Interventions to Enhance Achievement to Independent Oral Feeds in Premature Infants: A Scoping Review.

AIM: To assess the effectiveness of interventions aimed at facilitating the transition from full tube to independent oral feeds in premature infants. METHODS: Scoping review methodology using the Preferred Reporting items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA_ScR). A search of six databases (EMBASE, MEDLINE, CINAHL, Web of Science, COCHRANE, and OT Seeker), using keywords related to oral feeding and premature infants retrieved 11,870 articles. Full-text screening was completed for 36 articles, and 21 articles were included in this review. RESULTS: Review of the 21 articles revealed five intervention types: oral stimulation (n = 14), swallow/gustatory stimulation (n = 3), olfactory stimulation (n = 2), tactile/kinesthetic stimulation (n = 1), and auditory stimulation (n = 1). Oral stimulation had the most studies with consistent evidence supporting its beneficial effect to facilitate achievement to independent oral feeds, swallow/gustatory stimulation appeared to have some benefit, but evidence for olfactory, tactile/kinesthetic, and auditory stimulation was sparse. CONCLUSION: Oral stimulation has the most studies with consistent evidence, and thus is suggested as a suitable early intervention strategy that can be used by health providers to facilitate the achievement to independent oral feeds in premature infants. The alternate forms of stimulation have limited evidence and necessitate further studies to confirm their benefits.

Optimizing management for early-stage esophageal adenocarcinoma: longitudinal results from a multidisciplinary program.

BACKGROUND: The management of early-stage esophageal cancer is nuanced. A multidisciplinary approach may optimize management through selection of candidates for surgical or endoscopic therapies. The objective of this research was to examine long-term outcomes of patients with early-stage esophageal cancer who undergo treatment with endoscopic resection or surgery. METHODS: Data on patient demographics, co-morbidities, pathology results, OS and RFS were obtained for both the endoscopic resection group and esophagectomy group. Univariate analysis of OS and RFS were conducted using the Kaplan-Meier method with calculation of the log-rank test. Multivariate cox-proportional hazards models were created for OS and RFS using a hypothesis-driven approach. A multivariate logistic regression model was created to identify predictors of esophagectomy among patients undergoing initial endoscopic resection. RESULTS: A total of 111 patients were included. The median OS for the surgery group was 67.0 months compared to 74.0 months in the endoscopic resection group (log-rank p = 0.93). The median RFS for the surgery group was 109.4 months compared to 63.3 months in the endoscopic resection group (log-rank p = 0.0127). On multivariable analysis, patients undergoing endoscopic resection had significantly worse RFS (HR 2.55, 95% CI 1.09-6.00; p = 0.032), but equivalent OS (HR 1.03, 95% CI 0.46-2.32; p = 0.941), compared to patients undergoing esophagectomy. High-grade disease (OR 5.43, 95% CI 1.13-26.10; p = 0.035) and submucosal involvement (OR 7.75, 95% CI 1.90-31.40; p = 0.004) were identified as significant predictors of proceeding to esophagectomy. CONCLUSIONS: Through a multidisciplinary approach, patients with early-stage esophageal cancer achieve excellent RFS and OS. Submucosal involvement and high-grade disease place patients at increased risk for local disease recurrence; these patients may undergo endoscopic resection safely if treated with a multidisciplinary approach incorporating endoscopic surveillance and surgical consultation. Further risk-stratification models may enable better patient selection and optimization of long-term outcomes.

Role of Tranexamic Acid (TXA) in Preventing Bleeding Following Sleeve Gastrectomy: a Systematic Review and Meta-analysis.

BACKGROUND: Tranexamic acid (TXA) has drawn growing interest over the last decade for its benefit in optimizing post-operative bleeding, yet its role in bariatric surgery is poorly understood. METHODS: The medical librarian developed and executed comprehensive searches on September 28, 2022. The population of interest included adults who underwent elective bariatric surgery. The intervention was tranexamic acid administration while the comparison was placebo or standard peri-operative therapy. The primary outcome of interest was post-operative bleeding which was defined a priori. RESULTS: A total of four studies were identified comprising of 475 patients. Of those, 207 (50%) received TXA at induction and all underwent laparoscopic sleeve gastrectomy (LSG). The majority of patients were female (n = 343, 80.7%) with ages ranging from 17 to 70 years of age and mean BMIs ranging from 37 to 56 kg/m2. Post-operative bleeding after LSG ranged from 0 to 28% depending on bleed definition and TXA administration with no differences in venous thromboembolic events or mortality between groups. Meta-analysis of post-operative bleeding demonstrated a statistically significant benefit with TXA administration (OR 0.40; 95% CI 0.23-0.70; p = 0.001) for patients undergoing elective LSG. CONCLUSIONS: Intravenous tranexamic acid at the time of laparoscopic sleeve gastrectomy is associated with a significant reduction of post-operative bleeding with no observed differences in thromboembolic events or mortality. Further high-quality studies are needed to better delineate the ideal bariatric population to receives TXA in addition to the optimal timing, dose, and duration of TXA therapy.

Characterization of Pre- and Postpandemic 30-Day Follow-Up After Elective Bariatric Surgery: a Retrospective MBSAQIP Analysis of 834,646 Patients.

BACKGROUND: Effects of the COVID-19 pandemic on rates of early postoperative follow-up after bariatric surgery are poorly understood. Our study characterizes 30-day follow-up after bariatric surgery prior to COVID-19 (years 2015-2019) and during the pandemic of COVID-19 (year 2020) and evaluates general predictive factors of short-term follow-up. METHODS: Data was extracted from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry from 2015 to 2020. Cohorts were divided into pre-pandemic and pandemic years and patients with and without 30-day follow-up. Multivariable logistic regression analysis was used to identify general factors independently predictive of 30-day follow-up. The primary aim was to evaluate the impact of the COVID-19 pandemic on short-term 30-day follow-up adherence. A secondary outcome was to characterize general short-term postoperative 30-day follow-up associated with elective bariatric surgery and identify independent predictors of 30-day follow-up among bariatric surgery patients using multivariable logistic regression analysis. RESULTS: A total of 834,646 patients were identified. Follow-up rates significantly increased in the COVID era in 2020 (p < 0.0001). Patients who achieved 30-day follow-up were older and had an increased burden of medical comorbidities, including non-insulin and insulin-dependent diabetes mellitus, hypertension, dyslipidemia, as well as increased BMI compared to patients lacking follow-up. The cohort with successful 30-day follow-up was more likely to receive gastric bypass and had increased rates of metabolic comorbidities. After adjusting for comorbidities, the greatest independent predictors of follow-up were the 2020 COVID-19 era year, Asian race, black race, and gastroesophageal reflux disease. CONCLUSIONS: After adjusting for comorbidities, the 2020 COVID-19 era year was one of the greatest predictors of follow-up after bariatric surgery. Postoperative follow-up rates after elective bariatric surgery are excellent at > 95% and increased during the 2020 COVID-19 era year. Several independent predictors of follow-up were identified which may help in development of strategies aimed to mitigate lack of postoperative follow-up.

Effect of the COVID-19 pandemic on bariatric surgery in North America: a retrospective analysis of 834,647 patients.

BACKGROUND: COVID-19 has transformed surgical care, yet little is known regarding implications for bariatric surgery. OBJECTIVE: We sought to characterize the effect of COVID-19 on bariatric surgery delivery and outcomes. SETTING: The Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) collects data from 885 centers in North America. METHODS: The MBSAQIP database was evaluated with 2 cohorts described: the COVID-19 and the pre-COVID-19, with patients receiving surgery in 2020 and 2015-2019, respectively. Yearly operative trends were characterized, and bivariate analysis compared demographics and postoperative outcomes. Multivariable modeling evaluated 30-day readmission, reintervention, and reoperation rates and factors associated with undergoing Roux-en-Y gastric bypass. RESULTS: We evaluated 834,647 patients, with 155,830 undergoing bariatric surgery during the 2020 pandemic year. A 12.1% reduction in total cases (177,208 in 2019 versus 155,830 in 2020; P < .001) and 13.8% reduction in cases per center occurred (204.2 cases per center in 2019 versus 176.1 cases per center in 2020; P < .001). Patients receiving bariatric surgery during the pandemic were younger and had fewer co-morbidities. Use of sleeve gastrectomy increased (74.5% versus 72.5%; P < .001), and surgery during COVID-19 was associated with reduced Roux-en-Y gastric bypass procedure selection (odds ratio = .83; 95% CI: .82-.84; P < .001). Length of stay decreased significantly (1.4 ± 1.4 days versus 1.6 ± 1.4 days; P < .001), yet postoperative outcomes were similar. After adjusting for co-morbidities, patients during COVID-19 had decreased 30-day odds of readmission and reintervention and a small increase in odds of reoperation. CONCLUSION: The COVID-19 pandemic dramatically changed bariatric surgery delivery. Further studies evaluating the long-term effects of these changes are warranted.

A Qualitative Analysis of Methotrexate Self-injection Education Videos on YouTube: A Change in the Right Direction.

BACKGROUND: Patients are increasingly turning to the Internet for health guidance, requiring awareness from clinicians of constantly changing resources and quality of available information. A previous study demonstrated a minority of YouTube videos were useful for teaching methotrexate (MTX) self-injection; however, YouTube content constantly evolves, and previous results may not represent current videos. This study provides an update on previous work from 2014 evaluating the quality of YouTube videos demonstrating self-administered subcutaneous MTX injections. Our aim was to evaluate how YouTube videos on MTX injection have changed and evaluate the current video quality. METHODS: "Methotrexate injection" was searched on YouTube. The first 75 videos were analyzed independently by 2 reviewers. Videos were classified as useful, misleading/irrelevant, or a personal patient view and rated for reliability, comprehensiveness, and quality. RESULTS: Of the 75 videos reviewed, 12 were classified as useful (16%), 43 misleading/irrelevant (57.3%), and 20 personal patient views (26.7%). Although this represents a substantial increase from previous results in the proportion of videos deemed misleading/irrelevant (57.3% vs. 27.5%) ( p = 0.0011), their reliability and global quality scores were higher. CONCLUSIONS: Concordant with the previous study, only a small proportion of the total videos were deemed useful videos for MTX injection specifically. However, reliability and global quality scores for all videos increased from the previous study, suggesting more videos provide reliable information with regard to MTX overall, even if it does not speak to self-injection directly. Logistics of the YouTube algorithm may still impede access to the "best" videos for patient teaching; therefore, clinicians should be prepared to recommend strategies for patients to find high-quality videos.

Biological knee reconstruction for combined malalignment, meniscal deficiency, and articular cartilage disease.

PURPOSE: The aim of this study was to analyze patient-reported outcomes in those undergoing the triad of simultaneous osteotomy, meniscal transplantation, and articular cartilage repair. METHODS: Patients undergoing simultaneous meniscal transplantation, distal femoral or proximal tibial osteotomy, and articular cartilage surgery by a single surgeon (B.J.C.) were analyzed. Meniscal transplantation was performed using bone-in-slot techniques. Distal femoral and high tibial osteotomies were performed for valgus and varus malalignment, respectively. Microfracture, autologous chondrocyte implantation, and osteochondral autograft or allograft were performed for articular cartilage disease. Validated patient-reported and surgeon-measured outcomes were collected. Preoperative and postoperative outcomes and medial versus lateral disease were compared using Student t tests. RESULTS: Eighteen participants (mean age, 34 ± 7.8 years; symptomatic patients, 7.4 ± 5.6 years; 2.4 ± 1.0 surgical procedures before study enrollment; mean follow-up, 6.5 ± 3.2 years) were analyzed. Two thirds of participants had medial compartment pathologic conditions and one third had lateral compartment pathologic processes. At final follow-up, there were statistically significant clinically meaningful improvements in International Knee Documentation Committee (IKDC) subjective classification, Lysholm score, and 4 Knee Injury and Osteoarthritis Outcome Score (KOOS) subscores. Postoperative 12-item short form (SF-12) physical and mental component scores were not significantly different from preoperative scores. The Kellgren-Lawrence classification grade was 1.5 ± 1.1 at 2.5 ± 3.0 years after surgery. There was a significantly higher preoperative SF-12 physical composite score (PCS) in participants with lateral compartment pathologic conditions (v medial compartment conditions) (P = .011). Although there were 13 reoperations in 10 patients (55.5% reoperation rate), only one patient was converted to knee arthroplasty (5.6%) and one to revision cartilage surgery and meniscal transplantation (5.6% revision rate). The most common complication was arthrofibrosis (16.7%). CONCLUSIONS: Statistically significant and clinically meaningful improvements in validated patient-reported clinical outcome scores at long-term follow-up were observed in 18 participants undergoing combined meniscal transplantation, osteotomy, and articular cartilage surgery. Although there was a low rate of cartilage or meniscal revision (or both) and total knee arthroplasty, there was a high rate of reoperation. There was no significant difference in outcomes between participants with medial versus lateral pathologic conditions. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Single-row, double-row, and transosseous equivalent techniques for isolated supraspinatus tendon tears with minimal atrophy: A retrospective comparative outcome and radiographic analysis at minimum 2-year followup.

PURPOSE: The purpose of this study was to measure and compare the subjective, objective, and radiographic healing outcomes of single-row (SR), double-row (DR), and transosseous equivalent (TOE) suture techniques for arthroscopic rotator cuff repair. MATERIALS AND METHODS: A retrospective comparative analysis of arthroscopic rotator cuff repairs by one surgeon from 2004 to 2010 at minimum 2-year followup was performed. Cohorts were matched for age, sex, and tear size. Subjective outcome variables included ASES, Constant, SST, UCLA, and SF-12 scores. Objective outcome variables included strength, active range of motion (ROM). Radiographic healing was assessed by magnetic resonance imaging (MRI). Statistical analysis was performed using analysis of variance (ANOVA), Mann - Whitney and Kruskal - Wallis tests with significance, and the Fisher exact probability test <0.05. RESULTS: Sixty-three patients completed the study requirements (20 SR, 21 DR, 22 TOE). There was a clinically and statistically significant improvement in outcomes with all repair techniques (ASES mean improvement P = <0.0001). The mean final ASES scores were: SR 83; (SD 21.4); DR 87 (SD 18.2); TOE 87 (SD 13.2); (P = 0.73). There was a statistically significant improvement in strength for each repair technique (P < 0.001). There was no significant difference between techniques across all secondary outcome assessments: ASES improvement, Constant, SST, UCLA, SF-12, ROM, Strength, and MRI re-tear rates. There was a decrease in re-tear rates from single row (22%) to double-row (18%) to transosseous equivalent (11%); however, this difference was not statistically significant (P = 0.6). CONCLUSIONS: Compared to preoperatively, arthroscopic rotator cuff repair, using SR, DR, or TOE techniques, yielded a clinically and statistically significant improvement in subjective and objective outcomes at a minimum 2-year follow-up. LEVEL OF EVIDENCE: Therapeutic level 3.

Survival and reoperation rates after meniscal allograft transplantation: analysis of failures for 172 consecutive transplants at a minimum 2-year follow-up.

BACKGROUND: Meniscal allograft transplantation (MAT) is a treatment option for knee pain in young patients with meniscal deficiency in the setting of intact articular surfaces, ligamentous stability, and normal alignment. It is being performed with increasing frequency, and the need for reoperations is not uncommon. A mean survival rate of allografts and indications for reoperations would be helpful information when counseling patients regarding the procedure. Purpose/ HYPOTHESIS: The purpose of this study was to quantify survival for MAT and report findings at reoperation. The hypothesis was that the reoperation rate would be frequent and that the most common secondary surgery would be arthroscopic debridement. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review of a prospectively collected database of patients who underwent MAT from 2003 to 2011 was conducted; all surgeries were performed by a single surgeon. The reoperation rate, timing of reoperation, procedure performed at reoperation, and findings at surgery, including the status of the meniscal and articular cartilage, were reviewed. Survival was defined as a lack of revision MAT or knee arthroplasty. Descriptive statistics, log-rank testing, cross-tabulation, and χ2 testing were analyzed, with an α value of .05 set as significant. RESULTS: Of 200 patients who underwent MAT during the study period, 172 patients (86%; mean age, 34.3 ± 10.3 years) were evaluated at a mean of 59 months (range, 24-118 months) with a minimum 2-year follow-up. Forty-one percent of MATs were isolated, while 60% were performed with concomitant procedures. Sixty-four patients (32%) returned to the operating room after their index procedure. Arthroscopic debridement was performed in 59% (38/64) of these patients. The mean time to subsequent surgery was 21 months (range, 2-107 months), with 73% occurring within 2 years. Eight of 172 patients (4.7%) went on to require revision MAT or total knee replacement. Patients requiring secondary surgery within 2 years had an odds ratio of 8.4 (95% CI, 1.6-43.4) for future arthroplasty or MAT revision (P = .007). CONCLUSION: In this series, there was a 32% reoperation rate for MAT, with simple arthroscopic debridement being the most common surgical treatment (59%), and a 95% allograft survival rate at a mean of 5 years. Those requiring additional surgery still benefited, having an 88% allograft survival rate, but were at an increased risk of failure. Patients requiring secondary surgery within 2 years had an odds ratio of 8.4 for future arthroplasty or MAT revision.

Trends in the surgical treatment of articular cartilage lesions in the United States: an analysis of a large private-payer database over a period of 8 years.

PURPOSE: The purpose of this study was to quantify the current trends in knee cartilage surgical techniques performed in the United States from 2004 through 2011 using a large private-payer database. A secondary objective was to identify salient demographic factors associated with these procedures. METHODS: We performed a retrospective database review using a large private-payer medical record database within the PearlDiver database. The PearlDiver database is a publicly available, Health Insurance Portability and Accountability Act-compliant national database compiled from a collection of private insurer records. A search was performed for surgical techniques in cartilage palliation (chondroplasty), repair (microfracture/drilling), and restoration (arthroscopic osteochondral autograft, arthroscopic osteochondral allograft, autologous chondrocyte implantation, open osteochondral allograft, and open osteochondral autograft). The incidence, growth, and demographic factors associated with the surgical procedures were assessed. RESULTS: From 2004 through 2011, 198,876,000 patients were analyzed. A surgical procedure addressing a cartilage defect was performed in 1,959,007 patients, for a mean annual incidence of 90 surgeries per 10,000 patients. Across all cartilage procedures, there was a 5.0% annual incidence growth (palliative, 3.7%; repair, 0%; and restorative, 3.1%) (P = .027). Palliative techniques (chondroplasty) were more common (>2:1 ratio for repair [marrow-stimulation techniques] and 50:1 ratio for restoration [autologous chondrocyte implantation and osteochondral autograft and allograft]). Palliative surgical approaches were the most common technique, regardless of age, sex, or region. CONCLUSIONS: Articular cartilage surgical procedures in the knee are common in the United States, with an annual incidence growth of 5%. Surgical techniques aimed at palliation are more common than cartilage repair and restoration techniques regardless of age, sex, or region. LEVEL OF EVIDENCE: Level IV, retrospective database analysis.

Cartilage Repair With or Without Meniscal Transplantation and Osteotomy for Lateral Compartment Chondral Defects of the Knee: Case Series With Minimum 2-Year Follow-up.

BACKGROUND: Treatment decision making for chondral defects in the knee is multifactorial. Articular cartilage pathology, malalignment, and meniscal deficiency must all be addressed to optimize surgical outcomes. PURPOSE: To determine whether significant clinical improvements in validated clinical outcome scores are observed at minimum 2-year follow-up after articular cartilage repair of focal articular cartilage defects of the lateral compartment of the knee with or without concurrent distal femoral osteotomy and lateral meniscus transplant. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Symptomatic adults who underwent surgical treatment (microfracture, autologous chondrocyte implantation [ACI], osteochondral autograft or allograft) of full-thickness lateral compartment chondral defects of the knee with or without a postmeniscectomy compartment or valgus malalignment by a single surgeon with minimum 2-year follow-up were analyzed. Validated patient-reported and surgeon-measured outcomes were collected pre- and postsurgery. Pre- and postoperative outcomes were compared via Student t tests. RESULTS: Thirty-five subjects (mean age, 29.6 ± 10.5 years) were analyzed. Patients had been symptomatic for 2.51 ± 3.52 years prior to surgery and had undergone 2.11 ± 1.18 surgeries prior to study enrollment, with a mean duration of follow-up of 3.65 ± 1.71 years. The mean defect size was 4.42 ± 2.06 cm(2). Surgeries included ACI (n = 18), osteochondral allograft (n = 14), osteochondral autograft (n = 2), and microfracture (n = 1). There were 18 subjects who underwent concomitant surgery (14 lateral meniscus transplant, 3 distal femoral osteotomy, and 1 combined). Statistically significant (P < .05) and clinically meaningful improvements were observed at final follow-up in Lysholm, subjective International Knee Documentation Committee (IKDS), Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales, Short Form-12 (SF-12) scores, and patient satisfaction. At follow-up, patients undergoing isolated articular cartilage surgery had a significantly higher KOOS quality of life subscore than did those undergoing articular cartilage surgery and lateral meniscus transplant (P = .039). Otherwise, there were no significant postoperative differences between the isolated and combined surgery groups in any outcome score. Five patients underwent 6 reoperations (1 revision osteochondral allograft, 5 chondroplasties). No patient was converted to knee arthroplasty. CONCLUSION: In patients with lateral compartment focal chondral defects with or without lateral meniscal deficiency and valgus malalignment, surgical cartilage repair and correction of concomitant pathology can significantly improve clinical outcomes at 2-year follow-up with no significant differences between isolated and combined surgery and a low rate of complications and reoperations.