Effect of an Individualized Audit and Feedback Intervention on Rates of Musculoskeletal Diagnostic Imaging Requests by Australian General Practitioners: A Randomized Clinical Trial.

Importance: Audit and feedback can improve professional practice, but few trials have evaluated its effectiveness in reducing potential overuse of musculoskeletal diagnostic imaging in general practice. Objective: To evaluate the effectiveness of audit and feedback for reducing musculoskeletal imaging by high-requesting Australian general practitioners (GPs). Design, Setting, and Participants: This factorial cluster-randomized clinical trial included 2271 general practices with at least 1 GP who was in the top 20% of referrers for 11 imaging tests (of the lumbosacral or cervical spine, shoulder, hip, knee, and ankle/hind foot) and for at least 4 individual tests between January and December 2018. Only high-requesting GPs within participating practices were included. The trial was conducted between November 2019 and May 2021, with final follow-up on May 8, 2021. Interventions: Eligible practices were randomized in a 1:1:1:1:1 ratio to 1 of 4 different individualized written audit and feedback interventions (n = 3055 GPs) that varied factorially by (1) frequency of feedback (once vs twice) and (2) visual display (standard vs enhanced display highlighting highly requested tests) or to a control condition of no intervention (n = 764 GPs). Participants were not masked. Main Outcomes and Measures: The primary outcome was the overall rate of requests for the 11 targeted imaging tests per 1000 patient consultations over 12 months, assessed using routinely collected administrative data. Primary analyses included all randomized GPs who had at least 1 patient consultation during the study period and were performed by statisticians masked to group allocation. Results: A total of 3819 high-requesting GPs from 2271 practices were randomized, and 3660 GPs (95.8%; n = 727 control, n = 2933 intervention) were included in the primary analysis. Audit and feedback led to a statistically significant reduction in the overall rate of imaging requests per 1000 consultations compared with control over 12 months (adjusted mean, 27.7 [95% CI, 27.5-28.0] vs 30.4 [95% CI, 29.8-30.9], respectively; adjusted mean difference, -2.66 [95% CI, -3.24 to -2.07]; P < .001). Conclusions and Relevance: Among Australian general practitioners known to frequently request musculoskeletal diagnostic imaging, an individualized audit and feedback intervention, compared with no intervention, significantly decreased the rate of targeted musculoskeletal imaging tests ordered over 12 months. Trial Registration: ANZCTR Identifier: ACTRN12619001503112.

Stenting of the Brachiocephalic Vein Following Occlusion After Coronary Artery Bypass Surgery.

We describe a case of left arm swelling over nine months post coronary artery bypass grafting (CABG), due to occlusion of the left brachiocephalic vein. The patient's perioperative course, diagnosis, and management of this complication are presented. doi: 10.1111/jocs.12765 (J Card Surg 2016;31:432-434).

Emergency Endovascular Repair of Thoracic Aorta Via a Percutaneous Popliteal Approach Following an Iatrogenic Injury.

Iatrogenic arterial injuries are rare but well-recognised complications of spinal surgery. This paper presents a case of an iatrogenic arterial injury during a total en bloc spondylectomy resulting in significant haemorrhage and the patient's haemodynamic instability. The devastating complication was successfully treated with an emergency thoracic endovascular aortic repair via a percutaneous popliteal approach, while the patient remained in prone position. The patient had an uneventful recovery with no subsequent arterial injury or pseudoaneurysm to the access vessel.

The Role of Near Infrared Spectroscopy in Diagnosing Stump Ischaemia in Patients with Below Knee Amputation: Case Reports.

Introduction: Functional near infrared spectroscopy (fNIRS) can be used to quantify stump oxygen saturation (SaO2) as one of many possible causes of pain following major amputation. Although commonly used for cerebral perfusion monitoring during carotid or cardiac surgery, it can also be used to monitor tissue perfusion in the lower limb and predict healing following below knee amputation (BKA). The aim of this study was to measure the SaO2 trend as there is no validated oxygen threshold to diagnose insufficient flow into the arterial collateral network currently. Report: NIRS was used to measure SaO2 while performing treadmill exercise. Two BKA patients with chronic stump pain were asked to perform treadmill exercise while using their prosthesis and NIRS optode applied to the posterior stump to monitor SaO2. Cases 1 and 2 showed a decline in SaO2 of 25% and 18%, respectively, while walking on the prosthesis. After superficial femoral artery (SFA) recanalisation and stenting, Case 1 showed improvement by maintaining SaO2 between 54% and 60% throughout treadmill exercise. In Case 2, perfusion could not be further improved, and the patient underwent through knee amputation. Discussion: fNIRS detected compressive ischaemia and exercise induced ischaemia as mechanisms of stump pain. Findings provided the multidisciplinary team with objective information, aiding decision making to treat stump pain.

Endovascular repair of a ruptured abdominal aortic aneurysm in a patient with bilateral iliac dissections.

BACKGROUND: The presentation of a ruptured fusiform abdominal aortic aneurysm (AAA) co-occurring with bilateral iliac dissections is extremely rare. Endovascular repair of ruptured AAA is an accepted treatment modality for suitable patients; however, this approach may be complicated by the presence of iliac arterial pathology. METHODS AND RESULTS: We report the case of a 66-year-old man who presented with a ruptured AAA. Preoperative imaging demonstrated bilateral iliac artery dissections in addition to the ruptured AAA. We describe the technical aspects of the combined endovascular and open surgical repair required to manage this complex presentation. CONCLUSION: The combined presentation of ruptured AAA and bilateral iliac dissections has not been previously reported. Successful repair can be achieved using a combined endovascular and open surgical approach.

Acute life-threatening cardiovascular toxicity with umbilical cord blood infusion: the role of dextran.

Umbilical cord blood (UCB) is being increasingly used for hematopoietic stem cell transplantation due to its immediate availability. Dimethylsulfoxide (DMSO) and dextran-40 are commonly used for processing and cryopreservation of UCB. Adverse UCB infusion-related events are usually mild. However, reports of severe life-threatening events are now emerging. DMSO has been proposed as a possible cause of infusion-related reactions. In this report, we draw attention to an acute near-fatal reaction with UCB infusions resulting in myocardial ischemia and acute renal failure. We propose that dextran-40 in UCB infusion products be considered as a potential causative agent contributing to this infusion-related reaction, based on reports of known adverse reactions to dextran-40 in non-transplant settings.

Does a distal perfusion cannula reduce ischaemic complications of extracorporeal membrane oxygenation?

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) provides support to patients with severe but reversible cardiac or pulmonary failure. Vascular complications of ECMO are well recognized. METHODS: We performed a retrospective review of 70 patients (mean age 48 years; 15-85) who received peripheral veno-arterial ECMO from 2004 to 2010 in a single centre. For statistical analysis, chi-squared test and multivariate binary logistic regression analysis were used to assess for association between response variables (i.e. limb ischaemia, ECMO site bleeding and deep vein thrombosis (DVT)) and possible predictive variables. RESULTS: There were 14 (20%) cases of acute limb ischaemia with no statistically significant relationship between acute limb ischaemia and independent variables. Thirty-three patients received distal limb cannulas (47%). There was no statistically significant association between limb ischaemia and presence of distal limb cannula (P = 0.8). Multivariate binary logistic regression analysis identified insertion by cutdown as a predictor of lower probability of insertion site bleeding (n = 12, odds ratio 0.24, P = 0.04). Seven cases of DVT were identified; multivariate binary logistic regression analysis identified insertion by cutdown (odds ratio 0.08, P = 0.03) and days of ECMO less than five (odds ratio 0.08, P = 0.04) as predictive factors for reduced rates of DVT. CONCLUSION: Ischaemic complications of ECMO are common and occur despite the presence of a distal limb-perfusing cannula; however in our study the distal limb cannula was a limb-salvaging intervention in six patients. Prolonged time on ECMO is a risk factor for DVT, and a high index of suspicion must be maintained. Percutaneous insertion was associated with higher rates of bleeding and DVT.