. We used bivariate analyses and multivariable logistic regression models to assess associations between non-receipt of TKIs and ICIs and patient-level factors. Results: We present results for a preliminary sample (N=894). About half (55%) of the patients had NSCLC, 31% had GU cancer, and 14% had melanoma. The mean age was 62 (SD 12); 59% were male; 65% were White, 16% were Black, 11% were Hispanic, and 7% were Asian; 52% had Medicare, 29% had private insurance, 9% had Medicaid, and 4% had no insurance; 89% resided in urban areas, 11% resided in rural areas. 22% lived in a census tract area with >20% of the population living below the poverty level. The Table shows that in bivariate analyses, non-receipt of TKIs was associated with NSCLC, older age, male sex, non-white race, and non-private or no insurance (all p<0.05). After adjustment, non-receipt of TKIs was associated with NSCLC, older age, male sex, and race. Asian and Hispanic patients had lower rates of non-receipt, and Black patients had higher rates. In bivariate analyses, non-receipt of ICIs was associated with NSCLC and GU cancer (p=0.004); this association remained significant after adjustment. Conclusions: Non-receipt of TKIs was associated with important non-clinical factors including race and sex. Non-receipt of ICIs was associated only with cancer type. These findings suggest that policy-relevant factors such as out-of-pocket costs for oral cancer therapies and differential access to molecular sequencing may contribute to unwarranted variation in receipt of TKIs. Bivariate analyses of non-receipt. Did not Receive TKI Did not Receive ICI % P % P Cancer type NSCLC GU Melanoma 786572 0.002 313015 0.004 Age <50 50-64 65-74 75-84 85+ 5471757986 <0.001 2625302940 0.385 Sex Male Female 7670 0.048 2631 0.085 Race & Ethnicity White Black Hispanic Asian Other 7579655860 0.002 2329312927 0.981 Marital Status Married Unmarried 7373 0.645 2630 0.158 Insurance Medicare Medicaid Private Other government None 7075637080 <0.001 3130215031 0.101 Geography Urban Rural 7375 0.784 2826 0.567 % population below poverty level 0-5% 5-<10% 10-<20% 20-100% 69717774 0.314 29273222 0.138

Non-receipt of targeted and immunotherapies in diverse patients with metastatic cancers.

e13563 Background: The rapid evolution of molecularly targeted kinase inhibitors (TKIs) and immune checkpoint inhibitors (ICIs) in the treatment of metastatic cancer, coupled with high drug costs, raises potential for unwarranted variation in patient management. We evaluated correlates of non-receipt of TKIs and ICIs in a diverse, population-based sample of patients with metastatic non-small cell lung cancer (NSCLC), kidney and bladder (GU) cancer, and melanoma. Methods: We identified 2240 patients diagnosed in 2019 with metastatic NSCLC, GU cancer, or melanoma and reported to the Georgia or Los Angeles SEER registries. Using SEER registry data, we linked all patients to a managing oncology physician. We collected data from the managing physician regarding receipt of TKIs and ICIs. We used bivariate analyses and multivariable logistic regression models to assess associations between non-receipt of TKIs and ICIs and patient-level factors. Results: We present results for a preliminary sample (N=894). About half (55%) of the patients had NSCLC, 31% had GU cancer, and 14% had melanoma. The mean age was 62 (SD 12); 59% were male; 65% were White, 16% were Black, 11% were Hispanic, and 7% were Asian; 52% had Medicare, 29% had private insurance, 9% had Medicaid, and 4% had no insurance; 89% resided in urban areas, 11% resided in rural areas. 22% lived in a census tract area with ≥20% of the population living below the poverty level. The Table shows that in bivariate analyses, non-receipt of TKIs was associated with NSCLC, older age, male sex, non-white race, and non-private or no insurance (all p<0.05). After adjustment, non-receipt of TKIs was associated with NSCLC, older age, male sex, and race. Asian and Hispanic patients had lower rates of non-receipt, and Black patients had higher rates. In bivariate analyses, non-receipt of ICIs was associated with NSCLC and GU cancer (p=0.004); this association remained significant after adjustment. Conclusions: Non-receipt of TKIs was associated with important non-clinical factors including race and sex. Non-receipt of ICIs was associated only with cancer type. These findings suggest that policy-relevant factors such as out-of-pocket costs for oral cancer therapies and differential access to molecular sequencing may contribute to unwarranted variation in receipt of TKIs. [Table: see text]

E019 Management of idiopathic inflammatory myositis - a Northamptonshire audit of British Society for Rheumatology guidelines

Abstract Background/Aims The idiopathic inflammatory myopathies (IIM) are a rare group of multi-system autoimmune conditions characterised by muscle inflammation. They have an incidence of up to 19 per 1,000,000 person years in adults and a UK prevalence of 10,000 people. Last census data estimated the Northamptonshire population at approximately 785,200. The small cohort of patients reflects the limited evidence base for best practice. In March 2022, the first UK evidence guideline on IIM was published from the British Society for Rheumatology (BSR). In view of absence of prior guidance, there is expected variability in patient management within and between centres. To evaluate local practice against these standards an audit was conducted in Northampton General Hospital (NGH). Methods Using local MYOACT registry data and consultant caseload knowledge, a cohort of adult patients with IIM diagnoses consulted within the last 5 years were identified. Retrospective clinical letters were analysed for details of patient care and compared to the 26 recommendations as set out by the myositis guideline. Results A total of 12 patients were sampled as having attended the rheumatology department within the last five years at NGH. All 26 standards will be presented, but for the purposes of this abstract, key results for discussion include: • 100% of corticosteroids were tapered as the patient responded to treatment. • In presence of muscle inflammation 91% were treated with DMARDs. • In presence of active skin disease, 100% received treatment with csDMARD, IVIG or rituximab. • 100% of patients were screened for interstitial lung disease. • In presence of active muscle disease, 56% of patients received an exercise program led and monitored by therapists. • In 45% of patients’ psychological well-being and health was formally considered. Conclusion Initial service evaluation against BSR IIM recommendations reflects typical strengths and weaknesses encountered in delivering rheumatology services. There was strong concordance in diagnostic and pharmacological domains. However greater variability was encountered when considering multidisciplinary psychosocial domains involving access to therapy services and psychological support. Tools such as the 36 Item Short Form Survey, highlighted in BSR recommendations, may offer a validated method for physicians to formally consider and target psychosocial domains in management of idiopathic inflammatory myopathies. Disclosure N. Chauhan: None. S. Abushama: None. R. Jeffery: None.

Temporal Trends and Contemporary Regional Variation in Management of Patients Undergoing Carotid Endarterectomy.

The purpose of this study is to investigate regional variation and temporal trends in seven quality metrics amongst CEA patients: discharge on antiplatelet after CEA; discharge on statin after CEA; protamine administration during CEA; patch placement at conventional CEA site; continued statin usage at the time of most recent follow-up; continued antiplatelet usage at the time of most recent follow-up; and smoking cessation at the time of long term follow up. There are 19 de-identified regions within the VQI database in the United States. Patients were placed into one of three temporal eras based on the time of their CEA: 2003-2008; 2009-2015; and 2016-2022. We first investigated temporal trends across the seven quality metrics for all regions combined on a national basis. The percentage of patients in each time era with the presence/absence of each metric was identified. Chi-squared testing was performed to confirm statistical significance of the differences across eras. Next, analysis was performed within each region and within each time metric. We separated out the 2016-2022 patients within each region to serve as the status of each metric application in the most modern era. We then compared the frequency of metric non-adherence in each region utilizing Chi-squared testing. There was statistically significant improvement in achievement of all seven metrics between the initial 2003-2008 era and the modern 2016-2022 era. The most marked change in practice pattern was noted for lack of protamine usage at surgery (decreased from 48.7% to 25.9%), discharge home postoperatively without statin (decreased from 50.6% to 15.3%), and lack of statin usage confirmed at time of most recent long term follow up (decreased from 24% to 8.9%). Significant regional variation exists across all metrics (P < .01 for all). Lack of patch placement at the time of conventional endarterectomy ranges from 1.9% to 17.8% across regions in the modern era. Lack of protamine utilization ranges from 10.8% to 49.7%. Lack of antiplatelet and statin at the time of discharge varies from 5.5% to 8.2% and 4.8% to 14.4% respectively. Adherence to the various measures at the time of most recent follow up are more tightly aligned across regions with ranges of: 5.3% to 7.5% for lack of antiplatelet usage; 6.6% to 11.7% lack of statin utilization; and 13.3 to 15.4% for persistent smoking. Prior studies and societal initiatives on CEA documenting the beneficial effects of patch angioplasty, protamine use at surgery, smoking cessation, antiplatelet utilization and statin compliance have positively impacted adherence to these measures over time. In the modern 2016-2022 era the widest regional variation is noted in patch placement, protamine utilization and discharge medications allowing individual geographic areas to identify areas for potential improvement via internal VQI administrative feedback.

Use of Prognostic Factors and Scores in Selection of Patients with Colorectal Cancer Peritoneal Metastasis (CRPM) for Cytoreductive Surgery and Intraperitoneal Chemotherapy (CRS/IPC): Results of an International Survey Among Oncologic Clinicians

BackgroundNo universally accepted guidelines exist for treatment of patients with colorectal cancer peritoneal metastases (CRPM) undergoing cytoreductive surgery and intraperitoneal chemotherapy (CRS/IPC). Several uncertainties remain concerning almost every aspect of this treatment modality, resulting in marked variability in patient management and likely outcomes. This survey aimed to define variations and trends in clinician decision making more clearly.MethodsA 41-question web-based survey was distributed electronically via the Peritoneal Surface Oncology Group International (PSOGI), the International Society for the Study of Pleura and Peritoneum (ISSPP) as well as via social media (particularly Twitter). The survey sought to address and record clinician responses regarding patient workup/assessment, selection for preoperative systemic therapy, preoperative and intraoperative selection for CRS/IPC, and consideration of prognosis and complications.ResultsComplete responses were received from 60 clinicians from 45 centres in 22 countries. Upon assessment of survey responses, several interesting trends were noted in each section of the survey. Significant variability in surgeon practice and opinion were identified concerning almost every aspect of the treatment modality.ConclusionThis international survey provides the most comprehensive insight into clinician decision-making trends regarding patient assessment, selection and management. This should allow areas of variability to be more clearly defined and could potentially prompt development of initiatives for achieving consensus and standardisation of care in the future.

IRONMAN: A Novel International Registry of Men With Advanced Prostate Cancer.

To describe a newly established international registry recruiting diverse patients with advanced prostate cancer across academic and community practices to address unmet needs in this population. Initiated in 2017, IRONMAN (International Registry for Men with Advanced Prostate Cancer) is a prospective cohort of patients with advanced prostate cancer. The study will enroll 5,000 patients with metastatic hormone-sensitive prostate cancer (mHSPC) or castration-resistant prostate cancer (CRPC), recruited from Australia, the Bahamas, Barbados, Brazil, Canada, Ireland, Jamaica, Kenya, Nigeria, Norway, South Africa, Spain, Sweden, Switzerland, the United Kingdom, and the United States. The study is collecting datatypes to study variation in care and treatment of advanced prostate cancer across countries and across academic, community-based, and government practices with a focus on clinical outcomes, patient-reported outcomes, epidemiologic data, biologic subtypes, and clinician questionnaires. Through July 2022, 2,682 eligible patients were enrolled in 11 of 12 active countries. Sixty-six percent of patients have mHSPC, and 34% have CRPC. On the basis of self-report, 11% of patients are Black and 9% are Hispanic. Five Veterans Affairs Medical Centers are enrolling patients. Globally, 23% of patients report being veterans of military service. To our knowledge, this is the first international cohort of people newly diagnosed with advanced prostate cancer designed to describe variations in patient management, experiences, and outcomes. IRONMAN aims to identify optimal treatment sequences to improve survival, understand patient-reported outcomes, and explore novel biomarkers to understand treatment resistance mechanisms. Insights from IRONMAN will inform and guide future clinical management of people with mHSPC and CRPC. This cohort study will provide real-world evidence to facilitate a better understanding of the survivorship of people with advanced prostate cancer.

Management of patients at risk of adrenal crisis in the dental setting: a review of current practice in UK dental teaching hospitals.

Introduction Patients with impaired corticosteroid response due to Addison's disease or systemic glucocorticoid use are at risk of adrenal crisis when undergoing dental treatment. There is a lack of conclusive evidence to support dental teams in identifying patients at risk and their management to prevent an adrenal crisis.Aim To review the current practice in UK dental teaching hospitals regarding the management of patients at risk of adrenal crisis in the dental setting.Methods An electronic survey focused on patients who may be at risk of adrenal crisis due to systemic glucocorticoid therapy was sent to all 18 UK dental teaching hospitals. Information on the use of a policy or guidance was requested. Responses were evaluated for clinical decision-making, patient risk assessment and steroid cover dosing regimens.Results A 78% response rate was achieved. Only 29% of institutions had a written policy or guidance document. Variation exists in the threshold of steroid dose and duration of treatment in identifying patients at risk of adrenal suppression. Furthermore, the dose regime for steroid cover varied.Conclusion Further evidence on the management of patients at risk of adrenal crisis is required to inform national guidance and reduce variation in patient management.

Delivery and outcomes of end-of-life care in the Australian context: Experiences and reflections of general practitioners.

Previous research on general practitioners' (GPs') involvement in end-of-life care has largely focused on a specific aspect of care or has provided broad overviews that failed to capture individual variations in patient management. This qualitative study aimed to explore Australian GPs' feedback and reflections on the individual-level care provided for patients in their last year of life. The findings of the study were drawn from a nation-wide survey of GPs' experiences in end-of-life care. We analysed responses from 63 GPs for 267 of the 272 reported deaths. Factors influencing delivery of optimal end-of-life care reported by GPs were categorised into four groups: patient-related factors, carer-related factors, interactions between GPs and patients/carer-related factors and broader health system issues. Each group included both barriers and facilitators. Our study highlighted importance of the emotional dimensions of therapeutic relationships with patients and their family, availability and capacity of family support and smooth communication and continuity of care between GPs and hospitals in delivery of optimal end-of-life care. Lack of these facilitators, misconceptions of palliative care and conflicts on implementing care plans among patients and their family tended to impede delivery of such care. On the basis of our findings in the present study and previous literature, we conclude that improved end-of-life care in general practice requires comprehensive approaches to supporting both the GP and family to provide care in patients' preferred place, such as enhanced palliative care training and improved availability of external support for GPs, higher levels of hospital-based services reaching into community settings and broader community-based resources for families beyond simply the healthcare system.

Practice Variation among Canadian Stroke Prevention Clinics: Pre, During, and Post-COVID-19.

Stroke is a common and serious disorder. With optimal care, 90-day recurrent stroke risk can be reduced from 10% to about 1%. Stroke prevention clinics (SPCs) can improve patient outcomes and resource allocation but lack standardization in patient management. The extent of variation in patient management among SPCs is unknown. Our aims were to assess baseline practice variation between Canadian SPCs and the impact of COVID-19 on SPC patient care. We conducted an electronic survey of 80 SPCs across Canada from May to November 2021. SPC leads were contacted by email with up to five reminders. Of 80 SPCs contacted, 76 were eligible from which 38 (50.0%) responded. The majority (65.8%) of SPCs are open 5 or more days a week. Tests are more likely to be completed before the SPC visit if referrals were from clinic's own emergency department compared to other referring sources. COVID-19 had a negative impact on routine patient care including longer wait times (increased for 36.4% clinics) and higher number of patients without completed bloodwork prior to arriving for appointments (increased for 27.3% clinics). During COVID-19 pandemic, 87.9% of SPCs provided virtual care while 72.7% plan to continue with virtual care post-COVID-19 pandemic. Despite the time-sensitive nature of transient ischemic attack patient management, some SPCs in Canada are not able to see patients quickly. SPCs should endeavor to implement strategies so that they can see high-risk patients within the highest risk timeline and implement strategies to complete some tests while waiting for SPC appointment.

Surgical Management of Non-Metastatic Pancreatic Cancer in the United Kingdom: Results of a Nationwide Survey on Current Practice.

BackgroundIt is presently unclear what clinical pathways are followed for patients with non-metastatic PDAC in specialised centres for pancreatic surgery across the United Kingdom (UK).MethodsBetween August 2019 and August 2020 an electronic survey was conducted aiming at a national cohort of pancreatic surgeons in the UK. Participants replied to a list of standardised questions and clinical vignettes, and data were collected and analysed focusing on management preferences, resectability criteria, and contraindications to surgery.ResultsWithin the study period, 65 pancreatic surgeons from 27 specialist centres in the UK (96%) completed the survey. Multidisciplinary team meetings are utilised universally for the management of patients with PDAC, however, different staging systems for resectability classification are being applied. In borderline resectable PDAC, most surgeons were keen to proceed with surgical exploration post NAT, but differences were noted in preferred chemotherapy regimens. Surgeons from standard volume institutions performed fewer vein resections annually and were more likely to deem patients with locally advanced PDAC as unresectable. Intra-institutional variability in patient management was also present and ranging between 20-80%.ConclusionsSignificant variability in the surgical management of non-metastatic PDAC was identified both on inter- and intra-institutional level.

Defining cardiovascular toxicities of cancer therapies: an International Cardio-Oncology Society (IC-OS) consensus statement.

The discipline of Cardio-Oncology has seen tremendous growth over the past decade. It is devoted to the cardiovascular (CV) care of the cancer patient, especially to the mitigation and management of CV complications or toxicities of cancer therapies, which can have profound implications on prognosis. To that effect, many studies have assessed CV toxicities in patients undergoing various types of cancer therapies; however, direct comparisons have proven difficult due to lack of uniformity in CV toxicity endpoints. Similarly, in clinical practice, there can be substantial differences in the understanding of what constitutes CV toxicity, which can lead to significant variation in patient management and outcomes. This document addresses these issues and provides consensus definitions for the most commonly reported CV toxicities, including cardiomyopathy/heart failure and myocarditis, vascular toxicity, and hypertension, as well as arrhythmias and QTc prolongation. The current document reflects a harmonizing review of the current landscape in CV toxicities and the definitions used to define these. This consensus effort aims to provide a structure for definitions of CV toxicity in the clinic and for future research. It will be important to link the definitions outlined herein to outcomes in clinical practice and CV endpoints in clinical trials. It should facilitate communication across various disciplines to improve clinical outcomes for cancer patients with CV diseases.

Real-world management of non-alcoholic steatohepatitis differs from clinical practice guideline recommendations and across regions

Background & AimsDespite availability of diagnostic and management reference guidelines outlining standard of care for patients with non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH), national and regional guidelines are lacking, resulting in variations in patient management between regions. We retrospectively analyzed patient characteristics and management data from the Adelphi Real World NASH Disease Specific Programme™ for patients with NASH in the EU5, Canada, and the Middle East to identify gaps between real-world practice and that advocated by reference guidelines, irrespective of clinician awareness or consultation of guidelines.MethodsWe performed an analysis of physicians (hepatologists, gastroenterologists, diabetologists) and their patients diagnosed with NASH. Physicians completed patient record forms for the next 5 consulting patients, collecting information on patient care, including diagnosis and disease management.ResultsA total of 429 physicians provided data for 2,267 patients with NASH (EU5, n = 1,844; Canada, n = 130; Middle East, n = 293). Patient age, physician-defined fibrosis stage, comorbidities and symptoms, and diagnostic testing practices highlighted statistically significant differences across regions. Substantial disconnects between reference guidelines and real-world practice were observed. Use of liver function tests, non-invasive tests (e.g. ultrasound and transient elastography), and tests to exclude other conditions was suboptimal. Although lifestyle advice was widely provided, patients were less commonly referred to diet, exercise, and lifestyle specialists. Two-thirds of patients were receiving off-label treatment for NASH or associated underlying conditions with the aim of improving NASH, most commonly statins, metformin, and vitamin E.ConclusionReal-world NASH management approaches differ across regions and from proposed standard of care represented by reference multidisciplinary guidelines. Establishment and awareness of, and adherence to regional and national guidelines may improve identification and management of patients with NASH and potentially improve outcomes in this population.Lay summaryAlthough reference guidelines are available to guide the management of patients with NASH, these are not widely used and there is a lack of national guidelines. Our study shows how clinical practice in the EU, Canada, and Middle East differs from proposed standard of care, particularly relating to how patients are diagnosed and treated. Wider establishment of, awareness of, and reference to guidelines may improve how physicians identify and manage patients with NASH.

Geographic variation in management of patients with placenta accreta spectrum: An international survey of experts (GPASS).

To describe global geographic variations in the diagnosis and management of placenta accreta spectrum (PAS). An international cross-sectional study was conducted among PAS experts practicing at medical institutions in member states of the United Nations. Survey questions focused on diagnostic evaluation and management strategies for PAS. A total of 134 centers participated. Participating centers represented each of the United Nations' designated regions. Of those, 118 (88%) reported practicing in a medium-volume or high-volume center. First-trimester PAS screen was reported in 35 (26.1%) centers. Respondents consistently implement guideline-supported care practices, including utilization of ultrasound as the primary diagnostic modality (134, 100%) and implementation of multidisciplinary care teams (115, 85.8%). Less than 10% of respondents reported routinely managing PAS without hysterectomy; these centers were predominantly located in Europe and Africa. Antepartum management and availability of mental health support for PAS patients varied widely. Worldwide, there is a strong adherence to PAS care guidelines; however, regional variations do exist. Comparing variations in care to outcomes will provide insight into the clinically significant practice variability.

P–344 Clarifying tubo-ovarian abscess management: a risk score for predicting antibiotic failure

Abstract Study question Can antibiotic treatment failure of tubo-ovarian abscesses (TOA) be predicted based on clinical features at the time of diagnosis? Summary answer We propose a risk score including patient temperature, c-reactive protein and TOA size that could predict which patients are likely to fail parental antibiotic treatment. What is known already Current guidance is that the first line management of non-ruptured TOA is with parental antibiotics. However, it is reported that treatment failure rate is 20–30%. Alternative treatment modalities include radiological drainage or laparoscopic/open surgery. In patients who require intervention, outcomes, such as morbidity, length of hospital stay and fertility, are improved when this is performed early rather than later in their hospital admission. However, our current guidance is scant with regards to the decision making for interventional TOA management. Study design, size, duration This is a multicentre retrospective cohort study over 81 months (01/01/13- 30/09/19) identifying 214 consecutive patients admitted to hospitals in North-West London with diagnosed TOA. Participants/materials, setting, methods: Demographics, medical history, presenting symptoms, laboratory results, radiological findings, treatments administered, hospital length of stay and follow up data was collected. The patients were chronologically split with the first 150 being used for the development of our risk score. Univariate and bivariate analyses were employed to ascertain statistically significant variables in the failure of parental antibiotic. The remaining 64 patients were used for risk score validation. Main results and the role of chance Statistically significant variables were: temperature at admission (median= 37.1 °C vs 38.2 °C, p = 0.0001), C-reactive protein (CRP) at admission (151mg/L vs 243mg/L, p = 0.0001) and size of TOA (6.0cm vs 8.0cm, p = 0.0001). Those requiring intervention, stayed in hospital twice as long as those who did not (4 days vs 8 days, p &amp;lt; 0.001). A scoring system was formulated using the statistically significant variables. A score of ≥ 4 was associated with requiring radiological/surgical intervention (p &amp;lt; 0.001), with sensitivity 69% and specificity 88% (AUC 0.859) when tested on the validation cohort. Limitations, reasons for caution Being a retrospective study, which puts the data at risk of information and selection bias. Although there are merits to a multi-centre study, variation in patient management will invariably cause data heterogeneity. Wider implications of the findings: TOA patients may have their hospital management tailored early according to the postulated tool, alleviating uncertainty in their treatment as well as possibly reducing morbidity and length of hospital stay. Trial registration number Not applicable

Automated mechanical ventilation using Adaptive Support Ventilation versus conventional ventilation including ventilator length of stay, mortality, and professional social aspects of adoption of new technology.

Background Automation of mechanical ventilation allows for reduction of variation in patient management and has the potential to provide increased patient safety by strict adherence to computer driven ventilator protocols. Methods: A retrospective, observational study compared a group of 196 of general ICU patients managed exclusively on automated mechanical ventilation, adaptive support ventilation (ASV), to another group of 684 managed by usual, non-automated mechanical ventilation (No ASV). The data was collected in a unique access database designed to collect data for assessment of mechanical ventilation outcomes in a small medical center ICU. Results: The length of ventilator stay was non-significant between both groups, (81.7 ± 35.2 hours) in the ASV group; vs. (94.1 ± 35.1 hours) in the No ASV. Percent mortality was significantly less in the ASV group, 8.6% compared to 27.3% in the No ASV. Conclusion: Automated ventilation appears to be a safe ventilator strategy; however, cause effect relationships cannot be determined without further, more sophisticated studies. Keywords: Closed loop ventilation, ASV, Ventilator length of stay, Percent minute ventilation

Validation of two predictive models designed to aid clinicians in identifying Stevens-Johnson syndrome/toxic epidermal necrolysis: A single institution retrospective review

Validation of two predictive models designed to aid clinicians in identifying Stevens-Johnson syndrome/toxic epidermal necrolysis: A single institution retrospective review

The Lisbon Agreement on Femoroacetabular Impingement Imaging-part 3: imaging techniques.

Imaging diagnosis of femoroacetabular impingement (FAI) remains controversial due to a lack of high-level evidence, leading to significant variability in patient management. Optimizing protocols and technical details is essential in FAI imaging, although challenging in clinical practice. The purpose of this agreement is to establish expert-based statements on FAI imaging, using formal consensus techniques driven by relevant literature review. Recommendations on the selection and use of imaging techniques for FAI assessment, as well as guidance on relevant radiographic and MRI classifications, are provided. The Delphi method was used to assess agreement and derive consensus among 30 panel members (musculoskeletal radiologists and orthopedic surgeons). Forty-four questions were agreed on and classified into five major topics and recent relevant literature was circulated, in order to produce answering statements. The level of evidence was assessed for all statements and panel members scored their level of agreement with each statement during 4 Delphi rounds. Either "group consensus," "group agreement," or "no agreement" was achieved. Forty-seven statements were generated and group consensus was reached for 45. Twenty-two statements pertaining to "Imaging techniques" were generated. Eight statements on "Radiographic assessment" and 12 statements on "MRI evaluation" gained consensus. No agreement was reached for the 2 "Ultrasound" related statements. The first international consensus on FAI imaging was developed. Researchers and clinicians working with FAI and hip-related pain may use these recommendations to guide, develop, and implement comprehensive, evidence-based imaging protocols and classifications. • Radiographic evaluation is recommended for the initial assessment of FAI, while MRI with a dedicated protocol is the gold standard imaging technique for the comprehensive evaluation of this condition. • The MRI protocol for FAI evaluation should include unilateral small FOV with radial imaging, femoral torsion assessment, and a fluid sensitive sequence covering the whole pelvis. • The definite role of other imaging methods in FAI, such as ultrasound or CT, is still not well defined.

Surgical Management of Non-metastatic Pancreatic Cancer in the United Kingdom: Results of a Nationwide Survey on Current Practice

Background: Advancements in surgical technique and systemic treatment have evolved the concept of resectability in pancreatic adenocarcinoma (PDAC). It is presently unclear what clinical pathways are followed for patients with non-metastatic PDAC in specialised centres for pancreatic surgery across the United Kingdom (UK). Methods: Between August 2019 and August 2020 a nationwide electronic survey was conducted aiming at a national cohort of pancreatic surgeons in the UK. Participants replied to a list of standardised questions and clinical vignettes, and data were collected and analysed focusing on management preferences, resectability criteria, and contraindications to surgery. Results: Within the study period, 65 responders completed the survey, accounting approximately for 58% of all pancreatic surgeons from 27 specialist centres (96%) in the UK. A stratification in standard, high, and very-high volume institutions was performed for data analysis. Multidisciplinary team meetings are utilised universally for the management of patients with PDAC, however, different staging systems for resectability classification are being applied. In resectable PDAC, upfront surgical resection was the treatment of choice and neoadjuvant treatment (NAT) was considered in patients with CA19-9 >1000U/ml. In borderline resectable PDAC, most surgeons were keen to proceed with surgical exploration post NAT, but differences were noted in preferred chemotherapy regimens. Surgeons from standard volume institutions performed fewer vein resections annually and were more likely to deem patients with locally advanced PDAC as unresectable compared to their colleagues from high and very-high volume centres. Intra-institutional variability in patient management was also present and ranging between 20-80%. Conclusion: Significant variability in the surgical management of non-metastatic PDAC was identified both on inter- and intra-institutional level. These results demonstrate the necessity of establishing national audit mechanisms for outcome surveillance and optimisation of clinical pathways. Surgeon responses on five clinical vignettes based on real patients with different PDAC diagnoses

Inconsistent Management of Neonatal Herpes Simplex Virus Infections.

The incidence of neonatal herpes simplex virus (nHSV) infections is monitored periodically in the Netherlands, yet management and outcome is unknown. Comprehensive national guidelines are lacking. We aim to describe management and outcome in the last decade to explore current diagnostic and therapeutic challenges. We aim to identify possible variability in management of patients with a suspected nHSV infection. We conducted a retrospective case series of management and outcome of nHSV infections at 2 tertiary care center locations in the Netherlands. An nHSV infection was diagnosed in 1% (12 of 1348) of patients in whom polymerase chain reaction for HSV was performed. Of the patients with nHSV infection, 3 of 12 died, and 4 of 9 (44%) survivors suffered neurologic sequelae. Neurologic symptoms at presentation were seen in only 2 of 8 patients with nHSV encephalitis. A cerebral spinal fluid analysis was performed in 3 of 6 patients presenting with skin lesions. Only 3 of 6 patients with neurologic symptoms received suppressive therapy. nHSV infection was diagnosed in 8 of 189 (4%) patients who were empirically treated. Management of nHSV infection, particularly when presented with skin lesions, is inconsistent. Many infants without a HSV infection are exposed to antiviral medication. There is substantial interhospital variation in diagnostic and therapeutic management of a suspected infection. Comprehensive guidelines need to be developed to standardize management of suspected nHSV infection.

Variations in the Clinical Management of Multibacillary Leprosy Patients in Selected Hospitals in Metro Manila

Introduction. This paper documents the variations in the diagnosis and management of multibacillary leprosy patients in three of the biggest case-holding hospitals in Metro Manila. Furthermore, we aimed to discuss the implications of these variations on the country’s leprosy control and elimination program.&#x0D; Methods. Focus group discussions (FGD) were conducted with 23 health professionals composed of doctors and nurses with at least a year of experience in managing leprosy patients. The topics included procedures on patient diagnosis and management such as treatment duration, patient follow-up and definitions of treatment completion and default. The FGD participants provided suggestions to improve treatment compliance of patients. Their responses were compared with World Health Organization (WHO) standards and/or the 2002 DOH Manual of Operating Procedures (MOP) for leprosy. Transcripts of the recordings of the FGDs were prepared and thematic analysis was then performed.&#x0D; Results. There were variations in the hospitals’ procedures to diagnose leprosy, in treatment duration, and in patient follow-up. Definitions for treatment completion and default differed not just between hospitals but also with the WHO guidelines and the 2002 MOP. Hospitals extended treatment up to 24 or even 36 months, despite the 12 months stipulated in the MOP. Two hospitals required slit skin smear and skin biopsy in diagnosis, despite the MOP and WHO provisions that these were not mandatory. One hospital defined default as three consecutive months without treatment, which was different from the MOP and WHO standards and from the other hospitals.&#x0D; Conclusion. Given the variations in patient management, we recommended that effectiveness of the standard treatment relative to other regimens being practiced by specialists be evaluated.