Transiliac-Shortening Osteotomy to Treat Ischial Pressure Injury due to Fixed Pelvic Obliquity: A Case Report

CASE

A 17-year-old adolescent boy with Gross Motor Function Classification System 5 cerebral palsy and neuromuscular scoliosis underwent posterior spinal fusion and segmental spinal instrumentation from T3 to the pelvis. He developed a right ischial pressure injury a few months postoperatively, which persisted despite nonoperative measures. He subsequently underwent an ipsilateral transiliac-shortening osteotomy 16 months after spinal surgery to treat his residual pelvic obliquity and the ischial pressure injury, which healed completely. At the 1-year follow-up visit, there were no further signs of pressure injury.

CONCLUSION

This case report describes transiliac-shortening osteotomy as a viable treatment option for non-healing ischial pressure injuries secondary to fixed pelvic obliquity.

Surgeon and SterEOS agreement of spinal sagittal plane parameters in patients with adolescent idiopathic scoliosis

PURPOSE

To compare agreement between surgeons and sterEOS sagittal plane measurements.

METHODS

EOS radiographs of 74 patients with adolescent idiopathic scoliosis were reviewed. The measurements were generated by two surgeons and compared to sterEOS. Intraclass correlations (ICC) were calculated. Agreement was also analyzed for the following subgroups: Cobb angle < 70° vs ≥ 70°, lumbar modifier A vs B/C, and BMI of < 24.5 kg/m² vs ≥ 24.5 kg/m². Agreement was poor if the ICC was < 0.5, moderate if 0.5-0.75, good if 0.75-0.9, and excellent if > 0.9. Paired t tests were performed to compare the surgeon's and sterEOS means.

RESULTS

For the surgeons, agreement was good (0.75-0.89) except for pelvic tilt (PT) and sacral slope (SS), which were excellent (0.91-0.92). Agreement between the surgeons and sterEOS were good (0.78-0.9) except PT and SS, which were excellent (0.91-0.93). Agreement was negatively affected for T4-T12 kyphosis, PI, and SS in the ≥ 70°group, LL when BMI was ≥ 24.5 kg/m², and LL, PI, and SS in the lumbar modifier B/C group. The ICCs overlapped with the 95% confidence intervals (95% CI). Paired t-test showed a significant difference for T4-T12 kyphosis (p < 0.001). This was also true in the < 70° group (p < 0.001), the ≥ 70° group (p = 0.04), and the BMI < 24.5 kg/m² group. PT was significantly different for the ≥ 70° group.

CONCLUSIONS

There was good to excellent agreement between the surgeons and surgeons and sterEOS. Some variables may affect agreement. The surgeons overestimated T4-T12 kyphosis.

Genomic answers for children: Dynamic analyses of >1000 pediatric rare disease genomes

PURPOSE

This study aimed to provide comprehensive diagnostic and candidate analyses in a pediatric rare disease cohort through the Genomic Answers for Kids program.

METHODS

Extensive analyses of 960 families with suspected genetic disorders included short-read exome sequencing and short-read genome sequencing (srGS); PacBio HiFi long-read genome sequencing (HiFi-GS); variant calling for single nucleotide variants (SNV), structural variant (SV), and repeat variants; and machine-learning variant prioritization. Structured phenotypes, prioritized variants, and pedigrees were stored in PhenoTips database, with data sharing through controlled access the database of Genotypes and Phenotypes.

RESULTS

Diagnostic rates ranged from 11% in patients with prior negative genetic testing to 34.5% in naive patients. Incorporating SVs from genome sequencing added up to 13% of new diagnoses in previously unsolved cases. HiFi-GS yielded increased discovery rate with >4-fold more rare coding SVs compared with srGS. Variants and genes of unknown significance remain the most common finding (58% of nondiagnostic cases).

CONCLUSION

Computational prioritization is efficient for diagnostic SNVs. Thorough identification of non-SNVs remains challenging and is partly mitigated using HiFi-GS sequencing. Importantly, community research is supported by sharing real-time data to accelerate gene validation and by providing HiFi variant (SNV/SV) resources from >1000 human alleles to facilitate implementation of new sequencing platforms for rare disease diagnoses.

Colonoscopy competence assessment tools: a systematic review of validity evidence

BACKGROUND

Assessment tools are essential for endoscopy training, being required to support feedback provision, optimize learner capabilities, and document competence. We aimed to evaluate the strength of validity evidence that supports the available colonoscopy direct observation assessment tools using the unified framework of validity.

METHODS

We systematically searched five databases for studies investigating colonoscopy direct observation assessment tools from inception until 8 April 2020. We extracted data outlining validity evidence (content, response process, internal structure, relations to other variables, and consequences) from the five sources and graded the degree of evidence, with a maximum score of 15. We assessed educational utility using an Accreditation Council for Graduate Medical Education framework and methodological quality using the Medical Education Research Quality Instrument (MERSQI).

RESULTS

From 10 841 records, we identified 27 studies representing 13 assessment tools (10 adult, 2 pediatric, 1 both). All tools assessed technical skills, while 10 each assessed cognitive and integrative skills. Validity evidence scores ranged from 1-15. The Assessment of Competency in Endoscopy (ACE) tool, the Direct Observation of Procedural Skills (DOPS) tool, and the Gastrointestinal Endoscopy Competency Assessment Tool (GiECAT) had the strongest validity evidence, with scores of 13, 15, and 14, respectively. Most tools were easy to use and interpret, and required minimal resources. MERSQI scores ranged from 9.5-11.5 (maximum score 14.5).

CONCLUSIONS

The ACE, DOPS, and GiECAT have strong validity evidence compared with other assessments. Future studies should identify barriers to widespread implementation and report on the use of these tools in credentialing examinations.

Establishing key research questions for the implementation of artificial intelligence in colonoscopy: a modified Delphi method

BACKGROUND : Artificial intelligence (AI) research in colonoscopy is progressing rapidly but widespread clinical implementation is not yet a reality. We aimed to identify the top implementation research priorities. METHODS : An established modified Delphi approach for research priority setting was used. Fifteen international experts, including endoscopists and translational computer scientists/engineers, from nine countries participated in an online survey over 9 months. Questions related to AI implementation in colonoscopy were generated as a long-list in the first round, and then scored in two subsequent rounds to identify the top 10 research questions. RESULTS : The top 10 ranked questions were categorized into five themes. Theme 1: clinical trial design/end points (4 questions), related to optimum trial designs for polyp detection and characterization, determining the optimal end points for evaluation of AI, and demonstrating impact on interval cancer rates. Theme 2: technological developments (3 questions), including improving detection of more challenging and advanced lesions, reduction of false-positive rates, and minimizing latency. Theme 3: clinical adoption/integration (1 question), concerning the effective combination of detection and characterization into one workflow. Theme 4: data access/annotation (1 question), concerning more efficient or automated data annotation methods to reduce the burden on human experts. Theme 5: regulatory approval (1 question), related to making regulatory approval processes more efficient. CONCLUSIONS : This is the first reported international research priority setting exercise for AI in colonoscopy. The study findings should be used as a framework to guide future research with key stakeholders to accelerate the clinical implementation of AI in endoscopy.

Development and validation of a patient-reported scale for tolerability of endoscopic procedures using conscious sedation

BACKGROUND AND AIMS

Patient-reported experience measures (PREMs) assessing the tolerability of endoscopic procedures are scarce. In this study, we designed and validated a PREM to assess tolerability of endoscopy using conscious sedation.

METHODS

The patient-reported scale for tolerability of endoscopic procedures (PRO-STEP) consists of questions within 2 domains and is administered to outpatients at discharge from the endoscopy unit. Domain 1 (intraprocedural) consists of 2 questions regarding discomfort/pain and awareness, whereas domain 2 (postprocedural) consists of 4 questions on pain, nausea, distention, and either throat or anal pain. All questions are scored on a Likert scale from 0 to 10. Cronbach's alpha was used to measure internal consistency of the questions. Multivariable logistic regression was performed to assess predictors of higher scores, reported using adjusted odds ratios and confidence intervals.

RESULTS

Two hundred fifty-five patients (91 colonoscopy, 73 gastroscopy, and 91 ERCP) were included. Colonoscopy was the least tolerable procedure by recall, with mean intraprocedural awareness and discomfort scores of 5.1 ± 3.8, and 2.6 ± 2.7, respectively. Consistency between intraprocedural awareness and discomfort/pain yielded an acceptable Cronbach's alpha of .71 (95% confidence interval, .62-.78). Higher use of midazolam during colonoscopy was inversely associated with an intraprocedural awareness score of 7 or higher (per additional mg: adjusted odds ratio, .23; 95% confidence interval, .09-.54).

CONCLUSIONS

PRO-STEP is a simple PREM that can be administered after multiple endoscopic procedures using conscious sedation. Future work should focus on its performance characteristics in adverse event prediction.

Iliac screw instrumentation to the pelvis in children with neuromuscular and syndromic scoliosis. No lateral connectors and respect sagittal balance

STUDY DESIGN

One-center retrospective cohort study.

BACKGROUND

Compared to the traditional iliac screw technique, the modified iliac screw technique has a lower rate of distal implant failure in the treatment of neuromuscular scoliosis patients with pelvic obliquity. However, the reasons for decreased failure with the modified iliac screw technique are controversial.

QUESTIONS/PURPOSES

(1) Is distal implant failure, as evident by implant breakage or disconnection, more likely to occur in patients receiving the traditional iliac screw technique (PSIS) compared to the modified S2AI (MODS2) technique? (2) After controlling for relevant confounding variables, are there other identifiable risk factors for distal implant failure?

METHODS

We identified patients who underwent pelvic screw fixation by three pediatric spine surgeons from January 2007 to July 2017. Based on the starting point of the iliac screws, patients were divided into two groups. Group 1 consisted of PSIS fixation with an offset connector. Group 2 consisted of modified S2AI fixation without an offset connector. Demographic, operative, and radiographic data were obtained.

RESULTS

Cobb angle, lumbar lordosis, and pelvic obliquity were not significantly different between the two groups. Overall distal implant failure was 40/100 (40%) and significant between Group 1 PSIS 29/53 (55%) and Group 2 MODS2 11/47 (23%) (p = 0.002). No other complications were significant. Three risk factors were identified with implant failure: high pelvic incidence (17-fold increase, 95% confidence interval [CI] = 5.5 to 53.1, p < 0.001), high angle rod contour (3.8-fold increase, 95% CI = 1.2 to 11.9, p = 0.023), and use of an offset connector (3.2-fold increase, 95% CI = 1.0 to 10.3, p = 0.049). Failure did not correlate with the use of a cross-link, iliac screw diameter, or screw density. Revision surgery related to distal implant failure did not significantly differ between the two groups.

CONCLUSIONS

Compared to the use of an offset connector with PSIS fixation, MODS2 fixation had a lower rate of implant failure. Sagittal balance parameters, namely pelvic incidence and angle of rod bend, were the major risk factors for implant failure.

LEVEL OF EVIDENCE

III.

Assessment and management of disease burden and quality of life in patients with hereditary angioedema: a consensus report

BACKGROUND

Hereditary angioedema (HAE) is a rare disease characterized by unpredictable, potentially life-threatening attacks, resulting in significant physical and emotional burdens for patients and families. To optimize care for patients with HAE, an individualized management plan should be considered in partnership with the physician, requiring comprehensive assessment of the patient's frequency and severity of attacks, disease burden, and therapeutic control. Although several guidelines and consensus papers have been published concerning the diagnosis and treatment of HAE, there has been limited specific clinical guidance on the assessment of disease burden and quality of life (QoL) in this patient population. Practical guidance is critical in supporting effective long-term clinical management of HAE and improving patient outcomes. The objective of this review is to provide evidence-based guidelines for an individualized assessment of disease burden and QoL in patients with HAE.

METHODS

A consensus meeting was held on February 29, 2020, consisting of 9 HAE experts from the United States and Europe with extensive clinical experience in the treatment of HAE. Consensus statements were developed based on a preliminary literature review and discussions from the consensus meeting.

RESULTS

Final statements reflect the consensus of the expert panel and include the assessment of attack severity, evaluation of disease burden, and long-term clinical management of HAE caused by C1-esterase inhibitor deficiency. Patient-reported outcome measures for assessing HAE attack severity and frequency are available and valuable tools; however, attack frequency and severity are insufficient markers of disease severity unless they are evaluated in the broader context of the effect on an individual patient's QoL. QoL assessments should be individualized for each patient and minimally, they should address the interference of HAE with work, school, social, family, and physical activity, along with access to and burden of HAE treatment. Advances in HAE therapies offer the opportunity for comprehensive, individualized treatment plans, allowing patients to achieve minimal attack burden with reduced disease and treatment burden.

CONCLUSION

This consensus report builds on existing guidelines by expanding the assessment of disease burden and QoL measures for patients with HAE.

Safety and Tolerability of Subcutaneous IgPro20 at High Infusion Parameters in Patients with Primary Immunodeficiency: Findings from the Pump-Assisted Administration Cohorts of the HILO Study

PURPOSE

To evaluate the safety and tolerability of subcutaneous IgPro20 (Hizentra^®, CSL Behring, King of Prussia, PA, USA) administered at high infusion parameters (> 25 mL and > 25 mL/h per injection site) in patients with primary immunodeficiency.

METHODS

The Hizentra^® Label Optimization (HILO) study was an open-label, parallel-arm, non-randomized study (NCT03033745) of IgPro20 using a forced upward titration design for infusion parameters. Patients experienced with pump-assisted IgPro20 infusions received weekly IgPro20 infusions at a stable dose in the Pump-Assisted Volume Cohort (N = 15; 25-50 mL per injection site) and in the Pump-Assisted Flow Rate Cohort (N = 18; 25-100 mL/h per injection site). Responder rates (percentage of patients who successfully completed ≥ 75% of planned infusions), safety outcomes, and serum immunoglobulin G (IgG) trough levels were evaluated.

RESULTS

Responder rates were 86.7% (13/15, 25 mL) and 73.3% (11/15, 40 and 50 mL) in the Volume Cohort, and 77.8% (14/18, 25 and 50 mL/h), 66.7% (12/18, 75 mL/h), and 61.1% (11/18, 100 mL/h) in the Flow Rate Cohort. Infusion compliance was ≥ 90% in all patients in the Volume Cohort and in 83.3% of patients in the Flow Rate Cohort. The number of injection sites (Volume Cohort) and the infusion duration (Flow Rate Cohort) decreased with increasing infusion parameters. The rate of treatment-emergent adverse events per infusion was low (0.138 [Volume Cohort] and 0.216 [Flow Rate Cohort]). Serum IgG levels remained stable during the study.

CONCLUSION

Pump-assisted IgPro20 infusions are feasible at 50 mL and 100 mL/h per injection site in treatment-experienced patients, which may result in fewer injection sites and shorter infusion times.

TRIAL REGISTRATION

NCT03033745 ; registered January 27, 2017.

The amount of surgical correction of the main thoracic curve is the best predictor of postoperative clinical shoulder balance in patients with Adolescent Idiopathic Scoliosis

PURPOSE

This study sought to analyze factors that predict postoperative shoulder balance based on clinical photography.

METHODS

Based on inclusion criteria, 132 AIS patients were selected. Age, sex, and BMI of each patient were recorded. The following parameters were recorded from radiographs: clavicle angle, T1 tilt, the upper instrumented vertebra (UIV), lowest instrumented vertebra (LIV) thoracic kyphosis, lumbar modifier, preoperative and postoperative proximal thoracic Cobb angle, preoperative and postoperative main thoracic Cobb angle, and preoperative and postoperative thoracolumbar Cobb angle, if applicable. Two spine surgeons independently assigned the photographs shoulder balance grades based on the WRVAS (1-2 = Acceptable, 3-5 = Unacceptable). Surgeons were blinded as to whether the photographs were taken preoperatively or postoperatively. The shoulders were also graded as right high, left high, or balanced.

RESULTS

Of all variables analyzed, only main thoracic Cobb angle correction (MTCAC) showed a statistically significant relationship with postoperative shoulder balance (p = 0.01). Odds of having unacceptable shoulder balance increase by 21% for every 5° increase in MTCAC (Adjusted OR = 1.21, 95% CI 1.015-1.452). The odds of unbalanced shoulders are 4.7 times higher for patients whose MTCAC is 40° or more (p = 0.001). Inter-rater reliability was excellent (k =0 .7). Intra rater reliability was perfect for Surgeon 1 (kappa = 1.0) and showed substantial agreement for Surgeon 2 (kappa = 0.8) CONCLUSIONS: Greater correction of main thoracic Cobb angle predicts unacceptable postoperative shoulder balance with 40° of correction signifying a major dichotomy between acceptable and unacceptable.

Hereditary angioedema: Comprehensive management plans and patient support

Hereditary angioedema (HAE) is a rare disease. Regardless, patients with HAE have access to multiple state-of-the-art medications available for on-demand use and prevention that reduce the frequency and burden of HAE attacks. These treatments have greatly reduced the burden of disease and helped patients achieve improved quality of life. However, with greater numbers of therapeutic options, HAE care has become more complex. In this review, we addressed essential elements of an individualized comprehensive management plan for a patient with HAE. We focused on access to an expert physician, ongoing patient education, access to effective treatment options, coordination of care and management of treatment logistics, ongoing monitoring of attacks and treatments, and other resources for patient support. This plan will need to be communicated with the patient and other care providers, especially during emergent conditions, and accommodate the patient's lifestyle with consideration for work, school, travel, etc. Periodically, the physician and the patient will need to review information about attacks, triggers, and treatments to identify areas for improvement and update the plan.

Associations between endoscopist feedback and improvements in colonoscopy quality indicators: a systematic review and meta-analysis

BACKGROUND AND AIMS

Colonoscopy quality indicators such as adenoma detection rate (ADR) are surrogates for the effectiveness of screening-related colonoscopy. It is unclear whether endoscopist feedback on these indicators improves performance. We performed a meta-analysis to determine whether associations exist between endoscopist feedback and colonoscopy performance.

METHODS

We conducted a search through May 2019 for studies reporting on endoscopist feedback and associations with ADR or other colonoscopy quality indicators. Pooled rate ratios (RRs) and weighted mean differences were calculated using DerSimonian and Laird random effects models. Subgroup, sensitivity, and meta-regression analyses were performed to assess for potential methodological or clinical factors associated with outcomes.

RESULTS

From 1326 initial studies, 12 studies were included in the meta-analysis for ADR, representing 33,184 colonoscopies. Endoscopist feedback was associated with an improvement in ADR (RR, 1.21; 95% confidence interval [CI], 1.09-1.34). Low performers derived a greater benefit from feedback (RR, 1.62; 95% CI, 1.18-2.23) compared with moderate performers (RR, 1.19; 95% CI, 1.11-1.29), whereas high performers did not derive a significant benefit (RR, 1.06; 95% CI, 0.99-1.13). Feedback was not associated with increases in withdrawal time (weighted mean difference, +0.43 minutes; 95% CI, -0.50 to +1.36 minutes) or improvements in cecal intubation rate (RR, 1.00; 95% CI, 0.99-1.01).

CONCLUSION

Endoscopist feedback is associated with modest improvements in ADR. The implementation of routine endoscopist audit and feedback should be considered alongside other quality improvement interventions in institutions dedicated to the provision of high-quality screening-related colonoscopy.

Educational interventions are associated with improvements in colonoscopy quality indicators: a systematic review and meta-analysis

Background and study aims  The quality of screening-related colonoscopy depends on several physician- and patient-related factors. Adenoma detection rate (ADR) varies considerably between endoscopists. Educational interventions aim to improve endoscopists' ADRs, but their overall impact is uncertain. We aimed to assess whether there is an association between educational interventions and colonoscopy quality indicators. Methods  A comprehensive search was performed through August 2019 for studies reporting any associations between educational interventions and any colonoscopy quality indicators. Our primary outcome of interest was ADR. Two authors assessed eligibility criteria and extracted data independently. Risk of bias was also assessed for included studies. Pooled rate ratios (RR) with 95 % confidence intervals (CI) were reported using DerSimonian and Laird random effects models. Results  From 2,253 initial studies, eight were included in the meta-analysis for ADR, representing 86,008 colonoscopies. Educational interventions were associated with improvements in overall ADR (RR 1.29, 95 % CI 1.25 to 1.42, 95 % prediction interval 1.09 to 1.53) and proximal ADR (RR 1.39, 95 % CI 1.29 to 1.48), with borderline increases in withdrawal time, ([WT], mean difference 0.29 minutes, 95 % CI - 0.12 to 0.70 minutes). Educational interventions did not affect cecal intubation rate ([CIR], RR 1.01, 95 % CI 1.00 to 1.01). Heterogeneity was considerable across many of the analyses. Conclusions  Educational interventions are associated with significant improvements in ADR, in particular, proximal ADR, and are not associated with improvements in WT or CIR. Educational interventions should be considered an important option in quality improvement programs aiming to optimize the performance of screening-related colonoscopy.

Treatment of femoral fractures in children aged two to six

Aims

Current American Academy of Orthopaedic Surgeons (AAOS) guidelines for treating femoral fractures in children aged two to six years recommend early spica casting although some individuals have recommended intramedullary stabilization in this age group. The purpose of this study was to compare the treatment and family burden of care of spica casting and flexible intramedullary nailing in this age group.

Methods

Patients aged two to six years old with acute, non-pathological femur fractures were prospectively enrolled at one of three tertiary children’s hospitals. Either early closed reduction with spica cast application or flexible intramedullary nailing was accomplished under general anaesthesia. The treatment method was selected after discussion of the options by the surgeon with the family. Data were prospectively collected on patient demographics, fracture characteristics, complications, pain medication, and union. The Impact on Family Scale was obtained at the six-week follow-up visit. In all, 75 patients were included in the study: 39 in the spica group and 36 in the nailing group. The mean age of the spica group was 2.71 (2.0 to 6.9) years and the mean age of the nailing group was 3.16 (2.0 to 6.9) years.

Results

All fractures healed without evidence of malunion or more than 2.0 cm of shortening. The mean Impact on Family score was 70.2 for the spica group and 63.2 (55 to 99) for the nailing group, a statistically significant difference (p = 0.024) in a univariate analysis suggesting less impairment of the family in the intramedullary nailing group. There was no significant difference between pain medication requirements in the first 24 hours postoperatively. Two patients in the spica group and one patient in the intramedullary nailing group required additional treatment under anaesthesia.

Conclusion

Both early spica casting and intramedullary nailing were effective methods for treating femoral fractures in children two to six years of age. Intramedullary stabilization provides an option in this age group that may be advantageous in some social situations that depend on the child’s mobility. Fracture treatment should be individualized based on factors that extend beyond anatomical and biological factors. Cite this article: Bone Joint J 2020;102-B(8):1056–1061.

Impact of a national basic skills in colonoscopy course on trainee performance: An interrupted time series analysis

BACKGROUND

The Joint Advisory Group on Gastrointestinal Endoscopy basic skills in colonoscopy (BSC) course was introduced in 2009 to improve colonoscopy training within the United Kingdom, but its impact on trainee performance is unknown.

AIM

To assess whether attendance of the BSC could improve colonoscopy performance.

METHODS

Trainees awarded colonoscopy certification between 2011-2016 were stratified into 3 groups according to pre-course procedure count (< 70, 70-140 and > 140). Study outcomes, comprising the unassisted caecal intubation rate (CIR) and the performance indicator of colonic intubation (PICI), were studied over the 50 procedures pre and post- course. Interrupted time series analyses were performed to detect step-change changes attributable to the course.

RESULTS

A total of 369 trainees with pre-course procedure counts of < 70 (n = 118), 70-140 (n = 121) and > 140 (n = 130) were included. Over the 50 pre-course procedures, significant linear improvements in CIR were found, with average increases of 4.2, 3.6 and 1.7 percentage points (pp) per 10 procedures performed in the < 70, 70-140 and > 140 groups respectively (all P < 0.001). The < 70 procedures group saw a significant step-change improvement in CIR, increasing from 46% in the last pre-course procedure, to 51% in the first procedure post-course (P = 0.005). The CIR step-change was not significant in the 70-140 (68% to 71%; P = 0.239) or > 140 (86% to 87%; P = 0.354) groups. For PICI, significant step-change improvements were seen in all three groups, with average increases of 5.6 pp (P < 0.001), 5.4 pp (P = 0.003) and 3.9 pp (P = 0.014) respectively.

CONCLUSION

Attendance of the BSC was associated with a significant step-change improvement in PICI, regardless of prior procedural experience. However, CIR data suggest that the optimal timing of course attendance appears to be at earlier stages of training (< 70 procedures).

Langerhans Cell Histiocytosis of the Pediatric Thoracic Spine with Development of Neurological Compromise: A Case Report

CASE

This report describes a 7-year-old girl with Langerhans cell histiocytosis (LCH) of the thoracic spine who developed neurological deterioration during nonsurgical management. She was treated with decompression and instrumented fusion followed by chemotherapy, recovered completely after surgery, and was doing well at 6-year follow-up.

CONCLUSIONS

The best treatment of LCH of the spine is not clear, but in the setting of neurologic compromise after failing conservative management, surgical decompression with adjuvant chemotherapy should be considered.

Os Odontoideum in Children: Treatment Outcomes and Neurological Risk Factors

BACKGROUND

Treatment outcomes and risk factors for neurological deficits in pediatric patients with an os odontoideum are unclear.

METHODS

We reviewed the data for 102 children with os odontoideum who were managed at 11 centers between 2000 and 2016 and had a minimum duration of follow-up of 2 years. Thirty-one children had nonoperative treatment, and 71 underwent instrumented posterior cervical spinal arthrodesis for the treatment of C1-C2 instability. Nonoperative treatment consisted of observation (n = 29) or immobilization with a cervical collar (n = 1) or halo body jacket (n = 1). Surgical treatment consisted of atlantoaxial (n = 50) or occipitocervical (n = 21) arthrodesis. One patient also underwent transoral odontoidectomy.

RESULTS

Thirty children (29%) presented with neurological deficits, 28 of whom had radiographic atlantoaxial instability (atlantoaxial distance >5 mm) or limited space (≤13 mm) available for the spinal cord (risk ratio, 7.8 [95% confidence interval, 2.0 to 31] compared with children with no radiographic risk factors). The 27 children without neurological deficits or atlantoaxial instability at presentation underwent nonoperative treatment and remained asymptomatic. Of the initial nonoperative cohort, one child developed atlantoaxial instability, and another had a persistent neurological deficit; both children underwent spinal arthrodesis during the study period. One child with cervical instability declined surgery and remained asymptomatic. Spinal fusion occurred in 68 patients in the surgical group by the end of the study period (mean, 3.7 years; range, 2.0 to 11.8 years). Surgical complications occurred in 21 children, including nonunion in 12, new neurological deficits in 4, cerebrospinal fluid leak in 2, symptomatic instrumentation requiring removal 2, and vertebral artery injury in 1. Nine children underwent revision surgery. In the surgical group, Japanese Orthopaedic Association neurological function scores improved significantly from preoperatively to the latest follow-up for the upper extremities (p = 0.026) and lower extremities (p = 0.007).

CONCLUSIONS

The risk of developing a neurological deficit was strongly associated with atlantoaxial instability and limited space available for the spinal cord in children with os odontoideum. Nonoperative treatment was safe for asymptomatic patients without atlantoaxial instability. Spinal arthrodesis resolved the neurological deficits of children with symptomatic os odontoideum.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The isolated caecal patch lesion: a clinical, endoscopic and histopathological study

Objective

To describe and investigate the potential causes of the isolated caecal patch lesion, a previously undescribed endoscopic phenomenon of a lesion fulfilling endoscopic and histopathological criteria for chronic inflammatory bowel disease but without evidence of similar inflammatory pathology elsewhere at colonoscopy.

Methods

Cases were collected prospectively by one specialist gastrointestinal pathologist over a 10-year period. Full endoscopic and histopathological analysis was undertaken and follow-up sought to understand the likely cause(s) of the lesions.

Results

Six cases are described. Two had very close links with ulcerative colitis, one predating the onset of classical distal disease and the other occurring after previous demonstration of classical distal ulcerative colitis. Two occurred in younger patients and we postulate that these lesions may predict the subsequent onset of chronic inflammatory bowel disease. Finally two can be reasonably attributed to the effects of non-steroidal inflammatory agent therapy.

Conclusions

Caecal patch lesions can be demonstrated in isolation. Despite the strong association of caecal patch lesions with ulcerative colitis, solitary lesions may well have disparate causes but nevertheless possess a close relationship with chronic inflammatory bowel disease.

Certification of UK gastrointestinal endoscopists and variations between trainee specialties: results from the JETS e-portfolio

Introduction  In the UK, endoscopy certification is administered by the Joint Advisory Group on Gastrointestinal Endoscopy (JAG). Since 2011, certification for upper and lower gastrointestinal endoscopy has been awarded via a national (JETS) e-portfolio to the main training specialties of: gastroenterology, gastrointestinal surgeons (GS) and non-medical endoscopists (NME). Trends in endoscopy certification and differences between trainee specialties were analyzed. Methods  This prospective UK-wide observational study identified trainees awarded gastroscopy, sigmoidoscopy, colonoscopy (provisional and full) certification between June 2011 - 2017. Trends in certification, procedures and time-to-certification, and key performance indicators (KPIs) in the 3-month pre- and post-certification period were compared between the three main training specialties. Results  Three thousand one hundred fifty-seven endoscopy-related certifications were awarded to 1928 trainees from gastroenterology (52.3 %), GS (28.4 %) and NME (16.5  %) specialties. During the study period, certification numbers increased for all modalities and specialties, particularly NME trainees. For gastroscopy and colonoscopy, procedures-to-certification were lowest for GS ( P  < 0.001), whereas time-to-certification was consistently shortest in NMEs ( P  < 0.001). A post-certification reduction in mean cecal intubation rate (95.2 % to 93.8 %, P  < 0.001) was observed in colonoscopy, and D2 intubation (97.6 % to 96.2 %, P  < 0.001) and J-maneuver (97.3 % to 95.8 %, P  < 0.001) in gastroscopy. Overall, average pre- and post-certification KPIs still exceeded national minimum standards. There was an increase in PDR for NMEs after provisional colonoscopy certification but a decrease in PDR for GS trainees after sigmoidoscopy and full colonoscopy certification. Conclusion  Despite variations among trainee specialties, average pre- and post-certification KPIs for certified trainees met national standards, suggesting that JAG certification is a transparent benchmark which adequately safeguards competency in endoscopy training.

Training and assessment in flexible sigmoidoscopy: using a novel direct observation of procedural skills (DOPS) assessment tool

BACKGROUND AND AIMS

Data supporting milestone development during flexible sigmoidoscopy (FS) training are lacking. We aimed to present validity evidence for our formative direct observation of procedural skills (DOPS) assessment in FS, and use DOPS to establish competency benchmarks and define learning curves for a national training cohort.

METHODS

This prospective UK-wide (211 centres) study included all FS formative DOPS assessments submitted to the national e-portfolio. Reliability was estimated from generalisability theory analysis. Item and global DOPS scores were correlated with lifetime procedure count to study learning curves, with competency benchmarks defined using contrasting groups analysis. Multivariable binary logistic regression was performed to identify independent predictors of DOPS competence.

RESULTS

This analysis included 3,616 DOPS submitted for 468 trainees. From generalisability analysis, sources of overall competency score variance included: trainee ability (27%), assessor stringency (15%), assessor subjectivity attributable to the trainee (18%) and case-to-case variation (40%), which enabled the modelling of reliability estimates. The competency benchmark (mean DOPS score: 3.84) was achieved after 150-174 procedures. Across the cohort, competency development occurred in the order of: pre-procedural (50-74), non-technical (75-149), technical (125-174) and post-procedural (175-199) skills. Lifetime procedural count (p<0.001), case difficulty (p<0.001), and lifetime formative DOPS count (p=0.001) were independently associated with DOPS competence, but not trainee or assessor specialty.

CONCLUSION

Sigmoidoscopy DOPS can provide valid and reliable assessments of competency during training and can be used to chart competency development. Contrary to earlier studies, based on destination-orientated endpoints, overall competency in sigmoidoscopy was attained after 150 lifetime procedures.

Do Heavier Patients With Adolescent Idiopathic Scoliosis Have More Preserved Thoracic Kyphosis and Pulmonary Function?

STUDY DESIGN

Retrospective.

OBJECTIVES

We aimed to determine if heavier patients with adolescent idiopathic scoliosis (AIS) had more preserved thoracic kyphosis (TK), and as a result, more preserved pulmonary function.

SUMMARY OF BACKGROUND DATA

Some believe that childhood weight is predictive of adult sagittal plane parameters, with heavier children having greater TK as adults. Generally, thoracic scoliosis is coupled with loss of TK, which is associated with worsening pulmonary function.

METHODS

A total of 142 patients with AIS and a structural main thoracic curve were analyzed. We excluded patients with structural proximal thoracic curves (Lenke 2 and 4). Standing preoperative radiographs, pulmonary function tests, and preoperative body mass indices (BMIs) were reviewed. The main thoracic Cobb angle, T2-T12 TK, percentage predicted forced vital capacity (FVC) and BMI were recorded. Spearman correlation was determined. Linear regression analysis used FVC as the primary outcome and BMI, TK, and Cobb angle as the independent variables. BMI categories were overweight/obese (BMI ≥25) and normal (BMI <25). Wilcoxon rank-sum tests were performed to detect a difference in TK and BMI between the 2 groups. The Cobb angles between the two groups were analyzed by t tests.

RESULTS

Demonstrated correlations included BMI and FVC (0.37, p ≤.01), FVC and TK (0.26, p <.01), BMI and TK (0.23, p = .01), and FVC and Cobb angle (-0.23, p = .01). Linear regression revealed that Cobb angle (p ≤.01), TK (p <.01), and BMI (p <.01) remained statistically significant predictors of FVC. Wilcoxon rank-sum tests revealed a statistically significant difference between TK (p = .03) and FVC (p <.01) in the overweight/obese group and the normal group, with the overweight/obese group having greater values for both TK and FVC. The Cobb angles between the overweight/obese and normal group were not significantly different (p = .72).

CONCLUSIONS

Heavier AIS patients have greater values of TK and percentage predicted FVC.

LEVEL OF EVIDENCE

Level III.

Key ^{19}Ne States Identified Affecting γ-Ray Emission from ^{18}F in Novae

Detection of nuclear-decay γ rays provides a sensitive thermometer of nova nucleosynthesis. The most intense γ-ray flux is thought to be annihilation radiation from the β^{+} decay of ^{18}F, which is destroyed prior to decay by the ^{18}F(p,α)^{15}O reaction. Estimates of ^{18}F production had been uncertain, however, because key near-threshold levels in the compound nucleus, ^{19}Ne, had yet to be identified. We report the first measurement of the ^{19}F(^{3}He,tγ)^{19}Ne reaction, in which the placement of two long-sought 3/2^{+} levels is suggested via triton-γ-γ coincidences. The precise determination of their resonance energies reduces the upper limit of the rate by a factor of 1.5-17 at nova temperatures and reduces the average uncertainty on the nova detection probability by a factor of 2.1.

Changes in scoring of Direct Observation of Procedural Skills (DOPS) forms and the impact on competence assessment

BACKGROUND

Direct Observation of Procedural Skills (DOPS) is an established competence assessment tool in endoscopy. In July 2016, the DOPS scoring format changed from a performance-based scale to a supervision-based scale. We aimed to evaluate the impact of changes to the DOPS scale format on the distribution of scores in novice trainees and on competence assessment.

METHODS

We performed a prospective, multicenter (n = 276), observational study of formative DOPS assessments in endoscopy trainees with ≤ 100 lifetime procedures. DOPS were submitted in the 6-months before July 2016 (old scale) and after (new scale) for gastroscopy (n = 2998), sigmoidoscopy (n = 1310), colonoscopy (n = 3280), and polypectomy (n = 631). Scores for old and new DOPS were aligned to a 4-point scale and compared.

RESULTS

8219 DOPS (43 % new and 57 % old) submitted for 1300 trainees were analyzed. Compared with old DOPS, the use of the new DOPS was associated with greater utilization of the lowest score (2.4 % vs. 0.9 %; P < 0.001), broader range of scores, and a reduction in competent scores (60.8 % vs. 86.9 %; P < 0.001). The reduction in competent scores was evident on subgroup analysis across all procedure types (P < 0.001) and for each quartile of endoscopy experience. The new DOPS was superior in characterizing the endoscopy learning curve by demonstrating progression of competent scores across quartiles of procedural experience.

CONCLUSIONS

Endoscopy assessors applied a greater range of scores using the new DOPS scale based on degree of supervision in two cohorts of trainees matched for experience. Our study provides construct validity evidence in support of the new scale format.

New fragmenting bullet leads to unexpected injury pattern: A case report involving the Radically Invasive Projectile

New developments in bullet technology are challenging what is commonly known about penetrating injuries from gunshot wounds. The so-called ‘bullet-rule’ posits the number of wounds and projectiles associated with a patient should add to an even number. This trauma paradigm is being shattered by the advent of new fragmenting projectiles. These frangible rounds break into several pieces after soft tissue penetration changing the expected trajectory, injury location, and extent of tissue damage. In this case report, the authors describe the case of a 15-year-old boy injured by a G2 Radically Invasive Projectile (RIP). The patient’s resultant pattern of injuries and the diagnostic utility of imaging were imperative for guiding his clinical management. The case serves as a useful example of the challenges and recommended strategies in managing a patient injured by a new fragmenting bullet.

High complete resection rate for pre-lift and cold biopsy of diminutive colorectal polyps

BACKGROUND AND STUDY AIMS

 The majority of polyps removed at colonoscopy are diminutive (≤ 5 mm) to small (< 10 mm) and there are few guidelines for the best way for these polyps to be removed. We aimed to assess the feasibility and effectiveness of cold biopsy forceps polypectomy with pre-lift (CBPP) for polyps ≤ 7 mm. Our aims were to assess completeness of histological resection of this technique, to identify factors contributing to this and assess secondary considerations such as timing, retrieval and complication rates.

PATIENTS AND METHODS

We conducted a prospective cohort study on consecutive patients receiving a colonoscopy at Cheltenham General Hospital, as part of the National Bowel Cancer Screening Program (BCSP) in England. The study included only polyps that were judged as ≤ 7 mm by the colonoscopist. A small sub-mucosal pre-lift injection was administered prior to removal of the polyp using cold biopsy forceps. One or more biopsies were taken until the polyp was confidently assessed visually as being completely removed by the colonoscopist. The entire polypectomy site was then removed en bloc by endomucosal resection (EMR) with a margin of at least 1 to 2 mm around defect. This was sent for histopathological analysis to assess completeness of resection. Polypectomy timing, tissue retrieval, number of bites required for visual resection and complications were recorded at the time of the procedure.

RESULTS

Sixty-four patients were recruited and consented. Of them, 42 patients had a total of 60 polyps resected. Three patients had inflammatory polyps and were excluded from the study, leaving 57/60 polyps for final analysis. Seventeen were hyperplastic and 40 adenomatous polyps. Retrieval was complete for all 57 polyps and there were no complications both during or post- polypectomy. The complete resection rate (CRR) was 86 %. The technique was more effective in smaller polyps with 91.7 % of diminutive polyps (≤ 5 mm) completely excised.

CONCLUSIONS

CBPP is a safe and highly effective technique for polyps < 5 mm with a high complete resection and retrieval rate. The time taken for the procedure is significantly greater than cold forceps alone, or cold snare as seen in other studies.

A new composite measure of colonoscopy: the Performance Indicator of Colonic Intubation (PICI)

Cecal intubation rate (CIR) is an established performance indicator of colonoscopy. In some patients, cecal intubation with acceptable tolerance is only achieved with additional sedation. This study proposes a composite Performance Indicator of Colonic Intubation (PICI), which combines CIR, comfort, and sedation. METHODS : Data from 20 085 colonoscopies reported in the 2011 UK national audit were analyzed. PICI was defined as the percentage of procedures achieving cecal intubation with median dose (2 mg) of midazolam or less, and nurse-assessed comfort score of 1 - 3/5. Multivariate logistic regression analysis evaluated possible associations between PICI and patient, unit, colonoscopist, and diagnostic factors. RESULTS : PICI was achieved in 54.1 % of procedures. PICI identified factors affecting performance more frequently than single measures such as CIR and polyp detection, or CIR + comfort alone. Older age, male sex, adequate bowel preparation, and a positive fecal occult blood test as indication were associated with a higher PICI. Unit accreditation, the presence of magnetic imagers in the unit, greater annual volume, fewer years' experience, and higher training/trainer status were associated with higher PICI rates. Procedures in which PICI was achieved were associated with significantly higher polyp detection rates than when PICI was not achieved. CONCLUSIONS : PICI provides a simpler picture of performance of colonoscopic intubation than separate measures of CIR, comfort, and sedation. It is associated with more factors that are amenable to change that might improve performance and with higher likelihood of polyp detection. It is proposed that PICI becomes the key performance indicator for intubation of the colon in colonoscopy quality improvement initiatives.

Curve flexibility in cerebral palsy-related neuromuscular scoliosis: does the intraoperative prone radiograph reveal more flexibility than preoperative radiographs?

BACKGROUND

Spinal flexibility is determined preoperatively by manipulating the spine and assessing, radiographically, to what extent the amount of deformity reduces. Quantifying spinal flexibility is important when determining the approach to the planned operation in order to achieve the most optimal spinal correction and balance. Currently, supine traction radiography is a popular method used in patients with severe, cerebral palsy-related neuromuscular scoliosis. The different methods for determining spinal flexibility have been studied extensively in the adolescent idiopathic scoliosis population. No such studies exist in the cerebral palsy population. The purpose of this study was to determine how predictive the intraoperative prone radiograph is in determining spinal flexibility in patients with severe, cerebral palsy related neuromuscular scoliosis.  Furthermore, the intraoperative prone radiograph was compared to the preoperatively acquired supine and supine traction radiographs.

METHODS

Twenty-five consecutive patients with severe, cerebral palsy-related neuromuscular scoliosis were studied. The Cobb angles of the preoperative supine, preoperative supine traction, and intraoperative prone radiograph were measured and compared. The flexibility indices of these radiographs were calculated and compared. Traction was not applied during acquisition of the intraoperative prone radiograph. The radiograph was taken during the exposure to localize surgical levels, prior to instrumentation.

RESULTS

The supine traction radiograph and the intraoperative prone radiograph had higher flexibility indices than the preoperative supine radiograph. These comparisons were statistically significant. The comparison between the flexibility indices of the supine traction radiograph and intraoperative prone radiograph was not statistically significant. When looking at the preoperative supine traction radiograph separately, it was noted that the process of instrumentation led to 30% more correction of the Cobb angle.

CONCLUSIONS

The intraoperative prone radiograph is more predictive of spinal flexibility in patients with severe scoliosis related to cerebral palsy when compared to the preoperative supine radiograph but not the preoperative supine traction radiograph. The preoperative supine traction radiograph serves as the optimal method for determining spinal flexibility in patients with severe, cerebral palsy-related neuromuscular scoliosis.

Assessments and skills improvement for endoscopists

Different countries employ a range of assessment methods to monitor trainees from novice to independent practice. The optimal method to monitor and assess individuals' training in endoscopy has not been formally determined. The UK has developed a competency based assessment training and certification (credentialing) programme. The tools developed to provide endoscopy work based assessments (DOPS) have been validated and are used for trainees and independent endoscopists, providing formative feedback for targeted training. Summative assessments are used for trainee certification and independent colonoscopists wishing to provide part of the National Bowel Cancer Screening Programme. The UK was able to develop both clinical standards and an endoscopy training and certification process applied to all individuals and monitored by a single professional body. The supporting IT system enabled a structured and robust quality assurance process to be applied to all individuals and endoscopy units. Assessment of practising endoscopists relies on the development and measurement of surrogate measures, which represent key performance indicators for those individuals. These surrogates for performance are still evolving although they are now well established for colonoscopy practice. Monitoring of independent practice is dependent on clinical audit of these key performance indicators. Feedback of data to individuals helps benchmarking and identification of those with sub-optimal performance. Independent endoscopists now recognize the benefit of on-going training to help both skills development and to address sub-optimal performance. This chapter describes how the UK developed a web-based integrated training and certification system.

A non-destructive sampling protocol for field studies of seed dispersal by fishes

This paper presents a standardized protocol for the non-lethal capture of fishes, sampling of stomach contents and quantification of seed dispersal efficiency by frugivorous fishes. Neotropical pacu Piaractus mesopotamicus individuals were collected with fruit-baited hooks. The diets of 110 fish were sampled using a lavage method, which retrieved >90% of stomach contents of both juveniles and adults and allowed individuals to recover within 5 min of treatment. The proportional volume of six food categories was similar for stomachs and whole digestive tracts retrieved by dissection. Fruit pulp was proportionally lower in the stomach. The abundance and species richness of intact seeds increased with fish size independent of whether only stomachs or whole digestive tracts were analysed. The analysis of stomach contents accounted for 62·5% of the total species richness of seeds dispersed by P. mesopotamicus and 96% of common seeds (seed species retrieved from more than one fish). Germination trials revealed that seed viability was similar for seeds collected from the stomach via lavage and seeds that passed through the entire digestive tract. Therefore, stomach contents provide an unbiased representation of the dietary patterns and seed dispersal of frugivorous fishes.

Subsets of airway myeloid-derived regulatory cells distinguish mild asthma from chronic obstructive pulmonary disease

BACKGROUND

Subsets of myeloid-derived regulatory cells (MDRCs), which are phenotypically similar to the myeloid-derived suppressor cells found in patients with cancer, have recently been appreciated as critical regulators of airway inflammation in mouse models of asthma.

OBJECTIVE

We test the hypothesis that subsets of airway MDRCs contribute differentially to the inflammatory milieu in human asthma and chronic obstructive pulmonary disease (COPD).

METHODS

We used bronchoalveolar lavage to identify and characterize human airway MDRCs from 10 healthy subjects, 9 patients with mild asthma, and 8 patients with COPD, none of whom were treated with inhaled or systemic corticosteroids. We defined subsets of airway MDRCs using flow cytometry, the molecular mediators they produce, and their abilities to regulate proliferation of polyclonally activated autologous T lymphocytes.

RESULTS

We found substantial differences in the functional potential of MDRC subsets in healthy subjects, patients with asthma, and patients with COPD, with these differences regulated by the nitrosative and oxidative free radicals and cytokines they produced. Nitric oxide-producing MDRCs suppressed and superoxide-producing MDRCs enhanced proliferation of polyclonally activated autologous CD4 T cells. HLA-DR(+)CD11b(+)CD11c(+)CD163(-) superoxide-producing MDRCs, which stimulated proliferation of autologous T cells, comprised a high fraction of MDRCs in the airways of patients with mild asthma or COPD but not those of healthy control subjects. CD11b(+)CD14(+)CD16(-)HLA-DR(-) nitric oxide-producing MDRCs, which suppressed T-cell proliferation, were present in high numbers in airways of patients with mild asthma but not patients with COPD or healthy control subjects.

CONCLUSION

Subsets of airway MDRCs conclusively discriminate patients with mild asthma, patients with COPD, and healthy subjects from each other. The distinctive activities of these MDRCs in patients with asthma or COPD might provide novel targets for new therapeutics for these common disorders. [Corrected]

The Superior Articular Process as an External Landmark for Determining the Transverse Plane Angulation of Thoracic Pedicles

STUDY DESIGN

Computed tomographic (CT) study of thoracic spine pedicles.

OBJECTIVE

To analyze the usefulness of the superior articular process (SAP) as an external landmark for determining the transverse plane angulation of thoracic pedicles.

SUMMARY OF BACKGROUND DATA

The use of thoracic pedicle screws has become commonplace. Although most authors report them to be safe, their use poses a risk to neurovascular structures. Previous studies have provided useful information regarding thoracic pedicle anatomy, but this information is difficult to apply intra-operatively. To avoid neurovascular injury, it is important to determine the correct transverse plane angulation of screw insertion.

METHODS

Two separate investigators reviewed thoracic spine CT scans of 53 patients, 26 years of age or younger. Measurements were taken of the angular relationship of the pedicle and the SAP of T4-T11. A 90° angle was subtended from a line parallel to the SAP with a starting point at the midpoint of the lateral half of the SAP. Measurements were then adjusted laterally for medial breeches and medially for lateral breeches, to align the trajectory down the middle of the pedicle. The degree of correction was recorded. Each investigator made 3 sets of measurements. We calculated kappa values to assess intra-observer/interobserver agreement.

RESULTS

Of the 4,008 measurements, 95.2% were contained within bone, leaving 4.8% pedicle violations. The average correction made for medial and lateral breeches was 6.3% and 6.7%, respectively. The first rater had 92.6% agreement, and an intra-observer kappa value of 0.57. The second rater had a 95.3% agreement and an intra-observer kappa value of 0.40.

CONCLUSIONS

The results support the hypothesis that the SAP can be a useful external landmark for determining the transverse plane angulation of thoracic pedicle screw insertion.

The national colonoscopy audit: a nationwide assessment of the quality and safety of colonoscopy in the UK

OBJECTIVE

To perform a comprehensive audit of all colonoscopy undertaken in the UK over a 2-week period.

DESIGN

Multi-centre survey. All adult (≥16 years of age) colonoscopies that took place in participating National Health Service hospitals between 28 February 2011 and 11 March 2011 were included.

RESULTS

Data on 20,085 colonoscopies and 2681 colonoscopists were collected from 302 units. A validation exercise indicated that data were collected on over 94% of all procedures performed nationally. The unadjusted caecal intubation rate (CIR) was 92.3%. When adjusted for impassable strictures and poor bowel preparation the CIR was 95.8%. The polyp detection rate was 32.1%. The polyp detection rate for larger polyps (≥10 mm diameter) was 11.7%. 92.3% of resected polyps were retrieved. 90.2% of procedures achieved acceptable levels of patient comfort. A total of eight perforations and 52 significant haemorrhages were reported. Eight patients underwent surgery as a consequence of a complication.

CONCLUSIONS

This is the first national audit of colonoscopy that has successfully captured the majority of adult colonoscopies performed across an entire nation during a defined time period. The data confirm that there has been a significant improvement in the performance of colonoscopy in the UK since the last study reported seven years ago (CIR 76.9%) and that performance is above the required national standards.

Elevated levels of NO are localized to distal airways in asthma

The contribution of nitric oxide (NO) to the pathophysiology of asthma remains incompletely defined despite its established pro- and anti-inflammatory effects. Induction of the inducible nitric oxide synthase (iNOS), arginase, and superoxide pathways is correlated with increased airway hyperresponsiveness in asthmatic subjects. To determine the contributions of these pathways in proximal and distal airways, we compared bronchial wash (BW) to traditional bronchoalveolar lavage (BAL) for measurements of reactive nitrogen/oxygen species, arginase activation, and cytokine/chemokine levels in asthmatic and normal subjects. Levels of NO were preferentially elevated in the BAL, demonstrating higher level NOS activation in the distal airway compartment of asthmatic subjects. In contrast, DHE(+) cells, which have the potential to generate reactive oxygen species, were increased in both proximal and distal airway compartments of asthmatics compared to controls. Different patterns of cytokines and chemokines were observed, with a predominance of epithelial cell-associated mediators in the BW compared to macrophage/monocyte-derived mediators in the BAL of asthmatic subjects. Our study demonstrates differential production of reactive species and soluble mediators within the distal airways compared to the proximal airways in asthma. These results indicate that cellular mechanisms are activated in the distal airways of asthmatics and must be considered in the development of therapeutic strategies for this chronic inflammatory disorder.

Blood cultures for evaluation of fever after total joint arthroplasty

Fever after total joint arthroplasty (TJA) is common. Fearing the potential complications of bacteremia, physicians often obtain blood cultures to evaluate fever after TJA. In this study, we retrospectively examined the results of 102 sets (204 samples) of blood cultures that had been obtained from 50 patients (mean age, 67.3 years) during the first 2 postoperative days for evaluation of fever of 38.3 degrees C or higher. All patients had been receiving antibiotic prophylaxis. Of the 50 patients, 39 had undergone total knee arthroplasty, and 11 had undergone total hip arthroplasty. There had been 49 primary operations and 1 revision. Of the 204 blood culture samples, none had grown a pathogen. The cultures had been ordered by both surgical (61%) and medical (39%) services. The 2008 institution charge to process the 2 blood culture samples (1 set) routinely collected for each evaluation was $120 (true cost, $44.29). Therefore, in the current healthcare market, the charge to the payer for processing 102 sets would be $12,240. We conclude that blood cultures are neither useful nor cost-effective in evaluating fever immediately after TJA. We believe that the results of this study will be helpful to both orthopedists and medical consultants involved in the care of TJA patients.

Effects of dexmedetomidine on intraoperative motor and somatosensory evoked potential monitoring during spinal surgery in adolescents

BACKGROUND

Dexmedetomidine may be a useful agent as an adjunct to an opioid-propofol total intravenous anesthesia (TIVA) technique during posterior spinal fusion (PSF) surgery. There are limited data regarding its effects on somatosensory (SSEPs) and motor evoked potentials (MEPs).

METHODS

The data presented represent a retrospective review of prospectively collected quality assurance data. When the decision was made to incorporate dexmedetomidine into the anesthetic regimen for intraoperative care of patients undergoing PSF, a prospective evaluation of its effects on SSEPs and MEPs was undertaken. SSEPs and MEPs were measured before and after the administration of dexmedetomidine in a cohort of pediatric patients undergoing PSF. Dexmedetomidine (1 microg x kg(-1) over 20 min followed by an infusion of 0.5 microg x kg(-1) x h(-1)) was administered at the completion of the surgical procedure, but prior to wound closure as an adjunct to TIVA which included propofol and remifentanil, adjusted to maintain a constant depth of anesthesia as measured by a BIS of 45-60.

RESULTS

The cohort for the study included nine patients, ranging in age from 12 to 17 years, anesthetized with remifentanil and propofol. In the first patient, dexmedetomidine was administered in conjunction with propofol at 110 microg x kg(-1) x min(-1) which resulted in a decrease in the bispectral index from 58 to 31. Although no significant effect was noted on the SSEPs (amplitude or latency) or the MEP duration, there was a decrease in the MEP amplitude. The protocol was modified so that the propofol infusion was incrementally decreased during the dexmedetomidine infusion to achieve the same depth of anesthesia. In the remaining eight patients, the bispectral index was 52 +/- 6 at the start of the dexmedetomidine loading dose and 49 +/- 4 at its completion (P = NS). There was no statistically significant difference in the MEPs and SSEPs obtained before and at completion of the dexmedetomidine loading dose.

CONCLUSION

Using the above-mentioned protocol, dexmedetomidine can be used as a component of TIVA during PSF without affecting neurophysiological monitoring.