Endoscopic endonasal resection of Rathke cleft cysts: a single-institution analysis of 148 consecutive patients.

OBJECTIVE: The traditional treatment of sellar Rathke cleft cysts (RCCs) generally involves transsellar drainage; however, suprasellar RCCs present unique challenges to appropriate management and technical complexity. Reports on overall outcomes for the endoscopic endonasal approach (EEA) for this pathology are limited. The EEA for RCCs allows three surgical techniques: marsupialization, fenestration, and fenestration with cyst wall resection. METHODS: The authors performed a retrospective review of consecutive patients with RCCs that had been treated via an EEA at a single institution between January 2004 and May 2021. Marsupialization entailed the removal of cyst contents while maintaining a drainage pathway into the sphenoid sinus. Fenestration involved the removal of cyst contents, followed by separation from the sphenoid sinus, often with a free mucosal graft or vascularized nasoseptal flap. Cyst wall resection, either partial or complete, was added to select cases. RESULTS: A total of 148 patients underwent an EEA for RCC. Marsupialization or fenestration was performed in 88 cases (59.5%) and cyst wall resection in 60 (40.5%). Cysts were classified as having a purely sellar origin (43.2%), sellar origin with suprasellar extension (37.8%), and purely suprasellar origin (18.9%). Radiological recurrence was demonstrated in 22 cases (14.9%) at an average 39.7 months' follow-up (median 45 months, range 0.5-99 months), including 13 symptomatic cases (8.8%). Cases with cyst wall resection had no significantly different rate of recurrence (11.7% vs 15.9%, p = 0.48) or postoperative permanent anterior pituitary dysfunction (21.6% vs 12.5%, p = 0.29) compared to those of fenestrated and marsupialized cases. There was no significant difference in postoperative permanent posterior pituitary dysfunction based on technique, although such dysfunction tended to worsen with cyst wall resection (13.6% vs 4.0%, p = 0.09). Based on cyst location, purely suprasellar cysts were more likely to have a radiological recurrence (28.6%) than sellar cysts with suprasellar extension (12.5%) and purely sellar cysts (9.4%; p = 0.008). Most notably, of the 28 purely suprasellar cysts, selective cyst wall resection significantly improved the long-term (10-year) recurrence risk compared to fenestration alone (17.4% vs 80.0%, p = 0.0005) without any significant added risk of endocrinopathy. CONCLUSIONS: Endoscopic endonasal marsupialization or fenestration of sellar RCCs may be the ideal treatment strategy, whereas purely suprasellar cysts benefit from partial cyst wall resection to prevent recurrence. Selective cyst wall resection reduced long-term recurrence rates without significantly increasing rates of hypopituitarism.

Interim seasonal influenza vaccine effectiveness estimates as proxy for final estimates: analysis of systematically identified matched pairs of interim/final estimates from test-negative design studies in outpatient settings from 2010/11 to 2018/19.

OBJECTIVES: Limited time for seasonal influenza vaccine development means that the World Health Organization has to consider interim (early) rather than final vaccine effectiveness (VE) estimates in deciding influenza vaccine composition. We assessed agreement between interim and final VE estimates, and factors that may determine a substantial difference (≥10%) between point estimates. METHODS: This was a mixed methods study. We systematically searched, identified, and matched interim/final VE studies of test-negative design (TND) type in outpatient settings after the 2009/10 influenza pandemic. The chi-square statistic (χ2) was used to assess the statistical significance of the difference between paired interim/final VE estimates. We calculated the difference between point estimates and used multivariable logistic regression to assess factors that may determine a substantial difference. RESULTS: We identified 68 interim/final VE pairs. There was no statistically significant difference between almost all compared pairs. An inconsistent statistical model for interim/final VE estimation and interim VE estimation before the epidemic peak increased the odds of having a substantial difference between estimates. CONCLUSION: : Interim influenza VE appears to be sufficient for vaccine composition decision-making. Consistency in interim/final VE estimation, and interim VE estimation during/after epidemic peak may increase agreement between the VE estimates.

Decline in Seasonal Influenza Vaccine Effectiveness With Vaccination Program Maturation: A Systematic Review and Meta-analysis.

BACKGROUND: Evidence suggests that repeated influenza vaccination may reduce vaccine effectiveness (VE). Using influenza vaccination program maturation (PM; number of years since program inception) as a proxy for population-level repeated vaccination, we assessed the impact on pooled adjusted end-season VE estimates from outpatient test-negative design studies. METHODS: We systematically searched and selected full-text publications from January 2011 to February 2020 (PROSPERO: CRD42017064595). We obtained influenza vaccination program inception year for each country and calculated PM as the difference between the year of deployment and year of program inception. We categorized PM into halves (cut at the median), tertiles, and quartiles and calculated pooled VE using an inverse-variance random-effects model. The primary outcome was pooled VE against all influenza. RESULTS: We included 72 articles from 11 931 citations. Across the 3 categorizations of PM, a lower pooled VE against all influenza for all patients was observed with PM. Substantially higher reductions were observed in older adults (≥65 years). We observed similar results for A(H1N1)pdm09, A(H3N2), and influenza B. CONCLUSIONS: The evidence suggests that influenza VE declines with vaccination PM. This study forms the basis for further discussions and examinations of the potential impact of vaccination PM on seasonal VE.

Interventions on health care providers to improve seasonal influenza vaccination rates among patients: a systematic review and meta-analysis of the evidence since 2000.

BACKGROUND: Seasonal influenza vaccination (SIV) rates remain suboptimal in many populations, even in those with universal SIV. OBJECTIVE: To summarize the evidence on interventions on health care providers (physicians/nurses/pharmacists) to increase SIV rates. METHODS: We systematically searched/selected full-text English publications from January 2000 to July 2019 (PROSPERO-CRD42019147199). Our outcome was the difference in SIV rates between patients in intervention and non-intervention groups. We calculated pooled difference using an inverse variance, random-effects model. RESULTS: We included 39 studies from 8370 retrieved citations. Compared with no intervention, team-based training/education of physicians significantly increased SIV rates in adult patients: 20.1% [7.5-32.7%; I2 = 0%; two randomized controlled trials (RCTs)] and 13.4% [8.6-18.1%; I2 = 0%; two non-randomized intervention studies (NRS)]. A smaller increase was observed in paediatric patients: 7% (0.1-14%; I2 = 0%; two NRS), and in adult patients with team-based training/education of physicians and nurses together: 0.9% (0.2-1.5%; I2 = 30.6%; four NRS). One-off provision of guidelines/information to physicians, and to both physicians and nurses, increased SIV rates in adult patients: 23.8% (15.7-31.8%; I2 = 45.8%; three NRS) and paediatric patients: 24% (8.1-39.9%; I2 = 0%; two NRS), respectively. Use of reminders (prompts) by physicians and nurses slightly increased SIV rates in paediatric patients: 2.3% (0.5-4.2%; I2 = 0%; two RCTs). A larger increase was observed in adult patients: 18.5% (14.8-22.1%; I2 = 0%; two NRS). Evidence from both RCTs and NRS showed significant increases in SIV rates with varied combinations of interventions. CONCLUSIONS: Limited evidence suggests various forms of physicians' and nurses' education and use of reminders may be effective for increasing SIV rates among patients.

Seasonal influenza vaccination among cancer patients: A systematic review and meta-analysis of the determinants.

Cancer patients are among high-risk individuals for whom seasonal influenza vaccine (SIV) is recommended, but rates of vaccination in this subpopulation remain suboptimal; even in jurisdictions with universal influenza vaccination programs. We sought to summarize the evidence to better understand the determinants of SIV uptake (vaccine receipt) among cancer patients. We searched MEDLINE, Embase, and CINAHL from 2000 to February 12, 2020, focusing on articles on the determinants of seasonal influenza vaccination among cancer patients, published in English. Study selection was conducted independently by 2 reviewers. One reviewer extracted data from the included studies and another reviewer checked the extracted data for errors. Outcomes were sociodemographic and health-related factors. We pooled adjusted results from studies using the inverse variance, random-effects method, and reported the odds ratios (OR) and their 95% confidence intervals (CI). Out of 2664 citations, 10 studies (mostly from USA and South Korea) met our eligibility criteria. Overall, being older (OR 2.23, 95% CI 1.46-3.38; I2 92.3%, [6 studies]), a nonsmoker (1.43, 1.32-1.51; I2 0%, [4 studies]), having a chronic illness (1.18, 1.07-1.29; I2 15.7%, [5 studies]), having had a medical check-up in the past year (1.75, 1.65-1.86; I2 0%, [2 studies]), and having health insurance (1.39, 1.13-1.72; I2 21.8%, [3 studies]) were associated with increased SIV uptake. Compared with being African-American, being Caucasian was also associated with increased SIV uptake (1.79, 1.47-2.13; I2 10.7%, [3 studies]). Limited evidence suggests seasonal influenza vaccination among cancer patients may be determined by some sociodemographic and health-related factors.