Reduced Fluoroscopy Time With Physician-Controlled Fluoroscopy During Endoscopic Retrograde Cholangiopancreatography: A Community Hospital Experience.

Background and objective Fluoroscopy during endoscopic retrograde cholangiopancreatography (ERCP) is associated with radiation exposure and related health risks. Either the physician or the radiology technologist can activate fluoroscopy during ERCP. The aim of this study was to determine if physician-controlled fluoroscopy is associated with decreased fluoroscopy time, which may correspond to less radiation exposure to patients and staff.  Methods We conducted a single-center, retrospective study; data were collected on ERCP performed using physician-controlled and technologist-controlled fluoroscopy. Fluoroscopy time, procedure complexity level, and Stanford Fluoroscopy Score were compared between the two groups. Results The median fluoroscopy time significantly differed between the two groups with 108 seconds for physician-controlled and 146 seconds for technologist-controlled procedures (p=0.004). The ratio of median fluoroscopy time to procedure complexity level was significantly lower in the physician-controlled group at 73.0 seconds compared to 97.0 seconds in the technologist-controlled group (p=0.002). The ratio of median fluoroscopy time to Stanford Fluoroscopy Score was 25.5 seconds in the physician-controlled group compared to 39.3 seconds in the technologist-controlled group, which was also statistically significant (p<0.001). A subgroup analysis of physicians with advanced training in ERCP also showed a significantly reduced median fluoroscopy time to Stanford Fluoroscopy Complexity Score ratio: 25.5 seconds for physician-controlled versus 35.0 seconds for technologist-controlled (p=0.001). Conclusion The ERCP technique with physician-controlled fluoroscopy may be associated with shorter fluoroscopy time. This may correspond to decreased radiation exposure to patients compared to radiology technologist-controlled fluoroscopy. Further investigations with larger, prospective studies are warranted.

Increased Fetal Chromosome Detection with the Use of Operative Hysteroscopy During Evacuation of Products of Conception for Diagnosed Miscarriage.

STUDY OBJECTIVE: To determine whether incorporation of operative hysteroscopy with biopsy of products of conception, in conjunction with a suction curettage for a first trimester missed abortion, affected the rate of maternal cell contamination when chromosomal analysis was performed on the products of conception, and to determine the rates of retained products of conception with incorporation of hysteroscopy after suction curettage. DESIGN: Retrospective chart study. SETTING: Private, minimally invasive surgery and infertility practice with academic-community hospital affiliation. PATIENTS: Infertility patients undergoing evacuation of products of conception for documented first trimester miscarriages between 2006 and 2017. INTERVENTIONS: Suction curettage or hysteroscopic biopsy and suction curettage, followed by chromosomal analysis of products of conception for determination of fetal genetics. MEASUREMENTS AND RESULTS: A total of 264 charts were analyzed. Patients were categorized into 2 groups based on surgical collection of products of conception: group 1 (N = 174), suction curettage only, and group 2 (N = 90), a single procedure consisting of operative hysteroscopy with biopsy of products of conception followed by suction curettage and then diagnostic hysteroscopy to look for retained products. Data for chromosome detection and retained products of conception were available for 246 and 239 patients, respectively. No significant differences were detected between the groups for age, body mass index, ethnicity, gravida, parity, primary infertility, secondary infertility, spontaneous conception, single or multiple gestation, and surgical complications. Fetal chromosome detection was significantly higher without maternal contamination in group 2 (88.5%) compared with group 1 (64.8%) (p < .001). There was no significant between-group difference in postoperative retained products of conception. CONCLUSION: Obtaining fetal genetics can be useful when planning for a future successful pregnancy. The addition of operative hysteroscopy to biopsy the gestational sac, chorionic villi, and/or fetus significantly decreases the risk of maternal contamination and increases the ability to detect fetal chromosomes for genetic analysis without an increased risk of surgical complications. Despite the low risk of surgical complications, immediate second-look hysteroscopy after the completion of suction evacuation does not reduce the risk of postoperative retained products of conception.

Local parastomal hernia repair with biological mesh is safe and effective.

PURPOSE: The goal of this study was to evaluate the efficacy, morbidity and safety of local parastomal hernia repair using biological mesh. PATIENTS AND METHODS: A retrospective analysis of a prospectively maintained database was performed for parastomal hernia repairs. All patients who underwent local parastomal hernia repair with biological mesh between July 2006 and July 2015 were included in the study. Non-local (laparoscopic or midline incision) procedures were excluded. The type of repair, incision used, mesh placement and morbidity were analyzed. Time to recurrence was measured as an independent variable. RESULTS: 58 procedures with a median follow up of 3.8 years were analyzed. The majority (91%) of repairs were performed on an elective basis. Underlay technique was used in 24 patients (39%), overlay in 4 (7%) and both overlay and underlay (sandwich technique) in 33 (54%) of the cases. Overall, 11 patients (18.1%) experienced recurrence. Recurrence occurred in 8 patients in the underlay group (33%), 1 in the overlay group (25%), with 2 recurrences identified in the sandwich technique group (6%; p = 0.02). There was one occurrence of 30-day morbidity in our study population (0.016%). No difference was observed for recurrence or morbidity according to the type of biologic mesh used (human, bovine, or porcine). CONCLUSION: Our results demonstrate that local parastomal hernia repairs are associated with moderate recurrence rates, very low morbidity and consistent with the current literature. The sandwich technique was found to have a significantly lower recurrence rate compared to underlay or overlay techniques. Keyhole incisions were associated with less recurrence than traditional circular incisions. Our findings further reveal biologic mesh type was not associated with any difference in outcomes. Local parastomal hernia repair with biologic mesh is a safe procedure with very low morbidity and acceptable recurrence rate, especially using the sandwich repair technique.

Castleman's disease: a rare presentation in a retroperitoneal accessory spleen, treated with a minimally invasive robotic approach.

Unicentric Castleman's disease (UCD) is a rare disorder of unknown etiology characterized by localized lymphoid tissue proliferation and interfollicular hypervascularity. A 33-year-old Caucasian female presented with vague abdominal discomfort and pain with pressure. Ultrasound and computed tomography detected a large peripancreatic mass. Robotic-assisted resection of the mass along with en bloc dissection of the encased left adrenal gland was done. Frozen section examination confirmed UCD hyaline vascular variant in a retroperitoneal accessory spleen. Preoperative diagnosis of UCD is difficult due to its lack of specific symptoms and its cytologic similarity to reactive lymphadenopathy and other lymphoproliferative disorders. Surgical resection is standard treatment and provides the pathological specimen required for diagnostic confirmation. Here, robotic-assisted laparoscopy allowed visualization, mobilization, precise resection and extraction of the mass from a difficult to access retroperitoneal region.

Effect of Latitude on Vitamin D Levels.

CONTEXT: Vitamin D levels have been linked to bone health and to numerous diseases; however, an element that lacks substantial direct data and limits the evidence basis regarding whom to screen for vitamin D deficiency is the effect of latitude on vitamin D levels. OBJECTIVES: To determine whether latitude influences vitamin D levels and to investigate the influence of other factors that may affect vitamin D levels, including sex, race, skin type, and body mass index. METHODS: Osteopathic medical students were recruited from campuses in Bradenton, Florida, and Erie, Pennsylvania. Surveys were administered to obtain demographic information, and blood samples were drawn to measure total vitamin D levels. Two-sample t tests, Fisher exact test, and logistic regression was used to assess differences in total vitamin D levels between the 2 locations. RESULTS: A total of 359 medical students (aged 22-57 years) were included in the study, 194 at the Bradenton campus and 214 at the Erie campus. The mean (SD) vitamin D level was 34.5 (11.8) ng/mL among participants in Bradenton and 28.1 (12.4) ng/mL among participants in Erie. Logistic regression models revealed an adjusted OR of 3.3 (95% CI, 1.73-6.4) for deficient total vitamin D among Erie students. Non-white race, male sex, and high body mass index were also statistically significant risk factors for vitamin D deficiency in regression models (P<.05). CONCLUSION: Latitude was found to be a statistically significant risk factor for vitamin D deficiency. Additionally, the findings suggest that persons with darker skin tone and, to a lesser degree, men and persons who are overweight or obese are also at increased risk for vitamin D deficiency. Physicians should be cognizant of these risk factors when deciding whom to screen.

Weight-based contrast administration in the computerized tomography evaluation of acute pulmonary embolism: Challenges in optimizing imaging quality.

Compare individualized contrast protocol, or weight-based protocol, to standard methodology in evaluating acute pulmonary embolism.Retrospective chart review was performed on patients undergoing computed tomography angiography with standard contrast protocol (n = 50) or individualized protocol (n = 50). Computerized tomography images were assessed for vascular enhancement and image quality.Demographics were comparable, however, more patients in the individualized group were admitted to intensive care unit (48% vs 16%, P = 0.004). Vascular enhancement and image quality were also comparable, although individualized protocol had significantly fewer contrast and motion artifact limitations (28% vs 48%, P = 0.039). Fifteen percent decrease in intravenous contrast volume was identified in individualized group with no compromise in image quality.Individualized contrast protocol provided comparable vascular enhancement and image quality to the standard, yet with fewer limitations and lower intravenous contrast volume. Catheter-gauge flow rate restrictions resulting in inconsistent technologist exam execution were identified, supporting the need for further investigation of this regimen.

EXPLORING EQUALITY IN LEADERSHIP ROLES.

Women are underrepresented in physician leadership. Exploring the issue, researchers created a study focused on developing successful skills, behaviors and attitudes for 15 first-year female residents. In 2016, the American Association for Physician Leadership* named Advocate Health Care's Resident Leadership Develop- ment Institute the winner of its annual Leape Ahead Award. It recognizes organizations devoted to patient safety, health care improvement and developing future physician leaders. This article summarizes and includes excerpts from the comprehensive presentation that earned the award. Evaluators were impressed by the research focusing on leadership de- velopment for female residents, saying its assessment and metrics, as well as its mentoring of participants, made the program stand out. Learn about the recipient of the 2017 Leape Ahead Award, MUSC Health at Medical University of South Carolina, in our news section, which begins on page 62.

Survey study suggests that reverse total shoulder arthroplasty is becoming the treatment of choice for four-part fractures of the humeral head in the elderly.

PURPOSE: The role of reverse total shoulder arthroplasty (RTSA) for three and four-part proximal humerus fractures is evolving. However, there does not appear to be a clear consensus amongst surgeons. The purpose of this study is to further define the standard of care, assessing surgeon preference and treatment considerations for management of such fractures. METHODS: Orthopaedic surgeons were surveyed on their training, practice setting, and experience regarding management of four-part proximal humerus fractures. The survey also presented five representative cases to assess treatment preferences. RESULTS: Two hundred five surgeons responded to the survey with fellowship training in shoulder and elbow surgery (114), orthopaedic trauma (35) or sports medicine/other training (56). There was no difference between respondents with years in practice and confidence with performing RTSA, however, surgeons in the academic setting were more confident in performing the surgery. Surgeons preferred RTSA for management of four-part fractures in patients over age 65. However, they also trended to favour hemiarthroplasty with higher co-morbidities. Physicians with more than 11 years of experience were more likely to choose hemiarthroplasty for older and high comorbidity patients. RTSA was not the preferred treatment method for younger, active patients. Patient age and fracture pattern had a greater influence on the surgeon's decision. CONCLUSIONS: There is a consensus in our study population that RTSA is the preferred treatment for four-part proximal humerus fractures for elderly patients with patient age and fracture pattern being the most important factors in making management decisions. LEVEL OF EVIDENCE: Level III - Case controlled study.

Comparing Electronic and Manual Tracking Systems for Monitoring Resident Duty Hours.

BACKGROUND: Changes in the Accreditation Council for Graduate Medical Education (ACGME) duty hour requirements have created significant monitoring responsibilities for institutions. This study explored the types of tracking systems used and determined for each type of tracking system the number of violations identified and the number of ACGME citations issued. METHODS: An 8-question, anonymous, electronic survey was sent to 3,275 residency program coordinators across 24 ACGME-accredited specialties nationwide. The survey was developed by the study investigators to gather data on the type of system used by programs, perceived advantages and disadvantages of the system, the number and types of violations identified, and subsequent ACGME citations for duty hour noncompliance. RESULTS: Of the 889 responses (27.1% response rate), 780 (87.7%) reported using an electronic system, while 94 (10.6%) used a manual system. Programs found electronic systems significantly superior on most characteristics, including accuracy, effectiveness, ease of use, reliability, reporting variety, and time investment (all P<0.001). Electronic systems identified significantly more violations than their manual counterparts; however, violation identification did not correlate with an increase in ACGME duty hour citations for programs using electronic systems (all P>0.05). CONCLUSION: Although a relationship was seen between the tracking system and the number of violations identified, no significant relationship was detected between the system used and the number of citations issued by the ACGME. While programs have invested considerable time, effort, and expense in systems to track duty hours, the real meaning of the data collected and its value to programs, residents, the ACGME, and the healthcare system remains unclear.

Implementing a Protocol Using Glucose Gel to Treat Neonatal Hypoglycemia.

Neonatal hypoglycemia is a leading cause of admission of neonates to the NICU. Typical treatment for neonatal hypoglycemia includes supplementation with formula or, in some cases, intravenous glucose administration. These treatments, though effective at treating hypoglycemia, interrupt exclusive breastfeeding and interfere with mother-infant bonding. Our institution developed a treatment algorithm for newborns at risk for neonatal hypoglycemia. The new algorithm called for the oral administration of 40% glucose gel. This intervention resulted in a 73% decreasein admission rates to the NICU for hypoglycemia, and it supported exclusive breastfeeding, skin-to-skin contact, and mother-infant bonding.

Development of a urinary-specific antibiogram for gram-negative isolates: impact of patient risk factors on susceptibility.

BACKGROUND: Traditional antibiograms guide clinicians in selecting appropriate empiric antimicrobials, but they lack data on syndrome/disease-specific susceptibility, isolate location, polymicrobial infections, and patient risk factors. The aim of this study was to develop a urinary-specific antibiogram and to evaluate the impact of risk factors on antimicrobial susceptibility. METHODS: This retrospective descriptive study used culture and susceptibility data from January 1 to December 31, 2012. A urinary antibiogram specific for Escherichia coli (EC), Proteus mirabilis (PM), Klebsiella pneumoniae (KP), and Pseudomonas aeruginosa (PA) was developed. Urinary and standard antibiogram susceptibilities were compared. Urinary isolates were then stratified by risk factors-residence before admission, age, systemic antimicrobial use for ≤30 days, hospitalization for ≤30 days, and hospital unit-to determine the impact on antimicrobial susceptibility. RESULTS: There were 2,284 urinary isolate encounters. Overall antimicrobial susceptibility was increased, and the prevalence of extended-spectrum ß-lactamase-producing isolates was significantly greater (KP, 14% vs 7% [P = .001]; EC, 13% vs 9% [P < .001]; PM, 18% vs 10% [P = .004]) in the urinary antibiogram vs the standard antibiogram. Health care facility residence had the greatest impact on susceptibility for all urinary isolates, especially on fluoroquinolone susceptibility for EC and PM. CONCLUSIONS: Using a syndromic antibiogram and incorporating patient risk factors into susceptibility data may be more useful in guiding clinicians in selecting more appropriate empiric therapy.