The Effects of Age and Race on Calvarium, Tegmen, and Zygoma Thickness.

OBJECTIVE: Temporal bone spontaneous cerebrospinal fluid (sCSF) leaks are characterized by defects in the tegmen along with calvarial thinning without associated thinning of the extracranial zygoma. The authors sought to determine the effect of age and race on calvarial, tegmen, and zygoma thickness. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary Referral Center. PATIENTS: A total of 446 patients with high-resolution head computer tomography (CT) imaging from 2003 to 2018.Intervention(s): Calvarial, tegmen, and zygoma thicknesses were measured using 3D slicer.Main Outcome Measure(s): Effects of age and race on calvarium, tegmen, zygoma thickness. RESULTS: Among all patients, increased age was associated with increased thickness of the calvarium [95% CI, 0.0002 to 0.007 mm/year, P < 0.05] and tegmen [95% CI, 0.00039 to 0.0075 mm/year, P = 0.03], but decreased thickness of the zygoma [95% CI, -0.013 to -0.005 mm/year, P < 0.001]. When compared to white patients, black patients had thicker mean [SD] calvaria (2.63 [0.61] versus 3.30 [0.79] mm; difference, 0.67 mm; [95% CI, 0.57 to 0.77]; Cohen d, 1.02), tegmen (0.73 [0.34] versus 0.92 [0.36] mm; difference 0.19 mm; [95% CI, 0.101 to 0.279]; Cohen d, 0.533) and zygoma (4.89 [0.81] versus 5.55 [0.91] mm; difference, 0.66 mm; [95% CI, 0.53 to 0.79]; Cohen d, 0.78). CONCLUSIONS: Racial differences exist in calvarial and zygoma thickness. Aging generally leads to increased calvarium and tegmen thickness, suggesting that early onset of obesity and comorbid conditions known to thin the skull base may predispose patients to developing sCSF leaks by reversing the effects of age.

Endoscopic control of polyp burden and expansion of surveillance intervals in serrated polyposis syndrome.

BACKGROUND AND AIMS: Serrated polyposis syndrome (SPS) increases colorectal cancer risk. We describe the numbers of colonoscopies and polypectomies performed to achieve and maintain low polyp burdens, and the feasibility of expanding surveillance intervals in patients who achieve endoscopic control. METHODS: We retrospectively evaluated a prospectively collected database on 115 patients with SPS undergoing surveillance at Indiana University Hospital between June 2005 and May 2018. The endoscopist provided surveillance interval recommendations based on polyp burden. Endoscopic control was considered successful if surveillance examinations exhibited fewer polyps and if no or only an occasional polyp ≥1 cm in size was present at follow-up. Initial control was designated as the clearing phase and the maintenance phase was surveillance after control was established. RESULTS: In total, 87 patients (75.7%) achieved endoscopic control, with some others currently in the clearing phase. Achieving control required a mean of 2.84 colonoscopies (including the baseline) over 20.4 months and a mean total of 27.9 polyp resections. After establishing control, 71 patients were recommended to receive ≥24-month follow-up. Of those, 60 patients (69.0% of patients with initial control) continued surveillance at our center. The mean interval between colonoscopies during maintenance was 19.3 months with 6.74 mean polypectomies per procedure on polyps primarily <1 cm. There were no incident cancers or colon surgeries during maintenance. CONCLUSION: Most patients achieved control of polyp burden with 2 to 3 colonoscopies over 1 to 2 years. After reaching control, 60 patients returned at intervals up to 24 months with no incident cancers and no surgeries required. Expansion of surveillance intervals to 24 months is effective and safe for many patients with SPS who reach control of polyp burden.

SIC-8000 versus hetastarch as a submucosal injection fluid for EMR: a randomized controlled trial.

BACKGROUND AND AIMS: Viscous solutions provide a superior submucosal cushion for EMR. SIC-8000 (Eleview; Aries Pharmaceuticals, La Jolla, Calif) is a commercially available U.S. Food and Drug Administration-approved solution, but hetastarch is also advocated. We performed a randomized trial comparing SIC-8000 with hetastarch as submucosal injection agents for colorectal EMR. METHODS: This was a single-center, double-blinded, randomized controlled trial performed at a tertiary referral center. Patients were referred to our center with flat or sessile lesions measuring ≥15 mm in size. The primary outcome measures were the Sydney resection quotient (SRQ) and the rate of en bloc resections. Secondary outcomes were total volume needed for a sufficient lift, number of resected pieces, and adverse events. RESULTS: There were 158 patients with 159 adenomas (SIC-8000, 84; hetastarch, 75) and 57 serrated lesions (SIC-8000, 30; hetastarch, 27). SRQ was significantly better in the SIC-8000 group compared with hetastarch group (9.3 vs 8.1, P = .001). There was no difference in the proportion of lesions with en bloc resections. The total volume of injectate was significantly lower with SIC-8000 (14.8 mL vs 20.6 mL, P = .038). CONCLUSIONS: SIC-8000 is superior to hetastarch for use during EMR in terms of SRQ and total volume needed, although the absolute differences were small. (Clinical trial registration number: NCT03350217.).

Disagreement between high confidence endoscopic adenoma prediction and histopathological diagnosis in colonic lesions ≤ 3 mm in size.

BACKGROUND: Diminutive colorectal polyps resected during colonoscopy are sometimes histologically interpreted as normal tissue. The aim of this observational study was to explore whether errors in specimen handling or processing account in part for polyps ≤ 3 mm in size being interpreted as normal tissue by pathology when they were considered high confidence adenomas by an experienced endoscopist at colonoscopy. METHODS: One endoscopist photographed 900 consecutive colorectal lesions that were ≤ 3 mm in size and considered endoscopically to be high confidence conventional adenomas. The photographs were reviewed blindly to eliminate poor quality images. The remaining 644 endoscopy images were reviewed by two external experts who predicted the histology while blinded to the pathology results. RESULTS: Of 644 consecutive lesions ≤ 3 mm in size considered high confidence conventional adenomas by a single experienced colonoscopist, 15.4 % were reported as normal mucosa by pathology. The prevalence of reports of normal mucosa in polyps removed by cold snare and cold forceps were 15.2 % and 16.0 %, respectively. When endoscopy photographs were reviewed by two blinded outside experts, the lesions found pathologically to be adenomas and normal mucosa were interpreted as high confidence adenomas by endoscopic appearance in 96.9 % and 93.9 %, respectively, by Expert 1 (P = 0.15), and in 99.6 % and 100 %, respectively, by Expert 2 (P = 0.51). CONCLUSION: Retrieval and/or processing of tissue specimens of tiny colorectal polyps resulted in some lesions being diagnosed as normal tissue by pathology despite being considered endoscopically to be high confidence adenomas. These findings suggest that pathology interpretation is not a gold standard for lesion management when this phenomenon is observed.

Intraprocedural cleansing work during colonoscopy and achievable rates of adequate preparation in an open-access endoscopy unit.

BACKGROUND: Rates of adequate bowel preparation in the 60% to 80% range continue to be reported for colonoscopy. OBJECTIVE: To describe the rate of adequate bowel preparation and intraprocedural work needed to achieve this rate in an open-access endoscopy unit. Universal split dosing and regimens tailored to medical predictors of inadequate preparation were used. DESIGN: Prospective observational study. SETTING: Academic hospital outpatient endoscopy unit and ambulatory surgery center. PATIENTS: Outpatients undergoing colonoscopy. INTERVENTIONS: Prospective assessment of preparation quality for colonoscopy during insertion and after intraprocedural cleansing in 525 patients. MAIN OUTCOME MEASUREMENTS: Rates of adequate preparation and work required to improve cleansing quality. Work time for cleaning was measured with a stopwatch. RESULTS: Adequate preparation to allow recommendation of standard screening or surveillance intervals was achieved in 96% of patients, including 6% for whom preparation was adequate only after intraprocedural cleansing work. The mean time for intraprocedural cleaning was 4.1 minutes and constituted 17% of total procedure time. Work time for cleaning and fluid volume injected increased when worse preparation grades were identified before cleaning. LIMITATIONS: Single-center study with low percentage (4%) of patients receiving Medicaid. CONCLUSION: An open-access unit using split-dose bowel cleansing preparations can achieve high rates of adequate bowel preparation for colonoscopy. Intraprocedural cleansing accounts for a substantial fraction of the total procedure time in colonoscopy and is an important contributor to high rates of adequate preparation.

New colonoscope technology: impact on image capture and quality and on confidence and accuracy of endoscopy-based polyp discrimination.

BACKGROUND AND STUDY AIMS: A newer colonoscope series has optical magnification and improvement in image freezing function. We aimed to assess the impact on image capture, image quality, and polyp discrimination. PATIENTS AND METHODS: In consecutive patients undergoing outpatient colonoscopy images of colorectal polyps were taken with Olympus 190 or 180 series instruments. The number of image captures needed to obtain an adequate image, quality of stored images, proportion of polyps with a high confidence estimate of likely histology, and accuracy of interpretations were compared. RESULTS: An acceptable image at the first attempt was obtained in 97.3 % of photos with the 190 device vs. 83.8 % with the 180 instrument (P < 0.001). In the 190 group narrowband imaging (NBI) provided high confidence readings in 9 % more cases than in the 180 group, but did not improve accuracy of polyp categorization. The quality of the stored images was judged better for the 190 device. However, when images that had provided high confidence estimates of polyp histology were re-interpreted later by the original endoscopist, there was agreement with the original interpretation for > 98 % of polyps in both the 180 group and the 190 group. A second endoscopist agreed with the original high confidence interpretations for 90 % of polyps imaged with either the 180 or the 190 scope. CONCLUSION: The new colonoscope had less image blurring, improved subjective quality of stored images, and increased the proportion of high confidence endoscopic estimates of polyp histology, but did not improve accuracy in estimating polyp histology.

Speech Recognition Outcomes in Adults With Slim Straight and Slim Modiolar Cochlear Implant Electrode Arrays.

OBJECTIVE: To compare differences in audiologic outcomes between slim modiolar electrode (SME) CI532 and slim lateral wall electrode (SLW) CI522 cochlear implant recipients. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary academic hospital. METHODS: Comparison of postoperative AzBio sentence scores in quiet (percentage correct) in adult cochlear implant recipients with SME or SLW matched for preoperative AzBio sentence scores in quiet and aided and unaided pure tone average. RESULTS: Patients with SLW (n = 52) and patients with SME (n = 37) had a similar mean (SD) age (62.0 [18.2] vs 62.6 [14.6] years, respectively), mean preoperative aided pure tone average (55.9 [20.4] vs 58.1 [16.4] dB; P = .59), and mean AzBio score (percentage correct, 11.1% [13.3%] vs 8.0% [11.5%]; P = .25). At last follow-up (SLW vs SME, 9.0 [2.9] vs 9.9 [2.6] months), postoperative mean AzBio scores in quiet were not significantly different (percentage correct, 70.8% [21.3%] vs 65.6% [24.5%]; P = .29), and data log usage was similar (12.9 [4.0] vs 11.3 [4.1] hours; P = .07). In patients with preoperative AzBio <10% correct, the 6-month mean AzBio scores were significantly better with SLW than SME (percentage correct, 70.6% [22.9%] vs 53.9% [30.3%]; P = .02). The intraoperative tip rollover rate was 8% for SME and 0% for SLW. CONCLUSIONS: Cochlear implantation with SLW and SME provides comparable improvement in audiologic functioning. SME does not exhibit superior speech recognition outcomes when compared with SLW.

Middle Cranial Fossa Repair of Temporal Bone Spontaneous CSF Leaks With Hydroxyapatite Bone Cement.

OBJECTIVES: To determine the safety and effectiveness of the middle cranial fossa (MCF) approach in repairing spontaneous cerebrospinal fluid (sCSF) leaks. STUDY DESIGN: Retrospective cohort study. METHODS: Patient with sCSF leaks repaired by MCF approach between January 1, 2014 and August 31, 2019 were included. Demographic information, clinical and surgical findings, and postoperative outcomes were recorded. RESULTS: The cohort (n = 45) included 24 tegmen repairs by multilayer reconstruction using hydroxyapatite cement and 21 cases of multilayer repair without hydroxyapatite cement. Ten MCF repairs were performed on patients ≥65 years old. Twenty (53%) ears had multiple tegmen defects (range, 1-9 tegmen defects) and 78% of patients had ≥1 encephaloceles. All sCSF leaks were resolved with one surgical intervention. There were no major intracranial complications. Transient expressive aphasia occurred in 2 patients. Medical complications occurred in four patients. There were no short-term postoperative CSF leaks with bone cement reconstruction and two postoperative leaks without bone cement. One resolved with lumbar drain (LD) and the other resolved without treatment. The average (SD) length of stay (LOS) with bone cement was shorter than in patients without bone cement (2.54 [0.83] days vs. 3.52 [1.99] days, P < .05). There have been no long-term CSF leak recurrences with an average (SD) follow-up of 13.5 (12.9) months (range 0.25-46 months). CONCLUSIONS: MCF approach for sCSF repairs demonstrate efficacious outcomes, particularly with tegmen reconstruction using hydroxyapatite cement. The approach exhibited no serious adverse events and few complications requiring intervention. Therefore, MCF is a safe and effective approach to resolve sCSF leaks. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:624-632, 2021.

Impact of scribing history and physical notes and procedure reports on endoscopist efficiency during routine procedures: a proof-of-concept study.

BACKGROUND: Efficiency is an important aspect of endoscopic practice that has received limited study. We evaluated the impact of scribing electronic pre-procedure history and physical examinations, and electronic procedure reports on endoscopist efficiency. METHODS: We used a stopwatch to measure the time between the procedures (scope out to scope in), pre-procedure patient assessment time, and procedure report generation time for 180 consecutive procedures performed by a single endoscopist with or without a scribe for recording history and physical and procedure reports. Schedulers were unaware of whether a scribe would be present. RESULTS: Mean times for recording the pre-procedure history and physical and procedure reports were reduced by 34% (p = 0.001) and 71% (p < 0.0001), respectively, when scribes were used. The mean time saved by the endoscopist from scribing the history and the physical and procedure reports was 2.12 and 1.59 min, respectively. When both processes were scribed, the endoscopist spent 42% (p = 0.033) longer in the recovery area (absolute mean increase 1.01 min) compared with when no scribes were utilized. The total time saved per 6.5-h procedure block with both scribes averaged to 41.7 min. CONCLUSION: The use of scribes to record history and physical examination notes and procedure reports saved enough endoscopist time to allow additional procedures or longer procedures, or to free the time for other tasks.