Observing the use of knee arthroplasty appropriateness tools in clinical practice: do appropriateness criteria tools predict surgeon decision-making?

OBJECTIVE: The primary aim of this study was to evaluate the agreement between surgeons and two validated total knee arthroplasty (TKA) appropriateness tools, and secondarily to compare Australian appropriateness rates to those reported internationally. METHODS: A consecutive sample of patients from one public hospital arthroplasty clinic and a convenience sample from private rooms of surgeons in New South Wales, Australia (n = 11), referred for surgical opinion regarding TKA were enrolled over 1 year. Surgeons applied appropriateness tools created by Escobar et al. and the American Academy of Orthopaedic Surgeons (AAOS). Correlation between the appropriateness tools and surgeon's decisions were evaluated. RESULTS: There were 368 patients enrolled, and contrasting rates of being "appropriate" for surgery were identified between the Escobar (n = 109, 29.6%) and AAOS (n = 292, 79.3%) tools. Surgeon agreement with the Escobar tool was substantial (ĸ = 0.61, 95%CI: 0.53-0.69) compared to slight with the AAOS tool (ĸ = 0.11, 95%CI: 0.06-0.16). Of those advised against TKA (n = 179, 48.6%), the AAOS tool suggested many patients (n = 111, 62.0%) were "appropriate" compared to the Escobar tool (n = 12, 6.7%). CONCLUSIONS: Surgeons rated patients seeking opinion for TKA as appropriate over half the time, however the AAOS tool had low correlation with surgeons as opposed to the Escobar tool. This was illustrated by both tools rating a majority of patients to be operated on as appropriate, but only the AAOS tool considering most patients not chosen for surgery to be appropriate. When comparing previously published appropriateness rates, appropriateness in Australia, USA, Spain and Qatar was found to be similar.

Head Computed Tomography Scans in Elderly Patients with Low Velocity Head trauma after a Fall.

BACKGROUND: Recommendations for a head computed tomography (CT) scan in elderly patients without a loss of consciousness after a traumatic brain injury and without neurological findings on admission and who are not taking oral anticoagulant therapy, are discordant. OBJECTIVES: To determine variables associated with intracranial hemorrhage (ICH) and the need for neurosurgery in elderly patients after low velocity head trauma. METHODS: In a regional hospital, we retrospectively selected 206 consecutive patients aged ≥ 65 years with head CT scans ordered in the emergency department because of low velocity head trauma. Outcome variables were an ICH and neurological surgery. Independent variables included age, sex, disability, neurological findings, facial fractures, mental status, headache, head sutures, loss of consciousness, and anticoagulation therapy. RESULTS: Fourteen patients presented with ICH (6.8%, 3.8-11.1%) and three (1.5%, 0.3-4.2%) with a neurosurgical procedure. One patient with a coma (0.5, 0.0-2.7) died 2 hours after presentation. All patients who required surgery or died had neurological findings. Reducing head CT scans by 97.1% (93.8-98.9%) would not have missed any patient with possible surgical utility. Twelve of the 14 patients (85.7%) with an ICH had neurological findings, post-trauma loss of consciousness or a facial fracture were not present in 83.5% (95% confidence interval 77.7-88.3) of the cohort. CONCLUSIONS: None of our patients with neurological findings required neurosurgery. Careful palpation of the facial bones to identify facial fractures might aid in the decision whether to perform a head CT scan.

Maternity Providers' Perspectives on Barriers to Utilization of Intermittent Fetal Monitoring: A Qualitative Study.

There are 2 approaches to fetal assessment during labor: continuous electronic fetal monitoring (EFM) and intermittent auscultation (IA). The vast majority of healthy labors in the United States use EFM, despite professional organization recommendations against its use for low-risk pregnancies. This qualitative investigation explores maternity care team members' perspectives on why EFM is the dominant approach to fetal assessment instead of IA. Focus groups comprised of nurses, midwives, and physicians were conducted using a semistructured interview guide. Transcripts were analyzed using directed content analysis to identify themes related to clinical and nonclinical factors influencing the type of fetal assessment employed during labor. Seven focus groups with a total of 41 participants were completed. Seven themes were identified: clinical environment; technology; policies, procedures, and evidence-based protocols; patient-centered influences; fear of liability; providers as members of healthcare team; and deflection of responsibility. All maternity care team members had knowledge of the evidence base supporting IA use for low-risk care. Nurses identified unique challenges in having agency over monitoring decision making and executing best practices. Improved communication among team members can facilitate evidence-based approaches to IA use, facilitating increased utilization for low-risk labor care.

Allocation of liver grafts worldwide - Is there a best system?

BACKGROUND & AIMS: An optimal allocation system for scarce resources should simultaneously ensure maximal utility, but also equity. The most frequent principles for allocation policies in liver transplantation are therefore criteria that rely on pre-transplant survival (sickest first policy), post-transplant survival (utility), or on their combination (benefit). However, large differences exist between centers and countries for ethical and legislative reasons. The aim of this study was to report the current worldwide practice of liver graft allocation and discuss respective advantages and disadvantages. METHODS: Countries around the world that perform 95 or more deceased donor liver transplantations per year were analyzed for donation and allocation policies, as well as recipient characteristics. RESULTS: Most countries use the model for end-stage liver disease (MELD) score, or variations of it, for organ allocation, while some countries opt for center-based allocation systems based on their specific requirements, and some countries combine both a MELD and center-based approach. Both the MELD and center-specific allocation systems have inherent limitations. For example, most countries or allocation systems address the limitations of the MELD system by adding extra points to recipient's laboratory scores based on clinical information. It is also clear from this study that cancer, as an indication for liver transplantation, requires special attention. CONCLUSION: The sickest first policy is the most reasonable basis for the allocation of liver grafts. While MELD is currently the standard for this model, many adjustments were implemented in most countries. A future globally applicable strategy should combine donor and recipient factors, predicting probability of death on the waiting list, post-transplant survival and morbidity, and perhaps costs. LAY SUMMARY: An optimal allocation system for scarce resources should simultaneously ensure maximal utility, but also equity. While the model for end-stage liver disease is currently the standard for this model, many adjustments were implemented in most countries. A future globally applicable strategy should combine donor and recipient factors predicting probability of death on the waiting list, post-transplant survival and morbidity, and perhaps costs.

Challenges to and opportunities for the implementation of non-invasive positive pressure ventilation in the Asia-Pacific region.

Non-invasive positive pressure ventilation (NPPV) is undoubtedly one of the most significant advancements in mechanical ventilation technology in the past 30 years. With accumulating evidence from clinical studies and support from clinical guidelines, NPPV is now widely used in hospitals and increasingly prescribed for home therapy in the Asia-Pacific region. However, in comparison with the developed Western countries, overall use of NPPV in the region is lagging behind. This study reviews this imbalance of NPPV use both in the acute and domiciliary settings in the Asia-Pacific region. Important issues related to NPPV use are also discussed along with speculation around potential strategies that could promote wider implementation of NPPV in the region. We hope this review will stimulate interest in the clinical application and potential research avenues for NPPV in the Asia-Pacific region, and promote education and staff training in the technique.

Examiner Position in Ocular Point-of-Care Ultrasound: A Proposed Technique.

BACKGROUND: Ocular point-of-care ultrasound (POCUS) is a fast and safe non-invasive procedure used to evaluate the structural integrity and pathology of the eye. Ocular POCUS can be used for evaluation of posterior chamber and orbital pathology, including retinal detachment, vitreous detachment or hemorrhage, foreign body, lens dislocation, and increased intracranial pressure. DISCUSSION: The purpose of this brief communication is to describe a technique for conducting an ocular POCUS that may in some cases be easier and more comfortable by adjusting the position of the sonographer relative to the patient. CONCLUSIONS: To our knowledge, this proposed technique has not been described in previous literature and may result in greater comfort for both sonographer and patient.

Use of nitrous oxide in children. / Bruk av lystgass hos barn.

BACKGROUND: In July 2013, the Department of Paediatric and Adolescent Medicine at Østfold Hospital Trust introduced nitrous oxide as an option for procedural sedation of children and adolescents. MATERIAL AND METHOD: During the period 13 July 2013-25 August 2017, 311 procedures were performed with nitrous oxide in 238 patients aged 4-17 years. Age, sex, type and duration of procedure, any supplementary medications, complications and whether the procedure would previously have required general anaesthesia, were recorded in a form. The child rated the effectiveness of nitrous oxide using a graded age-appropriate 10-point pain scale, and the nurse rated it as good, moderate or none. RESULTS: The children reported a median pain score of 2/10 (interquartile range 0-4), and nurses rated effectiveness as good in 247 of 304 (81 %) cases. For 43 % of procedures, the nurse felt that general anaesthesia would have been necessary had the department not had access to nitrous oxide. Adverse effects, most often dizziness, were reported in 110 of 311 procedures (35 %). In 7 of 311 procedures (2 %), the patient experienced adverse effects that resulted in stoppage of the procedure. The procedure was completed in 286 (92 %) children. INTERPRETATION: Nitrous oxide is a useful option for children who require procedural sedation, and means that more procedures can be performed without general anaesthesia.

Impact of a Clinical Decision Support System on Guideline Adherence of Surveillance Recommendations for Colonoscopy After Polypectomy.

Background: Surveillance colonoscopy is required in patients with polyps due to an elevated colorectal cancer (CRC) risk; however, studies suggest substantial overuse and underuse of surveillance colonoscopy. The goal of this study was to characterize guideline adherence of surveillance recommendations after implementation of an electronic medical record (EMR)-based Colonoscopy Pathology Reporting and Clinical Decision Support System (CoRS). Methods: We performed a retrospective cohort study of patients who underwent colonoscopy with polypectomy at a safety-net healthcare system before (n=1,822) and after (n=1,320) implementation of CoRS in December 2013. Recommendations were classified as guideline-adherent or nonadherent according to the US Multi-Society Task Force on CRC. We defined surveillance recommendations shorter and longer than guideline recommendations as potential overuse and underuse, respectively. We used multivariable generalized linear mixed models to identify correlates of guideline-adherent recommendations. Results: The proportion of guideline-adherent surveillance recommendations was significantly higher post-CoRS than pre-CoRS (84.6% vs 77.4%; P<.001), with fewer recommendations for potential overuse and underuse. In the post-CoRS period, CoRS was used for 89.8% of cases and, compared with cases for which it was not used, was associated with a higher proportion of guideline-adherent recommendations (87.0% vs 63.4%; RR, 1.34; 95% CI, 1.23-1.42). In multivariable analysis, surveillance recommendations were also more likely to be guideline-adherent in patients with adenomas but less likely among those with fair bowel preparation and those with family history of CRC. Of 203 nonadherent recommendations, 70.4% were considered potential overuse, 20.2% potential underuse, and 9.4% were not provided surveillance recommendations. Conclusions: An EMR-based CoRS was widely used and significantly improved guideline adherence of surveillance recommendations.

Using Quality Improvement to Increase Utilization of Enteral Therapy in Pediatric Crohn Disease: Results and Outcomes.

INTRODUCTION: Exclusive enteral nutrition (EEN) for induction of remission in children with Crohn disease (CD) is recommended as first-line therapy, but underutilized in the United States related to real and perceived barriers. We hypothesized that quality improvement (QI) methodology could increase use of EEN. METHODS: We developed, implemented, and revised an algorithm and a set of tools to facilitate use of EEN. Through a series of Plan Do Study Act cycles, the approach was modified to overcome provider and patient/family barriers. The primary outcome, the percentage of newly diagnosed CD patients who receive EEN per month between July 2013 and October 2015, assessed using statistical process control. Secondary outcomes, including the short pediatric Crohn disease activity index (sPCDAI), body mass index (BMI) z score, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), albumin, and hemoglobin were compared before and after EEN. RESULTS: Among patients newly diagnosed with CD, 73 patients initiated EEN and were included (mean age 12.7 ±â€Š2.9 years, 49% girls, 86% white). Rates of utilization of EEN increased significantly from a baseline of <5% to an average of approximately 50%. Of the 73 patients who started EEN, 37 (50%) completed a minimum of 8 weeks. Of those completing therapy, 25 (71%) achieved remission, with a significant reduction of sPCDAI (33.6 ±â€Š14.4 to 10.7 ±â€Š12.3, P < 0.0001) CONCLUSIONS:: Use of QI methodology to systematically implement tools designed to improve utilization was effective in increasing the use of EEN. Among those completing therapy, EEN was effective in inducing remission.

Stress Electrocardiography vs Radionuclide Myocardial Perfusion Imaging among Patients Admitted for Chest Pain: Comparison of Teaching and Nonteaching Hospital Services.

OBJECTIVES: The American Board of Internal Medicine Foundation's Choosing Wisely initiative has identified the routine use of stress cardiac imaging among lower-risk patients as an expensive test that should be questioned by both physicians and patients. The objectives of this study were to determine how often patients hospitalized for chest pain are assessed with stress electrocardiography (stress ECG) compared with radionuclide myocardial perfusion imaging (rMPI) and to evaluate whether the cardiac testing guidelines of the American Heart Association and the Choosing Wisely campaign are being followed. We also sought to determine whether there were differences in practice patterns between a teaching and a nonteaching hospital service. METHODS: We conducted a retrospective chart review of 842 consecutive patients admitted with the primary diagnosis of chest pain to a 900-bed university-affiliated teaching hospital in Dayton, Ohio. After exclusions, we analyzed records from 111 teaching service and 94 nonteaching service patients. We assessed whether patients were evaluated with stress ECG or rMPI and compared the teaching service with the nonteaching service. RESULTS: The nonteaching service obtained rMPI more often than the teaching service (94% vs 51%, P < 0.001) and stress ECG less frequently than the teaching service (1% vs 12%, P < 0.003). Both groups may have overused rMPI, choosing it over the less costly alternative of stress ECG testing 71% of the time. CONCLUSIONS: Adherence to the Choosing Wisely recommendations for the appropriate use of stress ECG is suboptimal among both teaching and nonteaching physicians. Choosing stress ECG, when appropriate, could translate into substantial cost savings and reduce potentially harmful radiation exposure.

Fingerstick Glucose Monitoring in Veterans Affairs Nursing Home Residents with Diabetes Mellitus.

BACKGROUND/OBJECTIVE: Guidelines recommend less intensive glycemic treatment and less frequent glucose monitoring for nursing home (NH) residents. However, little is known about the frequency of fingerstick (FS) glucose monitoring in this population. Our objective was to examine the frequency of FS glucose monitoring in Veterans Affairs (VA) NH residents with diabetes mellitus, type II (T2DM). DESIGN AND SETTING: National retrospective cohort study in 140 VA NHs. PARTICIPANTS: NH residents with T2DM and older than 65 years admitted to VA NHs between 2013 and 2015 following discharge from a VA hospital. MEASUREMENTS: NH residents were classified into five groups based on their highest hypoglycemia risk glucose-lowering medication (GLM) each day: no GLMs; metformin only; sulfonylureas; long-acting insulin; and any short-acting insulin. Our outcome was a daily count of FS measurements. RESULTS: Among 17,474 VA NH residents, mean age was 76 (standard deviation (SD) = 8) years and mean hemoglobin A1c was 7.6% (SD = 1.5%). On day 1 after NH admission, 49% of NH residents were on short-acting insulin, decreasing slightly to 43% at day 90. Overall, NH residents had an average of 1.9 (95% confidence interval (CI) = 1.8-1.9) FS measurements on NH day 1, decreasing to 1.4 (95% CI = 1.3-1.4) by day 90. NH residents on short-acting insulin had the most frequent FS measurements, with 3.0 measurements (95% CI = 2.9-3.0) on day 1, decreasing to 2.6 measurements (95% CI = 2.5-2.7) by day 90. Less frequent FS measurements were seen for NH residents receiving long-acting insulin (2.1 (95% CI = 2.0-2.2) on day 1) and sulfonylureas (1.7 (95% CI = 1.5-1.8) on day 1). Even NH residents on metformin monotherapy had 1.1 (95% CI = 1.1-1.2) measurements on day 1, decreasing to 0.5 (95% CI = 0.4-0.6) measurements on day 90. CONCLUSION: Although guidelines recommend less frequent glucose monitoring for NH residents, we found that many VA NH residents receive frequent FS monitoring. Given the uncertain benefits and potential for substantial patient burdens and harms, our results suggest decreasing FS monitoring may be warranted for many low hypoglycemia risk NH residents.

Association between procedure appropriateness and patient-reported outcomes after percutaneous coronary intervention.

OBJECTIVE: The Appropriate Use Criteria (AUC) has been used to identify individuals who are likely to benefit from percutaneous coronary intervention (PCI) for stable ischaemic heart disease. However, whether physicians reliably grade PCI appropriateness and whether AUC categories stratify symptomatic improvement in real-world practice are unclear. METHODS: Patient-reported outcomes measures (PROMs) for angina (Seattle Angina Questionnaire (SAQ-7)), dyspnoea (Rose Dyspnea Scale (RDS)) and depression (Patient Health Questionnaire-2 (PHQ-2)) were collected on patients undergoing elective coronary angiography at an academic medical centre. Retrospectively, two physicians independently determined PCI appropriateness by the AUC criteria. RESULTS: Inter-rater agreement on appropriateness was moderate (κ=0.48, 95% CI 0.32 to 0.63). Of PCI procedures evaluated, 57 (47.1%) were appropriate (A-PCI), 62 (51.2%) were maybe appropriate (MA-PCI) and 2 (1.6%) were rarely appropriate. At baseline, A-PCI compared with MA-PCI patients had worse RDS scores (2.0 vs 1.2, p=0.01). At 30 days, the change in SAQ-7 summary score was similar between groups (A-PCI vs MA-PCI, +27.1 vs +20.7, p=0.11). The mean change in RDS score was greater in A-PCI than MA-PCI (-1.0 vs -0.5, p for group by time interaction=0.03). PHQ-2 scores were similar and did not improve at 30 days. CONCLUSION: In patients undergoing PCI with PROMs collected before and 30 days after PCI, similar improvements in angina were observed regardless of appropriateness. Inter-rater agreement on PCI appropriateness was only moderate. Use of PROMs may improve reliability of physician assessments of PCI appropriateness.

Using appropriateness criteria to identify opportunities to improve perioperative urinary catheter use.

BACKGROUND: The Michigan Appropriate Perioperative (MAP) criteria provide guidance regarding urinary catheter use. For Category A (e.g., laparoscopic cholecystectomy), B (e.g., hemicolectomy), and C (e.g., abdominoperineal resection) procedures, recommendations are to avoid catheter, remove POD 0 or 1, and remove POD 1-4, respectively. We applied MAP criteria to statewide registry data to identify improvement targets. METHODS: Retrospective cohort study of risk-adjusted catheter use and duration for appendectomy, cholecystectomy, and colorectal resections in 2014-2015 from 64 Michigan hospitals. RESULTS: 5.5% of 13,032 Category A cases used urinary catheters, including 26.9% of open appendectomies. 94.5% of 1,624 Category B cases used catheters (31.2% remained after POD 1). 98.3% of 700 Category C cases used catheters (4.6% remained POD5+). Variation in duration of use persisted after risk adjustment. CONCLUSIONS: Perioperative urinary catheter use was appropriate for most simple abdominal procedures, but duration of use varied in all categories.

Application of pigtail catheter tailing combined with long-wire swapping technique in cerebral angiography via the right radial artery.

The safety and feasibility of transradial approach for cerebral angiography has been confirmed previously. However, this approach has been limited used due to the difficulty during the procedure. This study aimed to introduce a pigtail catheter tailing and long-wire swapping technique to improve the success rate without increasing complications.From August 2015 to December 2018, 560 patients who underwent cerebral angiography via transradial approach were recruited. The data including the type of aortic arch, type of Simmon catheter were collected.The loop was successfully constructed in 553 patients using Simmon-2 or Simmon-1 catheter. Of these patients, 72 patients successfully underwent cerebral and renal angiography, while 481 patients underwent cerebral angiography. The time for angiography was 52.87 ±â€Š11.23 minutes and 47.8 ±â€Š11.8 minutes, respectively. There were 369 (66.7%), 135 (24.4%), and 49 (8.9%) patients with type I, type II, and type III aortic arches, respectively, and their success rates of looping using Simmon-2 catheter were 97.8%, 97.0%, and 89.8%, respectively. The success rates of angiography in the right internal carotid artery, right vertebral artery, left internal carotid artery, and left vertebral artery were 100%, 100%, 98.9%, and 98.9%, respectively. No serious complications were observed in all patients.The pigtail catheter tailing and long guidewire swapping is considered as a safe procedure with high success rate for loop construction using a Simmon-2 catheter through the right radial artery, subsequently improving the success rate as well as the efficiency of angiography.

Descriptive Analysis of Extubations Performed in an Emergency Department-based Intensive Care Unit.

INTRODUCTION: Extubation of appropriate patients in the emergency department (ED) may be a strategy to avoid preventable or short-stay intensive care unit (ICU) admissions, and could allow for increased ventilator and ICU bed availability when demand outweighs supply. Extubation is infrequently performed in the ED, and a paucity of outcome data exists. Our objective was to descriptively analyze characteristics and outcomes of patients extubated in an ED-ICU setting. METHODS: We conducted a retrospective observational study at an academic medical center in the United States. Adult ED patients extubated in the ED-ICU from 2015-2019 were retrospectively included and analyzed. RESULTS: We identified 202 patients extubated in the ED-ICU; 42% were female and median age was 60.86 years. Locations of endotracheal intubation included the ED (68.3%), outside hospital ED (23.8%), and emergency medical services/prehospital (7.9%). Intubations were performed for airway protection (30.2%), esophagogastroduodenoscopy (27.7%), intoxication/ingestion (17.3%), respiratory failure (13.9%), seizure (7.4%), and other (3.5%). The median interval from ED arrival to extubation was 9.0 hours (interquartile range 6.2-13.6). One patient (0.5%) required unplanned re-intubation within 24 hours of extubation. The attending emergency physician (EP) at the time of extubation was not critical care fellowship trained in the majority (55.9%) of cases. Sixty patients (29.7%) were extubated compassionately; 80% of these died in the ED-ICU, 18.3% were admitted to medical-surgical units, and 1.7% were admitted to intensive care. Of the remaining patients extubated in the ED-ICU (n = 142, 70.3%), zero died in the ED-ICU, 61.3% were admitted to medical-surgical units, 9.9% were admitted to intensive care, and 28.2% were discharged home from the ED-ICU. CONCLUSION: Select ED patients were safely extubated in an ED-ICU by EPs. Only 7.4% required ICU admission, whereas if ED extubation had not been pursued most or all patients would have required ICU admission. Extubation by EPs of appropriately screened patients may help decrease ICU utilization, including when demand for ventilators or ICU beds is greater than supply. Future research is needed to prospectively study patients appropriate for ED extubation.

The effects of hands on and hands off/poised techniques on maternal outcomes: A systematic review and meta-analysis.

BACKGROUND: Negative maternal outcomes such as perineal trauma and related perineal pain may cause both long-and short- term morbidities. Hands on and hands off/poised technique are two kinds of techniques to protect perineum during the second-stage of labor. Hands on technique has been the routine midwifery practice for a long time; nevertheless, the effects of hands on technique on protecting perineum has been doubted. Hands off/poised as a promising technique seems prevalent in clinical practice. However, there is no consensus on use of hands off/poised technique and hands on technique. The effects of these techniques on maternal outcomes have not been fully investigated. OBJECTIVE: To evaluate the effects of hands on hands off/poised technique on maternal outcomes during the second-stage of labor. DESIGN: Systematic review and meta-analysis of relevant quantitative studies. DATA SOURCES: Seven databases: PubMed, EMBASE, The Cochrane Library, CINAHL, WanFang Data, China National Knowledge Infrastructure (CKNI), SinoMed were systematically searched from inception to July 23,2018 for relevant quantitative studies comparing the effects of hands on and hands off/poised technique on maternal outcomes. REVIEW METHODS: Quantitative studies were retrieved for relevant studies. Two reviewers independently screened the studies, evaluated the methodological quality using JBI appraisal checklist tools and extracted the data. The included studies were divided into two groups for analysis according to study types. RESULTS: Nine RCTs with a total of 7112 participants and eight non-RCTs with 37,786 participants were included for meta-analysis. Based on the results from RCTs, this study did not find difference between hands on and hands off/poised technique regarding the risk of 2nd perineal tears, 3rd /4th degree perineal tears, duration of second-stage labor and incidence of postpartum hemorrhage (PPH>500 ml). The results from 9 non-RCTs were similar with that of RCTs, except for showing less 2nd degree perineal tears in hands off/poised technique than in hands on technique. CONCLUSION: Evidence in the present study indicated that hands off/poised technique may be a promising delivery technique to maintain intact perineum, and reduce perineal pain and episiotomy use among women with low-risk pregnancy undergoing vaginal delivery. In addition, hands off/poised technique might be safe to use as it did not increase the risk of severe perineal trauma, postpartum hemorrhage, and longer duration of second-stage labor when compared with hands on technique. More studies with stringent study design, especially large randomized controlled trial, should be conducted before strong recommendation of the hands off/poised technique.

The impact of concurrent Hashimoto thyroiditis on thyroid nodule cytopathology assessed by ultrasound-guided fine-needle aspiration cytology.

Objective: Thyroid nodules are highly prevalent and a common clinical problem worldwide. How to identify the nature of a nodule is a major concern of clinicians. Fine needle aspiration cytology (FNAC) has an established role and is well-utilized in nodule management. However, the unsatisfactory nondiagnostic and indeterminate rates limit its usage and lead to some unnecessary surgery. Hashimoto thyroiditis (HT) is prevalently found concurrent with thyroid nodules. Whether HT can influence the accuracy of cytopathological diagnosis of nodules is still controversial. Methods: We collected medical records of 1,063 patients with thyroid nodules who had done FNAC in our hospital from 2015 to 2016. Thyroid function, anti-thyroid autoantibody levels, thyroid ultrasound records, and cytological and histopathological results of nodules were reviewed to analyze the impact of HT on FNAC outcome. Results: A total of 1,063 patients with an average age of 44 ± 13 years old were retrospectively reviewed for pathological and clinical data. Patients with different cytological diagnoses had comparable positive rates of anti-thyroid autoantibodies. One hundred patients were confirmed to have concurrent HT by histopathology after surgery. The overall nondiagnostic and indeterminate cytology rates were 11.9% and 25% respectively. No statistical difference was found either in the rate of a nondiagnostic cytology results or in the rate of indeterminate cytology results between patients with positive anti-thyroid autoantibodies and patients with negative test for anti-thyroid autoantibodies (P > 0.05). The same was true between patients with histopathologically confirmed HT and HT-negative ones (P > 0.05). Conclusions: The presence of concurrent HT, whether clinically implied with positive anti-thyroid autoantibodies or pathologically confirmed, is unlikely to predispose an FNAC diagnosis of thyroid nodules to be non-diagnostic or indeterminate.

The Utility of Preoperative Labs in Predicting Postoperative Complications Following Primary Total Hip and Knee Arthroplasty.

BACKGROUND: Preoperative testing costs billions of dollars despite little evidence supporting its utility. The purpose of this study was to determine the relationship between abnormal preoperative laboratory tests and postoperative complications following total joint arthroplasty. METHODS: The NSQIP database was used to identify 45,936 primary total hip arthroplasty (THA) and 76,041 pri-mary total knee arthroplasty (TKA) cases performed between 2006 and 2013. Complications within 30 days of surgery were collected and multivariable regression modeling was performed incorporating all significant laboratory values as well as demographics and preoperative comorbidities. RESULTS: For THA patients, abnormal sodium (p = 0.016, OR = 1.89), white count (p = 0.043, OR = 1.73), and partial thromboplastin time (p = 0.028, OR = 1.43) were significantly associated with complications. For TKA patients, abnormal alkaline phosphatase (p = 0.04, OR = 2.12), creatinine (p = 0.003, OR = 1.56), and INR (p = 0.008, OR = 1.99) were significantly predictive of complications. CONCLUSION: Of the 13 laboratory values, only six were significantly associated with complications. These findings may have implications for risk stratification in the inpatient setting.

Baseline risk, timing of invasive strategy and guideline compliance in NSTEMI: Nationwide analysis from MINAP.

BACKGROUND: International guidelines recommend that for NSTEMI, the timing of invasive strategy (IS) is a function of patient's baseline risk. The extent to which this is delivered across and within healthcare systems is unknown. METHODS: Data were derived from 137,265 patients admitted with an NSTEMI diagnosis between 2010 and 2015 in England and Wales. Patients were stratified into low, intermediate and high-risk in keeping with international guidelines. Time to IS was categorised into early (24 h), intermediate (25-72 h) and late (>72 h). Multivariable logistic regression models were used to identify independent predictors of guidelines recommended receipt of IS. RESULTS: There were 3608 (2.6%) low, 5037 (3.7%) intermediate and 128,621 (93.7%) high-risk patients. Guidelines recommended use of IS was significantly lower in high-risk (16.4%) compared to intermediate (64.7%) and low-risk (62.5%) groups. Both men and women in the low-risk category were almost twice as likely to receive early IS compared to high-risk men (28.9% vs 17%, p < 0.001) and women (26.9% vs 15%, p < 0.001). Women (OR 0.91 95%CI 0.88-0.94), troponin elevation (OR 0.39 95%CI 0.36-0.43) and acute heart failure on admission (OR 0.65 95%CI 0.61-0.70) were strong negative predictors of receiving IS within recommended time in the high-risk group. CONCLUSION: Our study shows that IS for management of NSTEMI is not delivered according to international guidelines recommendations. Specifically, the disconnect between baseline risk and utility of IS increases with increasing risk and women achieve slower access than men to IS.