Citations

ObjectiveNot much is known regarding musculoskeletal ultrasound (MSUS) practices of rheumatologists in the United States. We sought to determine the current use of MSUS among past participants of the Ultrasound School of North American Rheumatologists (USSONAR) training program and, by extension, MSUS‐practicing rheumatologists and to understand barriers to its MSUS use.MethodsAn online survey was sent to 374 participants in the eight‐month USSONAR blended course (Fundamentals in Musculoskeletal Ultrasound and Train the Trainer) between 2009 and 2020. Each respondent had a unique identifier linked to their total number of submitted practice scans and examination scores during training.ResultsThe survey response rate was 28.1% (105 of 374), comprising 82% adult and 18% pediatric rheumatologists. Of the respondents, 71% were MSUS certified: 86.7% performed and/or interpreted diagnostic MSUS, 81.0% performed/interpreted procedural MSUS, 59.8% billed for at least 50% of diagnostic studies, and 78.8% billed for at least 50% of procedural studies. The top reasons for not doing diagnostic and procedural ultrasonography were lack of administrative support and limited time, respectively. For 25% of diagnostic ultrasonography and 12.9% of procedural ultrasonography, billing was done <50% of the time. Of the respondents, 78.0% reported that USSONAR training made them better rheumatologists.ConclusionMost USSONAR‐trained rheumatologists are certified, practicing both diagnostic and procedural MSUS and billing for most of their work. However, a substantial number of studies are not being billed due to time constraints, limited administrative support, and legal liability. Participants agreed that USSONAR training made them better rheumatologists.

Objective: This single-arm, pre–post interventional trial (clinicaltrials.gov, NCT04515095) investigates the safety, feasibility, and potential effectiveness of prolonged water-only fasting followed by a whole-plant-food diet in the long-term management of hypertension and other cardiometabolic disorders. Methods: Safety was assessed based on adverse events (AEs) that were recorded according to Common Terminology Criteria for Adverse Events (CTCAE) v5.0. Feasibility was assessed based on retention rate, ability to complete minimal fast length, and intervention acceptability. Twenty-nine participants with stage 1 and 2 hypertension and without type 2 diabetes were enrolled from a residential fasting center. Results: Study retention was 100% at the end of the refeed and 93% at the six-week follow-up visit. Median (range) fasting and refeeding duration were 11 (7–40) and 5 (3–17) days, respectively, and 90% of participants were able to complete at least 7 days of fasting. The majority of AEs were mild (grade 1) and transient and there were no higher-grade or serious AEs. At the end of the intervention, median systolic/diastolic blood pressure had normalized to below 130/80 mmHg, body weight reduced by >5%, and anti-hypertensive medication was completely discontinued. These results were sustained for at least six weeks and potentially up to one year. Conclusions: Our data suggest that the intervention may be a feasible, well-tolerated, low-risk option for lowering and managing high blood pressure, excess body weight, and other cardiometabolic disorders in people with stage 1 and 2 hypertension.

Background: Penile inversion vaginoplasty (PIV) entails considerable soft-tissue dissection to the perineal region and involves complex tissue rearrangement. This study examines the role of an enhanced recovery after surgery (ERAS) pathway after PIV in reducing opioid use and controlling postoperative pain. Methods: A retrospective study of 50 transfemale patients who underwent PIV at a single institution from June 2021 to January 2023 was completed. The study compared 2 groups of patients who were given different postoperative pain management regimens: group A received standard postoperative analgesics and group B received ERAS. Variables such as postoperative pain scores on the numeric pain rating scale (0–10), use of opioid medication, length of hospital stay, and patient comorbidities were recorded and compared across the 2 groups. Results: The average hospital stay length was 4.92 (±0.85) days. Group A had a slightly longer average stay compared with group B. The average pain level in both groups was 4.25 (SD ±1.51). Group A exhibited a slightly higher average pain level of 4.31 (±1.53), whereas group B exhibited 4.16 (SD±1.51) (P = 0.77). Although pain levels did not significantly vary between the 2 groups, there was a statistically significant decrease in the amount of opioid medication used in group B with a P value of 0.009. Conclusions: ERAS protocol is effective in decreasing opioid usage in the immediate postoperative setting after PIV.

Problem definition: Coordinated care network (CCN) is a burgeoning paradigm where patients’ diagnosis and treatment plans are developed based on collaboration between multiple, colocated medical specialties to holistically address patients’ health needs. A primary performance metric for CCNs is how quickly patients can complete their itinerary of appointments at multiple medical services in the network. Rapid completion is critical to care delivery but also presents a major operational challenge. Because information about a patient’s condition and treatment options evolves over the course of the itinerary, care paths are not known a priori. Thus, appointments (except for the first one) cannot be reserved in advance, which may result in significant delays if capacity is not allocated properly. Methodology/results: We study capacity allocation for the patient’s first (root) appointment as the primary operational lever to achieve rapid itinerary completion in CCNs. We develop a novel queueing-based analytical framework to optimize this root appointment allocation, maximizing the proportion of patients completing care by prespecified deadlines. Our framework accounts for the complex interactions among all patients in the network through the blocking process, which contrasts with conventional siloed planning. We provide an exact characterization of the itinerary time and develop a mean-field approximation with convergence guarantees that permits tractable solutions for large-scale network problems. In a simulation case study of Mayo Clinic, our solution improves on-time completion from 60% under the current plan to more than 93%. Managerial implications: We demonstrate that root appointment allocation is a multifaceted problem and that ignoring any of those facets can lead to poor performance. Simultaneously accounting for all of these complexities makes manual template design or traditional optimization methods inadequate, highlighting the significance of our integrated approach. Supplemental Material: The online appendix is available at https://doi.org/10.1287/msom.2022.0649 .

OBJECTIVE Many patients recruited in the Treatment of Brain Arteriovenous Malformations Study (TOBAS) are managed conservatively. The aim of this study was to monitor what happened to those patients. METHODS TOBAS comprises two randomized controlled trials and multiple prospective registries. All patients with brain arteriovenous malformations (AVMs) can participate. This report concerns patients selected for conservative management. The primary trial outcome measure is related death or dependency (modified Rankin Scale [mRS] score > 2) at 10 years. Secondary outcomes include intracranial hemorrhages, nonhemorrhagic neurological events, and serious adverse events (SAEs). For this report, outcome results are presented using patient-years, Kaplan-Meier survival curves, and Cox log-rank tests. There was no blinding. RESULTS From June 2014 to May 2021, 1010 patients were recruited, of whom 498 (49%) were proposed the prospective observation registry. After exclusions, 434 (87%) patients remained for analysis. The majority of patients had unruptured AVMs (378/434 [87%]), of which 195 (52%) were low grade (Spetzler-Martin grade I or II). During a mean follow-up period of 3.2 years (total 1368 patient-years), the primary outcome occurred in 23 of 434 (5%) patients, corresponding to an incidence of 1.7 (95% CI 1.1–2.5) per 100 patient-years. For unruptured AVMs the incidence was 1.1 (95% CI 0.7–1.9) per 100 patient-years, and for low-grade unruptured AVMs it was 0.6 (95% CI 0.2–1.7) per 100 patient-years. Poor outcomes were more frequent in patients with a history of rupture (HR 5.6 [95% CI 2.4–13.0], p < 0.001), infratentorial AVMs (HR 2.9 [95% CI 1.1–7.3], p = 0.027), and age ≥ 55 years (HR 3.2 [95% CI 1.4–7.6], p = 0.007). Major intracranial hemorrhage occurred in 35 of 434 (8%) patients (incidence of 2.6 [95% CI 1.9–3.6] per 100 patient-years; 2.0 [95% CI 1.3–2.9] per 100 patient-years for unruptured AVMs and 1.3 [95% CI 0.6–2.6] per 100 patient-years for low-grade unruptured AVMs). Major AVM hemorrhages were more frequent in ruptured (HR 4.4 [95% CI 2.1–8.9], p < 0.001), large (HR 2.6 [95% CI 1.1–6.6], p = 0.039), and high-grade (HR 2.5 [95% CI 1.2–5.3], p = 0.013) AVMs and those with deep venous drainage (HR 2.1 [95% CI 1.1–4.2], p = 0.032). SAEs occurred in 48 of 434 (11%) patients (incidence of 3.6 [95% CI 2.7–4.8] per 100 patient-years). For unruptured AVMs the incidence was 2.8 (95% CI 2.0–4.0) per 100 patient-years, and for low-grade unruptured AVMs it was 1.8 (95% CI 1.0–3.2) per 100 patient-years. CONCLUSIONS Nearly half of TOBAS participants were observed. Rates of untoward neurological events were within expected boundaries.