Variation In Current Practice Research Articles

Contemporary Practice and Considerations for Real-World Data Source Identification and Feasibility Assessment.

There has been rapid growth in the variety and number of real-world data (RWD) sources, as well as the number of regulatory documents that provide guidance for assessing the suitability of RWD sources for pharmacoepidemiology studies. This study aims to assess differences in RWD guidance and variability in current practice for identifying and assessing RWD for studies with regulatory purpose. Key criteria for feasibility assessment were mapped against relevant regulatory guidance documents across US, EU, and Asia-Pacific regions. An online survey was designed and deployed to International Society for Pharmacoepidemiology members to understand current practice. Findings were summarized and used to inform key considerations and recommendations. Eleven RWD guidance documents were identified and mapped against 14 RWD assessment criteria. Variability was seen across these documents in guidance for these criteria. Between December 2022 and January 2023, 37 survey respondents reported having used RWD for post-marketing commitments (34, 92%) and/or background epidemiology (28, 76%). RWD were mostly identified through literature (33, 89%) and data landscaping (26, 70%); guidance documents referenced included: Food and Drug Administration (20, 54%), European Network for Centres for Pharmacoepidemiology and Pharmacovigilance (17, 46%), European Medical Agency (16, 43%), and Structured Process to Identify Fit-For-Purpose Data (11, 30%). Challenges for conducting feasibility assessments included RWD accessibility, ability to complete validation, and RWD provider responsiveness. Existing guidelines are used extensively by researchers, but key criteria for RWD identification and feasibility assessment are not reflected consistently and challenges remain. Recommendations have been made reflecting study findings.

Clinical Practices and Opinions toward Gastrostomy Use in Patients with Atypical Parkinsonian Syndromes: A National Survey in the UK.

Severe dysphagia poses a significant challenge for clinicians regarding feeding tube choices, practices, and timing due to a lack of evidence-based guidance. To assess national clinical practices and opinions on gastrostomy use in patients with atypical parkinsonian syndromes (APS) across the UK. Online survey was administered to clinicians and allied health professionals regarding availability of services, current use, perceived advantages, and problems associated with gastrostomy insertion. We received responses from 47 respondents across 12 UK centers, including 44 clinicians specialized in APS. Consensus was observed regarding primary indications for gastrostomy insertion and circumstances justifying avoidance of the procedure. Limitations in recommending gastrostomy due to insufficient evidence on safety and outcomes, survival and quality of life were identified. Widespread agreement on delays in gastrostomy discussions was highlighted as a challenge in optimizing patient care, together with variability in current practices and concerns over the lack of a standardized gastrostomy pathway, emphasizing the need for further research to address existing evidence gaps. This multi-center survey highlights agreement among clinicians on key aspects of indication, challenges, and limitations such as delayed decision-making and the absence of standardized pathways regarding the timing, method, and overall approach to gastrostomy insertion in APS. This study identified next steps to facilitate a more structured approach to future research toward a consensus on best practices for gastrostomy in APS. Addressing these challenges is crucial for enhancing patient outcomes and overall care quality in APS.

Quantifying the Variability of “Fixed-Width” Buffers on Harvested Lands in Western Oregon and Washington

Abstract In contemporary forest management, buffers of unharvested trees are left along streams to protect riparian and aquatic ecosystems. Buffer regulations often focus on specific minimum width requirements, which aid in straightforward regulation and application, but minimum widths also suggest buffered edges are uniform and contain little variability. Conceptual papers suggest that alternative buffer configurations may offer greater flexibility in landscape-level protection, increase forest complexity, and enhance aquatic and riparian biodiversity. However, before considering alternatives to fixed-width buffers, it is necessary to quantify the inherent variability in current buffer practices present on the landscape. In this study, we used aerial imagery to quantify variability of buffer widths in two hundred randomly selected recently harvested units on managed land in Oregon and Washington with both fish-bearing and non-fish-bearing sections of stream. Wider buffers on larger streams had a greater magnitude of variability, but when normalized by stream size, variation was greater in smaller streams, and overall, variation ranged from 25% to 50% of the mean width. Despite local variability, buffer widths rarely fell below 9.14 m (30 ft). The variation quantified here provides an initial measure of variability to inform future management, given emerging interest in variable retention buffers. Study Implications: In contemporary forest management, riparian and aquatic habitat protection usually relies on minimum buffer width regulations. Minimum requirements create the perception that buffered edges are uniform distances from streams containing little variability, so conceptual papers have suggested alternative buffer configurations with variable retention edges to enhance ecological benefits. However, there are several reasons why, in practice, buffer widths may vary substantially from minimum sizes within and across harvest units under current forest management, but this potential variation has not been quantified. Before considering alternative riparian management options, it is necessary to quantify and understand the inherent variability in current practices. By utilizing high-resolution aerial imagery and digital elevation models, we quantified buffer width variation. Using a set of two hundred recently harvested units, we demonstrate notable buffer width variation across managed Pacific Northwest forests. We attribute the variation in buffer widths to the presence of road crossings, tributary junctions, underlying valley slope and slope variation, and flexibility in regulations that may be overlooked in broad evaluations of strict minimum widths. Understanding fundamental information about buffer width variability provides information about current practices and provides a standard against which proposed increases in variability may be compared.

Protocol Variation in Functional Coronary Angiography Among Patients With Suspected Angina With Non-Obstructive Coronary Arteries: A Nationwide Snapshot of Current Practice Within Australia and New Zealand

Functional coronary angiography (FCA) for endotype characterisation (vasospastic angina [VSA], coronary microvascular disease [CMD], or mixed) is recommended among patients with angina with non-obstructive coronary arteries. Whilst clear diagnostic criteria for VSA and CMD exist, there is no standardised FCA protocol. Variations in testing protocol may limit the widespread uptake of testing, generalisability of results, and expansion of collaborative research. At present, there are no data describing protocol variation across an entire geographic region. Therefore, we aimed to capture current practice variations in the approach to FCA to improve access and standardisation for diagnosis of coronary vasomotor disorders in Australia and New Zealand. Between July 2022 and July 2023, we conducted a national survey across all centres in Australia and New Zealand with an active FCA program. The survey captured attitudes towards FCA and protocols used for diagnosis of coronary vasomotor disorders at 33 hospitals across Australia and New Zealand. Survey responses were received from 39 clinicians from 33 centres, with representation from centres within all Australian states and territories and both North and South Islands of New Zealand. A total of 21 centres were identified as having an active FCA program. In general, respondents agreed that comprehensive physiology testing helped inform clinical management. Barriers to program expansion included cost, additional catheter laboratory time, and the absence of an agreed-upon national protocol. Across the clinical sites, there were significant variations in testing protocol, including the technique used (Doppler vs thermodilution), order of testing (hyperaemia resistance indices first vs vasomotor function testing first), rate and dose of acetylcholine administration, routine use of temporary pacing wire, and routine single vs multivessel testing. Overall, testing was performed relatively infrequently, with very little follow-on FCA performed, despite nearly all respondents believing this would be clinically useful. This survey demonstrates, for the first time, variations in FCA protocol among testing centres across two entire countries. Furthermore, whilst FCA was deemed clinically important, testing was performed relatively infrequently with little or no follow-on testing. Development and adoption of a standardised national FCA protocol may help improve patient access to testing and facilitate further collaborative research within Australia and New Zealand.

Limited consensus on the diagnosis and treatment of lymphedema after head and neck cancer: results from an International Delphi study

Purpose To explore current practice variation and degree of consensus among international clinical experts regarding the diagnosis, classification, measurement, and treatment of head and neck lymphedema (HNL) after head and neck cancer treatment. Materials and Methods We conducted an online Delphi study. Eligible participants were clinical researchers who had (co)authored at least one publication on HNL and healthcare professionals who had treated at least five patients with HNL the last two years. The first round was to collect views about current best practices. The second and third rounds delved deeper into these topics using statements with 7-point adjective rating scales. Results An expert panel of seventeen participants (7 clinicians, 8 researchers, and 2 others) from 8 countries completed all rounds. Regarding diagnosis, there was limited consensus on most subjects, with palpation being most endorsed. No consensus was reached on the need to use standardized classification systems. As a treatment method, complex decongestive therapy (CDT) was the most commonly used in practice and investigated in the literature. However, no consensus was reached on the importance of aspects of CDT. Conclusions There is substantial intra- and international practice variation in the management of HNL. This calls for more robust evidence and guidelines.

Understanding the use and outcomes of high-flow nasal cannula among infants admitted to Canadian hospitals with bronchiolitis (CanFLO): a protocol for a multicentre, retrospective cohort study

IntroductionBronchiolitis is the most common viral lower respiratory tract infection in children under 2 years of age. Respiratory support with high-flow nasal cannula (HFNC) is increasingly used in this patient...

Is Ophthalmia Neonatorum Associated With Invasive Bacterial Infection? A Single-Center Retrospective Study.

Ophthalmia neonatorum (ON) is a conjunctivitis occurring in neonates and can be caused by multiple bacterial pathogens. The risk of invasive bacterial infection (IBI) in neonates with ON is poorly known. Our objectives were to document the association of ON with IBI in term neonates and to investigate practice variation. This was a retrospective observational study of all neonates who presented to a single emergency department (ED) between January 2018 and December 2019. Participants were all children with a final diagnosis of ON according to the treating physician as registered in the ED computerized database. Newborns with craniofacial malformations and premature infants were excluded. The primary outcome was IBI as defined by growth of any bacterial pathogen in the blood or cerebrospinal fluid. Perinatal risk factors, ED visit details (symptoms on presentation, management, and treatment plan) as well as complications (ocular morbidity, death, and unscheduled return visits) were collected. Data were analyzed using descriptive statistics. Fifty-two term neonates were included. There were no cases of IBI associated with ON (0%; 95% confidence interval [CI], 0%-6.9%). Six ocular bacterial infections were identified, one of which was Chlamydia trachomatis. Although there were no IBIs, ocular complications, deaths, or unscheduled return visits to the ED, there was a wide variation in physician's management of ON. Physicians ordered investigations in 49% (95% CI, 34%-62%) of neonates, prescribed antibiotics to 87% (95% CI, 74%-94%), and involved specialists in 39% (95% CI, 27%-52%) of cases. Emergency department presentations of term neonates with ON are associated with a low risk of IBI. A better understanding of the current practice variation is needed to inform clinical guidelines for the management of neonates with ON presenting to the ED.

Overcoming distance: an exploration of current practices of government and charity-funded critical care transport and retrieval organizations

BackgroundFor critically ill and injured patients, timely access to definitive care is associated with a reduction in avoidable mortality. Access to definitive care is significantly affected by geographic remoteness. To overcome this disparity, a robust critical care transport (CCT) or retrieval system is essential to support the equity of care and overcome the tyranny of distance. While critical care transport or retrieval systems have evolved over the years, there is no universally accepted system or standard, which has led to considerable variation in practices. The objective of this mixed-methods study was to identify and explore the current clinical, operational, and educational practices of government and charity-funded critical care transport and retrieval organizations operating across access- and weather- challenged geography.MethodsThis study utilized a mixed-methods approach comprising a rapid review of the literature and semi-structured interviews with identified subject matter experts (SME).ResultsA total of 44 articles and 14 interviews with SMEs from six different countries, 12 different services/systems, and seven operational roles, including clinicians (physician, paramedic, and nurse), educator, quality improvement, clinical governance, clinical informatics and research, operations manager, and medical director were included in the narrative analysis. The study identified several themes including deployment, crew composition, selection and education, clinical governance, quality assurance and quality improvement and research.ConclusionThis mixed-methods study underscores the paucity of literature describing current clinical, operational, and educational practices of government or charity-funded CCT or retrieval programs operating across access- and weather- challenged geography. While many common themes were identified including clearly defined mission profiles, use of dedicated or specialized transport teams, central coordination, rigorous selection processes, service-sponsored graduate education, and strong clinical governance, there is little consensus and considerable variation in current practices. Further research is needed to identify and harmonize best practices within the CCT and retrieval environments.

Variation in processes and reporting of cerebrospinal fluid oligoclonal banding and associated tests and calculated indices across Canadian clinical laboratories

ObjectivesMultiple sclerosis is diagnosed based on clinical and laboratory findings, including cerebrospinal fluid (CSF) oligoclonal banding (OCB) analysis. The lack of updated CSF OCB laboratory guidelines in Canada has likely led to variation in processes and reporting across clinical laboratories. As a first step to developing harmonized laboratory recommendations, we examined current CSF OCB processes, reporting, and interpretation across all Canadian clinical laboratories currently performing this test. Design and methodsA survey of 39 questions was sent to clinical chemists at all 13 Canadian clinical laboratories performing CSF OCB analysis. The survey included questions regarding quality control processes, reporting practices for CSF gel electrophoresis pattern interpretation, and associated tests and calculated indices. ResultsThe survey response rate was 100%. Most (10/13) laboratories use ≥2 CSF-specific bands (2017 McDonald Criteria) as their CSF OCB positivity cut-off and only 2/13 report the number of bands with every report. Most (8/13 and 9/13) laboratories report an inflammatory response pattern and monoclonal gammopathy pattern, respectively. However, the process for reporting and/or confirming a monoclonal gammopathy varies widely. Variation was observed for reference intervals, units, and the panel of reported associated tests and calculated indices. The maximum acceptable time interval between paired CSF and serum collections varied from 24 h to no limit. ConclusionsProfound variation exists in processes, reporting, and interpretation of CSF OCB and associated tests and indices across Canadian clinical laboratories. Harmonization of CSF OCB analysis is required to ensure continuity and quality of patient care. Our detailed assessment of current practice variation highlights the need for clinical stakeholder engagement and further data analysis to support optimal interpretation and reporting practices, which will aid in developing harmonized laboratory recommendations.

Fluid Management for Critically Ill Patients with Acute Kidney Injury Receiving Kidney Replacement Therapy: An International Survey.

In critically ill patients receiving KRT, high ultrafiltration rates and persistent fluid accumulation are associated with adverse outcomes. The purpose of this international survey was to evaluate current practices and evidence gaps related to fluid removal with KRT in critically ill patients. This was a multinational, web-based survey distributed by seven networks comprising nephrologists and intensivists. Physicians involved in the care of critically ill patients were invited to complete a 39-question survey about fluid management practices on KRT. The survey was distributed from September 2021 to December 2021. There were 757 respondents from 96 countries (response rate of 65%). Most respondents practiced adult medicine (89%) and worked in an academic center (69%). The majority (91%) reported aiming for a 0.5- to 2-L negative fluid balance per day when fluid removal is indicated, although there was important variability in what respondents considered a safe maximal target. Intensivists were more likely than nephrologists to use adjunct volume status assessment methods ( i.e. , ultrasound, hemodynamic markers, and intra-abdominal pressure), while nephrologists were more likely to deploy cointerventions aimed at improving tolerance to fluid removal ( i.e. , osmotic agents and low-temperature dialysate). There was a broad consensus that rapid decongestion should be prioritized when fluid accumulation is present, but the prevention of hypotension was also reported as a competing priority. A majority (77%) agreed that performing trials that compare fluid management strategies would be ethical and clinically relevant. We have identified multiple areas of variability in current practice of fluid management for patients receiving KRT. Most nephrologists and intensivists agreed that several knowledge gaps related to fluid removal strategies should be investigated in future randomized controlled trials.

Practice variation in re-resection for recurrent glioblastoma: A nationwide survey among Dutch neuro-oncology specialists.

Despite current best treatment options, a glioblastoma almost inevitably recurs after primary treatment. However, in the absence of clear evidence, current guidelines on recurrent glioblastoma are not well-defined. Re-resection is one of the possible treatment modalities, though it can be challenging to identify those patients who will benefit. Therefore, treatment decisions are made based on multidisciplinary discussions. This study aimed to investigate the current practice variation between neuro-oncology specialists. In this nationwide study among Dutch neuro-oncology specialists, we surveyed possible practice variation. Via an online survey, 4 anonymized recurrent glioblastoma cases were presented to neurosurgeons, neuro-oncologists, medical oncologists, and radiation oncologists in The Netherlands using a standardized questionnaire on whether and why they would recommend a re-resection or not. The results were used to provide a qualitative analysis of the current practice in The Netherlands. The survey was filled out by 56 respondents, of which 15 (27%) were neurosurgeons, 26 (46%) neuro-oncologists, 2 (4%) medical oncologists, and 13 (23%) radiation oncologists. In 2 of the 4 cases, there appeared to be clinical equipoise. Overall, neurosurgeons tended to recommend re-resection more frequently compared to the other specialists. Neurosurgeons and radiation oncologists showed opposite recommendations in 2 cases. This study showed that re-resection of recurrent glioblastoma is subject to practice variation both between and within neuro-oncology specialties. In the absence of unambiguous guidelines, we observed a relationship between preferred practice and specialty. Reduction of this practice variation is important; to achieve this, adequate prospective studies are essential.

Multilateralism in the Twenty-First Century

The rise of geostrategic rivalry between the United States and China is changing international cooperation. As China seeks new influence and the United States seeks to contain China and to reduce its own international obligations, three dimensions of multilateralism are becoming particularly important. The first is the management of the superpower rivalry, through formal treaties, informal arrangements among states, and international institutions. The second is the capacity of the leadership of any international institution to foster cooperation beyond the immediate preferences of one or another of the most powerful member states. The third dimension is the legitimacy on which the authority of international institutions rests. The evolution of these three elements will shape the future of multilateralism, by which I refer to the arrangements created and agreed by states which facilitate cooperation by enshrining commitments to diffuse reciprocity and peaceful dispute settlement. The analysis of history and of variations in current practice in international cooperation underscores several ways in which international cooperation could be sustained even as the US-China rivalry strengthens. Global agencies can play a crucial role finding and highlighting areas where cooperation and competition can coexist, and where their own capacities to pool information, to reduce transactions costs, and to broker and monitor agreements can assist. This, in turn, requires high-quality leadership by people who can effectively broker agreements among countries, persuade countries to pool resources, and attract and organize an effective and highly motivated staff. Such leadership requires positive ongoing action by member states, to define what is required for effective leadership of the institutions they collectively create, to seek proven competence in each domain before appointing leaders, and to monitor ongoing performance. Finally, international institutions can buttress their legitimacy by finding better ways to ensure the participation of all stakeholders, and to respond rapidly and effectively to global crises and to provide global public goods.

Using the Neonatal Intensive Care Unit Wisely: A National Survey of Clinicians Regarding Practices for Lower-Acuity Care.

The objective of this study was to document the practices and preferences of neonatal care stakeholders regarding location and duration of care for newborns with low illness acuity. We developed a survey instrument that comprised 14 questions across 2 global scenarios and 7 specific clinical conditions. The latter included apnea of prematurity, gestational age for neonatal intensive care unit admission, jaundice, neonatal opioid withdrawal, thermoregulation, and sepsis evaluation. Respondents reported their current practice and preferences for an alternative approach. We administered the survey to individuals in the membership email distribution lists of the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine, the National Association of Neonatal Nurses, and the Vermont Oxford Network. Of 2284 respondents, 53% believed that infants were, in general, admitted to a higher level of care than was required, and only 13% reported that the level of care was too low. Length of stay was perceived to be generally too long by 46% of respondents and too short by 21%. Across 10 specific clinical questions, there was substantial variability in current practice and up to 35% of respondents reported discordance between current and preferred practice. These respondents preferred a lower level of care in 8 of 10 scenarios. A multidisciplinary sample of US clinicians reported significant variation in the level and duration of care for infants with low illness acuity. Among individuals reporting discordance between current and preferred practice, a majority believed that current management could be accomplished in a lower level of care location.

Optimal delivery of aerosolized medication to mechanically ventilated pediatric and neonatal patients: A scoping review.

Delivering aerosolized medication to patients during mechanical ventilation is a common practice in respiratory therapy for adult, pediatric, and neonatal populations. However, aerosol delivery in pediatric populations is inconsistent and challenging, impacting how the drug is delivered. Some factors that influence drug delivery efficiency are directly under the purview of the clinician or therapist administering the drugs. However, excessive variability exists amongst clinicians and therapists working at the same site and between different sites. This review aims to systematically summarize the literature to identify current practice variations, identify common practices, and provide suggestions to guide future research in this area. In addition, this scoping review aims to identify the available evidence and knowledge gaps in the literature regarding the delivery of aerosolized medication to pediatric populations during mechanical ventilation. More specifically, the question that guided our research was: What are the best strategies for optimizing aerosol delivery of medication to pediatric patients, including neonates, while on mechanical ventilation? A scoping review, using the Joanna Briggs Institute methodology, was conducted until September 2022 in the CINAHL, EMBASE (Ovid), and Medline (Ovid) databases. Our initial search yielded 248 articles. After screening the titles, abstracts, and full text of the articles according to inclusion and exclusion criteria, five articles were analyzed. We identified three main topics for discussion: the type of device used for administering aerosolized medication, appropriate mechanical ventilation settings, and optimal placement of the nebulizer delivery system. Of the three topics we intended to discuss, we only found enough evidence to suggest using mesh nebulizers to increase aerosol deposition. We found conflicting or outdated results for the other two topics. This demonstrates a significant gap in the literature since aerosol medications are routinely administered to mechanically ventilated neonatal and other pediatric patients.

Supportive Care Strategies in Myelodysplastic Syndromes and Acute Myeloid Leukemia in Older Adults: A National Survey of Canadian Hematologists

BACKGROUND: Myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML) represent a spectrum of severe myeloid disorders characterized by marrow failure, cytopenias, and complications related to bleeding and infection. Due to patient and disease factors, many patients are treated with less-intensive therapy, such as transfusion support, erythropoietin stimulating agents, luspatercept, lenalidomide and hypomethylating agents. However, optimal supportive care strategies to minimize bleeding and infectious complications among older adults receiving less intensive therapy have not been systematically evaluated. OBJECTIVES: The objectives of the survey were to: a) evaluate self-reported use of tranexamic acid (TXA) and antimicrobial prophylaxis; b) identify perceived barriers and facilitators to the use of TXA and antimicrobial prophylaxis; c) characterize the degree of uncertainty regarding the benefits and harms of TXA and prophylactic antimicrobials in this patient population; and d) assess physician interest in future clinical trials of TXA and/or prophylactic antimicrobials. METHODS: We conducted a national cross-sectional survey of Canadian hematologists to explore current practice variation regarding the use of TXA and prophylactic antimicrobials in patients with MDS and AML treated with less intensive therapy, and evaluate equipoise for future trials. Survey items were generated iteratively through a combination of literature review and discussion with content experts until thematic saturation was achieved. The questionnaire was pilot-tested by collaborators prior to dissemination to assess the required completion time and provide feedback on flow, clarity, redundancy and comprehensiveness. The electronic platform REDCap was used to create and disseminate the survey tool. The survey was distributed to all hematologists affiliated with a Canadian university, representing both key knowledge users and potential participants in an investigative network for future clinical trials. RESULTS: The survey response rate was 52% (159/304 invited participants). Of the 159 hematologists, 105 indicated that they treated MDS/AML patients with less intensive therapy and responded to the further questions about this patient population. Most (97/105; 92%) hematologists worked in an academic/tertiary care setting; 8% (n=8/105) worked in a community setting. Prophylactic TXA was used by 57% (n=60/105) of hematologists; the most frequent reason for not using TXA was uncertainty about the benefits or harms. Nearly all (95%; 100/105) hematologists agreed that a trial of TXA is needed (n=78), or potentially needed (n=22). Use of prophylactic antimicrobials varied by the chemotherapy treatment regimen. The most frequently prescribed antibacterials were fluroquinolones (36% of respondents; n=38), trimethoprim/sulfamethoxazole (9%; n=9), and amoxicillin-clavulanate (5%; n=5). The most commonly used antifungals were fluconazole (35% of respondents; n=37) and voriconazole (19%; n=20). Valacyclovir (29% of respondents; n=30) and acyclovir (15%; n=16) were the antivirals prescribed. The most common reason for not using prophylactic antimicrobials was an insufficient level of evidence (70%; n=73). The majority (78%, n=82) of respondents agreed that a trial is needed to evaluate optimal antimicrobial prophylaxis in this at-risk patient population. CONCLUSIONS: Among survey respondents, there was variation in the use of supportive case strategies to address bleeding and infection risk in older adults with MDS/AML. Most hematologists who treat MDS/AML with less intensive therapy felt that clinical trials are needed to define the use of TXA and prophylactic antimicrobials in this patient population.

67 Is Ophthalmia Neonatorum associated with Invasive Bacterial Infection? A single centre retrospective study

Abstract Background The immature immune system of neonates puts them at an increased risk of invasive bacterial infections (IBI). Ocular complications due to ophthalmia neonatorum (ON) are well described, unlike the association with IBI for which only case reports of ON with bacteremia and meningitis are documented. The risk of IBI in neonates with ophthalmia neonatorum (ON) is poorly known and part of the issue is the lack of clinical data. Objectives Our objective was to document the association of ON with IBI. Design/Methods This is a retrospective observational chart review of all afebrile neonates who presented to a single emergency department (ED) between January 2018 and December 2019 and were diagnosed with ON. Newborns with craniofacial malformations and premature infants were excluded. The primary outcome was IBI as defined by growth of any bacterial pathogen in the blood or cerebrospinal fluid. Perinatal risk factors, ED visit details (symptoms on presentation, management and treatment plan) as well as complications (ocular morbidity, death and unscheduled return visits to the ED) were collected. Data were analyzed using descriptive statistics. Results Fifty-two neonates were included in this retrospective review. There were no case of IBI associated with ON (0%, 95%CI 0-6.9%). Six ocular bacterial infections were identified, one of which was C trachomatis. Although there was no IBI, ocular complications, death or unscheduled return visits to the ED, there was a wide variation in physician management of ON. Physicians performed at least para-clinical investigation in 49% (95%CI: 34-62%) of neonates, prescribed antibiotics to 87% (95% CI: 74-94%) and involved specialists in 39% (95%CI: 27-52%) of cases. Most neonates were discharged home (92%; 95%CI: 81-98%) and three neonates (6%; 95%CI: 1-16%) were admitted to the hospital following their ED visit. Conclusion ED presentations of afebrile neonates with ON are associated with a low risk of IBI. A better understanding of the current practice variation is needed to inform clinical guidelines for the management of term neonates with ON presenting to the ED.

Application of Component Separation and Short-Term Outcomes in Ventral Hernia Repairs

IntroductionComponent separation (CS) techniques have evolved in recent years. How surgeons apply the various CS techniques, anterior component separation (aCS) versus posterior component separation (pCS), by patient and hernia-specific factors remain unknown in the general population. Improving the quality of ventral hernia repair (VHR) on a large scale requires an understanding of current practice variations and how these variations ultimately affect patient care. In this study, we examine the application of CS techniques and the associated short-term outcomes while taking into consideration patient and hernia-specific factors. MethodsWe retrospectively reviewed a clinically rich statewide hernia registry, the Michigan Surgical Quality Collaborative Hernia Registry, of persons older than 18 y who underwent VHR between January 2020 and July 2021. The exposure of interest was the use of CS. Our primary outcome was a composite end point of 30-d adverse events including any complication, emergency department visit, readmission, and reoperation. Our secondary outcome was surgical site infection (SSI). Multivariable logistic regression examined the association of CS use, 30-d adverse events, and SSI with patient-, hernia-, and operative-specific variables. We performed a sensitivity analysis evaluating for differences in application and outcomes of the posterior and aCS techniques. ResultsA total of 1319 patients underwent VHR, with a median age (interquartile range) of 55 y (22), 641 (49%) female patients, and a median body mass index of 32 (9) kg/m2. CS was used in 138 (11%) patients, of which 101 (73%) were pCS and 37 (27%) were aCS. Compared to patients without CS, patients undergoing a CS had larger median hernia widths (2.5 cm (range 0.01-23 cm) versus 8 cm (1-30 cm), P < 0.001). Of the CS cases, 49 (36%) performed in hernias less than 6 cm in size. Following multivariate regression, factors independently associated with the use of a CS were diabetes (odds ratio [OR]: 2.00, 95% confidence interval [CI]: 1.19-3.36), previous hernia repair (OR: 1.88, 95% CI: 1.20-2.96), hernia width (OR: 1.28, 95% CI: 1.22-1.34), and an open approach (OR: 3.83, 95% CI: 2.24-6.53). Compared to patients not having a CS, use of a CS was associated with increased odds of 30-d adverse events (OR: 1.88 95% CI: 1.13-3.12) but was not associated with SSI (OR: 1.95, 95% CI: 0.74-4.63). Regression analysis demonstrated no differences in 30-d adverse events or SSI between the pCS and aCS techniques. ConclusionsThis is the first population-level report of patients undergoing VHR with concurrent posterior or aCS. These data suggest wide variation in the application of CS in VHR and raises a concern for potential overutilization in smaller hernias. Continued analysis of CS application and the associated outcomes, specifically recurrence, is necessary and underway.

Variation in the use of infection control measures and infection-related revision incidence after breast implant surgery in the Netherlands

The use and effect of most infection control measures (ICMs) in breast implant surgery are still debated, likely resulting in undesired variation in current practices. This study investigated the relationship between the number and combinations of ICMs used and the infection-related revision incidence after breast implant surgery. Additionally, national variation between Dutch healthcare institutions in ICM use was evaluated. For this multicentre, population-based study, all patients who received a primary breast implant or tissue expander for breast augmentation or reconstruction between 2015 and 2019 were identified from the Dutch Breast Implant Registry. Seven prospectively collected ICMs were investigated: preoperative antibiotics, implant and/or pocket irrigation, glove change, nipple guards, insertion sleeve, postoperative drains, and postoperative antibiotics. This study included 52,415 implants (85% augmentation, 15% reconstruction).The median (IQR) number of ICMs used was 3 (3-4) for augmentation and 4 (4-5) for reconstruction. Median follow-up was 30 months for augmentation and 34 months for reconstruction. Infection-related revision incidence was 0.1% for augmentation and 2.1% for reconstruction. Most infection-related revisions occurred within 2 months for augmentation and 2.5 months for reconstruction. The impact of ICM use on infection-related revision incidence remained unclear, given its low incidence. A significant variation was observed between institutions in the use of postoperative antibiotics and drains. Although the use of different ICMs varied considerably between institutions, the infection-related revision incidence after breast implant surgery was generally low. Most surgeons used four ICMs for breast reconstruction and three ICMs for breast augmentation. Further studies on the causes and effects of the observed variation are needed.

Current practice, education and recommendations for training of central line insertion for trainees and fellows in adult intensive care units across Australia and New Zealand.

Central venous access device (CVAD) is a common procedure in ICU which, although generally safe, can lead to acute and delayed complications. Training and accreditation process for its insertion vary worldwide. The objective of this study was to explore variability in existing training and accreditation processes for central venous access device (CVAD) insertion among different intensive care units (ICU), current practices of CVAD insertion among fellows of the College of Intensive Care Medicine (CICM) working in Australia and New Zealand (ANZ) and their recommendations for improvement. A prospective cross-sectional web-based survey was sent through email and CICM e-newsletter to intensivists and directors of ICU across ANZ. All responses were tabulated, post-hoc exploratory analysis using multivariable ordinal logistic regression was used and free texts were analysed thematically and summarised. A total of 115 responses was received from various public and private ICU from all states of ANZ; 32% of the participants did not have any accreditation process for CVAD insertion skill in their ICU, whereas 91% of respondents revealed there were no processes to assess deskilling. Most intensivists recommended supervision, simulation, various education tools and ultrasound training to improve training and assessment. Thirty-five percent of the participants inserted 0-5 CVAD and more than half of the intensivists had inserted <10 CVAD in a 1-year period. Two-thirds of the respondents recommended inserting between 6 and 20 CVAD each year to maintain competence. The study identified wide variability in current practice, training methods and accreditation process for CVAD insertion among intensivists and ICU trainees in ANZ. Policy makers should consider revising the current clinical practice and training policies to new policies for accreditation and ongoing assessment for CVAD insertions across ANZ ICU.

Current management of secondary progressive multiple sclerosis in the UK: a multiple sclerosis specialist nurse perspective

Secondary progressive multiple sclerosis is a complex and multifaceted condition often characterised by a progressive worsening of neurological disability, independent of relapses, that follows an initial relapsing–remitting course. This article discusses the current management of this condition from a nursing perspective, highlighting some of the recent service-level and disease-specific challenges faced by specialist nurses involved in the diagnosis and management of secondary progressive multiple sclerosis. The review also considers ways the multiple sclerosis community can work together to maximise opportunities to optimise patient outcomes. This includes improving working relationships within clinical teams and defining clearer referral pathways when disease progression is suspected, embracing technology, as well as addressing recent evidence demonstrating variability in current practices for diagnosing secondary progressive multiple sclerosis and communicating diagnoses to patients.