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Introduction Femoral head collapse (FHC) is a rarely reported complication of hip intra-articular corticosteroid injection (IACSI). Upon observing a high rate of FHC after hip IACSI, we sought to (1) describe how we addressed the problem through a systematic evaluation of clinical data and institutional care practices followed by process improvement efforts; and (2) report our results. Methods Patients receiving hip IACSI during a 27-month period underwent retrospective review to determine the rate of FHC and to identify associated patient factors or practice shortfalls. Findings led to institution-wide interventions: (1) to improve patient/provider awareness of this association; and (2) to develop/implement practice guidelines. Rates of FHC after hip IACSI and practice patterns among providers before and after intervention were compared. Results Initial FHC rate after hip IACSI was 20.4%. Patient-related factors included body mass index (p = 0.025), history of cancer therapy (p = 0.012), Vitamin D level (p = 0.030), and multiple injections (p = 0.004). Volume/dose of injectate and post-injection surveillance methods varied widely. Quality improvement (QI) intervention resulted in fewer treatment referrals (from 851 to 436), fewer repeat injections (mean = 1.61 to 1.37; p = 0.0006), and a 5% lower FHC rate (p = 0.1292). Variation in practice patterns persisted, so a systems-based Clinical Pathway was established. Discussion When a high rate of FHC after hip IACSI was found to be associated with certain patient and practice factors, introduction of education materials and treatment guidelines decreased number of referrals, number of injections per patient, and FHC rate. In the absence of the systems-based Pathway, the type, dose, and volume of injectate and post-procedure follow-up remained variable.

Background: Nearly 1/3rd of patients undergoing coronary artery bypass graft surgery (CABG) have left ventricular systolic dysfunction. However, the extent, direction and implications of perioperative changes in left ventricular ejection fraction (LVEF) have not been well characterized in these patients., Methods: We studied the changes in LVEF among 549 patients with left ventricular systolic dysfunction (LVEF <50%) who underwent CABG as part of the Surgical Treatment for Ischemic Heart Failure (STICH) trial. Patients had pre- and post-CABG (4 month) LVEF assessments using identical cardiac imaging modality, interpreted at a core laboratory. An absolute change of >10% in LVEF was considered clinically significant., Results: Of the 549 patients (mean age 61.4±9.55 years, and 72 [13.1%] women), 145 (26.4%) had a >10% improvement in LVEF, 369 (67.2%) had no change and 35 (6.4%) had >10% worsening of LVEF following CABG. Patients with lower preoperative LVEF were more likely to experience an improvement after CABG (odds ratio 1.36; 95% CI 1.21-1.53; per 5% lower preoperative LVEF; p <0.001). Notably, incidence of postoperative improvement in LVEF was not influenced by presence, nor absence, of myocardial viability (25.5% vs. 28.3% respectively, p = 0.67). After adjusting for age, sex, baseline LVEF, and NYHA Class, a >10% improvement in LVEF after CABG was associated with a 57% lower risk of all-cause mortality (HR: 0.43, 95% CI: 0.26-0.71)., Conclusions: Among patients with ischemic cardiomyopathy undergoing CABG, 26.4% had >10% improvement in LVEF. An improvement in LVEF was more likely in patients with lower preoperative LVEF and was associated with improved long-term survival., Competing Interests: The authors have declared that no competing interests exist., (Copyright: This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.)