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The COVID-19 pandemic has affected the care of patients with other diseases. Difficulty in access to healthcare during these months has been especially relevant for persons with HIV infection (PWH). This study therefore sought to ascertain the clinical outcomes and effectiveness of the measures implemented among PWH in a region with one of the highest incidence rates in Europe.Retrospective, observational, pre-post intervention study to compare the outcomes of PWH attended at a high-complexity healthcare hospital from March to October 2020 and during the same months across the period 2016-2019. The intervention consisted of home drug deliveries and preferential use of non face-to-face consultations. The effectiveness of the measures implemented was determined by reference to the number of emergency visits, hospitalisations, mortality rate, and percentage of PWH with viral load50 copies, before and after the two pandemic waves.A total of 2,760 PWH were attended from January 2016 to October 2020. During the pandemic, there was a monthly mean of 106.87 telephone consultations and 2,075 home deliveries of medical drugs dispensed to ambulatory patients. No statistically significant differences were found between the rate of admission of patients with COVID-HIV co-infection and that of the remaining patients (1,172.76 admissions/100,000 population vs. 1,424.29,Our results show that the strategies implemented during the first 8 months of the pandemic prevented any deterioration in the control and follow-up parameters routinely used on PWH. Furthermore, they contribute to the debate about how telemedicine and telepharmacy can fit into future healthcare models.Introducción: La pandemia causada por el SARS-CoV-2 ha afectado a la atención de pacientes con otras enfermedades. La dificultad en el acceso a la asistencia sanitaria durante estos meses es especialmente relevante en las personas con infección por VIH (PWH). El objetivo del estudio fue conocer los resultados clínicos y la efectividad de las medidas implementadas en PWH en una de las regiones con mayor incidencia de Europa.Métodos: Estudio observacional retrospectivo, pre-post intervención, comparando los resultados de PWH atendidos en un hospital de alta complejidad entre marzo-octubre de 2020 y el mismo periodo de 2016 a 2019. La intervención consistió en el envío a domicilio de medicamentos y la realización preferente de consultas no presenciales. La efectividad de las medidas implementadas se determinó por el número de visitas a Urgencias, hospitalizaciones, mortalidad y porcentaje de PWH con carga viral50 copias antes y después de dos olas pandémicas.Resultados: Se atendieron 2.760 PWH entre enero de 2016 y octubre de 2020. Durante la pandemia se realizaron una media mensual de 106,87 consultas telefónicas y 2.075 envíos a domicilio de medicamentos de dispensación ambulatoria. No se encontraron diferencias estadísticamente significativas en la frecuentación de pacientes con co-infección COVID-VIH respecto al resto (1.172,76 ingresos/100.000 habitantes vs. 1.424,29, p = 0,401), ni en su mortalidad (11,54% vs. 12,96%, p = 0,939). El porcentaje de PWH con carga viral50 copias fue similar antes y después de la pandemia (1,20% pre-pandemia vs. 0,51% en 2020, p = 0,078).Conclusión: Nuestros resultados revelan que las estrategias implementadas durante los 8 primeros meses de pandemia han evitado el deterioro en parámetros de control y seguimiento empleados habitualmente en PWH. Además, contribuyen a la reflexión sobre el encaje de la telemedicina y telefarmacia en modelos asistenciales futuros.

INTRODUCTION AND OBJECTIVES Advanced lipoprotein phenotyping is a better predictor of atherosclerotic cardiovascular risk than cholesterol concentration alone. Lipoprotein profiling in heart failure (HF) is incompletely characterized. We aimed to describe the lipoprotein profile in patients with chronic HF compared with a matched control population. METHODS This cross-sectional study was performed from May 2006 to April 2014 and included ambulatory patients with chronic HF. Lipid concentrations and the size of main lipoprotein fractions (high-density lipoprotein [HDL], low-density lipoprotein [LDL], and very low-density lipoprotein) and the particle concentration of their 3 subfractions (large, medium and small) were assessed using 1H magnetic resonance spectroscopy. RESULTS The 429 included patients with chronic HF were compared with 428 matched controls. Patients with chronic HF had lower total cholesterol and lower mean LDL (1115 vs 1352 nmol/L; P

Immunomodulatory therapies improve the management of chronic diseases but can be associated with infectious risk. The present study was undertaken to examine the laboratory screening practices for hepatitis B virus (HBV), hepatitis C virus (HCV), and tuberculosis (TB) and rates of vaccination for pneumococcal and influenza in patients prescribed select immunosuppressive agents at our institution.A retrospective analysis was conducted to review patients who were prescribed a select immunosuppressive over 3 years. Data were extracted from electronic health records to identify rates of screening and vaccination prior to initiation or at any time. Logistic regression models were developed to identify predictors of screening and vaccination.We identified 2,396 patients prescribed immunosuppressive medications by rheumatology (52.6%) and non-rheumatology specialties. Rates of screening at any time point were 84.5% (2,025 of 2,396) for HBV, 76.7% (1,838 of 2,396) for HCV, and 71.8% (1,720 of 2,396) for TB. Patients who had either in-system primary care providers (PCPs) or rheumatologists were more likely to receive pneumococcal vaccinations (odds ratio [OR] 1.98 [95% confidence interval (95% CI) 1.55-2.54] and OR 4.08 [95% CI 2.76-6.02], respectively). Patients with dermatologic (OR 1.67 [95% CI 1.14-2.45]) or rheumatologic providers (OR 2.5 [95% CI 1.86-3.36]) were more likely to be vaccinated for influenza.More than 70% of patients were screened for either HBV, HCV, or TB at some point. Rates of pneumococcal vaccination were better than rates of influenza vaccination. Patients with in-system PCPs were more likely to be screened and vaccinated. Establishing and executing consistent processes for screening and vaccination prior to immunosuppressive treatment remains a priority in ambulatory settings.

A 36-year-old woman with levo-transposition of the great arteries presented for a programmed visit. She was asymptomatic and the clinical examination showed no signs of decompensated heart failure. Standard 12-lead ECG showed isorhythmic atrioventricular dissociation. A 24-hour ambulatory recording demonstrated sinus rhythm with intermittent periods of isorhythmic dissociation. This case highlights the association between two rare conditions.

INTRODUCTION AND OBJECTIVES The effect of a centrifugal continuous-flow left ventricular assist device (cfLVAD) on hemodynamic left ventricular unloading (HLVU) and the clinical conditions that interfere with hemodynamic optimization are not well defined. METHODS We retrospectively evaluated the likelihood of incomplete HLVU, defined as high pulmonary capillary wedge pressure (hPCWP)> 15mmHg in 104 ambulatory cfLVAD patients when the current standard recommendations for cfLVAD rotor speed setting were applied. We also evaluated the ability of clinical, hemodynamic and echocardiographic variables to predict hPCWP in ambulatory cfLVAD patients. RESULTS Twenty-eight percent of the patients showed hPCWP. The variables associated with a higher risk of hPCWP were age, central venous pressure, absence of treatment with renin-angiotensin-aldosterone system inhibitors, and brain natriuretic peptide levels. Patients with optimal HLVU had a 15.2±14.7% decrease in postoperative indexed left ventricular end-diastolic diameter compared with 8.9±11.8% in the group with hPCWP (P=.041). Independent predictors of hPCWP included brain natriuretic peptide and age. Brain natriuretic peptide

RATIONALE: Prehospital opportunities to predict infection and sepsis hospitalization may exist, but little is known about their incidence following common healthcare encounters. OBJECTIVES: To evaluate the incidence and timing of infection and sepsis hospitalization within 7 days of living hospital discharge, emergency department discharge, and ambulatory visit settings. METHODS: In each setting, we identified patients in clinical strata based on the presence of infection and severity of illness. We estimated number needed to evaluate values with hypothetical predictive model operating characteristics. RESULTS: We identified 97,614,228 encounters, including 1,117,702 (1.1%) hospital discharges, 4,635,517 (4.7%) emergency department discharges, and 91,861,009 (94.1%) ambulatory visits between 2012 and 2017. The incidence of 7-day infection hospitalization varied from 37,140 (3.3%) following inpatient discharge to 50,315 (1.1%) following emergency department discharge and 277,034 (0.3%) following ambulatory visits. The incidence of 7-day infection hospitalization was increased for inpatient discharges with high readmission risk (10.0%), emergency department discharges with increased acute or chronic severity of illness (3.5% and 4.7%, respectively), and ambulatory visits with acute infection (0.7%). The timing of 7-day infection and sepsis hospitalizations differed across settings with an early rise following ambulatory visits, a later peak following emergency department discharges, and a delayed peak following inpatient discharge. Theoretical number needed to evaluate values varied by strata, but following hospital and emergency department discharge, were as low as 15–25. CONCLUSIONS: Incident 7-day infection and sepsis hospitalizations following encounters in routine healthcare settings were surprisingly common and may be amenable to clinical predictive models.

Background: Patient-reported allergies (PRAs) are associated with suboptimal orthopaedic surgery outcomes and may serve as a proxy for mental health. While mental health disorders are known risk factors for increased opioid use, less is known about how PRAs impact opioid use after orthopedic surgery. The purpose of this study was to investigate the association between PRAs and postoperative opioid use, pain, and satisfaction following hand surgery. Methods: Patients who underwent ambulatory hand surgery at a single institution from May 2017 to March 2019 were retrospectively reviewed. Various scores, including the Mindfulness Attention Awareness Scale (MAAS), were collected preoperatively. Postoperatively, patients completed a 2-week pain diary, satisfaction, and visual analog scale (VAS) pain scores. Opioid consumption was converted to oral morphine equivalents (OMEs) using standard conversions. Results: A total of 137 patients were divided into 2 groups based on presence (≥1) (n = 73) or absence (0) (n = 64) of PRAs. At baseline, the ≥ 1 PRA group had significantly higher female composition ( P < .001) and pain ( P < .001) and lower PROMIS mental health scores ( P = .044). Postoperative OME consumption averaged 42.5 (range 0-416) in the entire cohort, with no differences between groups. Among patients with ≥ 1 PRA, increasing number of allergies significantly correlated with increasing OME consumption across all time points (week 1, P = .016; week 2, P = .001; total, P = .005). Conclusions: The presence of PRAs did not impact postoperative narcotic usage, pain, or satisfaction. Increasing numbers of PRAs did, however, significantly correlate with higher narcotic use. These results may have implications for postoperative pain management in this population.

BACKGROUND Ultrasonography (US) is the simplest method of evaluating thyroid volume (TV). The current normal TV in Liguria is not known. The aim of this study was to obtain normative data on TV in Liguria. MATERIALS AND METHODS From 3552 files of endocrine evaluations registered in a primary outpatient setting, we selected 483 files on euthyroid subjects (383 females and 100 males) with a normal echoic pattern on US. The inclusion criterion was the absence of thyroperoxidase autoantibodies and drugs known to interfere with thyroid hormone secretion or metabolism. TV was calculated by means of US. Anthropometric characteristics, smoking habits and the district where subjects lived were registered. RESULTS Less than 50% of patients were not taking any drug. The percentage of obesity was similar in both sexes. TSH levels were similar in males and females. Median TV was 8.0 ml (IQR 6.7 - 9.8 ml) in females and 11.8 ml (9.3 - 15.6 ml) in males (P

Background: It is unclear whether the prognostic value of blood pressure (BP) changes from day to night is modified by concomitant risk factors and organ damage. Methods: We studied 3247 clinically hypertensive patients who underwent off-therapy 24-hour ambulatory BP monitoring during their initial diagnostic work-up. Over a mean 9.9-year follow-up, 292 patients developed a first primary outcome event (composite of nonfatal myocardial infarction, nonfatal stroke, cardiovascular death, hospitalization for heart failure) and 281 died. The day-night BP changes were analyzed as night-to-day systolic BP ratio and included in semiparametric Cox models. Results: After allowance for age, sex, diabetes, cigarette smoking, low-density lipoprotein cholesterol, serum uric acid and average 24-hour systolic BP, the night-to-day systolic BP ratio maintained an independent association with outcome (hazard ratio, 1.17 [1.01–1.35]; P =0.041). When 2 markers of organ damage, chronic kidney disease and left ventricular hypertrophy, were added to the model, the night-to-day systolic BP ratio failed to maintain an independent association with outcome (hazard ratio, 1.19 [0.97–1.31]). The Akaike Information Criterion and the Schwarz-Bayes Information Criterion showed that, after allowance for other covariables, the night-to-day systolic BP ratio: (1) provided less information when compared with chronic kidney disease and left ventricular hypertrophy and (2) did not improve information provided by chronic kidney disease and left ventricular hypertrophy. Results were comparable on all-cause death as well as using categories of the night-day systolic BP ratio (extreme dippers, dippers, nondippers, reverse dippers). Conclusions: Chronic kidney disease and left ventricular hypertrophy are potent modifiers of the prognostic value of the circadian BP changes.

The Covid-19 pandemic necessitated a decrease in non-Covid-19 related diagnostic and therapeutic procedures in many countries. We explored the impact on tertiary hypertension care.We conducted an electronic survey regarding 6 key procedures in hypertension care within the Excellence Center network of the European Society of Hypertension.Overall, 54 Excellence Centers from 18 European and 3 non-European countries participated. From 2019 to 2020, there were significant decreases in the median number per centre of ambulatory blood pressure monitorings (ABPM: 544/289 for 2019/2020), duplex ultrasound of renal arteries (Duplex RA: 88.5/55), computed tomographic/magnetic resonance imaging angiography of renal arteries (CT/MRI RA: 66/19.5), percutaneous angioplasties of renal arteries (PTA RA: 5/1), laboratory tests for catecholamines (116/67.5) and for renin/aldosterone (146/83.5) (Diagnostic and therapeutic procedures related to hypertension were dramatically reduced during the first year of the Covid-19 pandemic, with the largest reduction during the first lockdown. The long-term consequences regarding blood pressure control and, ultimately, cardiovascular events remain to be investigated.

Introduction and objectives Masked or isolated ambulatory hypertension (IAH), a poor-prognosis condition, can be diagnosed with ambulatory blood pressure monitoring (ABPM), but ABPM is not available in many clinical practices. We developed and validated a score to screen for IAH among older adults, where limited information is available. Methods A total of 645 community-dwelling adults ≥ 65 years from the Seniors-ENRICA-2 cohort (derivation sample) and 327 from the Seniors-ENRICA-1 cohort (external-validation sample), with untreated casual BP Results Participants’ mean age was 70.8 years (46.7% men); 19.7% had IAH. Allocated score-points were: male sex (1 point), age ≥ 80 (2 points), body-mass index (2 points if 25–29; 3 if ≥30 kg/m2), the first BP measurement (2 points if ≥140/90 mmHg), and the mean of the second and third BP (2 points if 120–129/80–84; 4 if 130–139/85–89). Probabilities of having IAH for scores of 6, 7, 8, 9, or ≥10 points were 25%, 35%, 47%, 59%, and 72%, respectively. Area-under-the-ROC curve was 0.80 for the derivation and 0.73 for the validation-sample. Two subjects at high risk of IAH (>8 points) and 3 at middle risk (≥6) needed to undergo ABPM to detect 1 IAH case. Conclusions A simple score with 4 routine variables performed well identifying IAH in older adults. For high scores, using ABPM for diagnosing IAH was very size-efficient.

Study Objective To study the feasibility of virtual visits for ambulatory encounters in pediatric and adolescent gynecology Design A retrospective review Setting Boston Children's Hospital Participants Patients who were seen virtually through the Division of Gynecology between January 1, 2020 and June 1, 2020 Main Outcome measure(s) Patient demographics, visit diagnoses, and operational characteristics of the completed visits Results There were a total of 654 virtual visits for 614 patients. Ninety-one percent (n=558) of patients were in-state, and the median age of patients was 17 years (range 0 – 37 years). The majority were return visits (n=502, 76.8%), 115 (17.6%) were new patient visits, and 32 (4.89%) were post-operative visits. The median virtual visit duration was 12 minutes and 39 seconds (range 5 minutes to over 1 hour). The most common gynecologic diagnoses were dysmenorrhea/endometriosis (n=485, 74.2%), abnormal uterine bleeding (n=225, 34.4%), and pelvic pain (n=82, 12.5%). The percentage of virtual visits which required an in-person follow-up visit within 90 days was low (n=14, 2.1%). Five of these were within 30 days from the initial virtual visit, 6 were within 60 days, and 3 were within 90 days. Conclusion Telemedicine is a feasible method for expanding access to, and healthcare delivery for, pediatric and adolescent gynecology, with low rates of short interval in-person follow-up required. Virtual visits can be conducted for a range of patients with a variety of gynecologic conditions, upon initial presentation and follow-up.

Sleep disorders, including sleep apnea, have become a significant health issue in the United States. It is estimated that 22 million Americans suffer from sleep apnea, with 80 percent of the cases of moderate and severe obstructive sleep apnea going undiagnosed. This number continues to increase with the obesity epidemic. Sleep disordered breathing is associated with multiple cardiopulmonary diseases and has been shown to adversely affect disease outcomes. Hospitalized patients have a disproportionately high prevalence of cardiovascular and respiratory diseases. Screening for sleep disordered breathing in hospitalized patients provides an opportunity to identify the disease in individuals who may otherwise go unrecognized. As will be reviewed, data suggests that identification of sleep disordered breathing in hospitalized individuals may have a positive impact on the post hospital course. Unfortunately, sleep medicine currently remains an ambulatory practice. Hospital sleep medicine addresses this separation. We hereby discuss our experience and future potential of a hospital sleep medicine program.

Background Children often suffer from congenital or acquired diseases. Ambulatory cases represent the vast majority of pediatric surgical cases. COVID-19 pandemic-associated regulatory precautions had made the process of seeking medical advice at a suitable appointment such a big problem. We utilized telemedicine (online encounter) to deliver the required healthcare service for sorting and guiding pediatric ambulatory surgical patients. In this article, we aimed to: (1) present our experience, (2) evaluate the effectiveness, and (3) document the results of this technology to solve the problem of difficult healthcare accessibility. Materials and Methods In this study, we compared the utilization of telemedicine (virtual clinic via video consultation) prospectively in the current era of the COVID-19 pandemic in the period from June 2020 to July 2021 to the in-person clinic encounter at the outpatient department (OPD) retrospectively in the previous year (from June 2019 until the end of May 2020) for perioperative management of pediatric ambulatory surgical patients. The study was conducted at 3 tertiary care pediatric surgery centers. The information recorded for analysis included: demographic data, surgical condition distribution, time interval from the appointment request till the actual encounter with the surgeon, conversation duration, distance traveled, and ultimate fate of the consultations. For both groups, service was evaluated after the first follow-up visit by a patient survey questionnaire (Patient Experience Assessment form) including questions relevant to each encounter. Results A total of 1124 pediatric patients with various ambulatory surgical conditions had been scheduled for virtual clinic video encounters. Of them, 1056 cases were evaluated by video consultation, supervised by their parents or caregivers, thus, achieving an attendance rate of 94%. Of the remaining cases, 2% (n=23) were canceled and 4% (n=45) did not attend the virtual clinic. Two-thirds of the cases live in rural /remote areas. Patients’ overall satisfaction was 92%. This was in comparison to 872 pediatric ambulatory surgical patients scheduled for in-person clinic visits before the implementation of the virtual clinic. Of them, only 340 cases had attended the clinic, thus, achieving an attendance rate of 39%. Of the remaining cases, 450 cases (51.6%) were canceled and 82 cases (9.4%) did not attend the clinic (no show). About 48% of the cases live in rural areas. For this group, patients’ overall satisfaction was 63%. The mean encounter duration was similar for both groups (∼ 5 minutes). Surgical condition distribution was also similar (p-value: 0.694). For new cases, the time interval from appointment request till the actual encounter was very short for the virtual clinic group (range: 6-15 days) as compared to the in-person clinic group (range: 30-180 days). Patients were followed up for a median period of 14±3.25 months (range: 6-22 months) with no patient loss to follow-up. Conclusion Telemedicine can effectively bridge the patient-physician communication gap caused by the regulatory precautions mandated by the current COVID-19 pandemic. It achieved an attendance rate of 94% and parents’ / patients’ overall satisfaction of 92%.

Structured Abstract Objective : Preoperative functional status is appreciated as a key determinant of decision-making when evaluating patients for complex elective surgeries. We used the Vascular Quality Initiative (VQI) to analyze the effect of being able to independently ambulate on outcomes after open abdominal aortic aneurysm (AAA) repairs. Methods : We identified all patients who underwent elective or urgent open AAA repairs from January 2013 to August 2019 in the VQI registry. We recorded demographic variables, comorbidities, and operative factors such as approach, operative ischemia time, proximal clamp site, and presence of iliac aneurysms. Short-term and long-term outcomes included 30-day mortality, any perioperative complications, failure to rescue (defined as death after a complication), and one-year all-cause mortality. We dichotomized patients based on their ability to independently ambulate (Ambulatory) or inability to ambulate independently (Non-Ambulatory) and used both multivariable logistic regressions and cox-proportional hazards models to evaluate outcomes. Results : Of 5,371 patients, 328 (6.1%) could not ambulate independently and were more likely to be older (median age 69 vs 72), female (25% vs. 38%), and have greater comorbidities. Overall outcomes were: 4.3% for 30-day mortality, 38.7% for complications, 10.2% for failure-to-rescue, and 6.9% for one-year mortality. Univariate analysis showed higher rates of all adverse outcomes in non-ambulatory patients. On adjusted analysis, non-ambulatory patients had increased odds of complications by 46% (OR 1.46 [95%-CI 1.11-1.91]) and one-year mortality by 46% (HR 1.46 [95%-CI 1.06-1.99]), but not failure to rescue (OR 1.05 [95%-CI 0.67-1.62]) or 30-day mortality (OR 1.22 [95%-CI 0.82-1.81]). Increased hospital volume, age, and increased operative renal ischemia time were independently associated with adverse outcomes. Conclusions : Non-ambulatory status was observed in a small percentage of patients undergoing open AAA repair but was associated with higher rates of post-operative complications and one-year mortality. Ambulatory capacity is one of the key determinants of outcomes following open AAA repair. In patients with poor ambulatory function, a conservative approach is highly recommended over invasive open surgical intervention.

Atopic dermatitis (AD) is a pruritic, inflammatory skin disease associated with various comorbidities. However, comprehensive analyses of real-world comorbidities in adult patients with AD are limited.To characterize the real-world comorbidities associated with adult AD in an ambulatory population.We queried the MarketScan Commercial Claims and Encounters database from January 1, 2017 to December 31, 2017. Multivariable logistic regressions were performed to compare comorbidities in adult patients with AD versus age- and sex-matched controls.A total of 39,779 patients with AD and 353,743 controls were identified. Increased odds of psychiatric conditions, including anxiety (odds ratio [OR] 1.44) and mood disorders (OR 1.31), were observed in patients with AD. Patients with AD had higher likelihoods of autoimmune diseases, including vitiligo (OR 4.44) and alopecia areata (OR 6.01). Adult AD was also associated with infections, including impetigo (OR 9.72), methicillin-resistant Staphylococcus aureus (OR 3.92), and cellulitis (OR 2.52). Patients with AD were more likely to have systemic conditions, including lymphoid/hematopoietic malignancy (OR 1.91), atherosclerosis (OR 1.69), and metabolic syndrome (OR 1.47). For all the above, P .001.Retrospective analysis of health care claims data.Adult AD is associated with various psychiatric and systemic comorbidities, emphasizing the systemic nature of AD and the need for the collaborative management of these patients.

OBJECTIVES To compare risk of reoperation for femoral neck fracture patients undergoing fixation with cancellous screws (CS) or sliding hip screws (SHS) based on surgeon fellowship (trauma-fellowship-trained versus non-trauma-fellowship-trained). DESIGN Retrospective review of FAITH data. SETTING Eighty-one centers across eight countries. PATIENTS/PARTICIPANTS 819 patients ≥ 50 years-old with low energy hip fractures requiring surgical fixation. INTERVENTION Patients were randomized to CS or SHS in the initial dataset. MAIN OUTCOME MEASUREMENTS The primary outcome was risk of reoperation. Secondary outcomes included death, serious adverse events, radiographic healing, discharge disposition, and use of ambulatory devices postoperatively. RESULTS There was no difference in risk of reoperation between the two surgeon groups (p > 0.05). Patients treated by orthopaedic trauma surgeons were more likely to be overweight/obese and have major medical comorbidities (p < 0.05). There was a higher risk of serious adverse events, higher likelihood of radiographic healing, and higher odds of discharge to a facility for patients treated by trauma-fellowship-trained surgeons (p < 0.05). CONCLUSIONS Based on this data, risk of reoperation for low energy femoral neck fracture fixation is equivalent regardless of fellowship training. The higher likelihood of radiographic healing noted in the trauma-trained group does not appear to have a major clinical implication as it did not affect risk of reoperation between the two groups. Patient-specific factors present pre-injury, such as body habitus and medical comorbidities, may account for the lower odds of discharge to home and higher risk of postoperative medical complications for patients treated by orthopaedic trauma surgeons. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Objective To determine if there is an association between patient race and physician time spent with the patient during outpatient urology consultations. Methods We identified all adult urology new outpatient visits in the National Ambulatory Medical Care Survey dataset for 2012-2016. Patient race was dichotomized as White or non-White. Our primary outcome was time spent during the visit between the patient and urologist. Using population-level weighting, we compared differences in mean time spent during visits with White and non-White patients. Mixed-effects linear regression was used to adjust for confounding factors and to account for clustering among individual physicians. Secondary outcomes included number of services provided and if ancillary providers were seen. Results Over the 5 year period, 1668 raw visits met criteria and were used to estimate 21million new outpatient urology visits nationwide. 80% of all visits were with White patients. Mean physician time spent among visits with white patients was 23.9 minutes and 24.4 minutes for non-White patients. There was no difference in number of services provided but visits with non-white patients were less likely to include an ancillary provider. After adjustment, there was no significant difference in mean time spent with the urologist among visits with White and non-White patients (difference 0.9 minutes, 95% CI: -0.6-2.4). There were also no differences in adjusted mean time spent among return visits or new visits for hematuria, urologic cancers, or BPH. Conclusion We found no statistically significant difference in time spent with a urologist during outpatient office consultations between White and non-White patients.

Ambulatory surgery has proven benefits in patient wellbeing and cost reduction in healthcare systems. However, some patients referred for ambulatory surgery are refused and directed instead towards inpatient care, which generates several drawbacks. The reasons for this refusal have not been yet studied. The aim of this study is to identify, retrospectively, significant variables associated with patient refusal for ambulatory surgery and develop a mathematical tool able to predict with strong accuracy those who will be rejected.Over a 5-year period (2014 - 2018), all patients that underwent abdominal hernia repair in our hospital in an inpatient setting, and that had been previously refused for ambulatory surgery, were analysed for a total of 94 variables. A multivariate logistic regression model was developed to identify risk factors associated with refusal using data from 136 patients (65 refused vs 71 accepted). A prediction index for refusal in ambulatory surgery - IRAS - was derived and tested (n = 62 patients).The risk index included five significant risk factors: type 2 diabetes mellitus [OR 14.669 (2.982; 72.154)], physical status [OR 49.155 (15.532; 155.555)], prior malignancy [OR 14.518 (2.653; 79.441)], prior abdominal surgery [OR 3.455 (1.006; 11.866)] and usage of antiplatelet agents [OR 25.600 (4.309; 152.066)]. All risk factors were associated with a high risk of refusal (OR between 3.455 for history of prior abdominal surgery and 49.155 according to the American Society of Anaesthesiologists physical status classification). Defining five points as the maximum IRAS score that predicts suitability for ambulatory surgery resulted in a positive predictive value of 93.55% and negative predictive value of 87.10%.Significant patient variables for refusal of an ambulatory procedure were determined and an easy to use risk index - IRAS - was built that is able to predict with good accuracy which patients will be refused.IRAS is a useful tool that can contribute to reduce time to surgery and improve patients' quality of life.Introdução: A cirurgia de ambulatório tem benefícios comprovados no bem-estar dos doentes e na redução de custos dos sistemas de saúde. Porém, alguns doentes referenciados para cirurgia de ambulatório são recusados e encaminhados para internamento. Os motivos desta recusa ainda não foram estudados. Neste trabalho identificámos, retrospectivamente, variáveis significativas na recusa dos doentes e fornecemos uma ferramenta matemática capaz de prever de forma precisa aqueles que serão rejeitados. Material e Métodos: Ao longo de cinco anos (2014 - 2018), todos os doentes submetidos a correção cirúrgica de hérnia abdominal em regime de internamento no nosso centro hospitalar previamente recusados para cirurgia de ambulatório foram analisados para um total de 94 variáveis. Um modelo de regressão logística multivariada foi desenvolvido para identificar os fatores de risco para recusa usando dados de 136 doentes (65 recusados vs 71 aceites). Um índice preditivo para recusa de cirurgia em ambulatório, IRAS, foi criado e testado (n = 62 doentes). Resultados: O IRAS incluiu cinco fatores de risco significativos: diabetes mellitus tipo 2 [OR 14,669 (2,982; 72,154)], estado físico [OR 49,155 (15,532; 155,555)], neoplasia maligna prévia [OR 14,518 (2,653; 79,441)], cirurgia abdominal prévia [OR 3,455 (1,006; 11,866)] e uso de agentes antiplaquetários [OR 25,600 (4,309; 152,066)]. Todos os fatores de risco foram associados a elevado risco de recusa (OR entre 3,455 para história de cirurgia abdominal prévia e 49,155 de acordo com a classificação do estado físico segundo a American Society of Anaesthesiologists). A definição de cinco pontos como a pontuação máxima do IRAS que prevê adequação para cirurgia de ambulatório resultou num valor preditivo positivo de 93,55% e um valor preditivo negativo de 87,10%. Discussão: Foram determinadas variáveis significativas para recusa de um doente para cirurgia de ambulatório e construído um índice de risco de fácil utilização, IRAS, capaz de predizer que doentes serão recusados com boa precisão. Conclusão: O índice IRAS é uma ferramenta útil que pode contribuir para a redução dos tempos de espera e melhorar a qualidade de vida dos doentes.

Purpose Clinical practice forces the necessity to conduct a clinical trial concerning the group of outpatients with chronically advanced heart failure in III or IV NYHA functional class, frequently requiring hospitalizations due to HF exacerbation, and often left without any additional therapeutic option. The current trial aims to determine the efficacy and safety of repeated levosimendan infusions in the group of severe outpatients with reduced ejection fraction (HFrEF). Material and methods LEIA-HF (LEvosimendan In Ambulatory Heart Failure Patients) is a multicentre, randomized, double-blind, placebo-controlled, phase 4 clinical trial to determine whether the repetitive use of levosimendan reduces the incidence of adverse cardiovascular events in ambulatory patients with chronic, advanced HFrEF. A total of 350 patients will be randomized in a 1:1 ratio to receive either levosimendan or placebo, which will be administered as continuous 24 ​h infusions, every 4 weeks for 48 weeks (12 infusions in total – phase I), and followed by double-blind 6 visits, every 4 weeks (phase II of the trial including the option of restarting levosimendan or placebo, based on the fulfillment of additional criteria). The primary endpoint for efficacy assessment will be death from any cause or unplanned hospitalization for HF assessed together, whichever occurs first, in a 12-month follow-up period. Conclusions A well-designed study with a consistent protocol, including the drug side effects, comprehensive clinical assessment, appropriate definition of endpoints, and monitoring therapy, may provide a complete overview of the effectiveness and safety profile of the repetitive levosimendan administration in ambulatory severe HFrEF patients.

Purpose The impact of the SARS-CoV-2 (COVID-19) coronavirus has been felt worldwide, impacting all aspects of healthcare. We examined the quantitative impact during the first four weeks of hospital system and state-mandated restrictions on elective healthcare on an academic urban hand surgery practice. We hypothesized that the volume of overall ambulatory clinic encounters, office procedures, and surgical procedures and cases would dramatically decrease during this time and that the volume of non-elective care would remain unchanged. Methods We retrospectively reviewed all patient encounters in a 4-week time period from March 16, 2020 through April 12, 2020 for an academic orthopedic hand surgery practice and compared those to two control 4-week time periods: February 17, 2020 through March 15, 2020 and March 16, 2019 through April 12, 2019. Weekly encounter volumes and work relative value units (RVUs) were obtained for ambulatory clinic encounters, office procedures, and surgical procedures and cases. The type of ambulatory visit, in-person or telemedicine was also identified. Surgical cases were categorized into four types: fracture or dislocation, acute soft tissue or nerve injury, infection, or elective/non-urgent for the two most recent time periods. T-tests were performed to compare weekly volume and RVUs between time periods. Results After the implementation of mandated restrictions on elective healthcare, ambulatory hand surgery clinic encounters decreased 72-73%, clinic procedures decreased by 87-90%, and surgical cases decreased by 87-88%. The percentage of ambulatory visits performed via telemedicine increased from 0.06% to 74%. Similar impacts on RVUs were seen. All elective surgery was deferred. Surgeries for fractures and dislocations declined by 58% and those for acute soft tissue or nerve injury declined by 40%; the number of surgical procedures for infection remained unchanged. Conclusions The COVID-19 restrictions on elective healthcare led to an immediate, substantial impact on hand surgery practice. There was a significant decrease in ambulatory encounter volume, office procedures, and surgical cases. Non-elective surgical case volume also decreased by 47%. The long-term financial impact of this change in practice on providers, practices, patients and hospitals is still to be determined but based on the quantitative impacts seen, is likely to be substantial.

OBJECTIVE This study aimed to compare lipid and blood pressure (BP) control before and after implementing a certified pharmacy technician (CPhT) protocol that optimized electronic health record (EHR) capabilities and shifted work from clinical pharmacy specialists (CPSs) to CPhT. SETTING Kaiser Permanente Colorado's pharmacist-managed cardiac risk reduction service (which manages dyslipidemia, hypertension, and diabetes for all patients with atherosclerotic cardiovascular disease). PRACTICE DESCRIPTION In 2019, a protocol that optimized EHR capabilities and allowed work to be offloaded from CPS to CPhT was implemented. Filtered views within the EHR were created that bucketed patients with specific lipid results criteria. The CPhT protocol provided guidance to CPhT on determining whether patients were at low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein (non-HDL) goals, on appropriate statin intensity, adherent to medications, and whether the most recent BP was controlled. The CPhT notified CPS of uncontrolled patients who would assess and manage these patients, as necessary. The CPhT notified controlled patients of their results. PRACTICE INNOVATION Data on the outcomes of incorporating pharmacy technicians to support CPS clinical activities in ambulatory clinical pharmacy are limited. EVALUATION METHODS This retrospective study compared a "Pharmacist-Driven" (index date: January 1, 2016) with a "Tech-Enhanced" (index date: January 1, 2019) group. The primary outcome was the proportion of patients at all goals defined as LDL-C < 70 mg/dL, non-HDL

Many children gained insurance with the 2014 Affordable Care Act's (ACA) Medicaid Expansion (ME), yet its impact on access to pediatric tertiary surgical care remains unknown. We examined the effect of ME on rates of elective, ambulatory surgery (EAS), especially among publicly-insured and ethnoracial-minority patients.Surgical patients ≤18 years between 2012 and 2018 were identified using the Pediatric Health Information System. Interrupted time series analyses were conducted to predict the monthly proportion of publicly-insured patients and EAS rates in ME and nonexpansion states.3,270,842 patients were included. Nonexpansion states demonstrated a 1.10% (p0.05) increase in the proportion of publicly-insured patients at ACA implementation, which then plateaued. No immediate change was observed in ME states, but there was an annual 1.08% (p0.01) decrease in subsequent years. Publicly-insured EAS rates decreased by 1.09% (p0.01) in nonexpansion states; no change was observed in ME states. A 3.36% (p0.01) increase in EAS rates was observed in nonexpansion and ME states. The gap in EAS rates increased between private and publicly-insured patients in nonexpansion, but not ME states.Increased coverage for children in ME states was not associated with more access to tertiary pediatric surgical care; however, while nonexpansion states saw an increase in insurance-based disparities, ME states did not. Though insurance coverage is critical to access, other factors may be contributing to persistent disparities in access to pediatric surgical care.

Context Given a shortage of specialty palliative care clinicians and geographic variation in availability, telemedicine has been proposed as one way to improve access to palliative care services for patients with cancer. However, the enduring digital divide raises questions about whether unequal access will exacerbate healthcare disparities. Objectives To examine factors associated with utilization of telemedicine as compared to in-person visits by patients with cancer in the ambulatory palliative care setting. Methods We collected data on patients seen in Supportive Oncology clinic by palliative care clinicians with an in-person or telemedicine visit from March 1 to December 30, 2020. A logistic regression with generalized estimating equation was fit to assess the association between visit type and patient characteristics. Results A total of 491 patients and 1783 visits were identified, including 1061 (60%) in-person visits and 722 (40%) telemedicine visits. Female patients were significantly more likely to utilize telemedicine than male patients (OR 1.46; 95% CI 1.11–1.90). Spanish-speaking patients (OR 0.32, 95% CI 0.17–0.61), those without insurance (OR 0.28, 95% CI 0.15–0.52), and those without an activated patient portal (Inactivated: OR 0.46, 95% CI 0.26–0.82; Pending Activation: OR 0.29, 95% CI 0.18–0.48) were less likely to utilize telemedicine. Conclusion Our study reveals disparities in telemedicine utilization in the ambulatory palliative care setting for patients with cancer who are male, Spanish-speaking, uninsured, or do not have an activated patient portal. In the wake of the COVID-19 pandemic, we can better meet the palliative care needs of patients with cancer through telemedicine only if equity is kept at the forefront of our discussions.

As trials and treatments for Spinal Muscular Atrophy (SMA) rapidly evolve, understanding the natural history and potential utility of the 10-meter walk/run test (10MWRT) in ambulant individuals is critical. Study aims were to: 1) establish change over time and across age for 10MWRT time in an untreated natural history cohort of young, ambulatory participants with SMA and 2) identify relations between 10MWRT time and age, SMA type, SMN2 copy number and anthropometrics. Untreated individuals (n=56) age 2 to 21 years who were enrolled in a long-term natural history study between 2005 and 2014 and met inclusion criteria were included. Linear mixed effects models were used to assess changes in 10MWRT time with age and associations with SMA type, SMN2 copy number, and body mass. SMA type 3b (versus 3a), SMN2 copy number 4 (versus 3) and lower body mass were associated with faster 10MWRT. 10MWRT performance improved between 3 and 8 years of age, was stable between 9 and 10, and gradually declined from 11 to 18. Findings provide the first longitudinal natural history report of 10MWRT time in young individuals with SMA and offer a critical foundation for interpreting childhood change in short distance walking speed with pharmacologic treatment.

The transition from inpatient to outpatient shoulder arthroplasty critically depends on appropriate patient selection, both to ensure safety and to counsel patients preoperatively regarding individualized risk. Cost and patient demand for same-day discharge have encouraged this transition, and a validated predictive tool may help decrease surgeon liability for complications and help select patients appropriate for same-day discharge. We hypothesized that an accurate predictive model could be created for short inpatient length of stay (discharge at least by postoperative day 1), potentially serving as a useful proxy for identifying patients appropriate for true outpatient shoulder arthroplasty.A multicenter cohort of 5410 shoulder arthroplasties (2805 anatomic and 2605 reverse shoulder arthroplasties) from 2 geographically diverse, high-volume health systems was reviewed. Short inpatient stay was the primary outcome, defined as discharge on either postoperative day 0 or 1, and 49 patient outcomes and factors including the Elixhauser Comorbidity Index, sociodemographic factors, and intraoperative parameters were examined as candidate predictors for a short stay. Factors surviving parameter selection were incorporated into a multivariable logistic regression model, which underwent internal validation using 10,000 bootstrapped samples.In total, 2238 patients (41.4%) were discharged at least by postoperative day 1, with no difference in rates of 90-day readmission (3.5% vs. 3.3%, P = .774) between cohorts with a short length of stay and an extended length of stay (discharge after postoperative day 1). A multivariable logistic regression model demonstrated high accuracy (area under the receiver operator characteristic curve, 0.762) for discharge by postoperative day 1 and was composed of 13 variables: surgery duration, age, sex, electrolyte disorder, marital status, American Society of Anesthesiologists score, paralysis, diabetes, neurologic disease, peripheral vascular disease, pulmonary circulation disease, cardiac arrhythmia, and coagulation deficiency. The percentage cutoff maximizing sensitivity and specificity was calculated to be 47%. Internal validation showed minimal loss of accuracy after bias correction for overfitting, and the predictive model was incorporated into a freely available online tool to facilitate easy clinical use.A risk prediction tool for short inpatient length of stay after shoulder arthroplasty reaches very good accuracy despite requiring only 13 variables and was derived from an underlying database with broad geographic diversity in the largest institutional shoulder arthroplasty cohort published to date. Short inpatient length of stay may serve as a proxy for identifying patients appropriate for same-day discharge, although perioperative care decisions should always be made on an individualized and holistic basis.

Aims The role of increased blood pressure (BP) variability and a blunted day-night BP drop is still being debated, particularly in young hypertensive subjects. We investigated the contribution of BP variability and day-night BP changes combined to cardiovascular events in initially untreated young hypertensive individuals. Methods and results We selected 1794 subjects aged ≤45 years from the HARVEST and the PIUMA studies, two long-term observational studies in subjects with hypertension. The outcome was a composite pool of non-fatal myocardial infarction or stroke, heart failure needing hospitalization, death from cardiovascular causes, and myocardial or limb revascularization procedures. During an 11.3-year follow-up, 140 cardiovascular events were accrued. A multivariable Cox model which included BP variability and non-dipping was more informative (Akaike Information Criterion = 1536.9) than the model which included average of 24-h BP (Akaike Information Criterion = 1553.6). A higher hazard ratio (HR) was observed for non-dipping [HR 2.22; 95% confidence interval (CI): 1.55–3.17; P Conclusion In young hypertensive individuals, prognostic models including BP variability and non-dipping pattern provide better information than models with average 24-h ambulatory BP alone. More consideration should be given to BP variability and the day-night BP pattern beyond the average 24-h ambulatory BP in young hypertensive subjects.

Background Context Red blood cell transfusion can be associated with complications in medical and surgical patients. Acute anemia in ambulatory patients undergoing surgery can also impede wound healing and independent self-care. Current transfusion threshold guidelines are still based on evidence derived from critically-ill intensive care unit medical patients and may not apply to spine surgery candidates. Purpose We aimed to provide the reader with a synthesis of the best available evidence to recommend transfusion trigger thresholds and guidelines in adult patients undergoing spine surgery. Study Design/Setting This is a systematic review. Outcome measures Physiological measure: Blood transfusion thresholds and associated posttransfusion complications (morbidity, mortality, length of stay, infections, etc…) of the published articles. Patient Sample Adult spine surgery patients. Methods A systematic review of the literature using the PubMed, Google Scholar, and Web of Science electronic databases was made according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Focus was set on papers discussing thresholds for blood transfusion in adult surgical spine patients, as well as complications associated with transfusion after acute surgical blood loss in the operating room or postoperative period. Publications discussing pediatric cases, blood type analyses, blood loss prevention strategies and protocols, systematic reviews and letters to the editor were excluded. Results A total of 22 articles fitting our search criteria were reviewed. Patients who received blood transfusion in these studies were older, of female gender, had more severe comorbidities except for smoking, and had prolonged surgical time. Blood transfusion was associated with multiple adverse postoperative complications, including a higher rate of superficial or deep surgical site infections, sepsis, urinary and pulmonary infections, cardiovascular complications, return to the operating room, and increased postoperative length of stay and 30 day readmission. Analysis of transfusion thresholds from these studies showed that a pre-operative hemoglobin (Hb) of > 13 g/dL, and an intraoperative and post-operative Hb nadir above 9 and 8 g/dL, respectively, were associated with better outcomes and fewer wound infections than lower thresholds (Level B Class III). Additionally, it was generally recommended to transfuse autologous blood that was Conclusions Blood transfusion thresholds in surgical patients may be specialty-specific and different than those used for critically-ill medical patients. For adult spine surgery patients, red blood cell transfusion should be avoided if Hb numbers remain > 9 and 8 g/dL in the intraoperative and direct post-operative periods, respectively.

Introduction In 2013, the U.S. Preventive Services Task Force again recommended alcohol misuse screening and provision of brief behavioral counseling interventions to those engaged in risky drinking for all adults aged ≥18 years in primary care. This report presents national estimates of the provision of alcohol screening and brief intervention by U.S. primary care physicians, the screening methods, and the resources they identified as helpful in implementing alcohol/substance screening and intervention in primary care settings. Methods Data included 876 self-identified primary care physicians from the Physician Induction Interview portion of the 2015–2016 National Ambulatory Medical Care Survey, an annual nationally representative sample survey of nonfederal, office-based physicians in the U.S., encompassing all the 50 states and the District of Columbia. Descriptive estimates (annualized percentages) of alcohol misuse screening were generated for selected primary care physician characteristics. Estimates of how primary care physicians reported screening, the frequency of brief intervention, and resources identified as helpful in the implementation of screening/intervention procedures were also generated. Two-tailed significance tests were used to determine the differences between the compared groups. Data analyses were conducted in 2019–2020. Results In total, 71.7% of office-based primary care physicians reported screening patients for alcohol misuse. Statistically significant differences in screening were observed geographically and by provider specialty. Conclusions Less than 40% of primary care physicians who screened patients for alcohol misuse reported always intervening with patients who screened positive for risky alcohol use. Collection of data on resources that primary care physicians report as being helpful for alcohol/substance screening and intervention implementation may be useful in continuous improvement efforts.

Background For patients undergoing surgery at an Ambulatory Surgical Center, recent changes to Centers for Medicare and Medicaid Services policy allow for the omission of a 30-day preoperative History and Physical (H&P). Preoperative H&Ps for low-risk surgery may contribute to health care waste and lead to unnecessary preoperative testing and treatment cascades. Methods In this qualitative study, we conducted 30 semi-structured interviews with surgeons who frequently perform low-risk surgeries. We aimed to evaluate surgeon perspectives on the continued use of the 30-day preoperative H&P and specifically the potential risks and benefits associated with the elimination of a preoperative H&P requirement from institutional practice. We used an interpretive description approach to generate a thematic description. Results Most participants felt that the 30-day preoperative H&P was low value and frequently described it as “unnecessary,” “redundant,” or “just checking a box.” Many viewed the 30-day requirement as arbitrary and felt that new H&P findings were rare and unlikely to influence surgical care. The participants who favored the preoperative H&P felt it was a safeguard to ensure “nothing was missed” and were less likely to be burdened by the requirement than participants who felt it was low value. Conclusions Surgeons performing low-risk procedures question the utility and value of conducting a preoperative H&P within 30 days of surgery. De-implementation of the 30-day preoperative H&P for low-risk patients may increase convenience for patients and providers. Furthermore, it may improve value in surgery by increasing access to services for patients with greater need for preoperative assessment.

Objective To evaluate the association between kidney stones and risk of subsequent opioid misuse. Methods The Healthcare Cost and Utilization Project's (HCUP) inpatient, ambulatory, and emergency department databases from four states were queried to identify associations with a primary diagnosis code related to kidney stones followed by a diagnosis of opioid abuse, dependence, or overdose between 2005 and 2015. Logistic regression was performed to determine the strength and significance of the relationship between number of primary kidney stone episodes and subsequent diagnosis of opioid misuse. Results The final cohort included 783,929 patients across four states. On multivariable analysis the number of primary stone encounters (PSE) was strongly associated with the risk of developing an opioid-related disorder (ORD) when adjusting for relevant covariates (odds ratio 1.3). Patients seen in the emergency department (OR 1.4) and those treated in Iowa (OR 2.9) were at higher risk for ORD than those seen in different contexts or states. Younger age increased the strength of this association. Higher income (OR 0.7) and non-white race (OR 0.7) reduced the risk of ORD, while a diagnosis of chronic pain (OR 3.5) increased risk. Conclusions Risk of subsequent diagnosis of ORD is increased in patients who have multiple episodes of care related to kidney stones.

STUDY OBJECTIVES: To compare type 2 polysomnography (T2PSG) to the gold standard type 1 in-laboratory polysomnography (T1PSG) for diagnosing obstructive sleep apnea (OSA) in children; validate home T2PSG in children with suspected OSA. METHODS: Eighty-one participants (ages 6–18) with suspected OSA had simultaneous T1PSG and T2PSG in the sleep laboratory, 47 participants (ages 5–16) had T1PSG in the sleep laboratory and T2PSG performed at home. Sleep scientists staged and scored polysomnography data, and pediatric sleep physicians assigned a diagnosis of normal or OSA. Participant demographics, polysomnography variables, and diagnoses were compared using chi-square and Fisher’s exact tests for nominal variables, t test for continuous variables and Cohen’s kappa to assess concordance. RESULTS: Acceptable recordings were obtained for every home T2PSG. When T1PSG and T2PSG were simultaneous, correlation between the number of arousals, respiratory disturbance index, and sleep stages was excellent. T2PSG at home demonstrated less stage 2 sleep, more rapid eye movement sleep, and higher sleep efficiency. Comparison of home T2PSG to T1PSG for diagnosing OSA showed a false-positive rate of 6.6% and false-negative rate of 3% for those performed at home. CONCLUSIONS: T2PSG in the home is feasible with excellent concordance with T1PSG for the purposes of diagnosing OSA in children aged 5–18 years. Home T2PSG may be more representative of a “normal” night for children and could benefit those suspected of having OSA by reducing waiting times for laboratory PSG, improving access to PSG and possibly reducing costs of investigating and treating OSA. CITATION: Withers A, Maul J, Rosenheim E, O’Donnell A, Wilson A, Stick S. Comparison of home ambulatory type 2 polysomnography with a portable monitoring device and in-laboratory type 1 polysomnography for the diagnosis of obstructive sleep apnea in children. J Clin Sleep Med. 2022;18(2):393–402.

Purpose The purpose of this project was to prepare perioperative staff at a military ambulatory surgical center to respond to a malignant hyperthermia crisis effectively with the assistance the Stanford emergency manual cognitive aid. Design This is an evidence-based practice improvement project. Methods Multidisciplinary perioperative staff at a military ambulatory surgical center participated in an in-service about the Stanford emergency manual cognitive aid tool, and a simulation exercise was conducted to practice using the tool during a malignant hyperthermia crisis. Preproject and postproject implementation surveys were to used to measure staff perceptions of and willingness to use cognitive aids/emergency checklists during perioperative emergencies. Findings Staff positive perception of and willingness to use the Stanford emergency manual cognitive aid improved after implementation of an education session and simulation exercise with the checklist tool. Conclusions Introduction of the Stanford emergency manual cognitive aid to multidisciplinary perioperative staff with an in-service and simulated malignant hyperthermia scenario improved staff perception of cognitive aid use during emergencies. Use of cognitive aid checklists during simulated perioperative emergencies was shown to reduce missed critical treatment steps.

As the United States becomes more diverse, determining differences in health care utilization and costs in the management of skin cancers is fundamental to decision-making in health care resource allocation and improving care for underserved populations.To compare health care use and costs among non-Hispanic White, Hispanic White, and non-Hispanic Black patients with keratinocyte carcinoma.A nationwide cross-sectional study was performed using Medical Expenditure Panel Survey data from 1996 to 2015.Among 54,503,447 patients with keratinocyte carcinoma (weighted) over a 20-year period, 53,134,351 (97%) were non-Hispanic White; 836,030 (1.5%) were Hispanic White; and 170,755 (0.3%) were non-Hispanic Black. Compared to non-Hispanic White patients, Hispanic White patients had significantly more ambulatory visits per person per year (5.4 vs 3.5, P = .003). Compared to non-Hispanic White patients, non-Hispanic Black patients had significantly more ambulatory visits (13.1 vs 3.5, P = .027) and emergency department visits (2.3 vs 1.1, P .001), and incurred significantly higher ambulatory costs ($5089 vs $1131, P = .05), medication costs ($523 vs $221, P = .022), and total costs per person per year ($13,430 vs $1290, P = .032).Data for squamous cell carcinomas and basal cell carcinomas are combined.Keratinocyte carcinoma was more costly to treat and required more health care resources in non-Hispanic Black and Hispanic White patients than in non-Hispanic White patients.

Introduction The reuse of cardiac implantable electronic devices may help increase access to these therapies in low- and middle-income countries (LMICs). No published data exist regarding the views of patients and family members in LMICs regarding this practice. Methods and Results A paper questionnaire eliciting attitudes regarding pacemaker reuse was administered to ambulatory adult patients and patients’ family members at outpatient clinics at Centro Nacional Cardiologia in Managua, Nicaragua, Indus Hospital in Karachi, Pakistan, Hospital Carlos Andrade Marín and Hospital Eugenio Espejo in Quito, Ecuador, and American University of Beirut Medical Center in Beirut, Lebanon. There were 945 responses (Nicaragua – 100; Pakistan – 493; Ecuador – 252; Lebanon – 100). A majority of respondents agreed or strongly agreed that they would be willing to accept a reused pacemaker if risks were similar to a new device (707, 75%), if there were a higher risk of device failure compared to a new device (584, 70%), or if there were a higher risk of infection compared to a new device (458, 56%). A large majority would be willing to donate their own pacemaker at the time of their death (884, 96%) or the device of a family member (805, 93%). Respondents who were unable to afford a new device were more likely to be willing to accept a reused device (79% vs. 63%, P

This article presents a literature review of basic concepts of artificial airway patency in children during anesthetic management for prolonged dental procedures in outpatient surgery (MedLine, PubMed). The following considers the necessity to protect airways from the moment of onset of deep sedation, when verbal contact with a child is not always adequate, the le-vel of reflex activity is reduced, and vital functions control is not complete yet without additional supporting mechanisms. Airway patency management and selection algorithms are given depen-ding on various factors, such as the duration and invasiveness of dental intervention, the characteristics of the child’s anatomy, and concomitant pathologies, as well as associated emergency conditions with a strategy for their prevention. Comparative cha-racteristics of the use of laryngeal devices and various intubation techniques in the aspect of pediatric dentistry have been carried out. A separate paragraph in the article highlights the methods of monitoring in the operating theatre and the strategy of the Difficult Airway Society, the support and implementation of which is mandatory in any private structures of pediatric outpatient anesthesia practice in Europe and America., У статті наведений літературний огляд сучасного стану проблеми забезпечення прохідності дихальних шляхів під час анестезіологічного супроводу в амбулаторній дитячій стоматології. Розглянуті питання необхідності захисту дихальних шляхів з моменту настання глибокої седації, коли вербальний контакт з дитиною не завжди є адекватним, рівень рефлекторної діяльності знижений, а контроль над вітальними функціями вже не є повним без додаткових зовнішніх підтримуючих механізмів. Наведені алгоритми вибору методу забезпечення прохідності дихальних шляхів залежно від різних факторів, таких як тривалість і травматичність стоматологічного втручання, особливості анатомії дитини та супутніх патологій, а також вказані основні можливі асоційовані невідкладні стани із стратегією їх подолання. Проведені порівняльні характеристики застосування ларингеальних повітроводів і різних типів інтубацій в аспекті дитячої стоматології. Окремим пунктом статті виділені методи моніторингу в операційній і стратегія Difficult Airway Society (DAS), забезпечення та виконання якої є обов’язковим для анестезіологічного забезпечення в будь-яких структурах дитячої амбулаторної практики в країнах Європи та Америки.

Background The efficacy of renal denervation has been controversial, but the procedure has now undergone several placebo-controlled trials. New placebo-controlled trial data has recently emerged, with longer follow-up of one trial and the full report of another trial (which constitutes 27% of the total placebo-controlled trial data). We therefore sought to evaluate the effect of renal denervation on ambulatory and office blood pressures in patients with hypertension. Methods We systematically identified all blinded placebo-controlled randomized trials of catheter-based renal denervation for hypertension. The primary efficacy outcome was ambulatory systolic blood pressure change relative to placebo. A random-effects meta-analysis was performed. Results 6 studies randomizing 1232 patients were eligible. 713 patients were randomized to renal denervation and 519 to placebo. Renal denervation significantly reduced ambulatory systolic blood pressure (−3.52 mmHg; 95% CI −4.94 to −2.09; p < 0.0001), ambulatory diastolic blood pressure (−1.93 mmHg; 95% CI −3.04 to −0.83, p = 0.0006), office systolic blood pressure size (−5.10 mmHg; 95% CI −7.31 to −2.90, p < 0.0001) and office diastolic pressure (effect size −3.11 mmHg; 95% CI −4.43 to −1.78, p < 0.0001). Adverse events were rare and not more common with denervation. Conclusions The totality of blinded, randomized placebo-controlled data shows that renal denervation is safe and provides genuine reduction in blood pressure for at least 6 months post-procedure. If this effect continues in the long term, renal denervation might provide a life-long 10% relative risk reduction in major adverse cardiac events and 7.5% relative risk reduction in all-cause mortality.

Day surgery has been expanding since the year 2000 when the NHS set a target to perform 75% of surgeries as day procedures. Initially only elective cases were eligible, but nowadays there is a pathway for emergency surgeries as well. There are many advantages for ambulatory surgery, but for a good outcome and a low risk of complications, it is important to have a clear selection criteria, follow enhanced recovery protocols and to optimize the patient's medical conditions preoperatively.

Aims: The COVID-19 pandemic has caused strain on hospital systems and potential delay in diagnosis of type 1 diabetes (T1D). Outpatient diagnosis and treatment of metabolically stable young persons with new-onset T1D have been shown to be equivalent to inpatient. We describe an approach to outpatient management of newly diagnosed T1D during the COVID-19 pandemic using an interdisciplinary team, telemedicine, and diabetes technologies including rapid implementation of continuous glucose monitoring (CGM). Methods: Following the onset of the COVID-19 pandemic, new-onset cases of T1D were tracked. After laboratory confirmation of diagnosis and metabolic stability, patients and families were referred for ambulatory initiation of insulin therapy and diabetes education. These cases were reviewed using data extracted from the electronic health record, comments from multidisciplinary team members, and cloud-based glucose data. Results: We report on seven young people with new-onset T1D without diabetic ketoacidosis from April to June 2020, during the COVID-19 pandemic. Ages ranged 9–23 years with presenting hemoglobin A1c (HbA1c) values 10–14.5%. Initial evaluation was generally face-to-face, followed by frequent telemedicine visits. Five patients had a family history of T1D. Two patients had access to at-home HbA1c kits prompting evaluation in the absence of symptoms. Four patients required emergency department evaluation. Five patients presented with ketosis. All patients were prescribed CGM at the first visit, most starting within 1 month. Conclusions: Technology is extraordinarily useful for the care of young persons with new-onset T1D in the ambulatory setting during the COVID-19 pandemic. Large observational studies are needed to better understand outcomes of an outpatient, technology-focused approach.

Background Falls are common among People with Multiple Sclerosis (PwMS) and can result in significant consequences. Summary of the evidence of effectiveness of Physical Therapy (PT) to manage fall risks is needed. Objective To investigate the effectiveness of PT interventions to reduce fall related outcomes in PwMS. Methods Electronic databases of PubMed, PEDro, Web of Science, Scopus, SportDiscuss and CINAHL were searched. Randomized Controlled Trials (RCTs) and pre-post studies that examined the effectiveness of any PT interventions to target falls in PwMS were included. Two independent reviewers extracted the data. The Cochrane risk of bias assessment tool and the quality assessment tool for before-after studies were used for RCTs and pre-post studies, respectively. The Grading Recommendations, Assessment, Development and Evaluation- GRADE was used to rate the overall quality of evidence. Results Twenty articles with 819 participants were included in the review and 16 articles in meta-analysis. Only home-based exercise was found to significantly reduce the number of fallers (risk ratio = 0.53, 95% CI 0.31 to 0.91, P = 0.02) in ambulatory PwMS. Limited evidence exists on PT interventions to reduce falls among non-ambulatory PwMS. Conclusion The overall very low to moderate quality of evidence presented showed the effectiveness of PT interventions to reduce fall outcomes in PwMS is limited. However, home-based exercise showed potential to reduce fall outcomes in ambulatory PwMS. There is a need to develop PT interventions to reduce fall outcomes in non-ambulatory PwMS due to a scarcity of evidence in this population. Registration The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO: CRD 42020150297)

Introduction Patients with ambulatory advanced heart failure (HF) are increasingly considered for durable mechanical circulatory support (MCS) and heart transplantation and their effective triage requires careful assessment of the clinical trajectory. Methods REVIVAL, a prospective, observational study, enrolled 400 ambulatory advanced HF patients from 21 MCS/transplant centers in 2015-2016. Study design included a clinical re-assessment of Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile within 120 days after enrollment. The prognostic impact of a worsening INTERMACS Profile assigned by the treating physician was assessed at 1 year after the Early Relook. Results Early Relook was done in 325 of 400 patients (81%), of whom 24% had a worsened INTERMACS Profile, associated with longer HF history and worse baseline INTERMACS profile, but no difference in baseline LVEF (median 0.20), 6-minute walk, quality of life, or other baseline parameters. Early worsening predicted higher rate of the combined primary endpoint of death, urgent MCS, or urgent transplant by 1 year after Early Relook, (28% vs 15%), with hazard ratio 2.2 (95% CI 1.2- 3.8; p = .006) even after adjusting for baseline INTERMACS Profile and Seattle HF Model score. Deterioration to urgent MCS occurred in 14% vs 5% (p = .006) during the year after Early Relook. Conclusions Early Relook identifies worsening of INTERMACS Profile in a significant population of ambulatory advanced HF, who had worse outcomes over the subsequent year. Early reassessment of ambulatory advanced HF patients should be performed to better define the trajectory of illness and inform triage to advanced therapies.

Purpose of review Many surgical treatment options are available for patients who present with benign prostatic obstruction (BPO). This article reviews the current treatment options available and distinguishes them based on five clinical considerations: antithrombotic therapy, sexual function preservation, ambulatory procedures, anesthesia-related risks and duration of catheterization. Recent findings A comprehensive review of the literature was performed on 10 BPO procedures. Laser enucleation of the prostate (LEP), bipolar plasma transurethral vaporization of the prostate and photoselective vaporization (PVP) of the prostate reduces the risk of bleeding, which is recommended for anticoagulated men. Ejaculatory function is more likely to be preserved following transurethral incision of the prostate, Rezūm, Aquablation, UroLift and iTind. Same-day discharge is possible for LEP, PVP and prostatic arterial embolization (PAE). For patients with high anesthesia-related risks, procedures compatible with local anesthesia (UroLift, Rezūm, iTind and PAE) should be favored. Catheterization duration is shorter with UroLift, PVP and LEP. Summary BPO treatment options are growing rapidly. The optimal procedure for a given patient is based on factors such as associated risks, recovery and expected outcomes. Besides prostate volume, the clinical considerations in the present article can help elucidate the best surgical BPO treatment option for each patient based on their values, preferences, and risk tolerance.

Background The American Diabetes Association recommends glycosylated hemoglobin (A1C) to assess the management of diabetes mellitus (DM) and provides specific A1C goals to reduce the risk of DM-related complications. Although A1C is a convenient test to diagnose and monitor DM management over a 3-month time frame, certain conditions may affect the accuracy of the A1C. Case summary This case describes a woman diagnosed as having type 2 DM based on multiple A1C levels > 10%. The patient was treated by her primary care provider based on her A1C and was experiencing hypoglycemic and adverse events, despite a consistently elevated A1C. Discrepancies were noted between A1C results, random glucose monitoring at office visits, home blood glucose monitoring, and clinical presentation. Professional-use continuous glucose monitoring (CGM) and fructosamine levels were used to further assess the patient’s glycemic management. The patient was found to have a hemoglobin (Hb) Wayne variant by Hb electrophoresis and demonstrated a misdiagnosis of type 2 DM. Practice implications This report describes the importance of patient and clinician communication and highlights the limitations of using A1C levels that should be taken into consideration when the clinical picture does not align with the laboratory assessment. It also demonstrates the value of CGM technology for patients and offers a unique approach to using the ambulatory glucose profile report to promote engaging discussions with patients.

Purpose of Review The field of regional anesthesia has evolved tremendously in the last 15 years. New anesthesia protocols for ambulatory surgery and enhanced recovery after surgery have been developed as well. The focus of these techniques and protocols has centered on patient satisfaction and pain control while minimizing the use of opioids. The field of ambulatory surgery and anesthesia continues to evolve, and regional anesthesia and its plane techniques are at the center of these changes. Recent Findings Recent research has shown that regional techniques contribute to better pain control and patient experience and may decrease patient readmission rates. The safety of these techniques has been validated when performed by experienced practitioners. New techniques such as the erector spinae block (ESP) have been studied in the setting of laparoscopic surgery with promising results. Summary Regional anesthesia techniques for patients presenting for laparoscopic surgery are safe and seem to provide benefits. Those are related to patient experience, pain control, and readmission rates. Different techniques can be applied to a specific type of intervention. Application of these techniques depend on the clinical picture and patient. Future research may help us clarify how these techniques may improve patient satisfaction and operating room efficiency. New regional blocks may also develop based on what we know today.

Background Following the implementation of a new electronic health record (EHR) system at Columbia University Irving Medical Center (CUIMC), the demands of the novel coronavirus disease 2019 (COVID-19) pandemic forced an abrupt reallocation of resources away from EHR adoption. To assist staff in focusing on techniques for improving EHR utilization, an optimization methodology was designed referencing the Consolidated Framework for Implementation Research (CFIR) approach. Methods The study was performed using a methodology that comprised of two primary components as follows: (1) analysis of qualitative and quantitative data and (2) participation of frontline staff in project work groups. Working groups mapped out the current state of the identified workflows, designed and implemented interventions, monitored the effectiveness of each intervention, and scaled the proposed changes. Results As a result of the optimization methodology, clinical and operational workflows improved in the pilot department. Operationally, the pilot department increased enrollment of patients in the virtual patient portal by 20%, increased schedule utilization by 25%, and reduced average check-in time by 19%. Clinically, the pilot department had a statistically significant increase in dictation and NoteWriter tool note composition from their baseline month to their observed month. Compared with the control department, the pilot department had a statistically significant increase in SmartTool and dictation note composition. The control department showed smaller increases, and in some cases a decline in performance, in these areas of operational and clinical workflows. Conclusion The CFIR framework helped design an optimization methodology by applying a set of constructs to support effective organizational optimization, accounting for inner and outer settings. Through this methodology, the inner setting was supported in leading the identification and execution of interventions targeted to impact the outer setting. The phase-1 data at CUIMC suggest this strategy is effective in identifying opportunities, implementing interventions and creating a scalable process for continued organizational optimization.

Study Objective Preoperative detection of uterine leiomyosarcoma is important in hysterectomies performed for presumed benign indications. This study examined the effectiveness of endometrial sampling for preoperative diagnosis of leiomyosarcoma and the factors associated with a false negative. Design This is a retrospective analysis of linked data from the New York Statewide Planning and Research Cooperative System and the New York State Cancer Registry. Using procedure codes, we identified women who underwent preoperative endometrial sampling and hysterectomy in 2003-2015. We further limited the sample to women who had a subsequent diagnosis of uterine leiomyosarcoma based on histology, site and behavioral codes. We estimated the proportion of patients whose leiomyosarcoma was diagnosed preoperatively, and compared their characteristics with patients whose leiomyosarcoma was missed preoperatively (i.e., diagnosed postoperatively) using chi-square/Fisher's exact test and Wilcoxon rank sum test. Setting Inpatient and outpatient encounters at civilian hospitals and ambulatory surgery centers in New York state. Patients or Participants 79 adult women with leiomyosarcoma who underwent endometrial sampling (biopsy or dilation and curettage) within 90 days before hysterectomy. Interventions N/A Measurements and Main Results Among the 79 patients with leiomyosarcoma, 46 (58.2%) were diagnosed preoperatively, whereas 33 (41.8%) were diagnosed postoperatively. Patients diagnosed postoperatively did not differ significantly from those diagnosed preoperatively in cancer stage, grade, age, bleeding symptoms, or comorbidities. However, tumor size was larger among patients who were diagnosed postoperatively than those diagnosed preoperatively (median=12 versus 9 centimeters, p=0.04). The rate of preoperative diagnosis was higher among patients who underwent sampling with hysteroscopic guidance (66.7%) than sampling without hysteroscopic guidance (31.6%) (p=0.007). Among patients diagnosed postoperatively, 21.2% underwent a supracervical hysterectomy, compared to 0% among those diagnosed preoperatively (p=0.002). Conclusion Endometrial sampling was instrumental in diagnosing approximately half of uterine leiomyosarcomas preoperatively, which was more commonly achieved with hysteroscopic guidance.

Purpose To examine trends in Patient-Reported Outcome Measurement Information System (PROMIS) scores among orthopedic sports medicine patients undergoing surgery who completed PROMIS forms both in the ambulatory (preoperative) setting at the time of surgical scheduling, as well as on the day of surgery (perioperative) prior to their procedure. Methods Consecutive patients undergoing various sports medicine-related surgeries were recruited. Patients were included if they were scheduled for surgery and completed preoperative PROMIS on the day of surgical scheduling and on the day of surgery. Patients were excluded if they refused the questionnaire or had been administered perioperative anesthesia, which would interfere with questionnaire completion. Paired samples t-tests were run between preoperative and perioperative PROMIS scores to determine statistical significance. Results 153 patients were included with an average age of 46.5 years. The average (SD) time between completion of PROMIS questionnaires was 46.5 (44.4) days. The absolute value change in scores between preoperative and perioperative visits was 4.09 for PROMIS UE, 3.59 for PROMIS PF, 3.67 for PROMIS PI, and 4.13 for PROMIS D. The overall net change of scores between preoperative and perioperative visits were −.57 for PROMIS UE CAT, .16 points for PROMIS PF CAT, −.85 points for PROMIS PI CAT, and −2.14 points for PROMIS D CAT. Statistically significant differences in preoperative and perioperative PROMIS PI (P =.042) and PROMIS D (P =.004) scores were found. Conclusions Health states—as measured by PROMIS CAT forms completed among patients undergoing orthopedic surgery—can either improve or worsen preoperatively between the time of administration in both the ambulatory and perioperative setting. Despite the existence of these preoperative trends, it is important to consider patient and surgery-specific causes, such as the anatomic region, type of surgical intervention, and timing of preoperative PROMIS administration. Level of Evidence III, prognostic

Systems to address follow-up testing of clinically positive surveillance colonoscopy results are lacking. The impact of an ambulatory safety net (ASN) intervention on rates of colonoscopy completion was assessed. The ASN team identified patients using an electronic registry, conducted patient outreach, coordinated care, and tracked colonoscopy completion. In all, 701 patients were captured in the ASN program: 58.1% (407/701) had possible barriers to follow-up colonoscopy completion, with rates of 80.1% (236/294) if no barrier, and 40.9% (287/701) overall. Colonoscopy completion likelihood increased with prior polypectomy (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.1-2.3), and decreased with White race (OR, 0.5; 95% CI, 0.3-0.9), increased inpatient visits (OR, 0.6; 95% CI, 0.4-0.9), more outreach attempts (OR, 0.6; 95% CI, 0.5-0.7), and fair/poor/inadequate preparation (OR, 0.4; 95% CI, 0.2-0.7) in logistic regression models. An ASN model for quality improvement promotes colonoscopy completion rates and identifies patient barriers.