BACKGROUND: The use of abdominal radiography (AXR) apparently continues to be widespread despite its limited indications, the potential radiation and unnecessary costs associated. In addition, the interpretation and its report seem variable and not always performed by a radiologist. Our objective is to analyze the use, adequacy and usefulness of AXR in the emergency of a tertiary referral hospital.
METHODS: We retrospectively reviewed all the AXR performed in January 2020 in the emergency of our centre, as well as the patient\'s demographics and medical records, technical quality of the radiographs, indications according to the SERAM (Spanish Society of Radiology) Appropriateness Guidelines, presence of a formal radiology report, and impact on the clinical management of the patient. Of all non-appropriated AXR we calculated the radiation received by the patients and its extra costs.
RESULTS: In January 2020, 429 AXR (9.1% of all radiographies) were performed in the emergency of our centre. The most frequent indication was abdominal pain (40%, n = 176), followed by low back pain (21.4%, n = 92). 12.4% of AXR requested did not include any clinical information. Most of the AXR (79.6%) had sufficient technical quality. 61.3% (n = 263) of the AXR performed were not indicated, assuming an average unjustified radiation dose per patient of 0.50 ± 0.33 mSv, and a total additional cost of 6575;. Only 6% of the inadequate AXRs led to a change in the clinical management of the patient, compared to 29% of the adequate AXR (p < 0.001). Only 3% of the AXR had a formal radiology report.
CONCLUSIONS: AXR is still common in the emergency setting, although most of them might be inadequate according to the SERAM Appropriateness Guidelines. Its use should be optimized to avoid unnecessary radiation and costs. Radiologists must have a more active participation in the management of AXR.

OBJECTIVE: The study aimed to analyze and clinically correlate 10-year trends in the demographic characteristics of patients receiving electroconvulsive therapy (ECT) to provide an overview of ECT utilization in South Korea.
METHODS: Using health insurance claims data from 2008 to 2018 retrieved from Health Insurance Review and Assessment Service database in South Korea, we identified individuals undergoing ECT based on procedural codes. Descriptive analysis evaluated baseline clinical characteristics, and trend analysis used a linear regression model.
RESULTS: The prevalence of ECT increased by 240.49% (0.405/105 inhabitants in 2008 to 0.974/105 inhabitants in 2018). The increasing trend was more pronounced in younger and older patients. The proportion of women consistently exceeded that of men. A rise in the proportion of patients with affective disorders, and a decrease in the proportion of psychotic disorders was observed. More antidepressants and atypical antipsychotics were prescribed to patients undergoing ECT. The proportion of ECT sessions conducted in large hospital inpatient settings also decreased during the observation period. Despite increasing global trends, ECT prevalence in South Korea remains significantly lower than worldwide rates.
CONCLUSIONS: This study demonstrated an increasing trend of ECT across a wide range of population demographics and in more accessible settings. The comparatively low prevalence of ECT in Korea compared to other countries might be attributed to insufficient mental health literacy and the stigma associated with ECT. Given the elevated suicide rates in Korea, more extensive adoption of ECT appears imperative.

BACKGROUND: The number of urodynamic studies (UDS) has been declining steadily in recent decades, yet the reasons behind this trend remain poorly understood. This study aims to investigate the structural aspects of UDS in urology and explore the factors contributing to this decline.
METHODS: We surveyed all urological departments performing UDS as well as a representative sample of private practices in Germany in 2023. We examined structural situation, waiting times, capacities and limitations of UDS. All invasive urodynamic examinations were defined as UDS.
RESULTS: In 2019, 259/474 (55%) urological departments in Germany performed UDS. 206/259 (80%) urological departments responded to the survey. 163/200 (82%) urological departments stated that their capacities were exhausted, a main reason being lack of medical and nursing staff. 54.8% urological departments performed more than 50% of their UDS for referring physicians. Urological departments with a low number of UDS/year (≤ 100) showed a shorter waiting time (up to 4 weeks: 49% vs. 30%; p = 0.01), reduced UDS capacities (55% vs. 12%; p < 0.001) and these capacities were often not fully utilized (25% vs. 9%; p = 0.007). 122/280 (44%) office urologists responded to the survey. 18/122 (15%) office urologists performed UDS. Main reasons for not offering UDS were lack of personnel and low reimbursement.
CONCLUSIONS: In German urological departments, UDS capacities are consistently fully utilized, primarily due to staffing shortages. This trend towards centralization prompts questions about the role of UDS in urologists\' training.

OBJECTIVE: To characterize differences between urologists and advanced practice providers (APPs) in the utilization of cystoscopy for hematuria.
METHODS: We identified patients initially evaluated for hematuria by a urologist or urology APP between 2015 and 2020 in the MarketScan Research Databases. We determined whether they received a cystoscopy within 6 months of their urology visit and the number of days until cystoscopy. We used multivariable regression to analyze the association between these outcomes and whether the urology clinician was an advanced practice registered nurse (APRN), physician assistant (PA), or urologist.
RESULTS: We identified 34,470 patients with microscopic hematuria and 17,328 patients with gross hematuria. Patients evaluated by urologists more often received a same-day cystoscopy than those evaluated by APPs (13% vs 5.8%). The odds that patients evaluated for microscopic and gross hematuria received a cystoscopy were 46.2% and 26.2% lower, respectively, if they were evaluated by an APRN vs a urologist. Patients seeing an APRN for microscopic and gross hematuria also waited approximately 7 and 14 days longer for their cystoscopy, respectively. No differences were observed for patients evaluated by PAs vs urologists.
CONCLUSIONS: Patients evaluated for hematuria by an APRN were less likely to receive a cystoscopy and had a longer wait until the procedure compared to those evaluated by a urologist; however, no differences were observed between PAs and urologists. Better understanding APP integration into urology clinics is warranted.

UNASSIGNED: Sentinel lymph node biopsy in breast cancer is considered the standard of staging in cases of clinically negative lymph nodes. Its omission in favor of axillary dissection generates significant morbidity.
UNASSIGNED: To determine the total number of sentinel node biopsy procedures in breast cancer in Colombia from 2017 through 2020, model and analyze them as if they were performed only in stage I breast cancer patients, and integrate their results into the concepts of quality of medical care.
UNASSIGNED: Search in a database of the Ministry of Health and Social Protection of Colombia with sentinel lymph node biopsy codes, and filters of breast cancer and year. Their results are contrasted with the number of cases in stage I of breast cancer.
UNASSIGNED: Breast cancer TNM staging was reported in 22154 cases, 3648 stage I. In the same time frame, the number of sentinel lymph node biopsies for breast cancer in Colombia was 1045, 28.64% of the total cases reported in stage I.
UNASSIGNED: Colombia is far from complying with the standard indicator of sentinel lymph node biopsy. It is recommended to concentrate breast cancer cases in hospitals that provide the conditions for its performance.

OBJECTIVE: The objective was to describe the characteristics of the use of clinical ultrasound in two health centers (SC) of Health Area VII of the Region of Murcia (CS Murcia-Sur and CS Floridablanca).
METHODS: Observational, descriptive, longitudinal, prospective and multicenter study. SITE: CS Murcia-Sur and CS Floridablanca (Health Area VII of the Region of Murcia).
METHODS: One hundred and thirty-five patients were included.
METHODS: Performance of clinical ultrasound in the primary care (PC) consultation.
METHODS: Demographic variables (age, sex), as well as clinical variables (reason for consultation, type of ultrasound, results, referrals to the second hospital level, degree of diagnostic agreement) were collected.
RESULTS: One hundred and thirty-five patients were included, more than 50% were female. The main reason for consultation was musculoskeletal and soft tissue symptoms (44.4%), followed by digestive symptoms (21.5%). 44.4% of the ultrasounds were classified as normal, while pathological findings were found in 55.6%. Confirmatory tests were requested in 43.7% and the findings were confirmed in 67% of the patients.
CONCLUSIONS: The use of ultrasound in PC allows to show the high prevalence of pathological findings in the examination of patients. In a technique that helps the clinician in his diagnostic-therapeutic process. The integration of clinical ultrasound in the PC consultation can save complementary studies and referrals to a second level of care. Its implementation in PC requires proper training of professionals.

UNASSIGNED: To examine physical therapist awareness and utilization of imaging referral privileges in the United States (US) and how it relates to direct access frequency.
UNASSIGNED: This study utilized survey data collected in 2020-2021 from US physical therapists. Subjects were asked about imaging referral jurisdictional authority in their state. Responses were analyzed for accuracy and compared to the level of jurisdictional authority and its impact on imaging referral. Analysis of imaging skills performance and imaging referral practices were compared to direct access frequency.
UNASSIGNED: Only 42.0% of physical therapists practicing in states that allow imaging referral were aware of this privilege. Those practicing where imaging referral was allowed via state legislation were significantly more likely (p < 0.01) to be aware of this privilege (71.4%) compared to those granted by the state board (25.2%). Those aware of their imaging referral scope were more likely (p < 0.01) to practice imaging referral (44.5%) compared to those who were unaware (3.2%). Direct access frequency was positively associated with imaging skill performance and imaging referral practice (p < 0.01). Doctors of Physical Therapy, residency/fellowship-trained physical therapists, and board-certified physical therapists all reported practicing greater frequency of direct access (p < 0.01).
UNASSIGNED: There is a striking lack of awareness of imaging privileges among physical therapists as influenced by the level of jurisdictional scope. These results suggest that the lack of awareness may have a dampening effect on diagnostic imaging referrals. The American Physical Therapy Association should consider engaging with state boards to raise imaging privilege awareness.

BACKGROUND: Previous analyses of small-area appendicectomy rates showed significantly higher regional differences in the frequency of operations in women than in men OBJECTIVE: This work proposes valid measures to represent regional variations and analyzes gender-specific changes of appendicectomy rates at the county level in the time series.
METHODS: Appendicectomy frequencies for 2014, 2016 and 2018 by gender and at the county level were taken from the DRG statistics. Regional variations were calculated and assessed using the systematic component of variation (SCV). In comparison to the extreme ratio and coefficient of variation, the SCV is more robust with respect to strongly fluctuating denominator populations. The SCV values greater than 5 indicate high variation and greater than 10 indicate very high variation.
RESULTS: In the male population only minor regional variations in operation rates could be observed, remaining at similar levels over time (SCV2014 = 2.1, SCV2016 = 1.8, and SCV2018 = 2.0). For women the SCV was above 5 in 2014 as well as in 2016 (SCV2014 = 6.1, SCV2016 = 5.3) and dropped to 4.5 in 2018. Plots as a funnel plot account for higher scatter in surgery rates in counties with low populations.
CONCLUSIONS: Regarding women, a decreasing trend in regional variation of appendicectomy could be observed. It remains unclear whether this trend reflects a change in the indications or a modified clinical management when appendicitis is suspected. Using robust variation measures and the graphic preparation as funnel plots it is possible to distinguish systematically caused regional differences in care from random effects.
UNASSIGNED: HINTERGRUND: Frühere Analysen kleinräumiger Appendektomieraten zeigen erheblich höhere regionale Unterschiede der Operationshäufigkeiten bei Frauen als bei Männern. ZIEL: Die Arbeit identifiziert valide Messgrößen zur Darstellung regionaler Unterschiede und analysiert geschlechtsspezifische Veränderungen der Appendektomieraten auf Landkreisebene in der Zeitreihe.
METHODS: Datengrundlage sind die der DRG-Statistik entnommenen Appendektomiehäufigkeiten für 2014, 2016 sowie 2018 nach Geschlecht auf Landkreisebene. Die regionalen Unterschiede werden mittels der „systematic component of variation“ (SCV) berechnet und beurteilt. Die SCV ist im Vergleich zu Extrem-Ratio und Variationskoeffizient robuster gegenüber stark schwankender Nennerpopulationen. SCV-Werte über 5 geben einen Hinweis auf hohe Variationen und größer 10 auf sehr hohe Variationen.
UNASSIGNED: Bei der männlichen Population lassen sich nur geringe regionale Unterschiede der Operationsraten feststellen, die im Zeitverlauf stabil bleiben (SCV2014 = 2,1, SCV2016 = 1,8 und SCV2018 = 2,0). Bei Frauen hingegen liegt die SCV in den Jahren 2014 sowie 2016 (SCV2014 = 6,1, SCV2016 = 5,3) über 5 und sinkt 2018 auf 4,5 ab. Darstellungen als Funnel-Plot berücksichtigen höhere Streuungen der Operationsraten in Landkreisen mit niedrigen Einwohnerzahlen.
CONCLUSIONS: Bei Frauen ist ein rückläufiger Trend in den Appendektomiehäufigkeiten zu erkennen. Unklar ist, ob dieser Trend auf einer Veränderung der Indikationsstellung oder auf einem geänderten allgemeinen Behandlungsmanagement bei einem Appendizitisverdacht beruht. Durch robuste Variationsmaße und der graphischen Aufbereitung als Funnel-Plots ist es möglich, systematisch bedingte regionale Versorgungsunterschiede von Zufallseffekten zu unterscheiden.

UNASSIGNED: Numerous inflammatory markers may serve a role in prognostication of patients hospitalized with COVID-19 infection. Early in the pandemic, our health system created an admission order set which included daily d-dimer, c-reactive protein (CRP), lactate dehydrogenase (LDH), and ferritin. Given more available outcomes data, limiting standing order of labs that do not affect daily management could result in significant cost savings to the health system without adverse patient outcomes. The purpose of this study was to determine ordering and utilization patterns of inflammatory markers by physicians caring for patients hospitalized with COVID-19 infection.
UNASSIGNED: An anonymous 10-question survey was distributed to 125 physicians (Infectious Disease, Hospitalist, Pulmonary and Critical Care faculty). Responses were tallied and values greater than 50% were identified as the majority of the surveyed group.
UNASSIGNED: Of the 125 physicians surveyed, 77 (62%) responded. A total of 57.1% (44/77) of physicians reported ordering daily inflammatory markers for 3 - 10 days from admission. Another 31.2% (24/77) ordered markers until clinical improvement or hospital discharge. D-dimer was used for care decisions by 83.1% (64/77) of respondents; 93.8% (60/64) of those reported utilizing it in determining anticoagulation dose. CRP was used by 61% (47/77) of physicians to help identify a secondary infection or determine steroid dose or duration. LDH and ferritin were not used for management decisions by the majority of physicians. Inflammatory markers were not used routinely after isolation precautions had been discontinued, even when ongoing care required mechanical ventilation.
UNASSIGNED: Of the markers studied, both d-dimer and CRP were considered useful by most respondents. LDH and ferritin were used less frequently and were not considered as useful in guiding medical decision making. Discontinuation of standing daily LDH and ferritin orders is believed to have potential to result in cost savings to the health care system with no adverse patient outcomes.

BACKGROUND: Ureteroscopy is becoming the primary treatment for ureteral stones. As a standard of care, ureteroscopy is performed under the supervision of fluoroscopy. Recent advances in endourological technology make the need for fluoroscopy questionable.
OBJECTIVE: To summarize our experience with a no-fluoroscopy technique for selected cases of ureteral stones.
METHODS: Patients were considered suitable for fluoroless ureteroscopy if they had one or two non-impacted stones, in any location in the ureter, 5-10 mm size, with a normal contralateral renal unit and no urinary tract infection. Procedures were performed using rigid scopes, nitinol baskets/forceps for stone retrieval, and Holmium:YAG laser for lithotripsy. Stents were placed per surgeon\'s decision.
RESULTS: During an 18-month period, 103 patients underwent fluoroless ureteroscopy. In 94 patients stones were removed successfully. In six, the stones were pushed to the kidney and treated successfully on a separate session by shock wave lithotripsy. In three patients no stone was found in the ureter. In five patients, miniature perforations in the ureter were noted and an indwelling double J stent was placed.
CONCLUSIONS: Fluoroless ureteroscopy resulted in a high rate of success. We believe that in selected cases it can be used with minimal adverse events.