Characteristics of Participants in the American Urological Association Quality (AQUA) Registry and Early Impact of Participation on Quality of Care.

INTRODUCTION: The American Urological Association Quality Registry (AQUA) is an approved Qualified Clinical Data Repository that was created in 2013 to serve as a platform of quality assessment and improvement. Little is known about how such specialty specific platforms are adopted and used. We describe AQUA participants and report early impact on quality metrics. METHODS: We compared characteristics of practices and urologists participating in AQUA from 2014-2017 to those of the broader urologist workforce as reported in the 2017 American Urological Association Census, and examined pass rates of 4 measures reported to the Centers for Medicare and Medicaid Services after participation in AQUA. RESULTS: Participation increased during the first 4 years and included >125 practices and 1,148 urologists (9.2% of practicing U.S. urologists). Of AQUA participants 97.6% were in private practice, 1.9% were in academic practice and the rest (0.5%) were employed by private or public hospitals, compared to 59.1%, 25.5% and 11.2%, respectively, of urologists nationally. Among AQUA participants 95.9% lived in metropolitan areas, compared to 89.9% of urologists nationally. A total of 17 quality measures were reported to the Centers for Medicare and Medicaid Services through AQUA, of which 4 were urology specific and 13 were crosscutting. The average pass rate across the 4 select urological measures was 31.1% prior to AQUA dashboard access and 48.8% after access was gained, a 56.9% improvement (17.1% absolute difference). CONCLUSIONS: Early participants in AQUA were mostly community practitioners. Participation in AQUA seemed to facilitate quality score improvements, although whether this was due to improved measurement vs clinical care is unknown at this time.

Patient-specific models for lung nodule detection and surveillance in CT images.

The purpose of this work is to develop patient-specific models for automatically detecting lung nodules in computed tomography (CT) images. It is motivated by significant developments in CT scanner technology and the burden that lung cancer screening and surveillance imposes on radiologists. We propose a new method that uses a patient's baseline image data to assist in the segmentation of subsequent images so that changes in size and/or shape of nodules can be measured automatically. The system uses a generic, a priori model to detect candidate nodules on the baseline scan of a previously unseen patient. A user then confirms or rejects nodule candidates to establish baseline results. For analysis of follow-up scans of that particular patient, a patient-specific model is derived from these baseline results. This model describes expected features (location, volume and shape) of previously segmented nodules so that the system can relocalize them automatically on follow-up. On the baseline scans of 17 subjects, a radiologist identified a total of 36 nodules, of which 31 (86%) were detected automatically by the system with an average of 11 false positives (FPs) per case. In follow-up scans 27 of the 31 nodules were still present and, using patient-specific models, 22 (81%) were correctly relocalized by the system. The system automatically detected 16 out of a possible 20 (80%) of new nodules on follow-up scans with ten FPs per case.

Cerebellopontine angle metastasis from papillary carcinoma of the thyroid: case report and literature review.

BACKGROUND: Papillary thyroid carcinoma is the most common type of well-differentiated thyroid malignancy and typically has an excellent prognosis and a low incidence of distant metastasis. However, once metastasis has developed in a distant site, prognosis is markedly diminished. Brain metastases from papillary thyroid carcinoma are extremely rare. Currently, there are no established therapeutic guidelines for treating brain metastases from thyroid carcinoma. CASE DESCRIPTION: We report on the case of a patient who presented with worsening neurological symptoms 3 years after resection of a thyroid papillary carcinoma. Magnetic resonance imaging identified a lesion of the cerebellopontine angle that encased the lower cranial nerves. The patient underwent a left retrosigmoid craniotomy with a 98% resection of the mass and received postoperative adjuvant radioiodine therapy, external beam radiation, and Gamma Knife radiosurgery. The patient tolerated the procedure well and demonstrated significant progressive improvement in her neurological symptoms postoperatively. After the multimodal approach to therapy, she remains symptom-free at 3-year follow-up. Radiographic monitoring of the small tumor remnant reveals a decrease in size from the postoperative period. CONCLUSION: This article is the first formal case report of cerebellopontine angle metastasis from papillary thyroid carcinoma. Therapeutic protocols for brain metastases of papillary thyroid carcinoma are not firmly established. This case illustrates the unique event of a cerebellopontine angle metastasis from papillary thyroid carcinoma, which was successfully treated with a combination of surgical, chemical, and radiological modalities. This aggressive course of therapy has resulted in an excellent outcome in this instance.

Percutaneous dilatational tracheostomy: still a surgical procedure.

Although percutaneous dilatational tracheostomy (PDT) has been shown to be a cost-effective bedside alternative to open tracheostomy (OT), prior reports of the complications of the procedure are contradictory. Reported complications range from minor events to fatal ones, in varying percentages. This prospective study was designed to identify the type and severity of complications accompanying the introduction of PDT to a tertiary medical center. Surgical and medical intensive care unit (ICU) patients requiring elective tracheostomy were identified as appropriate for PDT using approved institutional criteria. All procedures were performed at an ICU bedside in the presence of a surgeon privileged to perform OT. Demographic data, procedural information, and patient outcome (including minor and major complications, length of stay, and survival) were collected. PDT was performed in 96 ICU patients, with complete data available for 95 patients. PDT was performed in an average of 13.1+/-1.0 minutes. Twenty-three major and minor complications occurred, including two perioperative deaths, in 15 patients (15.8%). A total of 37 PDT patients (38.9%) died in the hospital, indicative of the severity of illness of patients requiring tracheostomy. Based on the experience to date, Cedars-Sinai Medical Center (Los Angeles, CA) continues to require a surgeon privileged to perform OT to participate in all PDT procedures.

The ureteric ring.

A ureteric ring is a smooth, concentric ring-like narrowing occurring in the upper third of the ureter. It is nonobstructive and may be transient and bilateral. There is a slight female preponderance. They are seen in all age groups and are common in the neonate together with transient changes. A ureteric ring has a characteristic appearance and is believed to result from contraction of circular muscle.

Combined infratemporal fossa and transfacial approach to excising massive tumors.

Massive tumors of the infratemporal and pterygopalatine fossa are usually resected via the Fisch type C infratemporal fossa approach. This approach provides the surgeon with wide enough access to safely remove massive tumors, and it allows excellent control of the internal carotid artery without leaving facial scars. The disadvantages of this approach include a total loss of hearing on the affected side and the risk of damage to the facial nerve. The Fisch type D infratemporal preauricular approach provides a limited access to tumors, but it does preserve hearing. We studied the practice of combining the Fisch type D approach with a transfacial, transmaxillary approach. This allows the removal of massive tumors of the area without the necessity of resorting to the type C approach and the resultant loss of hearing and the possibility of facial paralysis. The flexibility of the type D infratemporal fossa approach allows the surgeon to combine it with transmaxillary, transmandibular, and periorbital approaches to remove tumors of all sizes from the infratemporal fossa, pterygopalatine fossa, parapharyngeal space, and orbit.

Endoscopic pituitary surgery: an in vivo model for transnasal transsphenoidal hypophysectomy.

The transseptal transsphenoidal approach to surgical intervention of the pituitary gland has been described for decades. Its gradual acceptance as the standard of therapy is indicative of general trends toward less invasive means of managing intracranial surgical disease. The evolution of the technique has coincided with advances in medical technology, including the introductions of intraoperative fluoroscopy and operative microscopy. Current progress in the field of endoscopy promises to further this evolution: endoscopic telescopes and instruments have improved on the optical and technical limitations of the microscope and require an even less invasive approach to the sella. To test the benefits and limitations of the endoscope in performing transnasal transsphenoidal hypophysectomy in an in vivo model, we operated on two live anesthetized pigs using 4.0-mm 0- and 30-degree 18-cm long endoscopes. The long lengths of the pig snouts precluded a transnasal approach to the sella; however, we were able to use the endoscopes to explore the sphenoid sinus, sella turcica, and parasellar regions via a transoral exposure. Digital images of the relevant skull base anatomy were captured. The benefits and limitations of the technique were noted and compared with our experience with microscopy in transsphenoidal hypophysectomy in humans.

Balloon occlusion versus wedged hepatic venography using carbon dioxide for portal vein opacification during TIPS.

Balloon occlusion hepatic venography using carbon dioxide (CO2) is proposed as a safer yet simpler alternative to wedged catheter techniques that have caused hepatic lacerations during the transjugular intrahepatic portosystemic shunt (TIPS) procedure. The image quality of CO2 wedged catheter and balloon occlusion venograms was comparable in our small series, with no venographic-related complications occurring in the balloon occlusion group.

Obstetrical factors governing the etiopathogenesis of lambdoid synostosis.

Lambdoid synostosis results in skull deformities of varying degrees characterized by occipital flattening over the involved suture and other compensatory changes in skull shape. Such changes include contralateral occipital bossing, contralateral frontal flattening, ipsilateral frontal bossing, and ipsilateral anteroinferior displacement of the pinna (ear shearing). These deformities tend to worsen during the first year of life. The etiology has been attributed to genetic factors and primary disorders of bone growth, in addition to secondary effects of other diseases and modulators of the in utero environment. To determine causal factors in the development of lambdoid synostosis, the authors reviewed medical records of the mothers of 13 children with lambdoid synostosis who were treated at the University Medical Center of the State University of New York at Stony Brook. Pre- and perinatal events, prior obstetrical, gynecological, medical, social, and family histories were considered. Births of normal infants immediately prior to and just after the affected babies were born were selected as controls. There is a significant association between increased duration of the first stage of labor and the development of lambdoid synostosis. Furthermore, our results indicate that this condition has a predilection toward male infants, and may be associated with preterm labor.

Evaluation of diagnostic criteria for borderline personality disorder.

A comparison of 17 narrowly defined borderline patients with 20 nonpatient control subjects indicated that certain individual and combinations of criteria may be more highly correlated with the disorder than others. Requiring any four or certain specific combinations of two or three of the five most discriminating criteria provided the optimal balance of sensitivity, specificity, predictive power, and diagnostic efficiency considerations. Fewer than five DSM-III-R criteria adequately identified the patients.

Core criteria for diagnosing borderline patients.

This study compares 17 hospitalized borderline personality disorder (BPD) patients with 20 normal control subjects. Four criteria sets--DSM III, Grinker, Gunderson, and Kernberg--were combined and used with the semistructured DIAGNOSTIC INTERVIEW BORDERLINES (DIB) Scale. Findings indicate that among BPD patients the following were most prominent: 1) impulsive episodes 2) unstable relationships 3) chronic feelings of depressive emptiness/loneliness 4) acting out behavior and, somewhat less prevalent, 5) identity disturbance. BPD patients can be discriminated by different patterns of disturbance while sharing other features in common with them. While DSM III requires five of eight items for BPD diagnosis, from the above group significantly less than five adequately made a positive diagnosis in this study. BPD seems to identify a heterogeneous group of patients with behavioral disturbances without particular personality specificity which share certain core characteristics among which additional features may further subtype component members.

Time-limit psychotherapy of the hospitalized borderline patient.

This article shows that borderline patients can be effectively treated by a time-limited hospitalization and psychotherapy which sets clear limits within a neutral corrective atmosphere. Clarification to the patients that they have the capacity of choice of behavior is essential. Two case histories are included.