Background: Modern imaging techniques are supposed to have best detection rates if properly performed and combined. Our study aimed at comparing the results of optimal preoperative imaging to state of the art intraoperative ultrasound with contrast media. Methods: 47 patients received CEUS, 3-phasic MDCT, 3 Tesla MRI with PrimovistÒ and intraop Palpation/IOUS/ CEIOUS. Histology was gold standard. All lesions were recorded and printed on liver schemes to be comparable between modalities. Diagnostic accuracy was defined as the statistical parameter to resemble a surgeons point of view. Uni-and multivariate as well as ROC analysis of lesion size was conducted to find the lesion size threshold at which accuracy decreased. Results: 47 patients with CRLM (M:F 33:14/ Colon:Rectum 29:18) were analyzed. 30% had been submitted to modern preoperative chemotherapy. Histopathology confirmed 264 lesions (245m:19b). Accuracy for detection:CEUS 63% (k 9%), CT/MRI 82% (k 27%) and PALP/IOUS/CEIOUS 99%(k 88). ROC analysis showed severe impairment of accuracy in lesion detection at 5mm size for preop Imaging. Co-Factors being significant on univariate analysis were excluded in multivariate analysis (MVA). MVA confirmed that preop imaging was much better in detection of lesions >5mm e accuracy of intraop imaging was not impaired. Conclusion: At 5mm lesion size all preoperative imaging loose accuracy of detection. Therefore CT scans are appropriate to develop a strategy. The only imaging that keeps accuracy is intraoperative imaging.
Background: Despite strong evidence recommending supportive care as the mainstay of management for most infants with bronchiolitis, prior studies suggest that many of these patients receive low-value interventions. Providing clinicians with their practice reports and peer comparator data or an achievable benchmark of care (audit and feedback) has been shown to be an effective strategy to improve adherence to guidelines. Aim Statement: To decrease low-value care (use of any or all of chest radiographs, viral testing and salbutamol) in infants with bronchiolitis by delivering individual physician reports in addition to Group Facilitated Feedback Sessions (GFFS) to pediatric emergency physicians (PEPs). Measures & Design: Our cohort included 3,883 patients ≤12 months old that presented to two emergency departments with a diagnosis of bronchiolitis from April 1, 2013 to April 30, 2018. Using administrative data we captured baseline characteristics and interventions. Consenting PEPs received two audit and feedback (A&F) reports which included their individual and peer comparator data. Two multi-disciplinary GFFS (including inpatient pediatricians, nurse, learners and respiratory therapists) presented data and identified barriers and enablers of reducing low-value care. The primary outcome was the proportion of patients who received any low-value intervention, and was analyzed using statistical process control charts. Process measures (consent to obtain report, attendance and evaluations from the feedback session) and balancing measures were also captured. Evaluation/Results: 78% of PEPs consented to receive their A&F reports. Patient baseline characteristics were similar in the baseline (n = 3109) and intervention period (n = 774). Following the baseline physician reports and the GFFS, low-value care decreased from 42.6% to 27.1% (absolute difference: -15.5%; 95% confidence interval (CI): -19.8% to -11.2%) and 78.9% to 64.4% (absolute difference: -14.5%; 95% CI: -21.9% to -7.2%) in patients who were not admitted and admitted, respectively. Balancing measures such as ICU admission (absolute difference: -0.6%; 95%CI: -5.7% to 4.4%) and ED revisit within 72 hours (absolute difference: -0.1%; 95% CI: -3.1% to 3.0% non-admitted patients, 1.0%; 95% CI: -1.2% to 3.2% admitted patients) were unchanged. Discussion/Impact: The combination of audit and feedback and a GFFS significantly reduced low-value care for pediatric patients with bronchiolitis by PEP's.
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