Contemporary procedure characteristics and outcomes of accessory atrioventricular pathway ablations in an integrated community-based health care system using a tiered approach.

BACKGROUND: Since the early descriptions of large series of accessory atrioventricular pathway ablations in adults and adolescents over 20 years ago, there have been limited published reports based on more recent experiences of large referral centers. We aimed to characterize accessory pathway distribution and features in a large community-based population that influence ablation outcomes using a tiered approach to ablation. METHODS: Retrospective analysis of 289 patients (age 14-81) who underwent accessory ablation from 2015-2019 was performed. Pathways were categorized into anteroseptal, left freewall, posteroseptal, and right freewall locations. We analyzed patient and pathway features to identify factors associated with prolonged procedure time parameters. RESULTS: Initial ablation success rate was 94.7% with long-term success rate of 93.4% and median follow-up of 931 days. Accessory pathways were in left freewall (61.6%), posteroseptal (24.6%), right freewall (9.6%), and anteroseptal (4.3%) locations. Procedure outcome was dependent on pathway location. Acute success was highest for left freewall pathways (97.1%) with lowest case times (144 ± 68 min) and fluoroscopy times (15 ± 19 min). Longest procedure time parameters were seen with anteroseptal, left anterolateral, epicardial-coronary sinus, and right anterolateral pathway ablations. CONCLUSIONS: In this community-based adult and adolescent population, majority of the accessory pathways are in the left freewall and posteroseptal region and tend to be more easily ablated. A tiered approach with initial use of standard ablation equipment before the deployment of more advance tools, such as irrigated tips and 3D mapping, is cost effective without sacrificing overall efficacy.

Use of Negative-Pressure Wound Therapy With Instillation and Dwell Time: An Overview.

SUMMARY: The use of negative-pressure wound therapy (NPWT) has become an established therapy for wound management. There have been many advancements in the technology of NPWT including NPWT with instillation and dwell (NPWTi-d). NPWTi-d promotes wound healing by wound cleansing, irrigation, and nonexcisional debridement. NPWTi-d has been shown in comparative clinical studies to decrease the time to definitive wound healing and length of hospitalization. NPWTi-d-using a reticulated open-cell foam dressing with "through" holes (ROCF-CC)-has been postulated to facilitate solubilization, detachment, and elimination of infectious materials, such as slough and thick exudate, before or after operative debridement, and in cases where surgical debridement is not an option. The authors provide an overview on the use of NPWTi-d by reviewing the components of the system, proposed mechanism of action, clinical outcomes, and current consensus guidelines for its utilization.

Use of Negative-Pressure Wound Therapy With Instillation and Dwell in Breast Reconstruction.

SUMMARY: The use of negative-pressure wound therapy (NPWT) has expanded over the last 3 decades, paralleled and documented by an increase in research. This article discusses the evolution and current applications of NPWT in modern breast reconstruction. Negative-pressure wound therapy with instillation and dwell (NPWTi-d) technology can be used to remove infectious material, facilitate salvaging compromised tissue, and stabilize the soft-tissue environment. Published consensus NPWTi-d guidelines can aid in treatment selection and implementation of this new technology. The therapeutic approach of simultaneously removing infectious material and actively improving mastectomy flap perfusion and thickness is a burgeoning concept, and illustrative cases are presented. NPWTi-d preliminary use has led to reconstruction salvage with reproducible early experience and outcomes, and it is hoped that it will raise interest and awareness of this promising application of the technology to improve breast reconstruction outcomes.

Forging ahead: Update on radiofrequency ablation technology and techniques.

Innovations in radiofrequency (RF) ablation and nonablative techniques have led to significant advances in addressing complex arrhythmogenic substrates for a variety of cardiac arrhythmias. Anatomical challenges, deep substrate, and mid-myocardial locations may pose difficulties and decrease success rates using routine methods. In this review, we provide an update on novel RF technology and techniques including (a) high-power, low-duration ablation, (b) ablation facilitated by low-ionic irrigant, and (c) bipolar ablation. In addition, we review emerging technologies including electroporation, needle catheter ablation, and ablation with the lattice catheter.

Practice patterns of South African audiologists in cerumen management: a pilot study.

OBJECTIVE: To determine the training, self-reported competence and practice patterns of South African audiologists (SAAs) regarding cerumen management (CM). DESIGN: Prospective cross-sectional survey. An online questionnaire was completed by SAA between July and September 2016. The questionnaire addressed sections on educational training, experience and practice patterns of SAAs regarding CM. STUDY SAMPLE: Three hundred and fifty-six SAAs responded to an email invitation sent to 382 actively-practicing audiologists. RESULTS: Majority of the participants (85%) were employed for less than 10 years. Forty-nine percent received less than 10 hours of theoretical training while 57% received less than 10 hours of clinical education. A total of 96% of the participants indicated they felt competent to perform CM, with 96% preferring manual, ear syringing, or a combination of the two. Handwashing pre- and post-procedure was the preferred method of infection prevention and control by 87% of the participants with 66% of these indicating they only wore gloves. Majority (85%) of the participants indicated that they always explained the possible complications of CM to their patients. CONCLUSION: Findings from this study indicate that South African audiologists feel that they are adequately trained and competent to perform CM.

Management of Early Deep Wound Infection After Thoracolumbar Instrumentation: Continuous Irrigation Suction System versus Vacuum-Assisted Closure System.

STUDY DESIGN: A retrospective study. OBJECTIVE: The aim of this study was to compare the clinical outcomes of continuous irrigation suction systems (CISS) or vacuum-assisted closure system (VACS) in early deep wound infection (DWI) after thoracolumbar instrumentation. SUMMARY OF BACKGROUND DATA: DWI after thoracolumbar instrumentation is challenging and debridement followed by either CISS or VACS has been proven to be effective. So far, which one of the system has more advantages over the other remains unclear. METHODS: Patients after thoracolumbar instrumentation were evaluated at our spine surgery center from 2005 to 2015. Patients who were diagnosed with early deep DWI after spinal instrumentation and treated by meticulous debridement in the operating room followed by either CISS or VACS were included. Detailed information was obtained from the medical records, including clinical features, results of laboratory examinations, medical therapies, and outcomes. A follow-up was conducted to observe whether recurrent spinal infection or other complications happened. RESULTS: We identified 11 patients in the CISS group and 12 patients in the VACS group. There were no significant differences in terms of age, gender, follow-up duration, symptoms of infection, laboratory examinations, etc. The number of CISS or VACS replacement was 1.3 and 1.6, respectively, before wound healing (P > 0.05). And there were significant differences in terms of hospital stay and extra cost of infection treatment between the two groups. In the follow-up period, we observed sinus tract formation and low back pain in both groups and one patient in the VACS group died of pulmonary infection 4 years after the initial surgery. CONCLUSION: Thorough debridement followed by CISS or VACS are comparable in treating early DWI after thoracolumbar instrumentation. The CISS treatment was statistically significant in comparison to the VACS treatment in terms of hospital stay and cost. LEVEL OF EVIDENCE: 4.

Regional differences in referral, procedures, and outcome after ablation for atrial fibrillation in Europe: a report from the Atrial Fibrillation Ablation Pilot Registry of the European Society of Cardiology.

AIMS: Ablation is an effective treatment of symptomatic and drug refractory atrial fibrillation (AF). Using data from the European AF Ablation Pilot Registry comprising 1410 patients from 10 European countries, we prospectively investigated regional differences in AF ablation regarding patient selection, ablation strategy, and outcome. METHODS AND RESULTS: Countries were divided into three regions: South (Greece, Italy, Spain), East (Czech Republic, Poland), and West/North (Belgium, Denmark, France, Germany, and the Netherlands). One-year success was defined as patient survival free from atrial arrhythmia, with or without antiarrhythmic drugs (AAD). In all regions, patients were symptomatic and treated extensively with beta-blockers and AAD pre-ablation. Patients in East had more co-morbidity, increased thromboembolic risk, were more likely to have paroxysmal AF, and they underwent more left atrial linear ablations. Adverse events remained within expected levels, albeit with a significantly higher reporting of adverse cardiovascular events in the West/North (4.7 vs. 1.4 and 1.5% in South and East, P = 0.0032). There was no significant difference in peripheral/vascular, neurological, pulmonary, gastrointestinal, or general adverse events. The 1-year success rate after ablation differed non-statistically between regions ranging from 69.1 to 74.7%. A second ablation was performed in 23.2% in West/North compared with 10.5 and 16.5% in South and East. The proportion of patients still on AADs was highest in the South region (51.6 vs. 42.3 and 38.8% in East and West/North). CONCLUSION: This study with all-comer patients shows that patient selection for ablation follows current guidelines but reveals significant differences regarding co-morbidity, medication, and ablation strategy. Despite this, 1-year outcomes are without significant differences and in line with previously published clinical trials.

Changes in the management of deep sternal wound infections: a 12-year review.

BACKGROUND: Deep sternal wound infection (DSWI) is a rare but life-threatening complication following cardiac surgery associated with increased morbidity and mortality. Management of these patients has evolved over the years and can include sternal rewiring, mediastinal irrigation, negative-pressure wound therapy (NPWT) dressing or repair with flaps. We reviewed changes in our management of DSWI and outcomes. METHODS: Using the Australian and New Zealand Society of Cardiac and Thoracic Surgeons database, 5472 underwent cardiac surgery at St Vincent's Hospital, Melbourne, and 42 were identified as developing DSWI requiring re-operation between June 2002 and September 2014. Data were collected pertaining to risk factors for DSWI, management strategies and outcomes. Patients were compared from a period prior to NPWT dressing use (June 2002-February 2006, n = 14) and since the NPWT has been used regularly in the management of DSWI (from March 2006, n = 28). Patients were also compared based on the requirement for flap closure of their sternal wound. RESULTS: Because of the widespread use of NPWT dressings, there is a trend towards fewer sternal infections requiring flap closure (25 versus 42.8%) and less post-operative complications after definitive closure (7.1 versus 28.6%). Before and after widespread NPWT use, patients require similar number of re-operations before closure and have no significant differences in time to definitive closure or length of hospital stay. CONCLUSION: The use of NPWT dressings as a bridge to definitive closure may reduce the need for more burdensome flap reconstruction, does not delay definitive reconstruction or prolong hospital stay and may reduce post-reconstruction complications requiring re-operation.

Arthroscopic washout of the knee: a procedure in decline.

BACKGROUND: Osteoarthritis (OA) of the knee is a chronic, progressive condition which often requires surgical intervention. The evidence for the benefits of arthroscopic debridement or washout for knee OA is weak and arthroscopy is currently only indicated in the UK if there is a history of mechanical locking of the knee. OBJECTIVES: To investigate whether there has been any change in the number of arthroscopies performed in the UK since the 2007 NICE guidance on knee arthroscopy and the 2008 Cochrane review of arthroscopic debridement for OA of the knee. METHODS: We interrogated data from the Hospital Episodes Statistics (HES) database with Office of Population Censuses and Surveys-4 (OPSC-4) codes pertaining to therapeutic endoscopic operations in the 60-74 year old and 75 and over age groups. RESULTS: The number of arthroscopic knee interventions in the UK decreased overall from 2000 to 2012, with arthroscopic irrigations decreasing the most by 39.6 per 100,000 population (80%). However, the number of arthroscopic meniscal resections increased by 105.3 per 100,000 (230%) population. These trends were mirrored in both the 60-74 and 75 and over age groups. CONCLUSIONS: Knee arthroscopy in the 60-74 and 75 and over age groups appears to be decreasing but there is still a large and increasing number of arthroscopic meniscal resections being performed.

[Joint infections. Known facts and new trends]. / Die Gelenkinfektion. Bekanntes und neue Trends.

Acute septic arthritis is a surgical emergency because rapid septic destruction of articular cartilage can lead to impairment or even loss of joint function. Diagnosis consists of patient history, clinical examination, laboratory results, (sonography- guided) joint aspiration and radiography. Emergency therapy is based on arthroscopic or open joint debridement and lavage combined with systemic antibiotic therapy. No data are available for the recommendation of local antibiotics but antiseptic solutions are not recommended because of cartilage damage. New trends in diagnostics are positron emission tomography/computed tomography (PET/CT), urine sticks for analysis of joint fluid and molecular pathology. Chronic joint empyema is more diagnostically demanding and is difficult to treat. In cases of necrotic and infected articular cartilage, joint resection has to be performed for quiescence of infection. Options following successful treatment of empyema are arthroplasty, arthrodesis or permanent resection.

A novel device to improve colon cleanliness during colonoscopy.

BACKGROUND AND STUDY AIM: Effective colonoscopy depends on adequate visualization of the intestine, which might be ensured by intraprocedural use of a cleansing device. We investigated the performance of a novel endoscopic device with regard to cleanliness, safety, and tolerability during colonoscopy, compared with standard cleansing. PATIENTS AND METHODS: At a single center, colonoscopy patients in whom the cecum was accessed and at least one bowel segment was inadequately cleansed were assigned to either use of a disposable catheter cleansing device (JetPrep), used through the endoscope working channel, or standard manual cleansing using a 50-ml syringe. The cleansing quality, for each segment and before and after irrigation, was recorded using a 4-point scale ranging from excellent (grade 1, no more than small bits of adherent feces) to poor (grade 4, large amount of fecal residue). RESULTS: 38 patients were included, 19 in each group. Reasons for referral included colorectal cancer screening (52 %), or blood loss (31 %). Each segment showed improvement after cleansing with JetPrep. Overall cleansing grade improved by a mean of 0.74 points (standard deviation [SD] 0.82) in the investigation group compared with 0.19 (0.40) in the control group (P < 0.0001), and right colon cleansing improved by 1.59 points (0.71) versus 0.31 (0.48) in the controls (P < 0.0001). There was no significant difference in procedure time between the groups. No adverse events or side effects were encountered. CONCLUSIONS: The JetPrep disposable catheter device is safe and efficient for intraprocedural cleansing of a suboptimally prepared colon, allowing higher quality colonoscopy.

A novel system for the improvement of colonic cleansing during colonoscopy.

Suboptimal bowel cleansing prior to colonoscopy impairs the efficacy and safety of the procedure. A new system for intracolonic cleansing has been developed, which includes a disposable catheter device that is inserted through the working channel of a standard colonoscope and an irrigation unit with predefined pressure and flow rate. The aim of the current study was to assess the safety and efficacy of this novel system for the improvement of bowel cleansing during colonoscopy. A total of 42 patients with suboptimal bowel preparation were systematically allocated, in a 1:1 ratio, to either the study group (JetPrep system, n = 21) or the control group (syringe irrigation, n = 21). The cleansing efficacy was evaluated using a segmental scoring scale to rate the bowel preparation level before and after irrigation. One patient from the study group was excluded from the efficacy analysis due to treatment with both techniques. The JetPrep system was significantly superior to syringe irrigation (P = 0.0001). No adverse events were reported. This study suggests that the safety profile of the JetPrep system is comparable to standard irrigation and shows that the device significantly improves suboptimal bowel preparation.

Waterjet dissection of peripheral nerves: an experimental study of the sciatic nerve of rats.

BACKGROUND: Although waterjet dissection has been well evaluated in intracranial pathologies, little is known of its qualities in peripheral nerve surgery. Theoretically, the precise dissection qualities could support the separation of nerves from adjacent tissues and improve the preservation of nerve integrity in peripheral nerve surgery. OBJECTIVE: To evaluate the potential of the new waterjet dissector in peripheral nerve surgery. METHODS: Waterjet dissection with pressures of 20 to 80 bar was applied on the sciatic nerves of 101 rats. The effect of waterjet dissection on the sciatic nerve was evaluated by clinical tests, neurophysiological examinations, and histopathological studies up to 12 weeks after surgery. RESULTS: With waterjet pressures up to 30 bar, the sciatic nerve was preserved in its integrity in all cases. Functional damaging was observed at pressures of 40 bar and higher. However, all but 1 rat in the 80 bar subgroup showed complete functional regeneration at 12 weeks after surgery. Histopathologically, small water bubbles were observed around the nerves. At 40 bar and higher, the sciatic nerves showed signs of direct nerve injury. However, all these animals showed nerve regeneration after 12 weeks, as demonstrated by histological studies. CONCLUSION: Sciatic nerves were preserved functionally and morphologically at pressures up to 30 bar. Between 40 and 80 bar, reliable functional and morphological nerve regeneration occurred. Waterjet pressures up to 30 bar might be applied safely under clinical conditions. This technique might be well suited to separate intact peripheral nerves from adjacent tumor or scar tissue. Further studies will have to show the clinical relevance of these dissection qualities.

Socioeconomic and other predictors of colonoscopy preparation quality.

BACKGROUND: Suboptimal bowel preparation prior to colonoscopy is a common occurrence, with a deleterious impact on colonoscopy effectiveness. Established risk factors for suboptimal bowel preparation have been proposed, but social factors, such as socioeconomic status and marital status, have not been investigated. AIMS: The aim of this study was to evaluate sociodemographic factors, including insurance status and marital status, as predictive of suboptimal preparation. METHODS: We analyzed a database of 12,430 consecutive colonoscopies during a 28-month period at Columbia University Medical Center. We collected the following variables: age, gender, indication for colonoscopy, location (inpatient vs. outpatient), race, marital status, and Medicaid status. Preparation quality was recorded and dichotomized as optimal or suboptimal. We employed multivariate regression to determine independent risk factors for suboptimal bowel preparation. RESULTS: Among the 10,921 examinations in which bowel preparation was recorded, suboptimal preparation occurred in 34% of Medicaid patients versus 18% of non-Medicaid patients (P < 0.0001); this remained significant in the multivariate analysis (odds ratio (OR) 1.84, 95% CI 1.61-2.11). Married patients had decreased rates of suboptimal preparation (OR 0.89, 95% CI 0.80-0.98). Other variables associated with suboptimal preparation included increased age (OR per 10 years 1.09, 95% CI 1.05-1.14), male gender (OR 1.44, 95% CI 1.31-1.59), inpatient status (OR 1.51, 95% CI 1.26-1.80), and later time of day (OR 1.89, 95% CI 1.71-2.09). CONCLUSIONS: Unmarried status and Medicaid status are predictive of suboptimal bowel preparation. Future studies are warranted to identify how these social conditions predict bowel preparation quality and to implement interventions to optimize bowel preparation in vulnerable populations.

Adenomas are detected more often in morning than in afternoon colonoscopy.

OBJECTIVES: The effectiveness of colonoscopy in preventing colon cancer depends on adenoma detection and removal. Adequacy of bowel preparation, careful mucosal visualization, and adequate withdrawal time are known to affect adenoma detection rate (ADR). Physician fatigue, which usually increases as the day progresses, might impair ADR. The aim of this study is to assess the effect of timing of colonoscopy, morning vs. afternoon, on ADR. METHODS: Medical records of 9,063 colonoscopies performed in 2006 were reviewed for patient demographics, indications, timing, and findings of colonoscopy. Asymptomatic outpatients who had adequate bowel preparation and complete colonoscopy were included. Morning colonoscopies were defined as those that started before 12 noon and afternoon colonoscopies as those that started after 12 noon. ADR is defined as the detection of at least one adenoma per colonoscopy. RESULTS: A total of 3,619 colonoscopies were included, of which 1,748 (48.3%) were done in the morning and 1,871 (51.7%) were done in the afternoon. ADR was 29.3% in the morning group compared with 25.3% in the afternoon group (P=0.008). There was a trend toward declining ADR for each subsequent hour of the day (P=0.01). In multivariable analysis, colonoscopy in the morning was significantly associated with increased ADR (odds ratio (OR) 1.2 (1.06, 1.4) P=0.006). CONCLUSIONS: Time of performance of colonoscopy seems to be an independent predictor for adenoma detection. ADR was significantly higher in morning colonoscopies than in afternoon colonoscopies. The reasons and implications of this finding should be studied further.

Trends of ear syringing at Ibadan, Nigeria.

Ear syringing is a procedure by which the external auditory canal is irrigated with a normal saline at body temperature. It is a procedure which every doctor or nurse should be able to perform proficiently. A study of 622 patients that needed ear syringing was done between December 1999 and June 2001 to determine its trend. There were 341(55%) males and 281(45%) females with age ranged from 3.5months to 89 years: 44.4% were in the first decade of life. Cerumen auris 99% remained the commonest indication for syringing in this study with bilateral cerumen auris constituting 53.1% while right and left cerumen auris constituted 24.4% and 21.5% respectively. Cerumen auris constituted 66% of total 933 Otologic cases seen during the study period. Other indications were otitis externa 0.7% (otomycosis 0.5%; bacterial 0.2%) and foreign body 0.3%. The majority of patients (86%) required between 500mls and 1000mls of fluid for irrigation and 94.9% required not more than one attempt at syringing. The complications recorded were mainly vertigo 0.2% and tympanic membrane perforation 0.2% respectively. Thus ear syringing, though simple and sometimes taken for granted may be fraught with dangers; it is a very safe procedure in trained hands and that after at least three attempts of ear syringing for cerumen auris and if it persists despite effective applications of cerumenolytic agents prior to irrigation, the procedure should be discontinued and other methods of imparted cerumen auris removal should be employed.