Open Ankle Fractures in Older Individuals: A Multi-center Study.

The purpose of this study is to identify demographics, etiology, comorbidities, treatment, complications, and outcomes for older patients with open ankle fractures. Patients ≥60 years old who sustained an open ankle fracture between January 1, 2004 - March 31, 2014 at 6 Level 1 trauma centers were retrospectively reviewed. Univariate analysis using Chi-squared or Student's T-test was performed to identify associations between preoperative variables and two postoperative outcomes of interest: amputation and 1-year mortality. Multivariate analysis was performed using stepwise logistical regression to identify independent predictors of postoperative amputation and 1-year mortality. Of the 162 total patients, the most common mechanism of injury was a ground-level fall (51.9%). The most common fracture types were bimalleolar fractures (52.5%) followed by trimalleolar fractures (26.5%), with 41.5% of the fractures classified as Gustilo Anderson Classification Type 2 and 38.6% classified as Type 3A. The average number of surgeries required per patient was 2.1. Complications included: 15.4% superficial infection rate, 9.9% deep infection rate, and 9.3% amputation rate. The 1-year mortality rate was 13.6% and the overall mortality rate was 25.9%. Male gender and fracture type were found to be independent predictors for amputation after surgery (P = 0.009, 0.005, respectively). Older age and having diabetes were independent predictors for 1-year mortality after surgery (P = 0.021, 0.005 respectively). Overall, open ankle fractures in older individuals were associated with high rates of amputation and mortality.

Point/Counterpoint: Static vs Articulating Spacers-Static Spacers for Resection Arthroplasty of the Knee.

Antibiotic spacers play a significant role in the treatment of periprosthetic joint infections. They help maintain soft-tissue tension and provide delivery of high dose of antibiotics to the local tissue. The use of static or dynamic spacers is based on multiple factors including the extent of soft-tissue, ligamentous and bone compromise, overall patient function, comorbid conditions, and virulence of the organism. There is no difference in reinfection incidence between static vs dynamic spacers following two-stage reimplantation. Static spacers can be customized to treat all cases of periprosthetic total knee infections and offer intraoperative flexibility to vary the cement quantity and amount of antibiotics in the spacer to provide high-dose local delivery of antibiotics to address the dead space, bone loss, and soft-tissue compromise. Static spacers are especially advantageous in cases of extensor mechanism and ligamentous compromise where articulating spacers may not be able to provide adequate stability.

Setting minimum standards for training in EUS and ERCP: results from a prospective multicenter study evaluating learning curves and competence among advanced endoscopy trainees.

BACKGROUND AND AIMS: Minimum EUS and ERCP volumes that should be offered per trainee in "high quality" advanced endoscopy training programs (AETPs) are not established. We aimed to define the number of procedures required by an "average" advanced endoscopy trainee (AET) to achieve competence in technical and cognitive EUS and ERCP tasks to help structure AETPs. METHODS: American Society for Gastrointestinal Endoscopy (ASGE)-recognized AETPs were invited to participate; AETs were graded on every fifth EUS and ERCP examination using a validated tool. Grading for each skill was done using a 4-point scoring system, and learning curves using cumulative sum analysis for overall, technical, and cognitive components of EUS and ERCP were shared with AETs and trainers quarterly. Generalized linear mixed-effects models with a random intercept for each AET were used to generate aggregate learning curves, allowing us to use data from all AETs to estimate the average learning experience for trainees. RESULTS: Among 62 invited AETPs, 37 AETs from 32 AETPs participated. Most AETs reported hands-on EUS (52%, median 20 cases) and ERCP (68%, median 50 cases) experience before starting an AETP. The median number of EUS and ERCPs performed per AET was 400 (range, 200-750) and 361 (range, 250-650), respectively. Overall, 2616 examinations were graded (EUS, 1277; ERCP-biliary, 1143; pancreatic, 196). Most graded EUS examinations were performed for pancreatobiliary indications (69.9%) and ERCP examinations for ASGE biliary grade of difficulty 1 (72.1%). The average AET achieved competence in core EUS and ERCP skills at approximately 225 and 250 cases, respectively. However, overall technical competence was achieved for grade 2 ERCP at about 300 cases. CONCLUSION: The thresholds provided for an average AET to achieve competence in EUS and ERCP may be used by the ASGE and AETPs in establishing the minimal standards for case volume exposure for AETs during their training. (Clinical trial registration number: NCT02509416.).

Competence in Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography, From Training Through Independent Practice.

BACKGROUND & AIMS: It is unclear whether participation in competency-based fellowship programs for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) results in high-quality care in independent practice. We measured quality indicator (QI) adherence during the first year of independent practice among physicians who completed endoscopic training with a systematic assessment of competence. METHODS: We performed a prospective multicenter cohort study of invited participants from 62 training programs. In phase 1, 24 advanced endoscopy trainees (AETs), from 20 programs, were assessed using a validated competence assessment tool. We used a comprehensive data collection and reporting system to create learning curves using cumulative sum analysis that were shared with AETs and trainers quarterly. In phase 2, participating AETs entered data into a database pertaining to every EUS and ERCP examination during their first year of independent practice, anchored by key QIs. RESULTS: By the end of training, most AETs had achieved overall technical competence (EUS 91.7%, ERCP 73.9%) and cognitive competence (EUS 91.7%, ERCP 94.1%). In phase 2 of the study, 22 AETs (91.6%) participated and completed a median of 136 EUS examinations per AET and 116 ERCP examinations per AET. Most AETs met the performance thresholds for QIs in EUS (including 94.4% diagnostic rate of adequate samples and 83.8% diagnostic yield of malignancy in pancreatic masses) and ERCP (94.9% overall cannulation rate). CONCLUSIONS: In this prospective multicenter study, we found that although competence cannot be confirmed for all AETs at the end of training, most meet QI thresholds for EUS and ERCP at the end of their first year of independent practice. This finding affirms the effectiveness of training programs. Clinicaltrials.gov ID NCT02509416.

Laparoscopic-assisted ERCP and EUS in patients with prior Roux-en-Y gastric bypass surgery: a dual-center case series experience.

BACKGROUND: Patients with Roux-en-Y gastric bypass (RYGB) develop pancreatobiliary issues after surgery. Endoscopic management via the conventional route with endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) is quite limited due to the altered anatomy. Laparoscopic-assisted ERCP (LA-ERCP) via the excluded stomach has been highly successful. Reported use of laparoscopic-assisted EUS (LA-EUS) is extremely rare. METHODS: A retrospective review was conducted at two tertiary referral centers for cases that involved laparoscopic-assisted ERCP and EUS. Patient demographic data were collected along with data regarding procedure, indication, complications and length of stay. RESULTS: A total of 16 cases involving 15 patients were identified: 11 cases of LA-ERCP and five cases of combined LA-EUS plus LA-ERCP were performed. Four patients had previously undergone failed endoscopy via the conventional route (27 %). There was a 100 % biliary/pancreatic cannulation and intervention rate. There were no endoscopic-related complications. Therapeutic interventions included laparoscopic cholecystectomy, lysis of adhesions, biliary and pancreatic sphincterotomy, biliary and pancreatic stent placement, stone removal including mechanical lithotripsy and EUS biopsy and diagnosis of pancreatic cancer. Average discharge was on postoperative day 3.4. However, 50 % were discharged after 1 day. CONCLUSIONS: LA-ERCP and combined LA-EUS plus LA-ERCP are safe and highly successful diagnostic and therapeutic modalities for a wide variety of pancreatobiliary ailments in RYGB patients.

High Definition Colonoscopy Combined with i-SCAN Imaging Technology Is Superior in the Detection of Adenomas and Advanced Lesions Compared to High Definition Colonoscopy Alone.

Background. Improved detection of adenomatous polyps using i-SCAN has mixed results in small studies. Utility of i-SCAN as a primary surveillance modality for colorectal cancer screening during colonoscopy is uncertain. Aim. Comparing high definition white light endoscopy (HDWLE) to i-SCAN in their ability to detect adenomas during colonoscopy. Methods. Prospective cohort study of 1936 average risk patients who had a screening colonoscopy at an ambulatory procedure center. Patients underwent colonoscopy with high definition white light endoscopy withdrawal versus i-SCAN withdrawal during endoscopic screening exam. Primary outcome measurement was adenoma detection rate for i-SCAN versus high definition white light endoscopy. Secondary measurements included polyp size, pathology, and morphology. Results. 1007 patients underwent colonoscopy with i-SCAN and 929 with HDWLE. 618 adenomas were detected in the i-SCAN group compared to 402 in the HDWLE group (p < 0.01). More advanced adenomas (≥10 mm) were found by i-SCAN, 79 versus 47 (p = 0.021) and based upon histology alone 37 versus 18 (p = 0.028). Conclusions. i-SCAN detected significantly more adenomas and advanced adenomas compared to high definition white light endoscopy.

Use of i-scan Endoscopic Image Enhancement Technology in Clinical Practice to Assist in Diagnostic and Therapeutic Endoscopy: A Case Series and Review of the Literature.

Background. i-scan is a software-driven technology that allows modifications of sharpness, hue, and contrast to enhance mucosal imaging. It uses postimage acquisition software with real-time mapping technology embedded in the endoscopic processor. Aims. To review applications of i-scan technology in clinical endoscopic practice. Methods. This is a case series of 20 consecutive patients who underwent endoscopic procedures where i-scan image enhancement algorithms were applied. The main outcome measures were to compare mucosal lesions with high-definition white light endoscopy (HD-WLE) and i-scan image enhancement for the application of diagnostic sampling and therapy. Results. 13 cases involving the upper GI tract and 7 cases of the lower GI tract are included. For upper GI tract pathology i-scan assisted in diagnosis or therapy of Barrett's esophagus with dysplasia, esophageal adenocarcinoma, HSV esophagitis, gastric MALT lymphoma, gastric antral intestinal metaplasia with dysplasia, duodenal follicular lymphoma, and a flat duodenal adenoma. For lower GI tract pathology i-scan assisted in diagnosis or therapy of right-sided serrated adenomas, flat tubular adenoma, rectal adenocarcinoma, anal squamous cell cancer, solitary rectal ulcer, and radiation proctitis. Conclusions. i-scan imaging provides detailed topography of mucosal surfaces and delineates lesion edges, which can directly impact endoscopic management.

Ossification within an adenomatous polyp: a case report and review of the literature.

Osseous metaplasia within the gastrointestinal tract is rare and occurs in benign, premalignant, and malignant neoplasms. Here, we report the youngest case of an adenomatous polyp with the presence of ossification and a concomitant review of the literature with regard to ossification of colonic polyps. A 28-year-old man underwent colonoscopy for 8 months of rectal bleeding. A 4.5-cm pedunculated polyp was found in the descending colon and excised. Histological examination showed adenomatous change with an area of calcification and osteoid formation. Ossification of colonic polyps is mainly associated with the clinical symptom of bleeding and may warrant consideration as a high-risk feature.

CD4+ T cells from Copolymer-1 immunized mice protect dopaminergic neurons in the 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine model of Parkinson's disease.

Adoptive transfer of lymphoid cells from Copolymer 1 (Cop-1) immunized mice leads to T cell accumulation within the substantia nigra, modulation of microglial responses, upregulation of glial cell derived neurotrophic factor, and protection of the nigrostriatum following 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) intoxication. We now demonstrate that T cells isolated from lymph nodes and spleens of Cop-1 immunized animals protect the nigrostriatal system from MPTP-induced neurodegeneration in a dose-dependent manner. CD4+ T cells elicited the most significant neuroprotective response while high titers of anti-Cop-1 antibodies showed no effect. These data further support the use of immunomodulatory strategies for Parkinson's disease.