Endoscopic Ultrasound-Guided Biliary Drainage.

Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD) are currently first- and second-line therapeutic options, respectively, for the relief of biliary obstruction. In recent years, however, endoscopic ultrasound-guided biliary drainage (EUS-BD) has become an established alternative therapy for biliary obstruction. There are multiple different techniques for EUS-BD, which can be distinguished based on the access point within the biliary tree (intrahepatic versus extrahepatic) and the location of stent placement (transenteric versus transpapillary). The clinical and technical success rates of biliary drainage for EUS-BD are similar to both ERCP and PTBD, and complication rates are favorable for EUS-BD relative to PTBD. As EUS-BD becomes more widely practiced and endoscopic tools continue to advance, the outcomes will likely improve, and the breadth of indications for EUS-BD will continue to expand.

Body mass index and additional risk factors for cancer in adults with cystic fibrosis.

BACKGROUND: Adults with cystic fibrosis (CF) have an increased risk of a variety of cancers, notably gastrointestinal cancers. In CF higher body mass index (BMI) is associated with improved long-term outcomes, yet in the general population high BMI is associated with increased cancer risk. We aimed to delineate associations between BMI and other factors with cancer risk in adults with CF. METHODS: This was a retrospective cohort study using CF Foundation Patient Registry data from 1992 to 2015. Data were collected on age, sex, CFTR mutation class, pancreatic insufficiency, and annualized data on BMI and FEV1. The primary analysis was the association between BMI and cancer, with secondary analyses focused on BMI trajectory. Multivariable logistic regression was performed, with analyses stratified by history of transplant. RESULTS: Of 26,199 adults with CF, 446 (1.7%) had cancer diagnosed by histology at a mean age of 40.0 years (SD 12.2), with a higher proportion of transplanted patients developing cancer (137 (3.8%) v 309(1.4%), p < 0.001). Among non-transplanted patients, there was no association between BMI and cancer (p for trend = 0.43). Pancreatic insufficiency (p < 0.01) and higher FEV1 (p < 0.01) were associated with increased cancer risk. In transplanted patients, higher BMI was associated with reduced risk of cancer (p for trend = 0.04). Older age was associated with increased risk in both groups (p < 0.001). BMI trajectories were not associated with cancer risk in either group. CONCLUSION: Higher BMI is associated with a reduced risk of cancer in transplanted adults with CF. Pancreatic insufficiency is a risk factor for cancer in non-transplanted CF patients.

Risk of Juvenile Idiopathic Arthritis and Rheumatoid Arthritis in Patients With Celiac Disease: A Population-Based Cohort Study.

INTRODUCTION: Celiac disease (CD) is associated with many immune-mediated conditions, but a definitive epidemiological association between CD and juvenile idiopathic arthritis (JIA) or rheumatoid arthritis (RA) has not been established. We quantified the risk of JIA and RA among patients with CD using a population-based cohort. METHODS: We identified patients diagnosed with biopsy-proven CD between 2004 and 2017 using data from a national histopathology cohort in Sweden. Each patient was matched by age, sex, calendar year, and geographic region to reference individuals in the general population. We calculated the incidence and estimated the relative risk, through Cox proportional hazards models, of JIA in individuals with CD aged <18 and of RA in individuals with CD aged ≥18. RESULTS: We identified 24,014 individuals with CD who were matched to 117,397 reference individuals from the general population. Among individuals aged <18, the incidence rate of JIA was 5.9 per 10,000 person-years in patients with CD and 2.2 per 10,000 person-years in the general population (n events = 40 and 73, respectively; hazard ratio [HR] 2.68, 95% confidence interval 1.82-3.95) over a follow-up of 7.0 years. Among individuals aged ≥ 18, the incidence of RA was 8.4 per 10,000 person-years in CD and 5.1 per 10,000 person-years in matched comparators (n events = 110 and 322, respectively; HR 1.70, 95% confidence interval 1.36-2.12) over a follow-up of 8.8 years. DISCUSSION: Among children with CD, JIA develops nearly 3 times as often as it does in the general population, and among adults with CD, RA occurs nearly 2 times as often. Clinicians caring for patients with CD with joint symptoms should have a low threshold to evaluate for JIA or RA.

Prevalence of Adenomas on Surveillance Colonoscopies for Patients with a History of Colonic Polyps of Unknown Histology.

BACKGROUND: Guidelines for surveillance colonoscopy depend on polyp histology. When patients present to a new healthcare system and report a personal history of "colon polyps," however, information on polyp histology is frequently unavailable. AIMS: To assess adenoma prevalence in patients with a history of colonic polyps of unknown histology and to compare it to patients undergoing either screening colonoscopy or surveillance colonoscopy for known adenomatous polyps. METHODS: This cohort study evaluated colonoscopies of patients ≥ 50 years of age over a 14-year period at a single institution. The exposure of interest was colonoscopy indication, categorized into three groups: screening colonoscopy, surveillance colonoscopy for history of colonic polyp(s) of unknown histology, and surveillance colonoscopy for history of adenoma(s). The primary outcome was adenoma detection rate. Multivariable logistic regression was used to assess the association between colonoscopy indication and adenoma detection rate. RESULTS: Of 31,856 colonoscopies, the adenoma prevalence was 26.1% for patients undergoing screening colonoscopy, 32.9% for patients with a history of polyps of unknown histology, and 41.9% for patients with a history of known adenomatous polyps. Relative to screening colonoscopies, there were higher odds of adenoma detection in surveillance colonoscopies for polyps of unknown histology (aOR compared to screening 1.42, 95% CI 1.30-1.55) and even higher odds among surveillance colonoscopies for a history of adenoma (aOR compared to screening 1.89, 95% CI 1.75-2.05). CONCLUSION: The adenoma prevalence on surveillance colonoscopy for patients with polyps of unknown histology was higher than that of screening colonoscopies but lower than that of surveillance colonoscopies for patients with adenomatous polyps.

A New Preoperative Planning Technique Can Reduce Radiation Exposure During the Performance of Medial Opening-Wedge High Tibial Osteotomy.

BACKGROUND: Medial opening-wedge high tibial osteotomy (HTO) is one of the most common and effective HTO techniques, in which the proximal tibia is cut medially, leaving an intact lateral hinge of bone that can be opened to a variable amount for the desired correction, but the technical complications of lateral cortex fracture and intra-articular fracture are well described. The lateral bone hinge for medial opening-wedge HTO is crucial. If the hinge is too small, the tibia can fracture and become unstable, requiring further fixation. If the hinge is too large, the osteotomy can propagate into the joint as an intra-articular fracture when opening the osteotomy. PURPOSE: We propose a new technique that utilizes digital preoperative templating to improve the accuracy of the cut. Preoperative digital templating may allow the surgeon to reproducibly obtain a lateral bone hinge of 10 mm, while also reducing radiation exposure relative to the traditional fluoroscopically assisted technique. METHODS: Ten cadaver extremities from five cadavers were matched into pairs and randomized into two groups: those with and without preoperative templating. The templating protocol measures the distance between two points on the medial and lateral cortices, and 20 mm is subtracted to determine the depth of the saw cut (10 mm for the hinge and another 10 mm because the proximal tibia is oval in shape). The control method was done by making the cut using fluoroscopy with tactile feedback. Postoperative computed tomography scans were obtained of all legs to measure the width of the lateral bone hinge. Intraoperative fluoroscopy used during both techniques and the numbers of fluoroscopy shots were recorded. RESULTS: We found neither the treatment group with preoperative planning nor the control group with the conventional technique had bone hinge widths that were different from the ideal 10 mm. The average hinge widths for the treatment and control groups were 11.2 and 11.5 mm, respectively. However, the treatment group was exposed to significantly less intraoperative fluoroscopy during the osteotomy cut. The average total number of fluoroscopy shots was 2.2 in the treatment group versus 6.3 for the control group. CONCLUSIONS: This new preoperative planning technique achieves similar accuracy of the lateral bone hinge when compared to current methods but exposes the patient, surgeon, and staff to significantly less intraoperative radiation.

Longitudinal Tracking of Sound Exposure and Hearing Aid Usage through Objective Data Logs.

Objective To use data-logging technology to objectively track and identify predictors of hearing aid (HA) usage and aided sound exposure. Study Design Case series with planned data collection. Setting Tertiary academic medical center. Subjects and Methods Individuals with HAs between 2007 and 2016 were included (N = 431; mean, 74.6 years; 95% CI, 73.1-76.0). Data-logging technology intrinsic to new-generation HAs was enabled to track usage and sound exposure. With multivariable linear regression, age, sex, number of audiology visits, duration of audiologic follow-up, pure tone average, and HA side were assessed as predictors of usage (hours/day) and aided sound exposure (dB-hours/day; ie, "dose" of sound per day). Results Mean follow-up was 319 days (95% CI, 277-360). Mean HA usage was 8.4 hours/day (95% CI, 8.0-8.8; N = 431). Mean aided sound exposure was 440 dB-hours/day (95% CI, 385-493; n = 110). HA use (ß < 0.001, P = .45) and aided sound exposure (ß = -0.006, P = .87) were both stable over time. HA usage was associated only with hearing loss level (pure tone average; ß = 0.030, P = .04). Aided sound exposure was associated only with duration of audiologic follow-up (ß = 0.100, P = .02). Conclusion While measurement of HA use has traditionally relied on subjective reporting, data logging offers an objective tool to longitudinally track HA use and sound exposure. We demonstrate the feasibility of using this potentially powerful research tool. Usage and sound exposure were stable among patients throughout the study period. Use was greater among subjects with greater hearing loss. Maximizing aided sound exposure might be possible through continued audiology follow-up visits.

Does the Chronicity of Anterior Cruciate Ligament Ruptures Influence Patient-Reported Outcomes Before Surgery?

BACKGROUND: The time between an anterior cruciate ligament (ACL) injury and ACL reconstruction (ACLR) may influence baseline knee-related and general health-related patient-reported outcome measures (PROMs). Despite the common use of PROMs as main outcomes in clinical studies, this variable has never been evaluated. PURPOSE: To compare baseline health-related quality of life measures and the prevalence/pattern of meniscal and articular cartilage lesions between patients who underwent acute and chronic ACLR so as to provide clinicians with benchmark PROMs in 2 different patient populations with ACL injuries. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A total of 1192 patients from the MOON (Multicenter Orthopaedic Outcomes Network) cohort who underwent primary ACLR were eligible. "Acute" ACLR was defined as <3 months (n = 853; 71.6%) and "chronic" ACLR as >6 months (n = 339; 28.4%) from injury. Patient demographics, surgical characteristics (articular cartilage injury, medial meniscal [MM] and lateral meniscal [LM] tears), and baseline PROM scores (Marx activity rating scale, International Knee Documentation Committee [IKDC] subjective form, Knee injury and Osteoarthritis Outcome Score [KOOS], and Short Form-36 Health Survey [SF-36]) were collected to determine whether the time from injury to ACLR influences (1) baseline PROMs and (2) the pattern and prevalence of concurrent articular cartilage and meniscal injuries. Analysis of covariance models were used to adjust for confounders on baseline outcome scores (age, sex, body mass index [BMI], smoking status, competition level, education). RESULTS: The median patient age was 23 years (interquartile range [IQR], 17-35 years), 530 (44.5%) were female, and the median BMI was 25.0 kg/m2 (IQR, 22.3-27.9 kg/m2); however, the chronic group was older, had a higher BMI, and consisted of fewer collegiate athletes. A significantly greater number of partial LM tears were seen in the acute group versus the chronic group (14.2% vs 6.5%, respectively; P < .001), but there were more meniscal tears overall (73.5% vs 63.2%, respectively; P = .001), complete MM tears (49.0% vs 22.5%, respectively; P < .001), and articular cartilage injuries (54.0% vs 32.8%, respectively; P < .001) in the chronic group versus the acute group. After controlling for confounders, patients in the chronic ACLR group reported a significantly lower baseline Marx score (7.75 vs 12.10, respectively; P < .001) but higher baseline IKDC, SF-36 physical functioning, and all KOOS subscale scores except the KOOS-quality of life subscale score compared to those in the acute ACLR group; however, only the KOOS-sports and recreation subscale exceeded the minimum clinically importance difference of 8 points (62.30 vs 48.26, respectively; P < .001). CONCLUSION: After controlling for age, sex, competition level, smoking, and BMI, patients in the chronic ACLR group participated in less pivoting and cutting sports but reported better pain/function. Whether decreased activity is deliberate after an ACL injury or patients who undergo chronic ACLR are simply less active and may be treated successfully without surgery warrants further investigation. Nonrandomized studies that utilize PROMs should consider time from injury in study design and data interpretation.

Outcomes of Surgical Treatment of Posterolateral Instability of the Knee.

The purpose of this review is to assess the outcomes of surgical treatment of posterolateral instability of the knee in an evidence-based manner. The majority of the existing outcomes literature on posterolateral instability consists of small, level IV case series and level III retrospective studies. Outcomes of surgical treatment of posterolateral instability of the knee are difficult to compare because of the heterogeneous presentation of posterolateral corner (PLC) injuries, the variability of their associated injuries, and their relative rarity. As such, three common types of surgical intervention for posterolateral instability are explored separately in this article, including acute repair, acute reconstruction, and chronic reconstruction. In general, the current literature supports early anatomic repair of all soft tissues and concomitant PLC reconstruction; however, because of the variability of posterolateral injury, surgical treatment options should be tailored to the patient, depending on the severity and chronicity of the posterolateral instability, as well as the associated injuries present.