Effect of Complementary Interventions to Redesign Care on Teamwork and Quality for Hospitalized Medical Patients : A Pragmatic Controlled Trial.

BACKGROUND: Multiple challenges impede interprofessional teamwork and the provision of high-quality care to hospitalized patients. OBJECTIVE: To evaluate the effect of interventions to redesign hospital care delivery on teamwork and patient outcomes. DESIGN: Pragmatic controlled trial. Hospitals selected 1 unit for implementation of interventions and a second to serve as a control. (ClinicalTrials.gov: NCT03745677). SETTING: Medical units at 4 U.S. hospitals. PARTICIPANTS: Health care professionals and hospitalized medical patients. INTERVENTION: Mentored implementation of unit-based physician teams, unit nurse-physician coleadership, enhanced interprofessional rounds, unit-level performance reports, and patient engagement activities. MEASUREMENTS: Primary outcomes were teamwork climate among health care professionals and adverse events experienced by patients. Secondary outcomes were length of stay (LOS), 30-day readmissions, and patient experience. Difference-in-differences (DID) analyses of patient outcomes compared intervention versus control units before and after implementation of interventions. RESULTS: Among 155 professionals who completed pre- and postintervention surveys, the median teamwork climate score was higher after than before the intervention only for nurses (n = 77) (median score, 88.0 [IQR, 77.0 to 91.0] vs. 80.0 [IQR, 70.0 to 89.0]; P = 0.022). Among 3773 patients, a greater percentage had at least 1 adverse event after compared with before the intervention on control units (change, 1.61 percentage points [95% CI, 0.01 to 3.22 percentage points]). A similar percentage of patients had at least 1 adverse event after compared with before the intervention on intervention units (change, 0.43 percentage point [CI, -1.25 to 2.12 percentage points]). A DID analysis of adverse events did not show a significant difference in change (adjusted DID, -0.92 percentage point [CI, -2.49 to 0.64 percentage point]; P = 0.25). Similarly, there were no differences in LOS, readmissions, or patient experience. LIMITATION: Adverse events occurred less frequently than anticipated, limiting statistical power. CONCLUSION: Despite improved teamwork climate among nurses, interventions to redesign care for hospitalized patients were not associated with improved patient outcomes. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Transcutaneous retrobulbar amphotericin B for rhino-orbital-cerebral mucormycosis: a multi-center retrospective comparative study.

PURPOSE: To assess whether transcutaneous retrobulbar amphotericin B injections (TRAMB) reduce exenteration rate without increasing mortality in rhino-orbital-cerebral mucormycosis (ROCM). METHODS: In this retrospective case-control study, 46 patients (51 eyes) with biopsy-proven ROCM were evaluated at 9 tertiary care institutions from 1998 to 2021. Patients were stratified by radiographic evidence of local orbital versus extensive involvement at presentation. Extensive involvement was defined by MRI or CT evidence of abnormal or loss of contrast enhancement of the orbital apex with or without cavernous sinus, bilateral orbital, or intracranial extension. Cases (+TRAMB) received TRAMB as adjunctive therapy while controls (-TRAMB) did not. Patient survival, globe survival, and vision/motility loss were compared between +TRAMB and -TRAMB groups. A generalized linear mixed effects model including demographic and clinical covariates was used to evaluate the impact of TRAMB on orbital exenteration and disease-specific mortality. RESULTS: Among eyes with local orbital involvement, exenteration was significantly lower in the +TRAMB group (1/8) versus -TRAMB (8/14) (p = 0.04). No significant difference in mortality was observed between the ±TRAMB groups. Among eyes with extensive involvement, there was no significant difference in exenteration or mortality rates between the ±TRAMB groups. Across all eyes, the number of TRAMB injections correlated with a statistically significant decreased rate of exenteration (p = 0.048); there was no correlation with mortality. CONCLUSIONS: Patients with ROCM with local orbital involvement treated with adjunctive TRAMB demonstrated a lower exenteration rate and no increased risk of mortality. For extensive involvement, adjunctive TRAMB does not improve or worsen these outcomes.

Neonatal neurosonography practices: a survey of active Society for Pediatric Radiology members.

BACKGROUND: While neonatal brain US is emerging as an imaging modality with greater portability, widespread availability and relative lower cost compared to MRI, it is unknown whether US is being maximized in infants to increase sensitivity in detecting intracranial pathology related to common indications such as hemorrhage, ischemia and ventriculomegaly. OBJECTIVE: To survey active members of the Society for Pediatric Radiology (SPR) regarding their utilization of various cranial US techniques and reporting practices in neonates. MATERIALS AND METHODS: We distributed an online 10-question survey to SPR members to assess practice patterns of neonatal cranial US including protocol details, use of additional sonographic views, perceived utility of spectral Doppler evaluation, and germinal matrix hemorrhage and ventricular size reporting preferences. RESULTS: Of the 107 institutions represented, 90% of respondents were split evenly between free-standing children's hospitals and pediatric departments attached to a general hospital. We found that most used template reporting (72/107, 67%). The anterior fontanelle approach was standard practice (107/107, 100%). We found that posterior fontanelle views (72% sometimes, rarely or never) and high-frequency linear probes to evaluate far-field structures (52% sometimes, rarely or never) were seldom used. Results revealed a range of ways to report germinal matrix hemorrhage and measure ventricular indices to assess ventricular dilatation. There was substantial intra-institutional protocol and reporting variability as well. CONCLUSION: Our results demonstrate high variability in neurosonography practice and reporting among active SPR members, aside from the anterior fontanelle views, template reporting and linear high-resolution near-field evaluation. Standardization of reporting germinal matrix hemorrhage and ventricular size would help ensure a more consistent application of neonatal US in research and clinical practice.

A Review of Midface Aging.

PURPOSE: To review and summarize studies on the anatomy and involutional changes of the midface. METHODS: A PubMed search was performed searching for studies on the anatomy and involutional changes concerning the midface. RESULTS: The anatomy of the midface is complex. Studies of involutional change vary in scientific quality and have conflicting results. However, it appears that among the more common changes, there is a decrease in the maxillary and pyriform angle, with changes to the orbital floor position. Further, there appears to be an inferior migration of the fat compartments of the midface during aging, exacerbating the hollow of the palpebromalar groove and causing a deepening of the nasojugal groove. Changes to the volume of the buccal extension of the buccal fat pad exacerbate these changes and contribute to the gestalt changes associated with facial aging. Here, we review the major characteristics of soft tissue and bony changes on the midface, with special reference to their anatomic relationships. CONCLUSIONS: The major findings characterizing midface aging are related largely to the soft tissue. However, more robust studies are required to quantify these changes and to appraise their impact on the overall manifestation of aging.

Orbital biopsy findings consistent with granulomatosis polyangiitis in a 14-year-old boy with Crohn's disease.

Both granulomatous polyangiitis (GPA) and Crohn's disease (CD) can cause orbital inflammation though rarely coincide and can often be differentiated by presenting features and histological findings. Here, we report the clinical and therapeutic course of a 14-year-old White male with binocular diplopia caused by orbital myositis. Imaging and biopsy obtained at presentation revealed necrosis and necrotizing granulomatous vasculitis suspicious for GPA. He subsequently developed gastrointestinal symptoms and terminal ileitis consistent with CD. Orbital symptoms responded well to high-dose steroids and remained quiet on methotrexate maintenance therapy. While clinical history, thorough physical exam, and complete laboratory work-up are essential in the management of pediatric orbital myositis, orbital biopsy can prove critical for diagnosis and suitable treatment strategy.

Utilization of neonatal sedation and anesthesia: an SPR survey.

BACKGROUND: There is little data regarding the use of sedation and anesthesia for neonatal imaging, with practice patterns varying widely across institutions. OBJECTIVE: To understand the current utilization of sedation and anesthesia for neonatal imaging, and review the current literature and recommendations. MATERIALS AND METHODS: One thousand, two hundred twenty-six questionnaire invitations were emailed to North American physician members of the Society for Pediatric Radiology using the Survey Monkey platform. Descriptive statistical analysis of the responses was performed. RESULTS: The final results represented 59 institutions from 26 U.S. states, the District of Columbia and three Canadian provinces. Discrepant responses from institutions with multiple respondents (13 out of 59 institutions) were prevalent in multiple categories. Of the 80 total respondents, slightly more than half (56%) were associated with children's hospitals and 44% with the pediatric division of an adult radiology department. Most radiologists (70%) were cognizant of the neonatal sedation policies in their departments. A majority (89%) acknowledged awareness of neurotoxicity concerns in the literature and agreed with the validity of these concerns. In neonates undergoing magnetic resonance imaging (MRI), 46% of respondents reported attempting feed and bundle in all patients and an additional 46% attempt on a case-by-case basis, with most (35%) using a single swaddling attempt before sedation. Sedation was most often used for neonatal interventional procedures (93%) followed by MR (85%), nuclear medicine (48%) and computed tomography (31%). More than half of respondents (63%) reported an average success rate of greater than 50% when using neonatal sedation for MR. CONCLUSION: Current practice patterns, policies and understanding of the use of sedation and anesthesia for neonatal imaging vary widely across institutions in North America, and even among radiologists from the same institution. Our survey highlights the need for improved awareness, education, and standardization at both the institutional level and the societal level. Awareness of the potential for anesthetic neurotoxicity and success of non-pharmacologic approaches to neonatal imaging is crucial, along with education of health care personnel, systematic approaches to quality control and improvement, and integration of evidence-based protocols into clinical practice.

Multiple Cranial Neuropathies as the Initial Presentation of Primary Ductal Adenocarcinoma of the Lacrimal Gland.

Primary ductal adenocarcinoma of the lacrimal gland is a rare, aggressive malignancy that clinically and histologically resembles salivary duct carcinoma. Similar to other malignant epithelial lacrimal gland tumors, ductal adenocarcinoma typically presents with unilateral proptosis, pain, upper eyelid swelling, palpable mass, diplopia, ptosis, and blurred or decreased vision. Rarely, primary malignant epithelial lacrimal gland tumors may first present with multiple cranial neuropathies due to occult spread to the cavernous sinus, as in this case. With such a vast differential diagnosis, a practical yet systematic approach to multiple cranial neuropathies, as guided by clinical history, exam, and neuroimaging, allows for a more targeted diagnostic evaluation, especially when multiple diagnostic tests and interventions return unrevealing. A repeat biopsy or complete excision of the lacrimal gland may be necessary to yield the correct diagnosis.

Peripheral Neurectomy With Customized Nerve Reconstruction for Periorbital Neuropathic Pain: Initial Experience and Clinical Outcomes.

PURPOSE: To describe a novel, minimally invasive surgical technique to treat severe, intractable periorbital neuropathic pain. METHODS: A retrospective analysis of patients with severe, treatment-refractory periorbital pain who underwent transection of affected sensory trigeminal branches with nerve repair was performed. Collected data included etiology and duration of neuropathic pain, comorbidities, prior treatment history, surgical technique including site of transected sensory nerves and type of nerve repair, preoperative and postoperative pain scores as well as follow-up duration. Differences between preoperative and postoperative values were analyzed by the Wilcoxon signed-rank test. RESULTS: A total of 5 patients with severe periorbital neuropathic pain underwent transection of affected supraorbital, supratrochlear, infratrochlear, infraorbital, zygomaticotemporal, and zygomaticofacial nerves with customized nerve reconstruction. All 5 had improvement of periorbital pain after surgery, with 3 (60%) noting complete resolution of pain and 2 (40%) experiencing partial pain relief over a median follow-up period of 9 months (interquartile range [IQR], 6-19 months). Of the 3 patients who had complete resolution of pain, all reported continued pain relief. Median McGill pain scores significantly decreased from 8.4 (IQR, 8.2-10.0) preoperatively to 0.0 (IQR, 0.0-4.8; p < 0.001) postoperatively. All patients reported satisfaction with the surgical procedure and stated that they would undergo the procedure again if given the option. One patient with history of postherpetic neuralgia (PHN) had reactivation of herpes zoster at postoperative month 3, which was self-limited, without worsening of her neuropathic pain. Another patient with PHN required a staged procedure to achieve complete pain relief. CONCLUSION: Peripheral neurectomy with customized reconstruction of involved sensory nerves can successfully reduce and even eradicate periorbital neuropathic pain that was previously recalcitrant to combination pharmacotherapy and prior neurolysis procedures.

Thrombogenicity of Hyaluronic Acid Fillers: A Quantitative Thrombodynamics Study.

PURPOSE: At present, there is a paucity of data regarding the thrombogenicity of hyaluronic acid fillers (HAFs). This article quantitatively analyses the thrombogenicity of 2 commonly used HAFs: Restylane Lyft and Juvéderm Ultra. METHODS: Thrombogenicity was assessed using the Thrombodynamics Analyzer System and plasma obtained from healthy controls. Following the addition of HAFs or control, spontaneous clot formation time, initial rate of clot growth, average rate of clot growth over 30 minutes, and clot size at 30 minutes was measured for each sample. The median of differences between each group were analyzed. RESULTS: Nine individuals with a mean (SD) age of 37 (17) years, participated in the study. Initial rate of clot growth was significantly lower in plasma mixed with Juvéderm compared to control (p = 0.008) or Restylane (p = 0.038). The average rate of clot growth more than 30 minutes was significantly lower in both HAF groups (Restylane vs. control p = 0.038; Juvéderm vs. control p = 0.008), there was no significant difference between HAF groups (p = 0.635). Final clot size was significantly smaller with Juvéderm (p = 0.038 vs. control and p = 0.013 vs. Restylane). Spontaneous clot formation time did not significantly change with the addition of either HAF. CONCLUSIONS: Juvéderm significantly reduces the initial rate of clot growth, the average rate of clot growth more than 30 minutes, and clot size, whereas the addition of Restylane decreases the average rate of clot growth without affecting overall clot size in healthy individuals.

Changes to Eye Whiteness and Eyelid/Brow Position With Topical Oxymetazoline in Aesthetic Patients.

BACKGROUND: Oxymetazoline hydrochloride 0.1% ophthalmic solution has recently been approved in the United States for the treatment of ptosis. OBJECTIVES: The aim of this study was to assess the upper and lower eyelid position as well as the brow position and the color of the sclera following the ophthalmic administration of oxymetazoline hydrochloride 0.1%. METHODS: In this prospective cohort study, consecutive patients presenting with ptosis received topical oxymetazoline 0.1%. The primary outcome was measurement of the upper eyelid height (margin-to-reflex distance 1 [MRD1]) and lower eyelid height (MRD2) relative to the center of pupil, along with assessment of brow height, measured on photographs at baseline and 2 hours after instillation of oxymetazoline. The secondary outcome was the assessment of the color of the sclera (eye whiteness) before and after treatment with a novel color space algorithm. RESULTS: Twenty-nine patients participated in the study. The mean [SD] MRD1 at baseline was 2.3 [0.6] mm. At 2 hours following oxymetazoline treatment, the mean MRD1 significantly increased to 4.2 [0.9] mm (P < 0.01). The mean MRD2 also significantly increased from 5.3 [0.9] mm to 5.7 [1.0] mm (P < 0.01). Brow position did not change with treatment (P = 0.4). Following treatment, the eye sclera became significantly whiter, with a mean ΔEab (color change) of 9.7 [3.9], with 57 out of 58 eyes experiencing a significant change in color. A change of ΔEab ≥2 is considered visually perceptible to the human eye. CONCLUSIONS: Within 2 hours of use, oxymetazoline significantly improves the size of the palpebral aperture (MRD1 + MRD2) and also makes the eye appear significantly whiter.

Technology acceptance and critical mass: Development of a consolidated model to explain the actual use of mobile health care communication tools.

OBJECTIVE: Secure mobile communication technologies are being implemented at an increasing rate across health care organizations, though providers' use of these tools can remain limited by a perceived lack of other users to communicate with. Enabling acceptance and driving provider utilization of these tools throughout an organization requires attention to the interplay between perceived peer usage (i.e. perceived critical mass) and local user needs within the social context of the care team (e.g. inpatient nursing access to the mobile app). To explain these influences, we developed and tested a consolidated model that shows how mobile health care communication technology acceptance and utilization are influenced by the moderating effects of social context on perceptions about the technology. METHODS: The theoretical model and questionnaire were derived from selected technology acceptance models and frameworks. Survey respondents (n = 1254) completed items measuring perceived critical mass, perceived usefulness, perceived ease of use, personal innovativeness in information technology, behavioral intent, and actual use of a recently implemented secure mobile communication tool. Actual use was additionally measured by logged usage data. Use group was defined as whether a hospital's nurses had access to the tool (expanded use group) or not (limited use group). RESULTS: The model accounted for 61% and 72% of the variance in intent to use the communication tool in the limited and expanded use groups, respectively, which in turn accounted for 53% and 33% of actual use. The total effects coefficient of perceived critical mass on behavioral intent was 0.57 in the limited use group (95% CI 0.51-0.63) and 0.70 in the expanded use group (95% CI 0.61-0.80). CONCLUSION: Our model fit the data well and explained the majority of variance in acceptance of the tool amongst participants. The overall influence of perceived critical mass on intent to use the tool was similarly large in both groups. However, the strength of multiple model pathways varied unexpectedly by use group, suggesting that combining sociotechnical moderators with traditional technology acceptance models may produce greater insights than traditional technology acceptance models alone. Practically, our results suggest that healthcare institutions can drive acceptance by promoting the recruitment of early adopters though liberal access policies and making these users and the technology highly visible to others.

Outcomes of adjunctive therapies post hedgehog inhibitors in the management of locally advanced basal cell carcinoma: A systematic review and pooled analysis.

Management of patients with locally advanced basal cell carcinoma (laBCC) with traditional strategies has yielded suboptimal outcomes. Targeted treatments including hedgehog inhibitor therapy (HHIT) present limitations when utilized as monotherapy. Herein, we report evidence-based outcomes from available literature on multimodality treatments adjuvant to HHIT in laBCC management. Utilizing a systematic search strategy in PubMed, we identified studies published from inception to April 15, 2020, screened for definitive inclusion/exclusion criteria, and performed individual study quality assessment and pooled analysis to assess impact of adjunctive treatment-based responses post-HHIT on clinical response and recurrence outcomes. Twenty-nine studies (n = 103) were included. Primary findings include a complete response (CR) rate of 90.5%, the median follow-up of 12 months post-HHIT completion. The recurrence rate was 10.8% with 12-month median time to recurrence. Mohs micrographic surgery (MMS) had 100% CR post-HHIT, while no difference was observed between surgery and radiation therapy (RT). MMS and surgery had comparable 2-year recurrence free rates (RFR) at 87% and 86% respectively, while RT had the lower 2-year RFR at 67%. Male gender portended a more advanced stage at diagnosis and worse outcomes. In a subset analysis, periorbital laBCCs with orbital involvement had a CR rate of 81.8% versus 100% in those without orbital involvement, with similar rates of recurrence. Limited available quantitative data and possible publication bias were limitations. Pooled analysis of observational data supports use of adjunctive therapies post-HHIT to improve treatment response in patients with laBCC. Longer-term follow-up is needed to study recurrence rates after combination therapy.

Corneal Neurotization for Postherpetic Neurotrophic Keratopathy: Initial Experience and Clinical Outcomes.

PURPOSE: To assess early outcomes of corneal neurotization for postherpetic neurotrophic keratopathy (NK). METHODS: Retrospective analysis of patients who underwent corneal neurotization for postherpetic NK by a single experienced oculoplastic surgeon was performed. Collected data included stage and etiology of NK as well as comorbidities, prior treatment history, neurotization technique, donor nerve site, preoperative and postoperative examination findings (i.e., ocular surface quality, corneal clarity, corneal sensation by Cochet-Bonnet esthesiometry, and visual acuity [VA]), and follow-up duration. Differences between preoperative and postoperative values were analyzed by Wilcoxon signed-rank test. RESULTS: Of 23 adult patients who underwent corneal neurotization, 3 (13%) had history of herpes simplex keratitis and/or endotheliitis, and 4 (17%) had history of herpes zoster ophthalmicus. One patient with herpes zoster ophthalmicus was excluded due to inadequate follow-up duration. Of the 6 patients included in the study, 3 (50%) had Mackie stage 1 disease, 1 (17%) had stage 2, and 2 (33%) had stage 3 with impending perforation, but all had markedly diminished corneal sensation, with a median denervation time of 11.8 months (interquartile range [IQR] 9.4-29.2 months). Following neurotization, median corneal sensation improved significantly from 1.6 cm (interquartile range 0.0-1.9 cm) to 3.6 cm (IQR 3.0-5.6 cm, p = 0.028), with 1 patient achieving full sensation by postoperative month 5. All patients with a persistent epithelial defect preoperatively showed complete corneal healing by their last follow-up visit. VA also improved postoperatively in all patients (p = 0.028). Median follow-up duration was 11.3 months (interquartile range 9.6-17.9 months). CONCLUSIONS: Corneal neurotization can successfully reinnervate corneas previously devitalized by herpetic disease and halt the progressive nature of postherpetic NK. If utilized appropriately and early in the disease process, neurotization may reduce morbidity and maximize visual potential in postherpetic NK.

Patient Satisfaction and Management of Postoperative Complications Following Ablative Carbon Dioxide Laser Resurfacing of the Lower Eyelids.

PURPOSE: To describe postoperative management following ablative carbon dioxide laser resurfacing of the lower eyelids. METHODS: A retrospective review of patients who consecutively underwent bilateral lower eyelid ablative carbon dioxide laser resurfacing by a single experienced oculoplastic surgeon over a 6-year period was conducted. Patient satisfaction, aesthetic outcomes, and postoperative complications were evaluated as adjunctive or monotherapy. RESULTS: Among 424 patients included in the study, most were female (n = 356, 84.0%) and Caucasian (n = 404, 95.3%), with Fitzpatrick skin types II-III (n = 381, 89.9%). Mean age was 62.8 years (standard deviation: 9.7 years). Most (n = 324, 76.4%) underwent fractional ablative carbon dioxide laser resurfacing of the lower eyelids, whereas 91 (21.5%) received traditional laser resurfacing and 9 (2.1%) had both fractional and traditional laser resurfacing during the same session. At the time of lower eyelid laser resurfacing, most patients also underwent concurrent procedures, including upper (n = 321, 75.7%) and lower blepharoplasty (n = 348, 82.1%); a small proportion of patients (n = 39, 9.2%) did not undergo any concurrent surgical procedure. In addition to ablative laser resurfacing of the lower eyelids, 25 (5.9%) had upper eyelid laser resurfacing, 60 (14.2%) had full-face laser resurfacing, 55 (13.0%) had neck laser resurfacing, and 42 (9.9%) had additional treatment of solar lentigines or dyschromias on the face. Median follow-up duration was 3.9 months (interquartile range: 2.0-11.0 months). In the immediate postoperative period, 22 patients (5.2%) developed contact dermatitis from topical antibiotic eye drops and/or ointment prescribed postblepharoplasty. Postinflammatory hyperpigmentation was observed in 40 patients (9.4%) despite topical prophylaxis; all were eventually successfully treated with a combination of topical nonprescription and prescription creams and/or oral tranexamic acid. A localized herpetic outbreak occurred in 3 (0.7%) who underwent full-face laser resurfacing and 1 (0.2%) who underwent periocular laser resurfacing only; all were successfully treated with oral antiviral therapy. Two (0.5%) developed culture-proven atypical mycobacterial infection of the resurfaced lower eyelid skin and were treated with combination antibiotic therapy for several months until resolution. A small scar was noted in 4 patients (0.9%), which resolved after local corticosteroid injections. No patient developed persistent scarring or ectropion. Patient satisfaction was overall high, with 363 (85.6%) very satisfied and 48 (11.3%) satisfied with the aesthetic outcome of lower eyelid laser resurfacing. CONCLUSIONS: Ablative carbon dioxide laser resurfacing of the lower eyelids can be a useful tool in the armamentarium of the experienced oculoplastic surgeon, with excellent aesthetic results, high patient satisfaction, and low complication rates as adjunctive or monotherapy. Proper and timely management of postoperative complications is essential to maximizing successful cosmetic outcomes.

Effect of radiologist pregnancy on the performance of pediatric fluoroscopic studies: a survey of Society for Pediatric Radiology members.

BACKGROUND: To our knowledge, the fluoroscopic practice patterns of pregnant diagnostic radiologists have not been documented. OBJECTIVE: To describe the fluoroscopic practice patterns during pregnancy among members of the Society for Pediatric Radiology (SPR) and potential impact on career and professional relationships. MATERIALS AND METHODS: After approval from the SPR, we sent all 1,847 SPR members an email link to an anonymous online survey that queried how pregnancy affects a practicing radiologist who performs fluoroscopy. RESULTS: Of the 398 responses (65% female, 35% male), most female respondents (78%) reported having been pregnant while practicing radiology and the majority (85%) performed fluoroscopy during pregnancy. Most performed fluoroscopy during all three trimesters (first 78%, second 90%, third 87%) and the majority (81%) used double-lead. Forty-six percent indicated that their fluoroscopic responsibilities during pregnancy were stressful. Of those who opted to perform fewer fluoroscopy studies, 20% indicated that it impacted negatively on their career or professional relationships. After witnessing a pregnant co-worker perform fewer fluoroscopic studies, 11% (4% male; 16% female; P<0.05) of respondents observed a subsequent negative impact on the co-worker's career or professional relationships. CONCLUSION: The majority of responding female SPR members had performed fluoroscopy during pregnancy and most performed fluoroscopy during their entire pregnancy with double-lead. Differences between self-reported adversity and observed adversity of performing less fluoroscopy during pregnancy speak to the lack of awareness of the issues, particularly among male colleagues. A clear policy with regard to performing fluoroscopy during pregnancy for all radiologists in every department is necessary.

Identification of clinical parameters to increase the diagnostic yield of the non-emergent upper gastrointestinal series in pediatric outpatients.

BACKGROUND: Outpatient, non-emergent upper gastrointestinal (GI) series are frequently requested in children with no surgical history who have nonspecific symptoms such as abdominal pain, failure to thrive and vomiting. The positive yield of an upper GI series in these patients, and, thus, its utility, has not been studied. OBJECTIVES: We evaluated the incidence of positive upper GI findings in children without a history of GI pathology or abdominal surgery in order to identify clinical indications associated with a greater diagnostic yield. MATERIALS AND METHODS: Findings of upper GI series performed between October 2015 and October 2017 in three institutions in children younger than 18 years of age were retrospectively reviewed. The upper GI series protocol for each institution was also reviewed. Children with a medical or surgical GI history, children with insufficient history in the chart and those with an incomplete upper GI series were excluded from the study. Exam indications, patient demographics and clinical history were obtained from the electronic medical records. RESULTS: Of 1,267 children who underwent outpatient upper GI series, 720 (median age: 2 years) had no GI history and were included in the study. The most common indications were non-bilious vomiting (62%), reflux symptoms (28%) and abdominal pain (20%). Upper GI series were normal in 605/720 cases (84%), including 25/26 children with reported bilious emesis. Of the 115 positive studies, 78 (68%) showed only gastroesophageal reflux (GER) (median age: 11 months). Of the remaining 37 studies, 19 demonstrated esophageal findings. One case of malrotation without midgut volvulus was identified in a patient who presented with dysphagia and reflux symptoms. Using a multinomial logistic regression model and adjusting for other variables, reflux symptoms and younger patient age were independent predictors of GER on upper GI series (relative risk ratios of 2.2 and 0.9, respectively). Dysphagia and/or foreign body sensation and older patient age were independent predictors of the presence of esophageal findings (relative risk ratios of 3.3 and 1.1, respectively). CONCLUSION: The yield of routine upper GI series in children with nonspecific symptoms, such as abdominal pain and vomiting, and no surgical history is low. Diagnostic yield was improved in older children and in those complaining of dysphagia and/or foreign body sensation. Routine upper GI series should be avoided in clinically well children with symptoms only of uncomplicated GER and no significant GI history. In children with a history of dysphagia and/or foreign body sensation, an esophagram/barium swallow can suffice.

Spaced radiology: encouraging durable memory using spaced testing in pediatric radiology.

Applied memory research in the field of cognitive and educational psychology has generated a large body of data to support the use of spacing and testing to promote long-term or durable memory. Despite the consensus of this scientific community, most learners, including radiology residents, do not utilize these tools for learning new information. We present a discussion of these parallel and synergistic learning techniques and their incorporation into a software platform, called Spaced Radiology, which we created for teaching radiology residents. Specifically, this software uses these evidence-based strategies to teach pediatric radiology through a flashcard deck system.

Is the Scout Out? The Utility of Scout Radiographs in the Pediatric Upper Gastrointestinal Examination.

OBJECTIVE: The aim of the study is to demonstrate the scout radiograph does not change patient management, alter planning, or contribute to interpretation of the outpatient pediatric upper gastrointestinal fluoroscopic examination (UGI). METHODS: We retrospectively reviewed 197 outpatient pediatric UGIs performed over a 2-year period. We performed a chart review on all patients to evaluate for potentially clinically significant findings on the scout radiograph. Scout findings were categorized into 4 groups: no new clinically significant findings (group 1), potentially clinically significant findings that were not directly addressed in the electronic medical record (group 2), incidental non-gastrointestinal (GI) findings that necessitated further workup, however, were later deemed insignificant (group 3), and clinically significant findings that changed patient GI management, altered the planning of the procedure, or contributed to the interpretation of the fluoroscopic study (group 4). RESULTS: A total of 197 UGIs were analyzed. A significant majority of cases (97.0%) were classified into group 1. Three cases (1.5%) were classified into group 2 with findings not addressed in the medical record. Two cases (1.0%) were classified into group 3, which, after further workup, were deemed not clinically significant. One case (0.5%) was classified into group 4, which resulted in a change in patient GI management. CONCLUSIONS: In our review, there was only 1 case in which the scout radiograph changed patient GI management, with moderate stool burden leading to a miralax cleanout, although there were no cases, which altered the planning of the procedure or contributed to the interpretation of the study. The scout radiograph can be omitted and/or substituted with the last image hold function to decrease radiation exposure.