Faculty Bibliography

BACKGROUND: The purpose of this study was to describe the clinicopathologic characteristics and oncologic outcomes of patients who underwent nephrectomy for cystic renal masses. PATIENTS AND METHODS: Using an institutional review board-approved database, we retrospectively reviewed the clinical, pathologic, radiologic, and oncologic outcome data of patients who received nephrectomy for a complex cystic renal mass. RESULTS: Sixty-one patients were identified who received nephrectomy for a complex cystic lesion. Average age was 64 years. Thirty-nine (64%) patients were male. At the time of resection, 1 (1.6%), 3 (4.8%), 53 (86.8%), and 4 (6.5%) had a Bosniak category II, IIF, III, and IV cystic lesion, respectively. Nineteen (31.1%) patients were initially managed expectantly but underwent surgery because of progression of complexity on follow-up. Mean pathologic tumor size was 3.3 cm (range, 0.7-12 cm). Forty-eight (78.6%) of the lesions were found to be malignant. Thirty-seven (77.1%), 5 (10.4%), 4 (8.3%), and 2 (4.1%) were stage T1a, T1b, T2a, and T3a, respectively. Clear cell was the most common histologic subtype (44%), followed by papillary (21.3%), and unclassified RCC (4.9%). With a mean and median follow-up of 48.4 and 43.0 months, respectively, no patients developed a local or metastatic recurrence. All patients were alive at last follow-up. CONCLUSION: In our series with moderate follow-up, cystic RCCs do not appear to recur or progress regardless of size, histologic subtype, or grade. These findings suggest the malignant potential of cRCCs is significantly less than solid RCCs. Further investigation is required to determine if cRCCs should be classified and managed independently from solid RCCs.

PURPOSE: To describe the performance of the nation's hospitals in terms of the Hospital Outpatient Quality Reporting Program's imaging efficiency measures. METHODS: Data were obtained from the Hospital Compare website and reflect outpatient Medicare claims of 4,118 hospitals for 5 imaging efficiency metrics: (1) frequency of combination abdominal CT (performed with and without intravenous contrast); (2) combination chest CT (performed with and without intravenous contrast); (3) simultaneous brain/sinus CT; (4) mammography follow-up (diagnostic imaging after screening mammography); and (5) lumbar spine MRI for low back pain without prior conservative therapy. Metrics were summarized and compared with other hospital characteristics. RESULTS: Median frequency was 36.7% for lumbar spine MRI for low back pain and ranged from 1.6% to 7.8% for the remaining measures; however, extreme outliers were observed (maximal frequencies of 79.2%-95.2% for mammography follow-up and combination chest and abdominal CT). Essentially no correlation was found among measures, aside from combination abdominal and chest CT. For some measures, relatively poor performance was more commonly observed among critical access hospitals and physician-owned/proprietary hospitals, and less commonly observed among U.S. News & World Report "best" hospitals and primary residency teaching sites. Frequencies for combination abdominal and chest CT improved from 2013 to 2014 among hospitals with relatively poorer performance. CONCLUSIONS: Although the imaging efficiency measures help identify individual hospitals and hospital categories with relatively inefficient imaging practices, they do not readily identify distinctly positively performing hospitals. Excess utilization was suggested for lumbar spine MRI. Frequency of combination abdominal and chest CT examinations improved over a short time interval.

RATIONALE AND OBJECTIVES: To retrospectively assess the appropriateness of outpatient abdominal and pelvic computed tomography (CT) and magnetic resonance imaging (MRI) examinations using the American College of Radiology Appropriateness Criteria (AC). MATERIALS AND METHODS: A total of 570 adult outpatient abdominopelvic CT (304) and MRI (266) studies performed in a 1-month period with available documentation of the clinical encounter generating the imaging order were included. On the basis of review of the imaging report and patient record, examinations were classified in terms of match to a specific AC variant, appropriateness score, and the presence of a significant result. Data were analyzed using Fisher's exact test. RESULTS: Forty-five percent of examinations matched an AC variant: 52% of CT and 38% of MRI (P < .001). Ninety-two percent of examinations matching the AC were appropriate: 96% of CT and 86% of MRI (P = .009). Appropriate examinations were more likely to provide a significant result than not appropriate studies (48% vs. 24%, P = .041). Although a significant result was related to the primary study indication more frequently in appropriate than not appropriate examinations, this difference was not significant (93% vs. 80%, respectively, P = .204). The most common indications not matching an AC were colon cancer follow-up (n = 14) and melanoma follow-up (n = 14) among CT, and hepatocellular carcinoma screening (n = 31) and elevated prostate-specific antigen (PSA) without prior biopsy (n = 14) among MRI. CONCLUSIONS: Most examinations matching the AC were appropriate, and appropriate examinations were more likely to have a significant result. However, most examinations, including 62% of MRI, had no relevant clinical condition, highlighting a critical area for future AC expansion and modification.

Free text fields are often used to store clinical drug data in electronic health records. The use of free text facilitates rapid data entry by the clinician. Errors in spelling, abbreviations, and jargon, however, limit the utility of these data. We designed and implemented an algorithm, using open source tools and RxNorm, to extract and normalize drug data stored in free text fields of an anesthesia electronic health record. The algorithm was developed using a training set containing drug data from 49,518 cases, and validated using a validation set containing data from 14,655 cases. Overall sensitivity and specificity for the validation set were 92.2% and 95.7% respectively. The mains sources of error were misspellings and unknown but valid drug names. These preliminary results demonstrate that free text clinical drug data can be efficiently extracted and mapped to a controlled drug nomenclature.

STUDY OBJECTIVE: To characterize the evolution of postoperative nausea and vomiting (PONV) prophylactic drug use. DESIGN: Retrospective data extraction and analysis of electronic anesthesia records. SETTING: Anesthesia department of an urban academic medical center. MEASUREMENTS: 144,134 anesthetics given by 57 attending anesthesiologists were studied. Administered doses of droperidol, ondansetron, dexamethasone, and metoclopramide were tabulated for each year for each practitioner. MAIN RESULTS: Ondansetron use in the periods before and after the Food and Drug Administration (FDA) warning concerning droperidol was 8% and 35%, respectively. Use of PONV prophylaxis increased for all included patient and anesthetic factors. Among those who used droperidol before the revised FDA warning, 61% stopped using it altogether. Afterwards, 75% (27-100%) of droperidol use was in combination with another agent. CONCLUSIONS: We found a significant and sustained decrease in droperidol use after the FDA-mandated labeling revision. We also found a significant increase in ondansetron use--an increase that exceeded the amount needed to substitute for the decreased droperidol use. The changes may be related to multiple factors, including the FDA warning, a trend toward more PONV prophylaxis, and the increasing predominance of serotonin antagonists for this indication.