Cochlear Implant Referral Criteria for the Spanish-Speaking Adult Population.

OBJECTIVE: To evaluate the effectiveness of the "60/60 Guideline" in a diverse patient population. STUDY DESIGN: Retrospective review. SETTING: Tertiary referral center. PATIENTS: Data were collected for adult patients (18 years and older) who underwent a cochlear implant evaluation (CIE) between January 2016 and March 2021. MAIN OUTCOME MEASURES: Development of the "60/60 Guideline" has provided better clarity on when to refer English-speaking patients for a CIE. Our study evaluated the effectiveness of this referral tool in the Spanish-speaking population. RESULTS: In our group of patients who underwent a traditional CIE (n = 402), 209 met unaided and aided traditional cochlear implant (CI) candidacy criteria. Of the 193 individuals who did not meet both components of traditional candidacy criteria, a majority met the aided component (86%) but only 4.6% met the unaided component. When applying the 60/60 Guideline to patients who met traditional criteria, there is a sensitivity rating of 84.7% and a specificity index of 50.3%. For English and Spanish speakers who met traditional criteria but did not meet the 60/60 Guideline, a majority (83.3% English, 87.5% Spanish) had a better ear word recognition score (WRS) greater than 60%, suggesting the unaided WRS is the more restrictive component of the "60/60 Guideline." CONCLUSION: Application of the "60/60 Guideline" is an effective method to identify potential CI candidates in the English-speaking population; however, it was less effective in the Spanish-speaking population. Spanish-speaking adults should be referred for a CIE when better ear pure tone average is greater than 60 dB hearing loss, regardless of their unaided WRS. This study highlights the need for inclusion of nonlinguistic test measures in the CI referral criteria and test battery to reduce CI access barriers for patients who speak a language other than English.

Outcomes and timing of aortic surgery in renal transplant patients.

BACKGROUND: Solid organ transplantation in elderly patients has become more common in recent years. An increasing number of patients present with renal failure requiring transplantation and comorbid occlusive or aneurysmal aortic pathology. The optimal strategy for the timing and management of the aortic disease and renal transplantation in these patients is unknown. Before the availability of endovascular therapies, our policy was to provide open repair of aortic disease before cadaveric transplantation, or by simultaneous aortic reconstruction with renal allotransplantation if a living donor was available. Since the wide acceptance of endovascular modalities, our strategy has changed to take advantage of endovascular treatment pre-transplant. This study examines the outcome of both approaches. METHODS: We performed a retrospective review of 12 patients between 1996 and 2009 who underwent both renal transplantation and a major abdominal aortic procedure either simultaneously (n = 6), metachronous, with the procedures occurring within the same month (n = 2), or distant, with the aortic procedures occurring between 5 and 24 months before or after transplantation (n = 4). All patients with occlusive disease underwent an aortobifemoral bypass, one before transplant, one subsequent to transplantation, and four simultaneous with a renal allograft. To assess renal transplant status, patients' serum creatinine levels were followed up every 3 months. Of the 12 patients, eight underwent open aortic procedures, whereas four underwent endovascular aortic aneurysm repair. Patients who underwent endovascular aortic aneurysm repair were followed up with ultrasound examinations at 6-month intervals, and with contrast computed tomography scans every other year. RESULTS: Aortic reconstruction was performed successfully in all the 12 patients irrespective of timing strategy. All the patients who underwent endovascular repair had functional renal allografts for the duration of follow-up. Two patients had simultaneous aortobifemoral bypass and pancreas-kidney transplantation without complication. Among the patients with open aortic repairs, there was one 5-year mortality and one patient had failure of two renal allografts. None of the patients had limb loss, and aortic grafts (one limb required a secondary procedure) remained patent. The 5-year patient survival of 90% and kidney survival of 75% appeared similar to results in the general transplant population without aortic disease. Two significant complications related to the open procedures were observed: two renal transplants developed postoperative hematomas requiring evacuation and one aortobifemoral bypass (ABF) developed a femoral wound infection requiring evacuation and sartorius flap closure. The 30-day mortality rate in all patients was zero. The length of stay for patients receiving simultaneous procedures ranged from 5 to 14 days (median, 10.5) and was significantly lower than the 10-52-day (median, 18) combined length of stay in the metachronous and/or distant groups (p = 0.016). CONCLUSION: The coexistence of aortic disease and renal transplantation is an increasingly common clinical scenario. Exclusion from transplantation of patients with major aortoiliac disease is commonplace in many transplant centers as early registry data suggested a poor outcome. Appropriate planning with a vascular surgical team can lead to outcomes, which are comparable with the general transplant population without significant aortic disease.

Repair of complex renal artery aneurysms by laparoscopic nephrectomy with ex vivo repair and autotransplantation.

OBJECTIVE: Renal artery aneurysms are being discovered more frequently due to increased use of non-invasive imaging. Complex renal artery aneurysms involving multiple secondary or tertiary branches are not amenable to in vivo or endovascular treatment and often require ex vivo repair with autotransplantation. In order to minimize incisional morbidity and hasten recovery, we developed a technique of laparoscopic nephrectomy combined with backbench ex vivo repair, followed by autotransplantation through a small laparoscopic extraction incision. This study describes our initial experience with this combined technique in patients that were not candidates for endovascular techniques or in vivo arterial reconstruction. METHODS: Seven patients with complex renal artery aneurysms underwent laparoscopic nephrectomy and ex vivo repair with multiple saphenous vein grafts and autotransplantation through the small laparoscopic extraction incision. The aneurysms ranged from 2.5 to 5.0 cm. In all cases, the aneurysm was resected ex vivo, leaving multiple branch arteries that were extended with saphenous vein grafts. Arterial inflow was then re-established with sequential saphenous vein anastomoses to the external iliac artery. Ureteral reconstruction was performed via standard Lich ureteroneocystostomy. Patients were followed postoperatively for two to eight years. RESULTS: Laparoscopic nephrectomy with ex vivo repair of complex aneurysms was successfully employed in seven patients with renal aneurysms that were not amenable to endovascular or in vivo repair. There were no incisional morbidities and all patients had significant improvements in symptoms post-operatively. Renal function remained unchanged and there were no ureteral complications following surgery. All patients had postoperative ultrasound imaging done at two years which demonstrated patency of the anastomoses. The mean hospital stay was four days (range, two to seven days). CONCLUSION: Repair of complex renal artery aneurysms involving distal branch arteries remains a challenge. This new technique combines the advantages of minimally invasive surgery with the effectiveness of ex vivo aneurysm repair.