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In 2016, regulators from around the world came to the United States for a landmark regulatory meeting organized by the National Council of State Boards of Nursing called Regulation 2030. During the past 5 years, work has continued on the findings from Regulation 2030. Although significant progress has been achieved, further research is needed to answer many of the questions that will propel regulation into the future. Thus, in March 2021, an international assembly of regulators and nursing leaders virtually gathered to identify these questions and develop an international research agenda via a forum called Envisioning the Future of Nursing Regulation Through Research. This article highlights the prioritized research questions identified by the forum and places them in the context of the current environment and state of the science.

Imaging-based characteristics associated with the progression of stable coronary atherosclerotic lesions are poorly defined. Utilizing a combination of optical coherence tomography (OCT) and intravascular ultrasound (IVUS) imaging, we aimed to characterize the lesions prone to progression through clinical validation of a semiautomated OCT computational program.Patients with stable coronary artery disease underwent nonculprit vessel imaging with IVUS and OCT at baseline and IVUS at the 12-month follow-up. After coregistration of baseline and follow-up IVUS images, paired 5-mm segments from each patient were identified, demonstrating the greatest plaque progression and regression as measured by the change in plaque burden. Experienced readers identified plaque features on corresponding baseline OCT segments, and predictors of plaque progression were assessed by multivariable analysis. Each segment then underwent volumetric assessment of the fibrous cap (FC) using proprietary software.Among 23 patients (70% men; median age, 67 years), experienced-reader analysis demonstrated that for every 100 μm increase in mean FC thickness, plaques were 87% less likely to progress (A semiautomated FC analysis tool confirmed the significant association between thinner FC and stable coronary plaque progression along entire vessel segments, illustrating the diffuse nature of FC thinning and suggesting a future clinical role in predicting the progression of stable coronary artery disease.

Background Worldwide, nursing regulatory bodies (NRBs) use the regulatory process to ensure the competency and fitness of nurses to practice; however, it is nurse executives who ensure the standard of care in clinical settings and promote cultures of safety. Purpose The purpose of this study is to identify barriers to adverse event reporting and to evaluate the National Council of State Boards of Nursing's new Adverse Event Decision Pathway (AEDP) tool, which was developed in collaboration with the American Organization for Nursing Leadership. Methods Nursing leaders in British Columbia and Ontario, Canada, were surveyed between May and November 2019 before and after receiving the AEDP tool. Generalized estimating equation models were used to assess changes in adverse event reporting frequency. Results The pre- and postsurvey response rates were 21% (663/3,155) and 34% (125/369), respectively. At baseline, director of nursing (30.6%) and nurse manager (22.1%) were the most common professional titles reported. Concern over possible legal ramifications (23.8%), knowing what constitutes a reportable offense (21.0%), knowing how to make a report (19.8%), and facility culture/policy (15.1%) emerged as reporting barriers. After the introduction of the AEDP tool, participants were 2.29 times (95% CI = 1.27-4.11) more likely to report that a nurse was terminated due to their role in a serious adverse event (p =.01). Conclusion Nurse executives regularly encounter barriers to adverse event reporting. The AEDP is an evidence-based tool that can be used to support facility decision-making and facilitate adverse event reporting to NRBs, which enhances patient safety globally.

Background The Safe Staffing for Quality Care Act under consideration in the New York (NY) state assembly would require hospitals to staff enough nurses to safely care for patients. The impact of regulated minimum patient-to-nurse staffing ratios in acute care hospitals in NY is unknown. Objectives To examine variation in patient-to-nurse staffing in NY hospitals and its association with adverse outcomes (ie, mortality and avoidable costs). Research design Cross-sectional data on nurse staffing in 116 acute care general hospitals in NY are linked with Medicare claims data. Subjects A total of 417,861 Medicare medical and surgical patients. Measures Patient-to-nurse staffing is the primary predictor variable. Outcomes include in-hospital mortality, length of stay, 30-day readmission, and estimated costs using Medicare-specific cost-to-charge ratios. Results Hospital staffing ranged from 4.3 to 10.5 patients per nurse (P/N), and averaged 6.3 P/N. After adjusting for potential confounders each additional patient per nurse, for surgical and medical patients, respectively, was associated with higher odds of in-hospital mortality [odds ratio (OR)=1.13, P=0.0262; OR=1.13, P=0.0019], longer lengths of stay (incidence rate ratio=1.09, P=0.0008; incidence rate ratio=1.05, P=0.0023), and higher odds of 30-day readmission (OR=1.08, P=0.0002; OR=1.06, P=0.0003). Were hospitals staffed at the 4:1 P/N ratio proposed in the legislation, we conservatively estimated 4370 lives saved and $720 million saved over the 2-year study period in shorter lengths of stay and avoided readmissions. Conclusions Patient-to-nurse staffing varies substantially across NY hospitals and higher ratios adversely affect patients. Our estimates of potential lives and costs saved substantially underestimate potential benefits of improved hospital nurse staffing.

Background While postoperative outcomes of acoustic neuroma (AN) resection commonly consider hearing preservation and facial function, headache is a critical quality of life factor. Postoperative headache is described in the literature; however, there is limited discussion specific to occipital neuralgia (ON) following AN resection. Objective The aim of this study is to investigate the effectiveness of conservative management and surgery. Methods We conducted a retrospective review of 872 AN patients who underwent resection at our institution between 1988 and 2017 and identified 15 patients (1.9%) that met International Classification of Headache Disorders criteria for ON. Results Of the 15 ON patients, surgical approaches included 13 (87%) retrosigmoid (RS), one (7%) translabyrinthine (TL), and one (7%) combined RS + TL. Mean clinical follow-up was 119 months (11–263). Six (40%) patients obtained pain relief through conservative management, while the remaining nine (60%) underwent surgery or ablative procedure. Three (38%) patients received an external neurolysis, four (50%) received a neurectomy, one (13%) had both procedures, and one (13%) received two C2 to 3 radio frequency ablations. Of the nine patients who underwent procedural ON treatment, seven (78%) patients achieved pain relief, one patient (11%) continued to have pain, and one patient (11%) was lost to follow-up. Of the six patients whose pain was controlled with conservative management and nerve blocks, five (83%) found relief by using neuropathic pain medication and one (17%) found relief on nonsteroidal anti-inflammatory drug. Conclusion Our series demonstrates success with conservative management in some, but overall a minority (40%) of patients, reserving decompression only for refractory cases.

Background The critical shortage of behavioral health professionals impairs the ability of the U.S. health care system to respond to the growing demand for services to address mental illness and substance use disorders. Purpose To identify how restrictive state regulations act as barriers to full utilization of psychiatric mental health advanced practice registered nurses (PMH-APRN), whose scope of practice enables them to provide a full range of behavioral health services. Methods A sequential mixed methods study combining interview data (n = 94) from a qualitative study of PMH-APRN practice with a subset of quantitative data (n = 699) from a national APRN survey examining the impact of state-mandated APRN/MD collaborative practice agreements. Discussion Data sources converged to portray challenges to optimal use of APRNs providing psychiatric/mental health services, including high out-of-pocket fees, irregular communication with supervisors, mandated chart reviews, and supervisor turnover. Conclusion Inconsistent and burdensome supervision requirements contribute to cost inflation and may limit patient access.

Background Evolving technologies and health care quality metrics have altered treatment algorithms for acoustic neuromas (ANs), increasing trends toward observation and radiosurgery, with proportionate declines in use of microsurgery. A correlation between increasing surgical volumes and superior outcomes has been investigated previously in numerous surgical diseases, including AN. Objective To re-evaluate the volume–outcome relationship of AN resection in a changing health care system, with evolving treatment strategies. Methods Patients who underwent AN resection between 2009 and 2013 were retrospectively identified in the State Inpatient Database subset of the Healthcare Cost and Utilization Project. Generalized linear mixed-effect models were used to assess odds of various outcome measures (length of stay [LOS], discharge disposition, and facial nerve or severe clinical complications). Institutions were grouped into low-volume centers (1–6 cases/year) and high-volume centers (HVC; ≥31 cases/year) for analysis. Results A total of 1873 patients underwent AN resection between 2009 and 2013 with a mean age of 50.1 ± 14.1 years (±standard deviation). For each additional case treated annually, patients were 2% (odds ratio [OR], 0.98; 95% confidence interval, 0.96–0.99) less likely to experience a severe complication (P = 0.004). Each additional case also trended toward a decreased rate of facial nerve complications and nonroutine discharge. Inpatient LOS was also shorter for patients at HVCs (median, 4 vs. 5 days; P Conclusions Despite a relative decline in microsurgery compared with previous eras, care at HVCs is still associated with superior short-term outcomes, such as decreased LOS, facial nerve or other severe complications, and nonroutine discharges.

Background Adjunctive immune-modulation can be safe and effective for treatment-resistant bipolar depression (TRBDD), but molecular work is needed to further characterize the safety and efficacy involved in treatment response and the reversal of treatment resistance. Here we profiled the kynurenine pathway (KP) for biomarkers associated with TRBDD and treatment response to celecoxib (CBX)-augmentation. Methods 47 TRBDD patients with moderately severe HAMD-17 scores were randomized to receive either escitalopram (ESC) (10 mg twice daily) + CBX (200 mg twice daily), or ESC (10 mg twice daily) + placebo (PBO) (twice daily). Plasma kynurenine pathway (KP) metabolite levels were measured at baseline, week 4, and week 8, and in a healthy control (HC) group of subjects (N = 35) once. Results Patients receiving ESC + CBX had 4.278 greater odds of responding (p = 0.021) with NNT=3, and 15.300 greater odds of remitting (p Conclusion Clinical response to CBX augmentation is not associated with altered neurotoxic or neuroprotective indices within the time frame of this study. TRBDD revealed alterations in neuroprotective and neurotoxic indices, in the context of low kynurenine/tryptophan and high tryptophan. Treatment responders revealed a depletion in tryptophan by week 8, without concomitant kynurenine pathway (KP) activation.

Objectives Treatment-resistance is high in bipolar disorder and is associated with a pro-inflammatory state and diversion of tryptophan toward the kynurenine pathway. This study as part of a large clinical trial, sought to determine, if modulation of the inflammatory response by inhibiting cyclooxygenase-2 (COX-2) with celecoxib combined with escitalopram, would convert treatment-resistant bipolar depression to response or remission and whether blood levels of quinolinic acid (QA) differ from healthy controls and change with treatment response. Methods This was a randomized, double-blind, two-arm, placebo-controlled study. Subjects who met study criteria were randomized to receive escitalopram + celecoxib, or escitalopram + placebo. Inflammation biomarkers and kynurenine pathway intermediates were determined at baseline and weeks 4 and 8. Results Patients receiving the celecoxib combination showed improved response and higher remission rate. All patients had significantly lower QA levels at baseline compared to healthy controls. QA values did not change significantly over time, but a downtrend was noted through treatment. Responders had marginally lower QA values than non-responders. Factors that might have led to low QA levels may include prior exposure to a variety of psychoactive agents. Conclusions Although QA did not significantly change, symptom reduction and remission occurred more frequently in the celecoxib group, demonstrating the beneficial effect of inflammation modulation.

The U.S. healthcare system is facing workforce shortages in rural and primary care settings. Despite growing demand for providers and comparable quality metrics, advanced practice registered nurses (APRNs) still face significant barriers to independent practice due to reduced scope of practice regulations. In this study, APRNs working in rural areas and APRN-managed private clinics were one and a half to six times more likely to be assessed Collaborative Practice Agreement (CPA) fees, often exceeding $6,000 and up to $50,000 annually. Similarly, APRNs subject to minimum distance requirements, fees to establish a CPA, and supervisor turnover reported a 30% to 59% uptick in restricted care. Such unnecessary regulation risks diverting health services away from and increasing costs in traditionally underserved areas, contributing to inequities in care. It is incumbent on state legislatures to address these disparities and make their constituents' access to high-quality care a top priority.

The purpose of this study is to assess the diagnostic performance of the American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TIRADS) for malignancy risk in pediatric thyroid nodules.Two radiologists reviewed ultrasound images of 74 tissue-proven thyroid nodules in 62 children. Points were given for individual features and then added to determine the ACR TI-RADS category, ranging from 1 (benign) to 5 (high suspicion). Kappa coefficients were generated to assess intra- and interobserver agreement. Generalized linear mixed-effects models were used to estimate the odds of malignancy with construction of a supplementary ROC curve.Fifty-four nodules were benign and 20 were malignant, with a median ACR TI-RADS category of 4 (interquartile range, 4-5). Nineteen of 20 (95.0%) malignant nodules were rated as TI-RADS category 4 or 5. There was substantial intraobserver agreement (κ = 0.69-0.77; p0.001) and moderate interobserver agreement (κ = 0.37; p = 0.002) for TIRADS category. Univariable analysis showed that, with every 1-unit increase of TI-RADS category, the likelihood of malignancy increased 2.63 times (95% CI, 1.08-6.41; p = 0.03). After adjusting for nodule size, TI-RADS category remained marginally associated with malignancy (adjusted odds ratio, 2.27; 95% CI, 0.93-5.54; p = 0.07). The AUC was 0.75 (95% CI, 0.64-0.86). An optimal cut point of TI-RADS category 5 was selected, with TI-RADS category 5 nodules 10.44 times (95% CI, 2.71-40.21; p0.0001) more likely than categories 1-4 nodules to be malignant.ACR TI-RADS discriminates well between malignant and benign nodules in a pediatric population, particularly at TI-RADS category 5.

Background Despite nurses’ responsibilities in recognition and treatment of sepsis, little evidence documents whether patient-to-nurse staffing ratios are associated with clinical outcomes for patients with sepsis. Methods Using linked data sources from 2017 including MEDPAR patient claims, Hospital Compare, American Hospital Association, and a large survey of nurses, we estimate the effect of hospital patient-to-nurse staffing ratios and adherence to the Early Management Bundle for patients with Severe Sepsis/Septic Shock SEP-1 sepsis bundles on patients’ odds of in-hospital and 60-day mortality, readmission, and length of stay. Logistic regression is used to estimate mortality and readmission, while zero-truncated negative binomial models are used for length of stay. Results Each additional patient per nurse is associated with 12% higher odds of in-hospital mortality, 7% higher odds of 60-day mortality, 7% higher odds of 60-day readmission, and longer lengths of stay, even after accounting for patient and hospital covariates including hospital adherence to SEP-1 bundles. Adherence to SEP-1 bundles is associated with lower in-hospital mortality and shorter lengths of stay; however, the effects are markedly smaller than those observed for staffing. Discussion Improving hospital nurse staffing over and above implementing sepsis bundles holds promise for significant improvements in sepsis patient outcomes.

Background:Coronary arterial plaques in patients with end-stage renal disease (ESRD) are assumed to have increased calcification due to underlying renal disease or initiation of dialysis. This relationship may be confounded by comorbid type 2 diabetes mellitus (DM).Methods:From a single-center OCT registry, 60 patients were analyzed. Twenty patients with ESRD and diabetes (ESRD-DM) were compared to 2 groups of non-ESRD patients: 20 with and 20 without diabetes. In each patient, one 20 mm segment within the culprit vessel was analyzed.Results:ESRD-DM patients exhibited similar calcium burden, arc, and area compared to patients with diabetes alone. When compared to patients without diabetes, patients with diabetes exhibited a greater summed area of calcium (DM: Median 9.0, IQR [5.3–28] mm2vs Non-DM: 3.5 [0.1–14] mm2, p = 0.04) and larger calcium deposits by arc (DM: Mean 45 ± SE 6.2° vs Non-DM: 21 ± 6.2°, p = 0.01) and area (DM: 0.58 ± 0.10 mm2vs Non-DM: 0.26 ± 0.10 mm2, p = 0.03). Calcification deposits in ESRD-DM patients (0.14 ± 0.02 mm) and patients with diabetes (0.14 ± 0.02 mm) were more superficially located relative to patients without diabetes (0.21 ± 0.02 mm), p = 0.01 for both.Conclusions:Coronary calcification in DM and ESRD-DM groups exhibited similar burden, deposit size, and depth within the arterial wall. The increase in coronary calcification and cardiovascular disease events seen in ESRD-DM patients may not be secondary to ESRD and dialysis, but instead due to a combination of declining renal function and diabetes.

IntroductionEfforts to enact nurse staffing legislation often lack timely, local evidence about how specific policies could directly impact the public’s health. Despite numerous studies indicating better staffing is associated with more favourable patient outcomes, only one US state (California) sets patient-to-nurse staffing standards. To inform staffing legislation actively under consideration in two other US states (New York, Illinois), we sought to determine whether staffing varies across hospitals and the consequences for patient outcomes. Coincidentally, data collection occurred just prior to the COVID-19 outbreak; thus, these data also provide a real-time example of the public health implications of chronic hospital nurse understaffing.MethodsSurvey data from nurses and patients in 254 hospitals in New York and Illinois between December 2019 and February 2020 document associations of nurse staffing with care quality, patient experiences and nurse burnout.ResultsMean staffing in medical-surgical units varied from 3.3 to 9.7 patients per nurse, with the worst mean staffing in New York City. Over half the nurses in both states experienced high burnout. Half gave their hospitals unfavourable safety grades and two-thirds would not definitely recommend their hospitals. One-third of patients rated their hospitals less than excellent and would not definitely recommend it to others. After adjusting for confounding factors, each additional patient per nurse increased odds of nurses and per cent of patients giving unfavourable reports; ORs ranged from 1.15 to 1.52 for nurses on medical-surgical units and from 1.32 to 3.63 for nurses on intensive care units.ConclusionsHospital nurses were burned out and working in understaffed conditions in the weeks prior to the first wave of COVID-19 cases, posing risks to the public’s health. Such risks could be addressed by safe nurse staffing policies currently under consideration.

Ten of the world's biggest rivers are located entirely within the Asian Monsoon region. They provide water, energy, and food for 1.7 billion people. To manage these critical resources, we need a better understanding of river discharge���how does it change over a long time? Are there common variation patterns among rivers? To answer these questions, we use information derived from tree rings to reconstruct average annual river discharge history at 62 gauges in 16 Asian countries. Our reconstruction reveals the riparian footprint of megadroughts and large volcanic eruptions over the past eight centuries. We show that simultaneous droughts and pluvials have often occurred at adjacent river basins in the past, because Asian rivers share common influences from the Pacific, Indian, and Atlantic Oceans. We also show how these oceanic teleconnections change over space and time. Our findings can inform big decisions made on water-dependent infrastructure, thus benefiting the riparian people of the Asian Monsoon region.

Purpose To compare radiation toxicity in endometrial cancer patients treated with adjuvant vaginal brachytherapy (VBT) vs. VBT with concurrent chemotherapy (CCT) or sequential chemotherapy (SCT) Methods We retrospectively analyzed 131 patients with endometrial cancer treated with VBT without external beam radiation therapy. Toxicities were graded according to the Common Terminology Criteria for Adverse Events v4.03. CCT was defined as VBT delivered between the first and last cycle of chemotherapy (CT); SCT was defined as VBT delivered before or after CT. Results Median followup was 36 months, with a 3-year survival rate of 88%. Of the 131 patients, 92 were treated with VBT alone, 34 with VBT and CCT, and 5 with VBT and SCT. The most common toxicity was vaginal stricture, with 30 (22.9%) patients affected. The distribution of toxicities was vaginal 28%, urinary 12%, rectal 11%, and fatigue 5%; none greater than Grade 2. Compared with patients treated with VBT alone, the addition of CT did not increase the chance of vaginal stricture formation (p = 0.84). The difference in system-specific toxicities between treatment modalities was not statistically significant. Conclusion The most common pelvic toxicity from VBT is vaginal stenosis with other toxicities being infrequent and generally Grade 1. The addition of CT in a sequential or concurrent fashion did not increase the rate of pelvic toxicity from VBT alone.

Background The management of a drain after Pancreaticoduodenectomy (PD) and distal pancreatectomy (DP) remains a controversial issue. Our aim in this study was to identify a safe time for drain removal. Study Design This is a retrospective study, of a prospective database, of patients who underwent a PD or DP at two tertiary care institutions. Results A total of 180 patients underwent PD and DP during the observation period. Seventeen patients developed fistulas (9.4%), with 70.6% (n = 12) developing in soft pancreatic remnants vs. 29.4% (n = 5) in firm pancreatic remnants. Patients with amylase levels greater than 173 U/L on a postoperative day three were 11.46 times more likely to form a fistula compared to those with an amylase level at or below 173 U/L (p Conclusion Fistula formation is associated with pancreas texture, duct size, and drain amylase following PD or DP. Patients with firm pancreatic texture and large ducts are less likely to develop fistulas than those with soft pancreatic texture and small ducts.

Objectives Assess impact of Ki-67 labeling index (LI; Ki-67 LI) on risk of recurrence or progression of WHO grade I meningiomas. Study Design Retrospective study of adult patients who underwent resection of cranial base meningioma between 2004 and 2016. Results 272 patients fulfilled criteria for inclusion in the study. Average age was 61.8 years; 196 (72%) were females. Simpson's grade 1 resection was noted in 77 patients (32%), grade 2 in 39 (16%), grade 3 in 36 (15%), and grade 4 in 88 (37%). The Ki-67 LI was low (1–4%) in 214 (78.7%), intermediate (5–9%) in 44 (16.2%), and high (>10%) in 14 (5.2%). Median follow-up was 39 months (IQR: 16–71 months); 221 (87.1%) tumors remained stable or did not recur, 19 (7.4%) recurred, and 14 (5.5%) progressed. Compared with tumors with low Ki-67 LI, those with intermediate Ki-67 LI had 2.47 times (2.47 [1.09–5.59], p = 0.03), and those with high Ki-67 LI had 3.38 times (3.38 [1.16–9.89], p = 0.03) higher risk of recurrence or progression. Tumors with Ki-67 LI > 4% had a shorter time to recurrence or progression (p = 0.01). Recurrence or progression-free survival rates at 3, 5, and 10 years for tumors with low Ki-67 LI were 95%, 89%, and 75%, respectively; tumors with intermediate Ki-67 LI, 87%, 69%, and 52%, respectively; tumors with high Ki-67 LI, 78%, 49%, and 49%, respectively. Conclusions Following surgical resection of a WHO grade I cranial base meningioma, Ki-67 LI > 4% may predict an increased risk of recurrence or progression of residual tumor.

Introduction Although boards of nursing (BONs) ensure nurse competency and fitness to practice through the regulatory process, it is nurse executives who enforce the Nurse Practice Act and standards of care in the clinical setting. As such, it is a nurse executive's responsibility to uphold the culture of safety. Aims To better understand nursing executives' current protocols for reporting serious adverse events to state BONs and to identify potential reporting barriers. Methods A national survey was administered to members of the American Organization of Nurse Executives and the National Association of Directors of Nursing Administration in January 2018. The study collected demographic and professional data, as well as health facility information and practice related to serious adverse event reporting. Analysis included a descriptive summary and univariable and multivariable ordinal logistic regression models to examine drivers of and barriers to serious adverse event reporting. Results A total of 441 participants completed the survey. Respondents included directors of nursing (35.6%), chief nursing officers (21.5%), chief nursing executives (17.2%), and nurse managers (9.1%). There was broad coverage across U.S. Census regions: South (33.9%), Midwest (30.8%), Northeast (19.1%), and West (16.2%). Executives who are aware of state BON guidelines (OR = 2.52, 95% CI: 1.56 – 4.09, p Conclusion Nurse executives encounter barriers to BON reporting. Additional resources to align facility practice related to nurse discipline are needed. Ongoing BON education and outreach will help facilitate serious adverse event reporting, which can enhance patient safety.

Purpose Bladder-preserving curative radiation therapy (RT) has been established as an excellent treatment option for select patients with muscle-invasive bladder cancer (MIBC). However, some clinicians have concerns that good outcomes are only achievable at high-volume facilities (HVFs) and academic centers (ACs), questioning successful reproducibility of curative RT at smaller centers. This study sought to determine whether treatment at ACs or HVFs was associated with better overall survival (OS) than treatment at nonacademic centers or lower-volume facilities. Methods and Materials We performed a retrospective cohort study of National Cancer Database patients (n=2763) with cT2 to cT4 N0 M0 transitional cell MIBC who received curative RT (60-70 Gy) with or without concurrent chemotherapy. Cox proportional hazards models were used to estimate the instantaneous hazard of death as a function of univariate and multivariate patient characteristics and clinical measures. Results Univariate analysis showed that academic facility type was significantly associated with improved OS (hazard ratio [HR], 0.88; 95% confidence interval [CI] 0.79-0.98; P =.02) whereas higher case volume was not associated with improved survival (HR, 0.97; 95% CI 0.92-1.01; P =.15). Multivariate analysis showed no differences in OS for treatment at ACs versus nonacademic centers (HR, 0.94; 95% CI 0.84-1.06; P =.31) or HVFs versus lower-volume facilities (HR, 0.99; 95% CI 0.94-1.04; P =.60). The 2-year OS rate was 54.5% (95% CI 52.5%-56.4%), and the 5-year OS rate was 28.9% (95% CI 27.0%-30.8%). Conclusions Although some providers are cautious about offering curative RT at all centers, this large hospital-based study suggests that facility type and volume are not significantly associated with OS for patients undergoing curative RT after we account for other clinically relevant risk factors. The results of this study demonstrate that curative RT in the treatment of MIBC may be considered for patients regardless of facility type or volume.

While some institutions deliver multiple fractions per implant for MRI-based planning, it is common for only one fraction to be delivered per implant with CT-based cervical brachytherapy. The purpose of this study was to compare physician costs, hospital costs, and overall costs for cervical cancer patients treated with either CT-based or MRI-based high-dose-rate (HDR) cervical brachytherapy to determine if MRI-based brachytherapy as described can be financially feasible.We identified 40 consecutive patients treated with curative intent cervical brachytherapy. Twenty patients underwent CT-based HDR brachytherapy with five fractions delivered in five implants on nonconsecutive days in an outpatient setting with the first implant placed with a Smit sleeve under general anesthesia. Twenty patients received MRI-based HDR brachytherapy with four fractions delivered in two implants, each with MRI-based planning, performed 1-2 weeks apart with an overnight hospital admission for each implant. We used Medicare reimbursements to assess physician costs, hospital costs, and overall cost.The median cost of MRI-based brachytherapy was $14,248.75 (interquartile range [IQR]: $13,421.32-$15,539.74), making it less costly than CT-based brachytherapy with conscious sedation (i.e., $18,278.85; IQR: $17,323.13-$19,863.03, p0.0001) and CT-based brachytherapy with deep sedation induced by an anesthesiologist (i.e., $27,673.44; IQR: $26,935.14-$29,511.16, p0.0001). CT-based brachytherapy with conscious sedation was more costly than CT-based brachytherapy with deep sedation (p0.001).MRI-based brachytherapy using the described treatment course was less costly than both methods of CT-based brachytherapy. Cost does not need to be a barrier for MRI-based cervical brachytherapy, especially when delivering multiple fractions with the same application.

ObjectiveTo evaluate variation in Illinois hospital nurse staffing ratios and to determine whether higher nurse workloads are associated with mortality and length of stay for patients, and cost outcomes for hospitals.DesignCross-sectional analysis of multiple data sources including a 2020 survey of nurses linked to patient outcomes data.Setting: 87 acute care hospitals in Illinois.Participants210 493 Medicare patients, 65 years and older, who were hospitalised in a study hospital. 1391 registered nurses employed in direct patient care on a medical–surgical unit in a study hospital.Main outcome measuresPrimary outcomes were 30-day mortality and length of stay. Deaths avoided and cost savings to hospitals were predicted based on results from regression estimates if hospitals were to have staffed at a 4:1 ratio during the study period. Cost savings were computed from reductions in lengths of stay using cost-to-charge ratios.ResultsPatient-to-nurse staffing ratios on medical-surgical units ranged from 4.2 to 7.6 (mean=5.4; SD=0.7). After adjusting for hospital and patient characteristics, the odds of 30-day mortality for each patient increased by 16% for each additional patient in the average nurse’s workload (95% CI 1.04 to 1.28; p=0.006). The odds of staying in the hospital a day longer at all intervals increased by 5% for each additional patient in the nurse’s workload (95% CI 1.00 to 1.09, p=0.041). If study hospitals staffed at a 4:1 ratio during the 1-year study period, more than 1595 deaths would have been avoided and hospitals would have collectively saved over $117 million.ConclusionsPatient-to-nurse staffing ratios vary considerably across Illinois hospitals. If nurses in Illinois hospital medical–surgical units cared for no more than four patients each, thousands of deaths could be avoided, and patients would experience shorter lengths of stay, resulting in cost-savings for hospitals.

Purpose Radiation therapy (RT)–specific aspects of a patient’s cancer care commonly are documented and scheduled through a radiation oncology electronic health record (rEHR). However, patients who receive RT also receive multidisciplinary care from providers who use the hospital EHR (hEHR). We created an electronic interface to integrate our hEHR and rEHR to improve communication of the RT aspects of care between our department and the rest of the hospital. The objective of this study was to assess the impact of rEHR and hEHR integration on the accessibility of the RT-specific aspects of patient care to providers. Methods and Materials We performed a preintegration and postintegration survey of 175 staff members at our academic cancer center. Respondents rated the importance and accessibility of several RT encounters and documents on a Likert scale. The Wilcoxon-Mann-Whitney, χ2, and Fisher’s exact tests were used to compare preintegration and postintegration responses. Results There were 32 and 19 responses to the pre- and postintegration surveys, respectively. rEHR items most commonly reported to be at least moderately important were the dates of first treatment (n = 29 [91%]), last treatment (n = 29 [91%]), brachytherapy (n = 22 [69%]), radiosurgery (n = 22 [69%]), and computed tomography simulation (n = 21 [66%]). A drastic improvement was found in most items made visible in the hEHR through the interface. Conclusion By integrating our hEHR and rEHR, we improved the communication of patient care between the RT department and the multidisciplinary team. Institutions should pursue and support integration of the EHRs to improve the quality of care provided to patients with cancer.

BACKGROUND AND PURPOSE: Small echogenic foci within pediatric thyroid nodules are commonly seen by ultrasound and are one of the features used to determine the level of suspicion for malignancy. These are sometimes termed “microcalcifications,” but their relation with malignancy is controversial due to the lack of standard terminology. Our aim was to evaluate sonographic patterns of echogenic foci in malignant pediatric thyroid nodules and describe the distribution of corresponding psammoma bodies and other histopathologic findings in thyroidectomy specimens. MATERIALS AND METHODS: Ultrasounds of 15 pathologically proved malignant thyroid nodules in children were retrospectively reviewed by 2 radiologists who separately classified echogenic foci into the 4 morphologic patterns described in the American College of Radiology Thyroid Imaging, Reporting and Data System and noted their presence and distribution. Interobserver agreement was assessed, and consensus was reached for nodules for which there was disagreement. Surgical pathology findings from thyroidectomy specimens were retrospectively reviewed for the presence and distribution of psammomatous and dystrophic/stromal calcifications and eosinophilic/sticky colloid. Ultrasound and histopathologic ratings were compared, and frequencies and percentages corresponding to observed agreement levels were calculated. RESULTS: Interobserver agreement between radiologists9 sonographic assessments for the presence and distribution of echogenic foci ranged from 53% to 100% for all categories. Punctate echogenic foci were present in all nodules, and macrocalcifications, in 27%. Histopathology of the 15 nodules revealed that only 4 (27%) had psammomatous calcifications, while 9 (60%) had stromal calcifications and 8 (53%) had sticky colloid. CONCLUSIONS: Sonographically detectable echogenic foci in malignant pediatric thyroid nodules can be reliably classified on the basis of American College of Radiology Thyroid Imaging, Reporting and Data System, with punctate echogenic foci composing the most common subtype. These echogenic foci do not represent psammomatous calcifications most of the time; instead, more than half of the malignant thyroid nodules with echogenic foci contained stromal calcifications or sticky colloid.

Clinical trials have demonstrated the efficacy of bladder-preserving chemoradiation therapy (BPT) in muscle-invasive bladder cancer but have differed in the radiation therapy dose/fractionations, radiation therapy targets, and concurrent chemotherapy regimens used. No data exist on the technical and practical approaches actually used in clinical practice throughout the United States when delivering BPT. We performed a survey to explore radiation oncologists' practice patterns.We conducted an electronic survey of US radiation oncologists regarding the management of patients with cT2-3N0M0 transitional cell muscle-invasive bladder cancer. The instrument included questions regarding the types of patients treated with BPT, as well as several aspects of treatment delivery. Descriptive statistics were reported for all responses. Pearson χIn total, 277 physicians completed our survey. Most respondents (58%) stated that they only treated 1 to 3 patients in the prior year. Seventy-four percent of respondents primarily treated patients deemed unfit for cystectomy, while only 28% saw patients prior to cystectomy for consultation to discuss BPT. The majority of radiation oncologists used conventional fractionation (91%) instead of hypofractionation (7.6%), but more variability existed for radiation therapy targets. Sixty percent used a small pelvis field, 29% used a whole-pelvis field, and 12% treated the bladder only. There was increased use of hypofractionation (29%) and bladder-only radiation therapy (34%) in patients who were not candidates for cystectomy or chemotherapy (P.001). Cisplatin-based concurrent chemotherapy was most commonly preferred (89%). In non-cisplatin candidates, most respondents preferred 5-fluorouracil plus mitomycin C (32%) or carboplatin (32%). Intensity modulated radiation therapy use and midtreatment cystoscopic re-evaluation were variable, while hyperfractionation use was low.Our study describes radiation oncologists' practice patterns for patients undergoing BPT. Although there are areas of consistency, variability exists in many technical and practical aspects of treatment delivery. Further research and education are needed to determine the optimal radiation therapy target, dose/fractionation, and concurrent chemotherapy regimen.

This study analyzes the simple ratio of anterior-to-posterior extension of large (>2.5 cm) acoustic neuromas relative to the internal auditory canal (ICA; anterior–posterior [A/P] index) as a tool for predicting risk of facial nerve (FN) injury. In total, 105 patients who underwent microsurgical resection for large acoustic neuromas were analyzed retrospectively. House–Brackmann (HB) scores were assessed immediately postoperatively, at 1 month, and at 1 year. Lateral–medial, inferior–superior, A/P, and maximum diameters were measured from preoperative magnetic resonance images. These measurements and the A/P index were analyzed using univariable and multivariable statistical models to assess relationship to FN outcomes. The retrosigmoid, translabyrinthine, and combined approaches were used, and the extent of resection was evaluated. For every 1 standard deviation increase in the A/P index, a patient was 3.87 times more likely have a higher postoperative HB score (p

Most historic trials demonstrating the outcomes with bladder-preserving radiotherapy (RT) used 64–66 Gy. However, newer data suggest improved outcomes with dose escalation up to 70 Gy. Our objective was to explore the impact of dose escalation on overall survival (OS) and to identify the optimal radiotherapy (RT) dose in patients with muscle-invasive bladder cancer (MIBC) treated with curative bladder-preserving RT. We conducted a retrospective cohort study of patients with cT2–4 N0–3 M0 transitional cell MIBC who were treated with curative RT (60–70 Gy in 1.8–2.0 Gy/fraction) using the National Cancer Database. Univariable (UVA) and multivariable (MVA) frailty survival analyses were employed to identify the association of dose escalation to 67–70 Gy, as well as different RT dose subgroups within 60–66 Gy, and OS. In total, 2531 patients met eligibility criteria. The 2-year OS was 53 and 56%, respectively, for patients receiving 60–66 and 67–70 Gy (p = .25). On MVA, there was no significant difference in survival for patients receiving 67–70 vs. 60–66 Gy (hazard ratio [HR], 0.91; 95% confidence interval [CI], 0.76–1.10; p = .33). Compared to doses of 64–66 Gy, OS was worse with 60–61 Gy (HR, 1.33; 95% CI, 1.17–1.52; p

Aims Historic trials suggested significant toxicity with adjuvant radiotherapy (ART) after radical cystectomy for muscle-invasive bladder cancer (MIBC). However, recent trials have found improved locoregional control and the 2016 National Comprehensive Cancer Network (NCCN) guidelines recommend ART consideration for select patients at high risk of local recurrence. ART practice patterns among US radiation oncologists are unknown and we carried out a survey to explore current trends. Materials and methods We conducted a survey of US radiation oncologists regarding the management of patients with cT2-3N0M0 transitional cell MIBC. Responses were reported using descriptive statistics. Chi-square and univariate logistic regression of clinical and demographic covariates were conducted, followed by multivariable logistic regression analysis to identify factors predicting for ART use. Results In total, 277 radiation oncologists completed our survey. Nearly half (46%) have used ART for MIBC at least once in the past. In ART users, indications for ART include gross residual disease (93%), positive margins (92%), pathological nodal involvement (64%), pT3 or T4 disease (46%), lymphovascular invasion (16%) and high-grade disease (13%). On univariate logistic regression, ART use was associated with the number of years in practice ( P =0.04), pre-cystectomy radiation oncology consultation ( P =0.004), primarily treating MIBC patients fit for cystectomy ( P =0.01) and intensity-modulated radiotherapy use ( P =0.01). On multivariable logistic regression analysis, routine pre-cystectomy radiation oncology consultation (odds ratio 1.91, 95% confidence interval 1.04–3.51; P =0.04) and intensity-modulated radiotherapy use (odds ratio 2.77, 95% confidence interval 1.48–5.22; P =0.002) remained associated with ART use. Conclusions ART use is controversial in bladder cancer, yet unexpectedly has commonly been used among US radiation oncologists treating patients with MIBC after radical cystectomy. NRG-GU001 was a randomised trial in the US randomizing patients with high-risk pathological findings for observation or ART after cystectomy. However, due to poor accrual it recently closed and thus it will be up to other international trials to clarify the role of ART and identify patients benefiting form this adjuvant therapy.

BACKGROUND The current study was conducted to compare the overall survival (OS) of concurrent chemoradiotherapy (CCRT) versus radiotherapy (RT) alone in elderly patients (those aged ≥80 years) with muscle-invasive bladder cancer (MIBC). METHODS Patients aged ≥80 years with cT2-4, N0-3, M0 transitional cell MIBC who were treated with curative RT (60-70 Gray) or CCRT were identified in the National Cancer Data Base. Univariable and multivariable frailty survival analyses, as well as 1-to-1 propensity score matching, were used to isolate the association between CCRT and OS. RESULTS A total of 1369 patients who were treated with RT from 2004 through 2013 met eligibility criteria: 739 patients (54%) received RT alone and 630 patients (46%) received CCRT. The median age of the patients was 84 years (range, 80-90 years). The median follow-up was 21 months. The 2-year OS rate was 48%. When comparing CCRT with RT alone, the 2-year OS rate was 56% versus 42% (P

The 2015 American Thyroid Association (ATA) Management Guidelines for Children with Thyroid Nodules and Differentiated Thyroid Cancer provides selection criteria for nodules prior to ultrasound-guided fine-needle aspiration biopsy. To evaluate the diagnostic performance of pediatric thyroid nodule risk stratification for predicting malignancy when applying the ultrasound (US) criteria recommended. US characteristics of 39 thyroid nodules in 33 pediatric patients who underwent US fine-needle aspiration biopsy were reviewed by two radiologists. Based on the aggregated US criteria from the ATA Guidelines, each nodule was assigned a level of malignancy risk. Kappa coefficients were estimated to assess intra- and interobserver reliability. Using each patient’s largest nodule observation (n = 33), univariable exact logistic regression analyses of US parameters were then conducted to estimate the odds of a malignant pathology diagnosis. A penalized Firth correction was employed in the univariable models analyzing composition, shape and level of suspicion due to quasi-complete data separation. Twenty-seven nodules in 21 patients (median age: 16 years; 17 female) were benign and 12 nodules in 12 patients (median age: 16.5 years; 11 female) were malignant. Intraobserver agreement was substantial to almost perfect for composition, echogenicity, shape and margins. Interobserver agreement was almost perfect for composite level of suspicion. High level of suspicion was assigned to all 12 malignant nodules versus 9/21 (43%) of the benign nodules. Level of suspicion, solid/predominantly solid composition, irregular margins and echogenic foci emerged as significant predictors of malignancy with odds ratios (OR) of 8.5 (95% confidence interval [CI]: 1.7–1,130, P = 0.001), 10.5 (95% CI: 1.1–1,417, P = 0.04), 53.2 (95% CI: 5.1–2,988, P