Wide Variation In Practice Research Articles

Assessment of Quality Management Practices across Asian Countries

Background and Objectives: Globally, there is a wide variation in Quality management practices and availability of Quality Standards. Because of a paucity of data on QM practices in BTS in various Asian countries, this study was undertaken to understand the quality assurance (QA) programme within the blood bank settings. Methods: The study was conducted by the Quality Working Group of Asian Association of Transfusion Medicine (AATM), by an online questionnaire having 25 questions which were circulated amongst various blood centres of member Countries of Asian Association of Transfusion Medicine (AATM). Results: 60 blood centres participated. 43 were Hospital based Blood Centres and 17 were from Stand-alone Blood Centres. The majority of the responders were from a tertiary care hospital (92%). More than 83% of blood centres, either accredited or planning to move forward, were conducting internal audits, more than 86% were having Quality policy and QMS. Conclusion: It is evident from this study that blood centres, by and large, maintain good practices as they are under the purview of regulatory bodies of the respective countries and hence follow Good Manufacturing Practices (GMP). As the Asian countries come under the LMIC category; hence the financial cost could be a major hindrance in achieving quality standards, but few extra miles to achieve quality standards or accreditation will ultimately lead to better patient care.

Provider’s perspectives regarding transitional urologic care process: A scoping review

ObjectiveTo generate a scoping review that summarizes perceptions and attitudes of urology providers towards the transitional urologic care process. Likewise, summarize their identified barriers, facilitators, and ideal transition care for patients with genitourinary conditions. MethodA systematic literature search was performed in Oct 2021. Records were identified for studies relevant to assessing urology specialists' practice variation, perception of barriers, and attitudes toward transitional care of patients needing life-long urologic care. The methodological quality of the cross-sectional studies was assessed using AXIS. The information extracted was clustered according to identified themes from the included studies. This scoping review was part of a systematic review registered on PROSPERO-(CRD42022306229). ResultsA total of 641 records were retrieved from electronic medical databases and cross-referencing. Ultimately, ten studies were included in this scoping review, conducted in the USA (n = 7), Canada, United Kingdom, and Italy. There is a wide variation in transitional care practices and preferences. However, the common themes extracted were: appropriate age to start the transition, additional training of the providers involved in transitional care, common transition plans, and practices, characteristics of multidisciplinary teams, potential barriers, areas of improvement, or facilitators for a better transitional process. ConclusionCommon to all reports, multiple barriers are perceived. Areas that require improvement and multidisciplinary systems are needed to enhance urologic transition care. In addition, factors such as the age cut-off between pediatric and adult care or which specialist should handle specific procedures and conditions before, during, and after transition are still unclear and typically depend on the stakeholders.

Geographic variation in induction of labor at 39-weeks in low-risk nulliparas across the United States

To investigate geographic variation in induction of labor (IOL) at 39-weeks gestation in low-risk nulliparas across the U.S. Data was collected from 2020 U.S. Vital Statistics birth certificates. Inductions and cesarean deliveries (CD) were examined in “low-risk” term (39-42 weeks of gestation) nulliparas, where “low-risk” was defined as patients without gestational or pre-gestational diabetes, chronic hypertension, or hypertensive disorders of pregnancy whose neonate was a vertex-presenting, non-anomalous singleton with birthweight 2500 to 5000 grams. We analyzed variation in 39-week induction rates in this population and whether this varied by various geographic regions, including the states, census divisions, and metro and urban characterization. We explored whether this variation was correlated to variation in cesarean delivery using Spearman Correlation testing. P-values < 0.05 were considered statistically significant. Rates of overall induction of labor at 39-42 weeks varied widely, from 14.2% to 59.1% across states (median 39.8%; IQR 37.0-49.0%). Similarly, rates of labor induction at 39 weeks specifically varied across states from 6.8% to 38.3% (median 17.9%; IQR 12.9-23.4%). Total induction rates and 39-week inductions rates were highly correlated across states (weighted Spearman correlation coefficient 0.90; p< 0.01) (Figure). Cesarean deliveries varied across states from 15.5% to 28.1%; however, this variation was not correlated with the variation in either total or 39-week inductions (p=0.61 and p=0.17, respectively). There was wide variation in 39-week induction rates at every geographic level (Table), varying up to 3-fold across census division from 9.7% in the Pacific to 30.2% in the East South Central. There is significant variation in rates of induction of labor at 39-weeks in low-risk nulliparous patients across the US. While this did not appear to correlate with variation in cesarean delivery, the reasons for this wide practice variation and implications on health and resource utilization should be further explored.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Fluid and electrolyte management in preterm infants with patent ductus arteriosus.

Optimal fluid management of preterm babies with suspected or confirmed diagnosis of patent ductus arteriosus (PDA) is frequently challenging for neonatal care physician because of paucity of clinical trials. There is wide variation in practice across neonatal units, resulting in significant impact on outcomes in Extremely Low Birth Weight (ELBW) babies with hemodynamically significant PDA. A delicate balance is required in fluid management to reduce mortality and morbidity in this population. The purpose of this review is to lay out the current understanding about fluid and electrolyte management in ELBW babies with hemodynamically significant PDA and highlight areas for future research.

Continuous Kidney Replacement Therapy Practices in Pediatric Intensive Care Units Across Europe

Continuous kidney replacement therapy (CKRT) is the preferred method of kidney support for children with critical illness in pediatric intensive care units (PICUs). However, there are no data on the current CKRT management practices in European PICUs. To describe current CKRT practices across European PICUs. This cross-sectional survey of PICUs in 20 European countries was conducted by the Critical Care Nephrology Section of the European Society of Pediatric and Neonatal Intensive Care from April 1, 2020, to May 31, 2022. Participants included intensivists and nurses working in European PICUs. The survey was developed in English and distributed using SurveyMonkey. One response from each PICU that provided CKRT was included in the analysis. Data were analyzed from June 1 to June 30, 2022. Demographic characteristics of European PICUs along with organizational and delivery aspects of CKRT (including prescription, liberation from CKRT, and training and education) were assessed. Of 283 survey responses received, 161 were included in the analysis (response rate, 76%). The attending PICU consultant (70%) and the PICU team (77%) were mainly responsible for CKRT prescription, whereas the PICU nurses were responsible for circuit setup (49%) and bedside machine running (67%). Sixty-one percent of permanent nurses received training to use CKRT, with no need for certification or recertification in 36% of PICUs. Continuous venovenous hemodiafiltration was the preferred dialytic modality (51%). Circuit priming was performed with normal saline (67%) and blood priming in children weighing less than 10 kg (56%). Median (IQR) CKRT dose was 35 (30-50) mL/kg/h in neonates and 30 (30-40) mL/kg/h in children aged 1 month to 18 years. Forty-one percent of PICUs used regional unfractionated heparin infusion, whereas 35% used citrate-based regional anticoagulation. Filters were changed for filter clotting (53%) and increased transmembrane pressure (47%). For routine circuit changes, 72 hours was the cutoff in 62% of PICUs. Some PICUs (34%) monitored fluid removal goals every 4 hours, with variation from 12 hours (17%) to 24 hours (13%). Fluid removal goals ranged from 1 to 3 mL/kg/h. Liberation from CKRT was performed with a diuretic bolus followed by an infusion (32%) or a diuretic bolus alone (19%). This survey study found a wide variation in current CKRT practice, including organizational aspects, education and training, prescription, and liberation from CKRT, in European PICUs. This finding calls for concerted efforts on the part of the pediatric critical care and nephrology communities to streamline CKRT education and training, research, and guidelines to reduce variation in practice.

Knowledge, Attitude and Practice on Dental Sedation among Pediatric Dentists in Nepal

Introduction: Recent years have evidenced an increase in the use of sedation in children for their dental treatment, with a wide variation in the global practice among the pediatric dentists. Objective: The purpose of this study was to assess the knowledge, attitude, and practice on dental sedation amongst the pediatric dentists of Nepal. Methods: This was an online-based questionnaire survey conducted from May to June 2021 among 29 pediatric dentists practicing in Nepal using a census sampling. Data were analyzed and presented in percentage, mean, and standard deviation along with charts and tabular forms. Results: Majority of the respondents 26 (89.7%) had adequate knowledge and 22 (76%) had adequate practice on sedation with a total positive mindset. The mean (Mean ± Standard Deviation) scores for knowledge, attitude, and practice were 3.759 ± 0.9124, 6.897 ± 1.1131, and 3.414 ± 1.3501, respectively. Nineteen (65.5%) of them practiced dental sedation that included general anesthesia, oral, inhalational, intravenous and intra-nasal routes. Conclusions: The study showed satisfactory knowledge, attitude, and practice of dental sedation among the pediatric dentists in Nepal. There was lack of training on emergency skills and formal sedation courses other than for inhalational sedation among the participants, and these were cited as the major barriers to their practice along with lack of adequate facilities. Hence, regular conduction of sedation trainings and life support skills targeting the pediatric dentists in Nepal is deemed essential.

Blood and coagulation product disposition in the modern era: An international multicenter survey endorsed by the European Association of Cardiothoracic Anesthesiology and Intensive Care (EACTAIC)

Study objectivePerioperative transfusion is associated with reduced survival and increased morbidity and mortality. Several studies report wide variation in clinical transfusion practice. However, the influence of simple, practical factors–such as which blood products are available, and when - is often disregarded. We hypothesized that these practical issues are relevant confounders of transfusion decisions.DesignWeb-based survey.SettingMulti-institutional.ParticipantsMembers of the European Association of Cardiothoracic Anesthesiology and Intensive Care (EACTAIC) society reached by monthly newsletter in November 2020.InterventionsNo interventions.MeasurementsSurvey responses.Main resultsThe newsletter was opened by 429 members. We collected 51 complete surveys, resulting in a response rate of 11.9%. 72% of participants reported having a local algorithm for the use of blood products and coagulation factors. Latency in the time of blood product delivery / availability and the possibility to store or return unused products were most often reported as having an influence on transfusion practice. For point-of-care test availability, 86% of addressees reported rotational thromboelastometry / -elastography, 76% hemoglobin tests, 24% international normalized ratio (INR) measurement and 22% platelet function testing. Six percent of the respondents did not have access to point-of-care tests. The majority of addressees reported that they were able to obtain more than 10 allogeneic blood products simultaneously (63%). Packed red blood cells were available with a delay of 10–15 min and platelets with a delay of 15–20 min.ConclusionsOur survey indicates a wide variability in the logistics of perioperative transfusion practice. The information gained could provide a solid basis for future improvements of the guidelines, but also in local transfusion practices.

Botulinum toxin in the management of myalgia in temporomandibular disorders: are all injections equal?

Botulinum toxin (BTX) is becoming widely used as an adjunct to conservative management of myalgia-predominant temporomandibular disorders (TMDs) with reports of improved quality of life. There is, however, no consensus on the optimal dosage. Based on previous studies, dose regimens vary between clinicians, and we know of no standard dose protocol for the administration of BTX for the purpose of TMD management. A survey was sent to members of the British Association of Oral and Maxillofacial Surgeons (BAOMS) Temporomandibular Joint Sub-Specialty Interest Group (TMJ SSIG) and an international mailing list of high-volume TMJ surgeons (the TMJ Internetwork) to ascertain variations in dose regimens between different clinicians. The survey found that 41 respondents offered BTX to patients. The masseter muscle group was the most commonly injected site, and the majority of respondents (34/41) used Botox® (Allergan). Brands less commonly used included Dysport® (Ipsen), and Xeomin® (Merz Pharma). Botox® doses varied between 30 and 100 units, whilst Dysport® doses ranged from 50 - 300 units/muscle. The number of injection sites/muscle also varied. This survey demonstrates the wide variation in practice amongst clinicians with respect to BTX administration. To ensure optimal dose and response titration, further studies and evidence-based research are needed to standardise its use for the treatment of TMDs.

Autologous Peripheral Blood Stem Cell Mobilisation Techniques, Stem Cell Yields and Practice Variation-By-Country in Patients with Myeloma Undergoing First Autologous Stem Cell Transplants in EBMT Centres between 2012 and 2021

The techniques employed to mobilise autologous peripheral blood stem cells in patients with myeloma have evolved over time and vary between countries. The most common methods are (1) Cyclophosphamide and Granulocyte - Colony Stimulating Factor (G-CSF) (Cyclophosphamide), (2) G-CSF only, (3) G-CSF and Plerixafor, and (4) Other. In general, chemotherapy, usually Cyclophosphamide, is used in Europe and single agent G-CSF in North America. We performed a retrospective analysis of the EBMT database to analyse stem cell mobilisation techniques in European patients undergoing a first ASCT for myeloma over the last decade. This data was available on a select cohort of patients for whom Med B form data had been submitted. A total of 76,923 patients received a first autologous stem cell transplant for myeloma in 501 EBMT-affiliated centres between 2012 and 2021. Detailed Stem cell mobilization data including CD34 results were available on 4,710 (M 58%: F 42%) patients from 87 centers. The Median (IQR) age was 61.3 (54.7-66.1) years. MM subtypes were IgG, IgA, Light Chain and Other in 56.6%, 19.2%, 20.8% and 3.4%, respectively. The stage at first transplant was CR, VGPR/PR, SD/MR, and Rel/Prog in 17.5%, 78.4%, 2.8% and 1.3%, respectively. The frequency of use of each of the stem cell mobilization techniques were as follows: Cyclophosphamide (n=3,017, 67.1%), G-CSF only (n=1,207, 26.9%), G-CSF + Plerixafor (n=222, 4.9%) and Other (47, 1.0%). Peripheral blood stem cells were the sole stem cell source in 4,705 (99.9%) of the transplants. The comparative median annual CD34 yields (x10e6/kg) are shown below and reveal that the yields following Cyclophosphamide-based mobilization were consistently higher (6.14-7.8) than those following either G-CSF (4.46-6.1) or G-CSF and Plerixafor (2.5-5.6). When analyzed in aggregate, the median (IQR) stem cell yields (x10e6/kg) following Cyclophosphamide, G-CSF, G-CSF and Plerixafor, and Other were 7.32 (4.9-10.14), 5.25 (3.88-7.38), 4.94 (3.42-6.85) and 4.9 (3.82-7.54), respectively. When analysed by MM subtype, there was no significant difference in yield between the IgG, IgA, Light Chain and Other categories (p=0.523). We next analyzed the median annual CD34 yields (x10e6/kg) by induction regimen (no. of pts): CTD (Cyclophosphamide, Thalidomide, Dexamethasone) (n=712) 7.56, Other (n=623) 5.86, PAD (Bortezomib, Adriamycin, Dexamethasone) (n=256) 5.8, VAD (Vincristine, Adriamycin, Dexamethasone) (n=172) 5.03, VCD (Bortezomib, Cyclophosphamide, Dexamethasone) (n=1,735) 6.21, VD (Bortezomib, Dexamethasone) (n=603) 5.97, VRD (Bortezomib, Lenalidomide, Dexamethasone) (n=811) 5.42 and VTD (Bortezomib, Thalidomide, Dexamethasone) (n=3,192) 7.12 (p<0.001), the highest yields being collected following CTD and VTD (<0.001). We finally examined mobilization trends in the seven largest countries in the dataset (France, Germany, Italy, the Netherlands, Spain, Turkey, and the United Kingdom) over time. Data was available for between 9.6% and 22.8% of patients in 6 of the 7 countries; however, it was only available in 2.9% of patients from Germany. Within these clear limitations, there were wide national variations in clinical practice both over time and between countries, as shown below. Over the last decade, two-thirds of patients in EMBT centres underwent autologous stem cell collection following Cyclophosphamide and G-CSF, one quarter following single agent G-CSF and 5% following G-CSF and Plerixafor. As reported previously, yields were consistently higher following chemotherapy-based mobilization. However, we have no data on associated morbidity such as the incidence of infection, the need for hospital admission or costs. As regards the effect of prior induction regimens, the highest yields were seen in patients who had received either CTD or VTD induction, possibly reflecting less stem cell toxicity due to chemotherapy and/or deeper remissions following these regimens. Finally, limited data on trends in practice appears to show considerable variation between countries combined with significant changes in some countries over the last decade. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Timing and Type of Venous Thromboembolic Chemoprophylaxis Is Associated with Acute Traumatic Brain Injury Outcomes.

Venous thromboembolic (VTE) prophylaxis in acute traumatic brain injury (TBI) is a controversial topic with wide practice variations. This study examined the association of VTE chemoprophylaxis with inpatient mortality and VTE events among isolated TBI patients. This was a retrospective cohort study of 87 trauma centers within a large hospital system in the United States analyzing 23,548 patients with isolated TBI, 7977 of whom had moderate-to-severe TBI. Primary outcomes were inpatient mortality and VTE events. The control group received no chemoprophylaxis. Other groups received low-molecular-weight heparin (LMWH), unfractionated heparin (UFH), and combined LMWH and UFH chemoprophylaxis. Multi-variable regression accounted for confounders. Outcomes were stratified by timing of administration, body mass index (BMI), and TBI type. Patients without VTE prophylaxis had the least VTE events. LMWH had the lowest mortality for both all-isolated and moderate-to-severe isolated TBI populations at adjusted odds ratio (aOR) 0.24 (95% confidence interval [CI], 0.14-0.43) and aOR 0.25 (95% CI, 0.14-0.44), respectively. Clinically significant progression of TBI was lowest among the LMWH group (0.1%; p value, 0.001). After stratifying by timing of VTE chemoprophylaxis, only patients with subdural hematoma and LMWH between 6 and 24 h (N = 62), as well as patients with ≥35 BMI and LMWH between 6 and 24 h (N = 65) or >24-48 h (N = 54), had no VTE events. VTE chemoprophylaxis timing may have prevented VTE in certain subgroups of isolated TBI patients. Though VTE chemoprophylaxis did not prevent VTE for most TBI patients, LMWH VTE chemoprophylaxis was associated with reduced mortality.

Quality Improvement Targeting Non-pharmacologic Care and As-needed Morphine Improves Outcomes in Neonatal Abstinence Syndrome.

We developed a protocol for NAS treatment emphasizing early transfer to general pediatric units, maximization of non-pharmacologic care, and use of as-needed morphine whenever pharmacologic treatment is required. Outcome metrics were the day of life at discharge and cumulative morphine exposure. As a process measure, we also monitored the day of life at transfer to general pediatric units. In addition, we utilized statistical process control charts to track changes in performance. Twenty-eight patients met the inclusion criteria for analysis over 24 months following project initiation. Day of life at discharge decreased by 61% (20.0 versus 7.89 days, P < 0.001), and cumulative morphine exposure decreased by 81% (13.66 versus 2.57 mg morphine, P ≤ 0.001). Day of life at transfer to general pediatric units decreased by 49% (11.13 versus 5.7 days, P = 0.002). There were no readmissions or other identified adverse events. We achieved significant improvements in NAS outcomes using improved non-pharmacologic care and as-needed morphine. Moreover, the improvement did not require transitioning to a new scoring system. These results support the efficacy and safety of as-needed morphine for NAS management.

ISCCM Guidelines for Hemodynamic Monitoring in the Critically Ill.

Kulkarni AP, Govil D, Samavedam S, Srinivasan S, Ramasubban S, Venkataraman R, et al. ISCCM Guidelines for Hemodynamic Monitoring in the Critically Ill. Indian J Crit Care Med 2022;26(S2):S66-S76.

A Population-Based Study on the Treatment and Long-Term Outcomes of Thymoma: A 25-year Single Institution Retrospective Review

<h3>Purpose/Objective(s)</h3> Thymomas are rare neoplasms arising from the thymic epithelium and there are a limited number of prospective studies in this setting to guide its management. The purpose of this study was to conduct a population-based analysis of patient and tumor factors associated with overall survival (OS) and progression-free survival (PFS) in patients with thymoma. <h3>Materials/Methods</h3> A retrospective review was performed on all thymoma patients diagnosed and treated between January 1994 and December 2019 at our center. Baseline demographic, tumor, surgery, radiotherapy, chemotherapy, and survival data were collected using our institution's cancer registry. Overall survival (OS) and progression-free survival (PFS) were analyzed using the Kaplan-Meier method. Cox regression analysis was used to identify risk factors for survival. <h3>Results</h3> 245 patients were identified for analysis. The median follow up was 77 months. A total of 214 patients underwent definitive surgery. Of these, 103 (48%) underwent surgery alone, 84 (34.2%) received adjuvant radiotherapy, 3 (1.4%) received adjuvant chemotherapy, and 6 (2.8%) received adjuvant concurrent chemoradiation. 10 (4.1%) patients underwent neoadjuvant chemotherapy followed by definitive surgery and 8 (3.7%) patients underwent neoadjuvant chemoradiation followed by definitive surgery. A total of 31 patients did not receive definitive surgery. Of these, 9 (29%) received concurrent chemoradiation, 5 (16.1%) received palliative chemotherapy, 7 (22.6%) received palliative radiotherapy, and 10 (32.3%) had supportive management. At presentation, 36 (16.8%) patients presented at Masaoka-Koga Stage I, 135 (63.1%) at stage II, 32 (15.0%) at stage III, and 11 (5.1%) at stage IV. Among the patients who received definitive radiotherapy, a median dose of 50 Gy was given. A median dose of 30 Gy was given for palliative radiotherapy. 91 (81%) patients had 3DCRT, 18 (15%) had VMAT and 5 (4%) patients were treated with IMRT. Preliminary analysis shows a 10-year OS and PFS rate of 74% and 70% respectively. The 10-year OS for stages I, II, III, and IV were 89%, 82%, 67%, and 44% respectively. The 10-year PFS for stages I, II, III, and IV were 89%, 78%, 64%, and 33% respectively. On multivariate analysis, worse OS was significantly associated with greater age at diagnosis (Hazard Ratio [HR], 1.03; 95% Confidence Interval [CI], 1.00-1.05; P=0.009), Masaoka Stage IV vs. Stage I (HR, 3.51; CI, 1.07-11.50, P=0.038), and no definitive surgery vs. definitive surgical management (HR, 3.47; CI, 1.10-10.98, P=0.034). Both age at diagnosis (HR, 1.04; CI 1.01-1.07, P=0.001) and stage IV vs stage I (HR, 11.20; CI, 3.45-36.38; P<0.001) were associated with worse PFS. <h3>Conclusion</h3> Thymoma is a clinically heterogenous disease with a wide variation in treatment practices. Survival rates in our population are comparable to previous published reports. Late Masaoka-Koga stage, age at diagnosis, and definitive surgical management are important prognostic factors for overall survival.

Thermoregulation and golden hour practices in extremely preterm infants: an international survey

BackgroundAre thermoregulation and golden hour practices in extremely preterm (EP) infants comparable across the world? This study aims to describe these practices for EP infants based on the neonatal intensive care unit’s (NICUs) geographic region, country’s income status and the lowest gestational age (GA) of infants resuscitated.MethodsThe Director of each NICU was requested to complete the e-questionnaire between February 2019 and August 2021.ResultsWe received 848 responses, from all geographic regions and resource settings. Variations in most thermoregulation and golden hour practices were observed. Using a polyethylene plastic wrap, commencing humidity within 60 min of admission, and having local protocols were the most consistent practices (>75%). The odds for the following practices differed in NICUs resuscitating infants from 22 to 23 weeks GA compared to those resuscitating from 24 to 25 weeks: respiratory support during resuscitation and transport, use of polyethylene plastic wrap and servo-control mode, commencing ambient humidity >80% and presence of local protocols.ConclusionEvidence-based practices on thermoregulation and golden hour stabilisation differed based on the unit’s region, country’s income status and the lowest GA of infants resuscitated. Future efforts should address reducing variation in practice and aligning practices with international guidelines.ImpactA wide variation in thermoregulation and golden hour practices exists depending on the income status, geographic region and lowest gestation age of infants resuscitated.Using a polyethylene plastic wrap, commencing humidity within 60 min of admission and having local protocols were the most consistent practices.This study provides a comprehensive description of thermoregulation and golden hour practices to allow a global comparison in the delivery of best evidence-based practice.The findings of this survey highlight a need for reducing variation in practice and aligning practices with international guidelines for a comparable health care delivery.

Pediatric Ventilation Liberation: A Survey of International Practice Among 555 Pediatric Intensivists.

IMPORTANCE:Pediatric ventilation liberation has limited evidence, likely resulting in wide practice variation. To inform future work, practice patterns must first be described.OBJECTIVES:Describe international pediatric ventilation liberation practices and regional practice variation.DESIGN, SETTING, AND PARTICIPANTS:International cross-sectional electronic survey. Nontrainee pediatric medical and cardiac critical care physicians.MAIN OUTCOMES AND MEASURES:Practices focusing on spontaneous breathing trial (SBT) eligibility, SBT practice, non-SBT extubation readiness bundle elements, and post-extubation respiratory support.RESULTS:Five-hundred fifty-five responses representing 47 countries were analyzed. Most respondents reported weaning followed by an SBT (86.4%). The top SBT eligibility variables reported were positive end-expiratory pressure (95%), Fio2 (93.4%), and peak inspiratory pressure (73.9%). Most reported use of standardized pressure support regardless of endotracheal tube size (40.4%) with +10 cm H2O predominating (38.6%). SBT durations included less than or equal to 30 minutes (34.8%), 31 minutes to 1 hour (39.3%), and greater than 1 hours (26%). In assigning an SBT result, top variables were respiratory rate (94%), oxygen saturation (89.3%), and subjective work of breathing (79.8%). Most reported frequent consideration of endotracheal secretion burden (81.3%), standardized pain/sedation measurement (72.8%), fluid balance (83%), and the endotracheal air leak test as a part of extubation readiness bundles. Most reported using planned high flow nasal cannula in less than or equal to 50% of extubations (83.2%). Top subpopulations supported with planned HFNC were those with chronic lung disease (67.3%), exposed to invasive ventilation greater than 14 days (66.6%), and chronic critical illness (44.9%). Most reported using planned noninvasive ventilation (NIV) following less than or equal to 20% of extubations (79.9%). Top subpopulations supported with planned NIV were those with neuromuscular disease (72.8%), chronic lung disease (66.7%), and chronic NIV use for any reason (61.6%). Regional variation was high for most practices studied.CONCLUSION AND RELEVANCE:International pediatric ventilation liberation practices are heterogeneous. Future study is needed to address key evidence gaps. Many practice differences were associated with respondent region, which must be considered in international study design.

From the Editor

Sustainable growth is one of the key inputs in the income approach. I have seen wide variation in practice over time with respect to selection of a sustainable growth rate ranging from long-term targets for inflation, expected industry growth rates, T-Bond yields and expected growth of the Gross Domestic Product. This list is clearly not exhaustive; I have seen many different variations with high growth companies. Shannon Pratt illustrated the significance of the long-term growth rate in the following passage from Valuing a Business:As the example illustrates, minor differences in sustainable growth rates can have very significant impacts on an opinion of value. This issue contains two papers that directly address the issue of sustainable growth. Dr. Gene Trevino analyzes the issue from the standpoint of the accuracy of using historical industry growth rates, historical gross domestic product growth rates and expected inflation rates as sustainable long-term growth rates, while Dr. Brad Cornell and Richard Gerger approach the topic by analyzing historic growth of public companies. Their findings are surprisingly similar.David Neuzil and Joe Thompson revisit the Value Driver Formula and illustrate short-comings of a traditional Gordon Growth Model in valuing a business that invest heavily in research and development.Finally, the issue has a Special Report from the International Valuation Standard Council (“IVSC”) on Environmental, Social and Governance (“ESG”) issues in valuation. The IVSC has been busy developing technical resources for valuation professional in the evolving area of ESG and its application in business valuation. The Special Report provides an overview of those resources and ongoing work in the area.To all our readers, enjoy the issue and let me know if you have any strong opinion or further thoughts on our articles – letters to the editor are welcome.

Comparison of short-term outcomes of 35-weeks' gestation infants cared for in a level II NICU vs mother-baby, a retrospective study.

Late preterm infants are at high risk for medical complications and represent a growing NICU population. While 34-weeks' gestation infants are generally admitted to the NICU and 36-weeks'gestation infants stay in mother-baby, there is wide practice variation for 35-weeks'gestation infants. The objective of this study was to compare short-term outcomes of 35-weeks' gestation infants born at two hospitals within the same health system (DUHS), where one (DRH) admits all 35-weeks' gestation infants to their level II NICU and the other (DUH) admits all 35-weeks' gestation infants to mother-baby, unless clinical concern. We conducted a retrospective cohort analysis of 35-weeks' gestation infants born at DUHS from 2014-2019. Infant specific data were collected for birth, demographics, medications, medical therapies, LOS, ED visits and readmissions. 35-weeks' gestation infants at each hospital (DRH vs DUH) that met inclusion criteria were compared, regardless of unit(s) of care. 726 infants of 35-weeks' gestation were identified, 591 met our inclusion criteria (DUH -462, DRH -129). Infants discharged from DRH were more likely to receive medical therapies (caffeine, antibiotics, blood culture, phototherapy, NGT), had a 4 day longer LOS, but were more likely to feed exclusively MBM at discharge. There were no differences in ED visits; however, more infants from DUH were readmitted within 30 days of discharge. Our findings suggest admitting 35-weeks' gestation infants directly to the NICU increases medical interventions and LOS, but might reduce hospital readmissions.

Guideline Adherence As An Indicator of the Extent of Antithrombotic Overuse and Underuse: A Systematic Review.

Thromboembolic events are a common risk in adults with atrial fibrillation, those with previous cerebrovascular accidents and undergoing emergency or elective surgeries. The widespread availability of antithrombotic agents and differing guidelines contribute to practice variations and increased risk of complications and deaths. The objective of this review was to investigate the extent of overuse and underuse of antithrombotics for primary or secondary prevention as measured by deviation from prescribing guideline recommendations. We conducted a systematic review of Medline and EMBASE for quantitative articles published between 2000 and 2021 and used a modified version of the Hoy’s risk of bias assessment tool. Here we report evidence from the past decade about wide practice variations in hospitals and primary care, and discuss clinician and patient-driven determinants of non-adherence to guidelines. Finally, we summarise implications for practice, identify enhanced ways of measuring overuse and underuse, and propose potential solutions to the measurement challenges.

Pin-site Infection: A Systematic Review of Prevention Strategies

IntroductionCircular frame fixation remains a key tool in the armamentarium of the limb reconstruction surgeon. One of the key drawbacks is the onset of pin-site infection (PSI). As a result of limited evidence and consensus of PSI prevention, a wide variation in practice remains.AimThe principal aim of this review is to synthesise primary research concerning all aspects of treatment regarded as relevant to PSI in frame constructs.Materials and methodsComparative studies until week 26, 2021, were included in the trial. Studies were included that concerned patients undergoing management of a musculoskeletal condition in which pin-site care is necessary for over 4 weeks.ResultsEighteen studies over a 13-year period were captured using the search strategy. Sulphadiazine and hydrogen peroxide cleansing was found to reduce PSI, with the use of low-energy fine wires and hydroxyapatite (HA)-coated pins also associated with lower infection rate. The remainder of studies found no significant improvement across interventions.ConclusionThere is no superiority between weekly and daily care. Low-energy pin-insertion technique had lower rates of infection. Sulphadiazine has positive results as a pin-care solution, but more research is necessary to determine the most effective care regime. Current literature is limited by absence of established definitions and by a lack of studies addressing all aspects of care relevant to PSI.How to cite this articleShields DW, Iliadis AD, Kelly E, et al. Pin-site Infection: A Systematic Review of Prevention Strategies. Strategies Trauma Limb Reconstr 2022;17(2):93–104.

Knowledge, attitudes and practices of resident doctors and interns on safe blood transfusion practices: a survey-based study

IntroductionThe knowledge of clinicians regarding blood transfusion services may impact patient care and transfusion outcome. The wide variation in transfusion practices among clinicians leads to inappropriate blood product usage and jeopardizes patient safety. Hence, this survey study aimed to assess knowledge, attitude and practice among the residents and interns of safe blood transfusion. MethodsThe online survey was based on self-administered questionnaires of three sections: 1. Demography; 2. Knowledge, and; 3. Attitude and Practice. One point was assigned for the correct response of each question in every section. The knowledge score was further categorized into three categories, depending on the points obtained. The participants were also divided into four groups, depending on their experience. The Kruskal-Wallis test was applied to determine the difference of knowledge and practice scores in three designated groups of residents and interns. A p-value of less than 0.05 was considered to be significant. ResultA total of 247 residents and interns participated in this study. Thirteen participants had an incomplete response. Out of 234 participants, Senior Residents (SR), Junior Residents (JR), and interns were 70, 96 and 68 participants, respectively. The knowledge scores of interns were significantly low, as compared to SRs and JRs. Practice scores of interns were also significantly low, compared to the JRs. However, most of the residents and interns (85%) were aware of the pre-transfusion testing. ConclusionTherefore, the mandatory incorporation of the transfusion medicine subject in the undergraduate curriculum can help the young budding doctors to better implement the patient blood management.