A non-randomised single centre cohort study, comparing standard and modified bowel preparations, in adults with cystic fibrosis requiring colonoscopy.

BACKGROUND: Adults with cystic fibrosis (CF) have been reported to be at five to ten-fold risk (25 to 30 fold risk after solid organ transplant) of colorectal cancer (CRC) than the general population. Limited publications to date have reported on practical aspects of achieving adequate colonic cleanse producing good visualisation. In this study, we compared two bowel preparation regimens, standard bowel preparation and a modified CF bowel preparation. METHODS: A non-randomised study of adults with CF attending a single centre, requiring colonoscopy investigation were selected. Between 2001 and 2015, 485 adults with CF attended the clinic; 70 adults with CF had an initial colonoscopy procedure. After five exclusions, standard bowel preparation was prescribed for 27 patients, and modified CF bowel preparation for 38 patients. Demographic and clinical data were collected for all consenting patients. RESULTS: There was a significant difference between modified CF bowel preparation group and standard bowel preparation group in bowel visualisation outcomes, with the modified CF bowel preparation group having a higher proportion of "excellent/good" GI visualisation cleanse (50.0% versus 25.9%) and lower rates of "poor" visualisation cleanse (10.5% versus 44.5%) than standard bowel preparation (p = 0.006). Rates of "fair" GI cleanse visualisation were similar between the two groups (39.4% versus 29.6%) (Additional file 1: Table S1). Detection rates of adenomatous polyps at initial colonoscopy was higher in modified CF bowel preparation cohort than with standard preparation group (50.0% versus 18.5%, p < 0.01). Positive adenomatous polyp detection rate in patient's age > 40 years of age was higher (62.5%) than those < 40 years of age (24.3%) (p = 0.003). Colonic adenocarcinoma diagnosis was similar in both groups. CONCLUSION: This study primarily highlights that standard colonoscopy bowel preparation is often inadequate in patients with CF, and that colonic lavage using modified CF bowel preparation is required to obtain good colonic visualisation. A higher rate of polyps in patients over 40 years of age (versus less than 40 years) was evident. These results support adults with CF considered for colonoscopy screening at 40 years of age, or prior to this if symptomatic; which is earlier than CRC screening in the non-CF Australian population.

Bochdalek hernia masquerading as a tension pneumothorax.

A rare case of congenital diaphragmatic defect presenting with clinical signs of an acute tension pneumothorax is described. The clinical findings were eventually attributable to a herniation of abdominal contents into the chest (Bochdalek hernia). Attempted decompression of the chest by needle thoracocentesis and subsequent introduction of a chest drain caused gastric perforation, requiring repair at laparotomy. It is suggested that if needle thoracocentesis does not result in immediate clinical improvement, or if there is abdominal pain, a portable chest radiograph should be performed before tube thoracostomy to exclude Bochdalek hernia. All emergency department staff should be taught to recognise the radiological appearance of a Bochdalek hernia.

Superior mesenteric vein stenosis complicating Crohn's disease.

BACKGROUND: Superior mesenteric vein stenosis as a consequence of mesenteric fibrosis, causing the development of small bowel varices, is an unrecognised association of Crohn's disease. CASE REPORTS: Two cases of gastrointestinal bleeding occurring in patients with Crohn's disease, and a third case, presenting with pain and diarrhoea, are described. In all three patients, visceral angiography showed superior mesenteric vein stenosis with dilatation of draining collateral veins in the small bowel. Overt gastrointestinal bleeding or iron deficiency anaemia resulting from mucosal ulceration is common in Crohn's disease, but acute or chronic bleeding from small bowel varices as a result of superior mesenteric vein stenosis due to fibrosis has not previously been reported.

Endolymphatic sac obliteration for large vestibular aqueduct syndrome.

The objective of this study was to investigate the effects of endolymphatic sac obliteration for stabilization of progressive hearing loss in patients with the large vestibular aqueduct syndrome. This was a retrospective case review conducted at a private neurootologic office in a metropolitan area. Seven ears in six patients were subjected to surgery for obliteration of the endolymphatic sac in an effort to stabilize progressive hearing loss associated with the large vestibular aqueduct syndrome. The study population was composed of four boys and two girls 4-17 years of age. The large vestibular aqueduct was unilateral in two patients and bilateral in four patients. All seven ears demonstrated progressive sensorineural hearing loss preoperatively. Surgical tissue obliteration was performed via a transmastoid approach in seven ears. The main outcome measure was comparison of pre- and postoperative hearing levels and stability. Magnetic resonance imaging also was performed in all cases at least 6 months postoperatively to determine patency of the endolymphatic sac and vestibular aqueduct. Six of seven ears maintained stable hearing during the follow-up period, which ranged from 6 months to 6 years (mean 3.2 years). One patient showed continued progression of hearing loss postoperatively. All seven ears demonstrated continued obliteration on postoperative imaging studies. Surgical obliteration of the endolymphatic sac may stabilize hearing in patients with the large vestibular aqueduct syndrome and progressive hearing loss. These results support the theory of pressure or fluid reflux into the labyrinth as a cause of progressive hearing loss in these patients.

Magnetic resonance imaging-enhancing lesions of the labyrinth and facial nerve. Clinical correlation.

OBJECTIVE: Gadolinium-enhanced magnetic resonance imaging (MRI) is useful in assessing inflammatory and neoplastic lesions of the labyrinth and facial nerve. The following cases demonstrate the ability of MRI to differentiate neoplastic from inflammatory lesions within the labyrinth. PATIENTS OR OTHER PARTICIPANTS: Nine patients were selected with enhancing lesions of the labyrinth and the facial nerve identified on MRI. INTERVENTION: Acyclovir and prednisone were prescribed for herpes zoster oticus; surgical removal of neoplastic lesions was performed. MAIN OUTCOME MEASURE: The hypothesis was developed in the course of clinical practice. No planned outcome was emphasized, as this article is based on the differential diagnoses of the cases reported. RESULTS: Gadolinium-enhanced MRI is useful in differentiating neoplastic from inflammatory lesions within the labyrinth. Axial and coronal 3-mm sections with gadolinium enhancement were necessary for identifying these lesions and particularly for recognizing the sharp enhancement of the neoplastic margin in contrast to the dull cloudy margins of an inflammatory lesion. CONCLUSIONS: The MRI differentiation of these lesions is helpful in providing appropriate medical and surgical management of neoplastic and inflammatory lesions of the labyrinth.

The sensitivity of auditory brainstem response testing in small acoustic neuromas.

Auditory brainstem response (ABR) testing is a reliable and sensitive test for retrocochlear pathology in neurotologic diagnosis. Several investigators have reported the sensitivity of ABR testing as 95% or greater. Fifty-one consecutive patients with surgically confirmed acoustic neuromas were examined. Forty patients had sufficient hearing preoperatively for assessment with ABR. In addition, all had been evaluated with gadolinium-enhanced magnetic resonance imaging and conventional electronystagmography. Overall, 34 of 40 patients (85%) had abnormal ABRs. One of 25 patients with extracanalicular tumors had a normal ABR for a false-negative rate of 4%; however, 5 of 15 patients with intracanalicular tumors had normal ABRs for a false-negative rate of 33%. Tumor size and nerve of origin were important factors affecting the ABR sensitivity. The ABR was less sensitive in detecting intracanalicular tumors than in detecting extracanalicular tumors.

Argon laser stapedotomy.

Lasers have been used in otology for 10 years. There have been reports of excellent hearing results using laser energy in surgery for otosclerosis. We used the argon laser in 75 consecutive primary stapedotomy procedures. The postoperative air-bone gap was 10 dB or less in 87% of patients and 20 dB or less in 95%. One ear (1.5%) had no postoperative hearing secondary to a granulomatous reaction. Complications were otherwise uncommon and mild. Most patients were treated on an outpatient basis. Our results compare favorably with other reports of laser surgery for otosclerosis. We conclude that excellent hearing results can be obtained using the argon laser for stapedotomy procedures.

Transmastoid infralabyrinthine approach to petrous temporal bone.

The most direct approach to the anterior and inferior regions of the petrous temporal bone skull base is transmastoid infralabyrinthine. This approach provides an exposure for draining and aerating cholesterol granulomas or obtaining tissue for micropathologic diagnosis. It obviates the exposure of the intracranial space, thereby producing minimal care, as in mastoid-type surgical procedures. The procedure is described and illustrated. Two cases with petrous temporal bone cholesterol granulomas demonstrate the definitive effectiveness of this procedure.

Lidocaine in the middle ear.

Anesthesia of the ear canal is produced by injection of lidocaine hydrochloride into the skin of the lateral external ear canal. Ear canal, tympanic membrane, and middle ear surgeries are performed with this injection. The fluid found in the middle ear during tympanotomy was collected and analyzed. The percentage of lidocaine in the fluid was calculated by an enzyme immunoassay technique. Fifteen surgical cases were undertaken in which perilymphatic fluid in the middle ear would not be suspected, such as tympanotomy for otosclerosis. Lidocaine was found in all middle ears in which there was sufficient fluid to collect. The authors question the validity of using the presence of clear fluid in the middle ear, even with reaccumulation, as the sole criterion for identifying perilymph and cerebrospinal fluid.

Effects of pentoxifylline on experimental skin flap survival.

We studied the effects of pentoxifylline on experimental skin flap survival in the domestic pig. Random skin flaps were designed using a length-width ratio of 5:1. The pigs were then given pentoxifylline (25 mg/kg/d) or placebo for seven days. Fluorescein sodium was used to help determine surviving skin flap length seven days postoperatively. Results showed no significant difference in mean surviving skin flap length between the study and control groups. We question the value of pentoxifylline in increasing skin flap survival.