Virtual Reality as an Adjunct to Traditional Patient Counseling in Patients With Newly Diagnosed Localized Prostate Cancer.

OBJECTIVE: To determine the utility of a virtual reality (VR) model constructed using patient-derived clinical imaging to improve patient understanding of localized prostate cancer (PCa) diagnosis and surgical plan. METHODS: Patients undergoing robotic radical prostatectomy were selected and demographic data recorded. Patients completed a questionnaire to assess baseline knowledge of their diagnosis after consultation and shared-decision making with their surgeon. A trained non-clinical staff member then guided the patient through a VR experience to view patient-specific anatomy in a 3-dimensional space. Patients then completed the same questionnaire, followed by an additional post-VR questionnaire evaluating patient satisfaction. Questions 1-7 (patient understanding of prostate cancer and treatment plan) and 11-17 (patient opinion of VR) used a standard Likert scale and Questions 8-10 were multiple choice with 1 correct answer. RESULTS: In total, 15 patients were included with an average age of 64.1 years. 6 of 7 questions showed an improvement after VR (P <.001). The percentage of correct responses on Questions 8-10 was higher after VR but not statistically significant (P >.13). Mean responses range from 4.3 to 4.8 (Likert scale, 1 through 5) for the post-VR questionnaire, with a mean total of 31.9 out of 35. CONCLUSION: This small preliminary investigation of a novel technology to improve the patient experience showed potential as an adjunct to traditional patient counseling. However, due the small sample size and study design, further research is needed to determine the value VR adds to prostate cancer surgical counseling.

Association of day of surgery and distance traveled with length of stay in patients undergoing robotic-assisted partial nephrectomy (RAPN) at a tertiary medical center.

The objective of this study is to analyze the association between surgical day of the week and distance traveled with prolonged length of stay (LOS) following robotic-assisted partial nephrectomy (RAPN). 563 consecutive RAPN performed by a single surgeon were evaluated. Early week RAPN was considered Monday through Wednesday, while late-week RAPN was defined as surgery performed Thursday through Friday. Distance traveled for RAPN was evaluated as greater than or less than 60 miles. The respective groups were compared to see if the surgical day of the week or distance traveled influenced the hospital stay or prolonged hospital stay (defined as hospital length of stay equal or greater than 3 days). Overall, 213 patients (38.0%) undergoing RAPN experienced a prolonged LOS. A total of 380 patients underwent early week RAPN compared to 183 late-week RAPN. Patients undergoing late-week RAPN were more likely to have a prolonged LOS compared to early week RAPN (n = 81, 44% vs. n = 133, 35%, respectively; p = 0.004). 229 patients traveled less than 60 miles, while 332 patients traveled more than 60 miles to receive RAPN. 135 patients (40.7%) traveling more than 60 miles experienced a prolonged stay compared to 78 patients (34.1%) traveling less than 60 miles, although this difference was not statistically significant (p = 0.128). Patients who underwent RAPN at the end of the week were more likely to have a prolonged LOS, while distance traveled for RAPN did not appear to affect likelihood of prolonged LOS.

Simulation: An Effective Method of Teaching Cosmetic Botulinum Toxin Injection Technique.

BACKGROUND: Learning to inject botulinum toxin for cosmetic purposes is difficult for beginners, given the nature of the procedure and patient population. Simulation training is an effective modality for medical professionals to acquire skills in an environment that provides low stress and ample opportunity for questions and correction of mistakes. OBJECTIVES: Compare posttraining comfort, knowledge, and practical botulinum toxin injection scores among trainees who underwent simulation vs video training only. METHODS: A total of 20 nurse practitioners, physician assistants, and resident physicians underwent cosmetic botulinum toxin injection training either through lecture and video, or lecture and hands-on simulation training. Comfort, knowledge, and practical test scores were recorded and compared between the groups. RESULTS: There was no evidence of a statistically significant difference in comfort or knowledge scores between simulation and video groups. The median (range) practical score was significantly higher in the simulation group compared to the video group (59.0 [31-60] vs 44.5 [27-57]; P < 0.01). CONCLUSIONS: Despite feeling similarly comfortable and having similar written knowledge test scores, the trainees who underwent simulation training had significantly higher hands-on practical test scores compared to trainees who underwent video training only for cosmetic botulinum toxin injections.

Development and validation of a prediction model for adenoma detection during screening and surveillance colonoscopy with comparison to actual adenoma detection rates.

OBJECTIVE: The adenoma detection rate (ADR) varies widely between physicians, possibly due to patient population differences, hampering direct ADR comparison. We developed and validated a prediction model for adenoma detection in an effort to determine if physicians' ADRs should be adjusted for patient-related factors. MATERIALS AND METHODS: Screening and surveillance colonoscopy data from the cross-sectional multicenter cluster-randomized Endoscopic Quality Improvement Program-3 (EQUIP-3) study (NCT02325635) was used. The dataset was split into two cohorts based on center. A prediction model for detection of ≥1 adenoma was developed using multivariable logistic regression and subsequently internally (bootstrap resampling) and geographically validated. We compared predicted to observed ADRs. RESULTS: The derivation (5 centers, 35 physicians, overall-ADR: 36%) and validation (4 centers, 31 physicians, overall-ADR: 40%) cohort included respectively 9934 and 10034 patients (both cohorts: 48% male, median age 60 years). Independent predictors for detection of ≥1 adenoma were: age (optimism-corrected odds ratio (OR): 1.02; 95%-confidence interval (CI): 1.02-1.03), male sex (OR: 1.73; 95%-CI: 1.60-1.88), body mass index (OR: 1.02; 95%-CI: 1.01-1.03), American Society of Anesthesiology physical status class (OR class II vs. I: 1.29; 95%-CI: 1.17-1.43, OR class ≥III vs. I: 1.57; 95%-CI: 1.32-1.86), surveillance versus screening (OR: 1.39; 95%-CI: 1.27-1.53), and Hispanic or Latino ethnicity (OR: 1.13; 95%-CI: 1.00-1.27). The model's discriminative ability was modest (C-statistic in the derivation: 0.63 and validation cohort: 0.60). The observed ADR was considerably lower than predicted for 12/66 (18.2%) physicians and 2/9 (22.2%) centers, and considerably higher than predicted for 18/66 (27.3%) physicians and 4/9 (44.4%) centers. CONCLUSION: The substantial variation in ADRs could only partially be explained by patient-related factors. These data suggest that ADR variation could likely also be due to other factors, e.g. physician or technical issues.

Impact of an Endoscopic Quality Improvement Program Focused on Adenoma Detection on Sessile Serrated Adenoma/Polyp Detection.

BACKGROUND: Sessile serrated adenomas/polyps (SSA/P) are an under-recognized disease with a unique malignant pathway. Improved endoscopic recognition and pathological interpretation is needed. AIMS: To determine whether an educational intervention that improved adenoma detection rate (ADR) could improve SSA/P detection rate after reclassification of previously termed "hyperplastic" polyps. METHODS: We reanalyzed data from a prospective randomized trial of an educational intervention aimed at increasing ADR. All hyperplastic polyps ≥6 mm reported in a previously published study were rereviewed and reclassified using standardized criteria for serrated lesions. Detection rates of sessile serrated adenomas/polyps and other clinically relevant serrated polyps were calculated in the baseline and post-training phases of the original study. RESULTS: Of 263 available for rereview, 33 (12.5%) were reclassified as SSA/P (N = 32) or traditional serrated adenoma (TSA) (N = 1). Reclassification was more common in the right colon (18 vs. 8%, p = 0.02). Baseline SSA/P detection rate was 0.7% in the untrained group and 1.3% in the trained group. Post-training, the SSA/P detection rate increased to 2.1 and 1.5%, respectively. The clinically relevant serrated polyp detection rate at baseline was 14.2% in the untrained group and 11.3% in the trained group. After the educational intervention, the clinically relevant serrated polyp detection rates increased to 16.5 and 14.8% in the untrained and trained groups, respectively. The estimated odds of an endoscopist detecting either a SSA/P or other clinically relevant serrated polyp during colonoscopy increased by only 3% with the educational intervention (OR 1.03, 95% CI 0.61-1.74, p = 0.91). CONCLUSIONS: Pathological re-interpretation of larger serrated polyps resulted in the reclassification of 12.5% of lesions. Quality improvement methods focused on adenoma detection did not impact SSA/P detection, and thus specific methods for serrated polyp detection are needed.

Predictors of Suboptimal Gain in Exercise Capacity After Cardiac Rehabilitation.

Cardiac rehabilitation (CR) improves exercise capacity (EC), but not all CR participants achieve such improvements. Our primary aim was to develop a tool to identify those with suboptimal improvement in EC after CR. We retrospectively analyzed 541 patients enrolled in a phase-II CR program after a cardiac event or intervention from 2003 to 2014. EC was assessed with the 6-minute walk test. We developed a multivariate linear regression model and corresponding nomogram to predict EC after CR. The predictors included in the final model were age, gender, baseline EC, primary referral diagnosis, body mass index, systolic blood pressure at rest, triglycerides, low-density lipoprotein cholesterol, lipid-lowering medication use, and an interaction term of low-density lipoprotein cholesterol with lipid-lowering therapy. The prediction model was internally validated using bootstrap methods, and a nomogram was created for ease of use. In conclusion, this tool helps to identify those patients with suboptimal improvement in EC who could be targeted for individualized interventions to increase their performance.

Prevalence of BCL-2/J(H) Translocation in Healthy African Americans.

The translocation t(14;18)(q32;q21) (BCL-2/J(H)) is present in over 80 % of all follicular lymphomas and is detectable in peripheral blood lymphocytes (PBL) of healthy individuals. The prevalence of this translocation has not been studied in African Americans (AAs). Given the higher incidence of follicular lymphomas in whites compared to AAs in the United States (USA), we hypothesized that the translocation prevalence in the blood of AAs would be lower. DNA was isolated from PBL from blood samples collected from participants from FL. Polymerase chain reaction was performed on the BCL-2/J(H) major (MBC) and minor breakpoint cluster (mBC) regions. Eight of the 77 (10.4 %) blood samples from AA participants were positive for MBC (95 % CI, 4.6-19.5 %), and three (3.9 %) were positive for mBC (95 % CI, 0.81-10.97 %) of BCL-2/J(H), with a total of 11 (14.3 %) participants with positive samples (95 % CI, 7.35-24.13 %). In 167 white patient samples, 22 (13.2 %; 95 % CI, 8.44-19.26 %) were positive for MBC, and five (3.0 %; 95 % CI, 0.98-6.85 %) were positive for mBC, with a total of 25 (15 %) participants with positive samples (CI, 9.93-21.30 %). The prevalence of t(14;18)(q32;q21) is not significantly different among AAs and whites from the USA. The lower prevalence of follicular lymphomas in AAs compared with whites is likely a result of differences in secondary molecular alterations involved in follicular lymphoma development. This study is the first report of prevalence of t(14;18) in an AA cohort.

Effect of an endoscopic quality improvement program on adenoma detection rates: a multicenter cluster-randomized controlled trial in a clinical practice setting (EQUIP-3).

BACKGROUND: Colonoscopy is protective against colorectal cancer, but its quality and protective benefits can vary. Adenoma detection rate (ADR) is associated with quality and the degree of protection against colorectal cancer and death. In a previous, single academic center, randomized, controlled trial, we demonstrated that an endoscopic quality improvement program increased ADR (EQUIP-1) and that those increases were durable (EQUIP-2). We hypothesized that EQUIP training would increase ADR in a multicenter clinical practice setting. METHODS: Nine large clinical practice sites were recruited. After a baseline period (phase I), 5 sites were randomized to receive supplemental in-person EQUIP training with active feedback. After follow-up (phase II), the changes in ADRs at these sites were compared with the changes at 4 control sites that did not receive training or feedback until after study completion. RESULTS: Twenty-two thousand three hundred sixteen colonoscopies were included. There was a statistically significant increase in ADR at the training sites (odds ratio [OR], 1.28; P = .004) with a raw ADR of 31% in phase I and 42% in phase II after the intervention. However, raw ADRs also increased at the control sites (from 36% to 39%). As a result, there was limited evidence of a training effect (OR, 1.03; 95% confidence interval [CI], 0.84-1.25; P = .78). CONCLUSIONS: ADRs increased at the sites participating in the endoscopic quality improvement program. However it is not clear to what extent the training program is responsible for the changes, because raw ADRs also increased at the control sites but to a lesser extent. (Clinical Trials Registration number: NCT02325635.).

Preoperative Clinical Characteristics That Identify Potential Low-Volume Transfusion Candidates Among Orthotopic Liver Transplant Patients.

OBJECTIVES: The primary aim of this study was to determine whether specific preoperative clinical characteristics were associated with low-volume transfusion in liver transplant recipients. Low-volume transfusion was defined as transfusion of < 2100 mL of packed red blood cells intraoperatively during liver transplant. The ability to accurately predict low-volume transfusion could increase patient safety, decrease complications associated with transfusion, improve blood management, and decrease transplant case cost. MATERIALS AND METHODS: Data were retrieved by retrospective chart review of 266 patients who received a liver transplant at the Mayo Clinic (Jacksonville, FL, USA). The primary outcome was low-volume transfusion. Associations of preoperative information with low-volume transfusion were explored using single-variable and multivariable logistic regression models; missing data were imputed with the sample median for continuous data and the most frequent category for categorical variables. RESULTS: Low-volume transfusion occurred in 23% of first-time liver transplant recipients (62/266 patients; 95% confidence interval, 18%-29%). History of hepatitis C virus infection (P = .048), history of hepatocellular carcinoma (P = .050), short cold ischemia time (P = .006), and low international normalized ratio (P = .002) were independently associated with low-volume transfusion during liver transplant in a multivariable logistic regression model. CONCLUSIONS: Multiple studies have shown increased morbidity and mortality after orthotopic liver transplant when more than 6 U of packed red blood cells are administered within 24 hours of surgical incision. A method to identify low-volume transfusion candidates could help predict patient outcomes, decrease blood handling, and reduce costs. If patients with low-volume transfusion could be identified, fewer blood products would need to be prepared in advance. Although elevated preoperative coagulation parameters decrease the probability of low-volume transfusion, a definitive profile of a low-volume transfusion liver transplant recipient was not established.

Contrast-induced nephropathy in outpatients with preexisting renal impairment: a comparison between intravenous iohexol and iodixanol.

BACKGROUND: Concern for contrast-induced nephropathy (CIN) may result in administration of more costly agents. We prospectively compared outpatient CIN incidence of iodixanol to iohexol. METHODS: Patients were randomized to receive 100ml of iohexol (n=47) or iodixanol (n=55). We compared patients who developed CIN using the Wilson score interval and also calculated an odds ratio for the development of CIN. RESULTS: CIN rate for iohexol was 2% compared to 9% for iodixanol. Those receiving iodixanol were almost 5 times more likely to experience CIN. CONCLUSION: These results do not suggest a benefit of iodixanol over iohexol in the study population.

Prospective evaluation of the association of adherent perinephric fat with perioperative outcomes of robotic-assisted partial nephrectomy.

OBJECTIVE: To prospectively analyze the association of adherent perinephric fat (APF) with perioperative outcomes of robotic-assisted partial nephrectomy (RAPN). METHODS: We analyzed 100 consecutive RAPNs performed by a single experienced surgeon and defined APF as the necessity of subcapsular renal dissection to mobilize the kidney and isolate the renal tumor for RAPN. Our primary analysis focused on comparing perioperative outcomes, including operative time, warm ischemia time, estimated blood loss, postoperative complications, length of stay, and margins, ischemia, and complications score between patients with and without APF. To control the probability of obtaining a false-positive finding at 5% after the numerous statistical comparisons that were performed, we used a Bonferroni correction for multiple comparisons, after which P values of ≤.0042 were considered to be statistically significant. RESULTS: Thirty patients (30%) had APF. Presence of APF was not significantly associated with blood loss, warm ischemia time, hospital stay, postoperative complications, or margins, ischemia, and complications score. We noted some evidence of longer operative times in patients with APF compared with those without APF (median, 223 vs199 minutes; P = .026); however, this was not significant after adjustment for multiple comparisons. In multivariate analysis, we noted stronger evidence of associations with increased operative time for RENAL score (P <.001) and body mass index (P = .020) than for the presence of APF (P = .32). CONCLUSION: APF may be associated with slightly longer operative times but does not appear to affect perioperative complications or outcomes.

Mayo adhesive probability score: an accurate image-based scoring system to predict adherent perinephric fat in partial nephrectomy.

BACKGROUND: Image-based renal morphometry scoring systems are used to predict the potential difficulty of partial nephrectomy (PN), but they are centered entirely on tumor-specific factors and neglect other patient-specific factors that may complicate the technical aspects of PN. Adherent perinephric fat (APF) is one such factor known to make PN difficult. OBJECTIVE: To develop an accurate image-based nephrometry scoring system to predict the presence of APF encountered during robot-assisted partial nephrectomy (RAPN). DESIGN, SETTING, AND PARTICIPANTS: We prospectively analyzed 100 consecutive RAPNs performed by one surgeon and defined APF as the need for subcapsular renal dissection to isolate the renal tumor for RAPN. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The scoring algorithm to predict the presence of APF was developed with a multivariable logistic regression model using a forward selection approach with a focus on improvement in the area under the receiver operating characteristic curve. RESULTS AND LIMITATIONS: Thirty patients (30%; 95% confidence interval, 21-40) had APF. Single-variable analysis noted an increased likelihood of APF in male patients (p<0.001), higher body mass index (p=0.003), greater posterior perinephric fat thickness (p<0.001), greater lateral perinephric fat thickness (p<0.001), and those with perirenal fat stranding (p<0.001). Two of these variables, posterior perinephric fat thickness and stranding, were most highly predictive of APF in multivariable analysis and were therefore used to create a risk score, termed Mayo Adhesive Probability (MAP) and ranging from 0 to 5, to predict the presence of APF. We observed APF in 6% of patients with a MAP score of 0, 16% with a score of 1, 31% with a score of 2, 73% with a score of 3-4, and 100% of patients with a score of 5. CONCLUSIONS: MAP score accurately predicts the presence of APF in patients undergoing RAPN. Prospective validation of the MAP score is required. PATIENT SUMMARY: The Mayo Adhesive Probability score that we we developed is an accurate system that predicts whether or not adherent perinephric, or "sticky," fat is present around the kidney that would make partial nephrectomy difficult.

Development and validation of the Mayo Clinic Bowel Prep Tolerability Questionnaire.

BACKGROUND: Bowel cleansing is paramount for colonoscopy quality. Unfortunately, an adequate bowel preparation is often limited by side effects and/or patient's intolerance to bowel preparation solutions. Comparisons among different preparations are limited by the lack of validated instruments designed to assess patient's tolerability. AIM: To develop and validate a simple, comprehensive instrument to assess bowel preparation tolerability in patients undergoing colonoscopy. METHODS: Development and validation by phases: Phase I (bibliographic search and questionnaire design); Phase II (assessment of content validity and modification of the questionnaire); Phase III (assessment of reproducibility, final validation, and definitive version of the questionnaire). RESULTS: The initial draft of the questionnaire was generated based on a systematic literature review and feedback from a panel of consultants. Content validity was tested in a focus group of 25 patients undergoing colonoscopy. Patients' suggestions were reviewed by the research team and a second draft of the questionnaire was generated. Final validation and reproducibility were successfully tested (agreement: 86-100%, kappa: 0.77-1.00) in a convenience sample of 100 patients undergoing bowel preparation with different cleansing solutions. CONCLUSION: The Mayo Clinic Bowel Prep Tolerability Questionnaire is a simple, comprehensive instrument suitable to evaluate the tolerability of various types of bowel preparations.

Ultrasound-guided transversus abdominis plane blocks for patients undergoing laparoscopic hand-assisted nephrectomy: a randomized, placebo-controlled trial.

Postoperative pain is a common complaint following living kidney donation or tumor resection using the laparoscopic hand-assisted technique. To evaluate the potential analgesic benefit of transversus abdominis plane blocks, we conducted a randomized, double-blind, placebo-controlled study in 21 patients scheduled to undergo elective living-donor nephrectomy or single-sided nephrectomy for tumor. Patients were randomized to receive either 20 mL of 0.5% ropivacaine or 20 mL of 0.9% saline bilaterally to the transversus abdominis plane under ultrasound guidance. We found that transversus abdominis plane blocks reduced overall pain scores at 24 hours, with a trend toward decreased total morphine consumption. Nausea, vomiting, sedation, and time to discharge were not significantly different between the two study groups.

A clinical scoring system to identify patients with sebaceous neoplasms at risk for the Muir-Torre variant of Lynch syndrome.

PURPOSE: The Muir-Torre syndrome variant of Lynch syndrome is characterized by the presence of sebaceous neoplasms (adenoma, epithelioma/sebaceoma, carcinoma) and Lynch syndrome-associated cancers (colon, endometrial, and others). Several clinical scoring systems have been developed to identify patients with colon cancer at high risk of Lynch syndrome. However, no such system has been described for patients presenting with sebaceous neoplasms. METHODS: Based on logistic regression analysis, a scoring system was developed for patients with sebaceous neoplasm to identify those with the highest likelihood of having Muir-Torre syndrome. The final version of the scoring system included variables such as age at presentation of initial sebaceous neoplasm, total number of sebaceous neoplasms, personal history of a Lynch-related cancer, and family history of Lynch-related cancers. RESULTS: Patients with a score of 3 or more were more likely to have Muir-Torre syndrome (28 of 29 patients), those with a score of 2 had intermediate likelihood (12 of 20 patients), and no patient with a score of 0 or 1 was diagnosed with Muir-Torre syndrome. CONCLUSION: The Mayo Muir-Torre syndrome risk scoring system appears to identify whether patients who present with sebaceous neoplasms are in need of further Lynch syndrome evaluation using easily ascertained clinical information. Abnormal mismatch repair gene immunohistochemistry of a sebaceous neoplasm is a poor predictor in regard to diagnosing Lynch syndrome.

Classification system for identifying women at risk for altered partial breast irradiation recommendations after breast magnetic resonance imaging.

PURPOSE: To study the utility of preoperative breast MRI for partial breast irradiation (PBI) patient selection, using multivariable analysis of significant risk factors to create a classification rule. METHODS AND MATERIALS: Between 2002 and 2009, 712 women with newly diagnosed breast cancer underwent preoperative bilateral breast MRI at Mayo Clinic Florida. Of this cohort, 566 were retrospectively deemed eligible for PBI according to the National Surgical Adjuvant Breast and Bowel Project Protocol B-39 inclusion criteria using physical examination, mammogram, and/or ultrasound. Magnetic resonance images were then reviewed to determine their impact on patient eligibility. The patient and tumor characteristics were evaluated to determine risk factors for altered PBI eligibility after MRI and to create a classification rule. RESULTS: Of the 566 patients initially eligible for PBI, 141 (25%) were found ineligible because of pathologically proven MRI findings. Magnetic resonance imaging detected additional ipsilateral breast cancer in 118 (21%). Of these, 62 (11%) had more extensive disease than originally noted before MRI, and 64 (11%) had multicentric disease. Contralateral breast cancer was detected in 28 (5%). Four characteristics were found to be significantly associated with PBI ineligibility after MRI on multivariable analysis: premenopausal status (P=.021), detection by palpation (P<.001), first-degree relative with a history of breast cancer (P=.033), and lobular histology (P=.002). Risk factors were assigned a score of 0-2. The risk of altered PBI eligibility from MRI based on number of risk factors was 0:18%; 1:22%; 2:42%; 3:65%. CONCLUSIONS: Preoperative bilateral breast MRI altered the PBI recommendations for 25% of women. Women who may undergo PBI should be considered for breast MRI, especially those with lobular histology or with 2 or more of the following risk factors: premenopausal, detection by palpation, and first-degree relative with a history of breast cancer.

Overdrainage shunt complications in idiopathic normal-pressure hydrocephalus and lumbar puncture opening pressure.

OBJECT: Management of idiopathic normal-pressure hydrocephalus (iNPH) is hard because the diagnosis is difficult and shunt surgery has high complication rates. An important complication is overdrainage, which often can be treated with adjustable-shunt valve manipulations but also may result in the need for subdural hematoma evacuation. The authors evaluated shunt surgery overdrainage complications in iNPH and their relationship to lumbar puncture opening pressure (LPOP). METHODS: The authors reviewed the charts of 164 consecutive patients with iNPH who underwent shunt surgery at their institution from 2005 to 2011. They noted age, sex, presenting symptoms, symptom duration, hypertension, body mass index (BMI), imaging findings of atrophy, white matter changes, entrapped sulci, LPOP, valve opening pressure (VOP) setting, number of valve adjustments, serious overdrainage (subdural hematoma requiring surgery), radiological overdrainage (subdural hematomas or hygroma seen on postoperative imaging), clinical overdrainage (sustained or postural headache), other complications, and improvements in gait, urine control, and memory. RESULTS: Eight patients (5%) developed subdural hematomas requiring surgery. All had an LPOP of greater than 160 mm H2O and an LPOP-VOP of greater than 40 mm H2O. Radiological overdrainage was more common in those with an LPOP of greater than 160 mm H2O than in those with an LPOP of less than 160 mm H2O (38% vs. 21%, respectively; p = 0.024). The BMI was also significantly higher in those with an LPOP of greater than 160 mm H2O (median 30.2 vs. 27.0, respectively; p = 0.005). CONCLUSIONS: Serious overdrainage that caused subdural hematomas and also required surgery after shunting was related to LPOP and LPOP-VOP, which in turn were related to BMI. If this can be replicated, individuals with a high LPOP should have their VOP set close to the LPOP, or even higher. In doing this, perhaps overdrainage complications can be reduced.

Patient perception of Medicare reimbursement to orthopedic surgeons for THA and TKA.

A survey study was performed of individuals in an orthopedic clinic waiting room regarding their knowledge of Medicare reimbursement to orthopedic surgeons for primary THA and TKA. A total of 1200 surveys were submitted by individuals (median age 64 years, 61% female, 50% with Medicare as their primary insurance and 29% having had THA or TKA). The median amount respondents felt that a reasonable fee to the orthopedic surgeon for performing THA or TKA was $5000, while they estimated the Medicare reimbursement to be much less. When asked what was the most they would be willing to pay out-of-pocket to have the surgery performed or for advanced technology related to the procedure, the median was $2000. Most respondents were willing to wait 3-7 weeks for surgery to be performed. Participants tended to value THA and TKA more relative to Medicare payments and tended to overestimate Medicare reimbursement to surgeons for THA and TKA.

Procedure time and the determination of polypoid abnormalities with experience: implementation of a chromoendoscopy program for surveillance colonoscopy for ulcerative colitis.

BACKGROUND: Procedure length and agreement in detection of abnormalities may limit implementation of chromoendoscopy (CE) for dysplasia surveillance in ulcerative colitis (UC). We investigated these factors among endoscopists inexperienced in this technique. METHODS: Six investigators performed surveillance colonoscopy with white light endoscopy (WLE) followed by CE on 75 patients with long-standing UC. Interobserver agreement for WLE and CE images of polyps and nonpolypoid mucosa was determined. Withdrawal times from the cecum were compared based on number of colonoscopies performed. Dysplasia detection rate with WLE was compared with CE. RESULTS: The analysis of 586 images (266 WLE and 320 CE) from 57 patients included images of 160 polyps (64 flat) with 29 dysplastic lesions. All investigators identified 10/11 WLE images of dysplasia and 4 identified all 18 CE dysplasia images, 1 missed 1 and 1 missed 3. Four dysplastic lesions were not identified by 1 or more investigators and all measured <5 mm. Interobserver agreement for lesions was high with kappa scores of 0.91 and 0.86 for WLE and CE, respectively. Among the 75 patients enrolled, dysplasia was found in 9.3% with WLE compared with 21.3% with WLE and CE (P = 0.007). Median colonoscopy withdrawal time improved from 31 minutes for endoscopists performing fewer than 5 procedures to 18 minutes for 5 to 14 and 19 minutes for more than 15 procedures. CONCLUSIONS: Indigo carmine CE for UC surveillance resulted in high rates of interobserver agreement for polyp detection, acceptable withdrawal times, and enhanced dysplasia detection. These results are encouraging for the implementation of CE programs for chronic UC.

Predictors of accuracy in preoperative parathyroid adenoma localization using ultrasound and Tc-99m-Sestamibi: a 4-quadrant analysis.

PURPOSE: To compare the accuracy of preoperative parathyroid adenoma localization in patients with primary hyperparathyroidism (pHPT) due to a single adenoma using a detailed 4-quadrant analysis and to identify patient and tumor characteristics associated with accurate preoperative localization. MATERIALS AND METHODS: Retrospective review of 203 patients who underwent parathyroidectomy for pHPT due to a single adenoma between 2008 and 2011. Results from preoperative ultrasound and Tc-99m-sestamibi were compared to operative findings to determine accuracy of localization studies. Associations between clinicopathologic features and accurate preoperative adenoma localization were evaluated. RESULTS: Ultrasound was performed on 198 patients, sestamibi on 177 patients, and both on 172 patients. Accurate localization occurred significantly more often for ultrasound than sestamibi (63% vs. 41%, P<0.001). For ultrasound, accurate localization was found in patients with larger or heavier adenomas, those with adenomas located inferiorly, patients not having a reoperative procedure, and patients with higher post-operative serum calcium levels. For sestamibi, greater adenoma size or weight, adenomas located inferiorly, and patients with associated thyroid cancer on pathology were most predictive of accurate preoperative localization. CONCLUSIONS: Our results provide evidence that ultrasound is more accurate in localizing parathyroid adenomas in patients with pHPT due to a single adenoma when compared to sestamibi scan using 4-quadrant location analysis and may be the preferred preoperative imaging modality in these patients. No significant preoperative patient factors were associated with accurate localization by ultrasound or sestamibi, but adenoma size, weight, and location in an inferior position were predictive of accurate preoperative localization.