Improved Outpatient Communication Decreases Unplanned Readmission in Necrotizing Pancreatitis.

BACKGROUND: Unplanned readmission rates in necrotizing pancreatitis (NP) are among the highest of any medical disease (72%). Recent work has identified several potentially preventable causes of unplanned readmission in NP. We hypothesized that intensive outpatient communication would identify developing problems and decrease unplanned hospital readmission. MATERIALS AND METHODS: A review of NP patients treated at a single institution between 2016 and 2019 compared patients 2 y before (NP-pre, 2016-2018) and 1 y after (NP-post, 2018-2019) the establishment of a dedicated pancreatitis nurse coordinator. Unplanned hospital readmission and emergency room visits were compared between groups. RESULTS: A total of 178 NP patients were treated-112 patients in the NP-pre group and 66 patients in the NP-post group. No differences between groups were observed in age, sex, comorbidities, pancreatitis etiology, NP severity, or mortality. A mean of 5.4 ± 0.2 outpatient communications per patient with the pancreatitis nurse coordinator was documented in the NP-post group. Unplanned readmission rates decreased significantly from 64% (NP-pre) to 45% (NP-post; P = 0.02). The frequency of readmission decreased from 1.6 readmissions per patient (NP-pre) to 0.8 readmissions per patient (NP-post; P = 0.001). Readmissions because of symptomatic necrosis, failure to thrive, nonnecrosis infection, and drain dysfunction decreased (P < 0.05). Overall disease duration was similar (NP-pre, 4.6 ± 0.3 mo; NP-post, 5.0 ± 0.3 mo; P = 0.4); however, the mean number of unplanned inpatient days decreased from 15.4 ± 2.2 d (NP-pre) to 7.8 ± 1.6 d (NP-post; P = 0.02). CONCLUSIONS: Improved outpatient communication identifies treatable problems and significantly decreases unplanned readmission in NP patients.

Comparative efficacy of antiepileptic drugs in children and adolescents: A network meta-analysis.

OBJECTIVE: To estimate the comparative efficacy among antiepileptic drugs in the pediatric population (0-18 years). METHODS: Using the Embase and MEDLINE databases, we updated to February 2017 the search strategy of the National Institute for Health and Care Excellence guidelines for epilepsy. We only included randomized clinical trials conducted in children and mixed-age populations. According to the PRISMA network meta-analysis guideline, the study-level quality assessment was made with the Cochrane risk-of-bias tool. Three investigators independently selected articles. The efficacy outcome was considered to be seizure freedom or ≥50% seizure reduction. RESULTS: We selected 46 randomized clinical trials. A total of 5652 individuals were randomized to 22 antiepileptic drugs and placebo. The point estimates of carbamazepine and lamotrigine efficacy showed their superiority with respect to all comparator antiepileptic drugs for the treatment of newly diagnosed focal epilepsy. In refractory focal epilepsy, levetiracetam (odds ratio [OR] = 3.3, 95% credible interval [CrI] = 1.3-7.6) and perampanel (OR = 2.5, 95% CrI = 1.1-5.8) were more effective compared to placebo. Ethosuximide and valproic acid were both superior to lamotrigine against absence seizures. The OR point estimate showed the superiority of adrenocorticotropic hormone over all comparators in infantile spasms. A wide heterogeneity in the length of follow-up was observed among the studies. SIGNIFICANCE: This network meta-analysis suggests that the quality of studies should be improved through the use of comparative designs, relevant outcomes, appropriate follow-up length, and more reliable inclusion criteria.

Sonographic and cyst fluid cytologic changes after EUS-guided pancreatic cyst ablation.

BACKGROUND AND AIMS: The effect of EUS-guided pancreatic cyst ablation (PCA) on sonographic morphology and cyst fluid cytology is unknown. The aim of this study was to evaluate morphologic, cytologic, and change in cyst fluid DNA after PCA. METHODS: In a prospective single-center study, consecutive patients with suspected benign 10- to 50-mm pancreatic cysts underwent baseline EUS-FNA and EUS-PCA followed 2 to 3 months later by repeat EUS, cyst fluid analysis, and possible repeat PCA. Surveillance imaging after ablation was performed at least annually and classified as complete response (CR), partial response, or persistent, with <5%, 5% to 25%, and 25% of the original cyst volume, respectively. RESULTS: Thirty-six patients underwent EUS-PCA with ethanol alone (n = 8) or ethanol and paclitaxel (n = 28), and CR occurred in 19 patients (56%). After EUS-PCA, EUS showed an increase in wall diameter in 68%, decreased number of septations in 24%, increased debris in 24%, loss of mural nodule or novel calcification in 21%, and alteration of fluid viscosity in 48%. Follow-up cytology showed increased epithelial cellularity in 27%, loss or decreased cellular atypia in 15%, increased or appearance of macrophages in 24%, and inflammatory cells in 15%. Postablation DNA amount increased and quality decreased in 71% each. Between the CR and non-CR patients, there was no significant difference in frequency of sonographic or cytologic features. In the CR group, mean DNA quantity was significantly increased after ablation (P = .023) without a change in quality (P = .136). CONCLUSIONS: EUS-PCA induces morphologic and cytologic changes of pancreatic cysts, none of which appears to predict overall imaging-defined response to ablation. (Clinical trial registration numbers: NCT00233038 and NCT01643460.).

Pancreatitis Quality of Life Instrument: A Psychometric Evaluation.

OBJECTIVES: Chronic pancreatitis is a significant medical problem that impacts a large number of patients worldwide. In 2014, we developed a disease-specific instrument for the evaluation of quality of life in this group of patients: pancreatitis quality of life instrument (PANQOLI). The goal of this study was to evaluate its psychometric properties: its reliability and its construct validity. METHODS: This is a cross-sectional multi-center study that involved 12 pancreatic disease centers. Patients who met the inclusion/exclusion criteria for chronic pancreatitis were invited to participate. Those who accepted were asked to complete seven questionnaires/instruments. Only patients who completed the PANQOLI were included in the study. Its reliability and its construct validity were tested. RESULTS: A total of 159 patients completed the PANQOLI and were included in the study. They had a mean age of 49.03, 49% were male, and 84% were Caucasian. Six of the 24 items on the scale were removed because of lack of inter-item correlation, redundancy, or lack of correlation to quality of life issues. The final 18-item scale had excellent reliability (Cronbach's alpha coefficient: 0.914) and excellent construct validity with good correlation to generic quality of life instruments (SF-12 and EORTC QLQ-C30/QLQ-PAN26) and lack of correlation to non-quality of life instruments (MAST and DAST). Through exploratory factor analysis, the PANQOLI was found to consist of four subscales: emotional function scale, role function scale, physical function scale, and "self-worth" scale. CONCLUSIONS: PANQOLI is the first disease-specific instrument to be developed and validated for the evaluation of quality of life in chronic pancreatitis patients. It has a unique subscale for "self-worth" that differentiates it from other generic instruments. Studies are currently under way to evaluate its use in other populations not included in this study.

EUS-guided liver biopsy for parenchymal disease: a comparison of diagnostic yield between two core biopsy needles.

BACKGROUND AND AIMS: EUS-guided biopsy of the liver has a variable diagnostic accuracy and specimen adequacy. A new core biopsy needle has been developed that may improve performance. The objective of this study was to compare the diagnostic yield of a new core biopsy needle with the previous standard needle. METHODS: In this cross-sectional study, consecutive patients who underwent EUS-guided core liver biopsy over a 7-year period for suspected parenchymal disease were prospectively evaluated. Between 2007 and 2011, all biopsies were performed with a 19-gauge Tru-cut biopsy needle (Quick-core [QC]), whereas a novel reverse bevel needle (PC) was used exclusively from 2011 to 2014. All specimens were examined by 1 of 3 experienced, blinded pathologists for the following: presence of visible core, aggregate specimen length, number of complete portal tracts, and specimen adequacy. RESULTS: A total of 75 patients (mean age 51 years, 51 female) underwent liver biopsy by using the QC (n = 45) or PC (n = 30) needle. The QC and PC groups had similar demographics, indications for EUS, indications for liver biopsy, and liver findings on EUS. Compared with those of the QC, biopsies with the PC required fewer passes (median 2 vs 3; P < .0001) but produced longer aggregate length (median 20 mm vs 9 mm; P < .0001) with more complete portal tracts (median 5 vs 2; P = .0003) and adequate specimens (P < .01). Two patients had abdominal pain after liver biopsy with the QC needle. CONCLUSIONS: Compared with the QC needle, EUS-guided core liver biopsy with the PC needle produced longer aggregate length, more complete portal tracts, and more adequate specimens despite fewer passes (Clinical trial registration number: NCT00586313.).

Fetal programming and systemic sclerosis.

OBJECTIVE: This study investigated whether birthweight is linked to an increased risk of the development of systemic sclerosis. STUDY DESIGN: This was a multicenter case-control study with perinatal data that were obtained from 332 cases with systemic sclerosis and 243 control subjects. Birthweight was treated as a dichotomous variable (<2500 g vs ≥2500 g); low birthweight was defined as a weight <2500 g; small for gestational age was defined as birthweight <10th percentile for gestational age adjusted for sex. The relationship between systemic sclerosis and both low birthweight and small for gestational age was expressed with the crude (univariate analysis) and adjusted (multivariate analysis) odds ratio (OR). RESULTS: Significantly increased ORs were observed in the univariate analysis for low birthweight (OR, 2.59; 95% confidence interval [CI], 1.39-5.05) and small for gestational age (OR, 2.60; 95% CI, 1.34-5.32) subjects. Similarly increased risks were confirmed for both conditions in the multivariate analysis (OR, 3.93; 95% CI, 1.92-8.07; and OR, 2.58; 95% CI, 1.28-5.19), respectively. CONCLUSION: Low birthweight and small for gestational age at birth are risk factors for the adult onset of systemic sclerosis.

Actual implementation of sick children's rights in Italian pediatric units: a descriptive study based on nurses' perceptions.

BACKGROUND: Several charters of rights have been issued in Europe to solemnly proclaim the rights of children during their hospital stay. However, notwithstanding such general declarations, the actual implementation of hospitalized children's rights is unclear. The purpose of this study was to understand to which extent such rights, as established by the two main existing charters of rights, are actually implemented and respected in Italian pediatric hospitals and the pediatric units of Italian general hospitals, as perceived by the nurses working in them. METHODS: Cross-sectional study. A 12-item online questionnaire was set up and an invitation was sent by email to Italian pediatric nurses using professional mailing lists and social networks. Responders were asked to score to what extent each right is respected in their hospital using a numeric scale from 1 (never) to 5 (always). RESULTS: 536 questionnaires were returned. The best implemented right is the right of children to have their mothers with them (mean score 4.47). The least respected one is the right of children to express their opinion about care (mean 3.01). Other rights considered were the right to play (4.29), the right to be informed (3.95), the right to the respect of privacy (3.75), the right to be hospitalized with peers (3.39), the right not to experience pain ever (3.41), and the right to school (3.07). According to the majority of nurses, the most important is the right to pain relief. Significant differences in the implementation of rights were found between areas of Italy and between pediatric hospitals and pediatric units of general hospitals. CONCLUSION: According to the perception of pediatric nurses, the implementation of the rights of hospitalized children in Italian pediatrics units is still limited.

Total Pancreatectomy with Percutaneous Islet Autotransplant after Remote Islet Processing: A Viable Paradigm?

OBJECTIVES: Total pancreatectomy with islet autotransplant (TPIAT) is important therapy for select chronic pancreatitis (CP) patients. The specialized technique of islet isolation limits widespread TPIAT use. We hypothesized that remote islet isolation provides satisfactory islet yield and perioperative outcomes. METHODS: Retrospective review of TPIAT patients between 2020 and 2022. Islet isolation was performed off-site, with percutaneous intraportal islet autotransplant (IAT) completed the morning following pancreatectomy. Demographics and perioperative outcomes were analyzed. RESULTS: Fourteen patients underwent TPIAT; median age was 43 [interquartile range 12.5] years. Operation occurred 7.5 [14.8] years after pancreatitis diagnosis. The most common pancreatitis etiology was genetic (50%). All patients underwent preoperative endoscopic therapy; three underwent prior pancreatectomy. Operative time was 236 [51] minutes; subsequent percutaneous IAT time was 87 [35] minutes. The islet equivalent (IEQ)/kilogram (kg) yield was 3,456 [3,815] IEQ/kg. Nine patients had positive islet cultures. Two thromboembolic events and one bacteremia occurred. One perihepatic hematoma occurred after percutaneous portal venous access. Median postoperative length of stay was 14.5 days, and five patients (36%) were readmitted within 90 days. All patients were discharged home on insulin. No mortality occurred. CONCLUSION: Total pancreatectomy with remote islet isolation provides excellent islet yield for autotransplant and satisfactory perioperative outcomes.

HyM3D: A hybrid method for the automatic 3D reconstruction of a defective cranial vault.

BACKGROUND AND OBJECTIVE: The ability to accomplish a consistent restoration of a missing or deformed anatomical area is a fundamental step for defining a custom implant, especially in the maxillofacial and cranial reconstruction where the aesthetical aspect is crucial for a successful surgical outcome. At the same time, this task is also the most difficult, time-consuming, and complicated across the whole reconstruction process. This is mostly due to the high geometric complexity of the anatomical structures, insufficient references, and significant interindividual anatomical heterogeneity. Numerous solutions, specifically for the neurocranium, have been put forward in the scientific literature to address the reconstruction issue, but none of them has yet been persuasive enough to guarantee an easily automatable approach with a consistent shape reconstruction. METHODS: This work aims to present a novel reconstruction method (named HyM3D) for the automatic restoration of the exocranial surface by ensuring both the symmetry of the resulting skull and the continuity between the reconstructive patch and the surrounding bone. To achieve this goal, the strengths of the Template-based methods are exploited to provide knowledge of the missing or deformed region and to guide a subsequent Surface Interpolation-based algorithm. HyM3D is an improved version of a methodology presented by the authors in a previous publication for the restoration of unilateral defects. Differently from the first version, the novel procedure applies to all kinds of cranial defects, whether they are unilateral or not. RESULTS: The presented method has been tested on several test cases, both synthetic and real, and the results show that it is reliable and trustworthy, providing a consistent outcome with no user intervention even when dealing with complex defects. CONCLUSIONS: HyM3D method proved to be a valid alternative to the existing approaches for the digital reconstruction of a defective cranial vault; furthermore, with respect to the current alternatives, it demands less user interaction since the method is landmarks-independent and does not require any patch adaptation.

Pancreatitis associated anxiety, depression, and stress: Hypothesis, definition, and intervention.

Necrotizing pancreatitis is characterized by a prolonged disease course requiring frequent hospitalization and intervention. Necrotizing pancreatitis patients have high rates of intensive care unit admission and organ failure. Critical illness is an identified risk factor for the development of anxiety, depression, and posttraumatic stress disorder. Limited literature examines quality of life in necrotizing pancreatitis patients, and studies examining psychiatric sequalae of necrotizing pancreatitis including depression, anxiety, and posttraumatic stress disorder are virtually nonexistent. Here, we review critical literature examining risk factors for poor mental health outcomes during and after necrotizing pancreatitis, identify several screening instruments to quantify mental health outcomes, and propose an intervention to improve mental health outcomes in patients with necrotizing pancreatitis. We conclude that establishing the incidence of mental health disorders and implementing strategies to improve mental health outcomes are critical to holistic care of necrotizing pancreatitis patients.

3D-Printed Patient-Specific Casts for the Distal Radius in Children: Outcome and Pre-Market Survey.

BACKGROUND: Orthopaedic and Trauma surgery is expected to undergo profound transformation as a result of the adoption of 3D technology. Among the various applications, patient specific manufacturing of splints and casts would appear to be, particularly in children, an interesting implementation. This study aims to assess the safety of patient specific 3D casts obtained with a newly developed 3D-scanning devise in a small case series. We therefore conducted a clinical outcome and pre-marketing study in 10 consecutive patients with distal radius fractures treated at an Academic Level I Pediatric Trauma Center. After the application of the 3D cast, patients underwent three consecutive evaluations in the following 21 days. The main outcome measurements were: pain, skin lesions and general comfort, and acceptance of the cast. The three domains were measured with the Visual Analogue Scale (VAS), the NPUAP/EPUAP classification and the Positive affect-Negative affect Scale for Children (PANAS-C), the Self-Assessment Manikin (SAM) clinical psychology tests and a Likert-type five item questionnaire, respectively. A final mechanical analysis of the cast was carried out to confirm product integrity. RESULTS: The results obtained were consistently positive in the investigated domains of general comfort, efficacy of contention and mechanical integrity of the 3D-printed cast as well as in the practicability of the supply chain. CONCLUSIONS: This study provides Level IV evidence that patient specific 3D printed casts obtained with a specifically designed software were safe in the management of "buckle" fractures of the distal radius in children. These results encourage to extend the technology to the treatment of more demanding fractures.

Genetic and pathobiologic characterization of pandemic H1N1 2009 influenza viruses from a naturally infected swine herd.

Since its initial identification in Mexico and the United States, concerns have been raised that the novel H1N1 influenza virus might cause a pandemic of severity comparable to that of the 1918 pandemic. In late April 2009, viruses phylogenetically related to pandemic H1N1 influenza virus were isolated from an outbreak on a Canadian pig farm. This outbreak also had epidemiological links to a suspected human case. Experimental infections carried out in pigs using one of the swine isolates from this outbreak and the human isolate A/Mexico/InDRE4487/2009 showed differences in virus recovery from the lower respiratory tract. Virus was consistently isolated from the lungs of pigs infected with A/Mexico/InDRE4487/2009, while only one pig infected with A/swine/Alberta/OTH-33-8/2008 yielded live virus from the lung, despite comparable amounts of viral RNA and antigen in both groups of pigs. Clinical disease resembled other influenza virus infections in swine, albeit with somewhat prolonged virus antigen detection and delayed viral-RNA clearance from the lungs. There was also a noteworthy amount of genotypic variability among the viruses isolated from the pigs on the farm. This, along with the somewhat irregular pathobiological characteristics observed in experimentally infected animals, suggests that although the virus may be of swine origin, significant viral evolution may still be ongoing.

A prospective, randomized study of EUS-guided celiac plexus neurolysis for pancreatic cancer: one injection or two?

BACKGROUND: The technique of alcohol injection during EUS-guided celiac plexus neurolysis (CPN) in patients with pancreatic cancer-related pain has not been standardized. OBJECTIVE: To compare pain relief and safety of alcohol given as 1 versus 2 injections during EUS-guided CPN (EUS-CPN). Secondary outcomes examined were characteristics that predict response and survival. DESIGN: Single-blinded, prospective, randomized, parallel-group study. SETTING: Tertiary-care center. PATIENTS: This study involved patients with pancreatic cancer-related pain. INTERVENTION: EUS-CPN done by injecting 20 mL of 0.75% bupivacaine and 10 mL 98% alcohol into 1 or 2 sites at the celiac trunk. Participants were interviewed by telephone at 24 hours and weekly thereafter. MAIN OUTCOME MEASUREMENTS: Time until onset of pain relief, duration of pain relief, complications. RESULTS: Fifty patients (mean age 63 years; 24 men) were enrolled and randomized (29 in 1-injection, 21 in 2-injections groups). Pain relief was observed in 37 (74%) patients: 20 (69%) in the 1-injection group and 17 (81%) in the 2-injection group (chi-square P = .340). Median onset of pain relief was 1 day for both 1-injection (range 1-28 days) and 2-injection (range 1-21 days) groups (Mann-Whitney P = .943). Median duration of pain relief in the 1-injection and 2-injection groups was 11 weeks and 14 weeks, respectively (log-rank P = .612). Complete pain relief was observed in 4 (8%) patients total, 2 in each group. There were no long-term complications. LIMITATIONS: Single-blinded study. CONCLUSION: There were no differences in onset or duration of pain relief when either 1 or 2 injections were used. There was no difference in safety or survival between the 2 groups.

Prospective Analysis of the Mechanisms Underlying Ineffective Deep Vein Thrombosis Prophylaxis in Necrotizing Pancreatitis.

BACKGROUND: Patients with necrotizing pancreatitis (NP) have the highest rate of venous thromboembolism (VTE) of any hospitalized patient (57%). We hypothesized that VTE prophylaxis might be inadequate in the setting of this profound inflammatory disease and that early detection of deep vein thrombosis would limit pulmonary embolism. STUDY DESIGN: All patients with NP treated at a single center between August 2018 and December 2019 were enrolled in prospective, weekly VTE screening, including 4-extremity duplex ultrasound. Routine chemoprophylaxis included low-molecular-weight or unfractionated heparin. Peak serum anti-factor Xa concentration was measured during weekly screening (goal prophylaxis 0.2 to 0.4 IU/mL). RESULTS: Eighty-five patients with NP underwent a total of 201 screening events (mean 2.4 per patient). VTE developed in 55 patients (65%), including splanchnic vein thrombosis in 41 patients (48%) and extremity deep vein thrombosis (eDVT) in 32 patients (38%). Extremity DVT was diagnosed a mean ± SD of 44 ± 30 days after NP onset. Symptomatic pulmonary embolism was prevented in all patients diagnosed with eDVT and no contraindication to anticoagulation (0 of 29). Prophylactic anti-factor Xa concentration was only achieved in 21% (12 of 57 screening events); no eDVTs developed in patients achieving prophylactic anti-factor Xa concentration. CONCLUSIONS: In patients with NP, identification of eDVT by screening ultrasound permits early treatment and prevents symptomatic pulmonary embolism. Fixed dosing of chemical prophylaxis is inadequate in most patients with NP and likely contributes to the mechanism of increased VTE in NP.

Impact of SARS-CoV-2 Pandemic and Strategies for Resumption of Activities During the Second Wave of the Pandemic: A Report From Eight Paediatric Hospitals From the ECHO Network.

The Severe Acute Respiratory Syndrome CoronaVirus type 2 (SARS-CoV-2) pandemic impacted the organization of paediatric hospitals. This study aimed to evaluate the preparedness for the pandemic among a European network of children's hospitals and to explore the strategies to restart health care services. A cross-sectional, web-based survey was distributed in May 2020 to the 13 children's tertiary care hospitals belonging to the European Children's Hospitals Organisation. Responses were obtained from eight hospitals (62%). Significant reductions were observed in accesses to the emergency departments (41.7%), outpatient visits (35.7%), intensive and non-intensive care unit inpatient admissions (16.4 and 13%, respectively) between February 1 and April 30, 2020 as compared with the same period of 2019. Overall, 93 children with SARS CoV-2 infection were admitted to inpatient wards. All the hospitals created SARS-CoV-2 preparedness plans for the diagnosis and management of infected patients. Routine activities were re-scheduled. Four hospitals shared their own staff with adult units, two designated bed spaces for adults and only one admitted adults to inpatient wards. The three main components for the resumption of clinical activities were testing, source control, and reorganization of spaces and flows. Telemedicine and telehealth services were used before the SARS-CoV-2 pandemic by three hospitals and by all the hospitals during it. Conclusion: The present study provides a perspective on preparedness to SARS-CoV-2 pandemic among eight large European children's hospitals, on the impact of the pandemic on the hospital activities and on the strategies adopted to restart clinical activities.

Molecular recognition in copper trafficking.

From the basic export of unwanted metal ions in simple organisms to the complex orchestration of metal handling and usage in higher eukaryotes, cellular systems are based on a variety of molecular mechanisms that constrain the right metal to bind to the right protein partner at the right time when needed. A failure to overcome the challenges inherent in this task can lead to pathological states that compromise the life of the cell. This is indeed the case with copper, a metal ion that is essential but which can however also create toxic effects when its intracellular concentration and distribution are not properly controlled. Research in this field increasingly indicates that a subtle interplay between metal coordination chemistry and protein-protein interactions finely tunes molecular recognition.

EUS-guided ethanol versus saline solution lavage for pancreatic cysts: a randomized, double-blind study.

BACKGROUND: Surgery for pancreatic cysts is associated with significant morbidity. A pilot study previously demonstrated the safety of EUS-guided ethanol lavage of pancreatic cysts. OBJECTIVE: To determine whether EUS-guided ethanol lavage would decrease pancreatic cyst size more than saline solution lavage. DESIGN: Prospective, multicenter, randomized trial. SETTING: Two tertiary referral hospitals in the United States. PATIENTS: Patients referred for EUS with a 1- to 5-cm unilocular pancreatic cyst were randomized to blinded ethanol or saline solution lavage. Three months later, the cyst diameter was remeasured by EUS, and a second unblinded ethanol lavage was performed. INTERVENTIONS: EUS-guided pancreatic cyst lavage. MAIN OUTCOME MEASUREMENTS: Cyst ablation based on size changes from follow-up EUS, CT, and histology of resected specimens. RESULTS: Of 58 patients randomized, 16 were excluded and 42 underwent initial ethanol (n = 25) or saline solution (n = 17) lavage. Ethanol lavage resulted in a greater mean percentage of decrease in cyst surface area (-42.9; 95% CI, -58.4 to -27.4) compared with saline solution alone (-11.4; 95% CI, -25.0 to 2.2; P = .009). Nineteen (76.0%) of 25 and 14 (82.3%) of 17 patients randomized to ethanol and saline solution, respectively, underwent a second ethanol lavage. A follow-up CT scan demonstrated resolution in 12 (33.3%) of 36 cysts. Histology of 4 resected cysts demonstrated epithelial ablation ranging from 0% (saline solution alone) to 50% to 100% (1 or 2 ethanol lavages). Complication rates were similar in all groups. LIMITATION: Short-term follow-up. CONCLUSIONS: EUS-guided ethanol lavage results in a greater decrease in pancreatic cyst size compared with saline solution lavage with a similar safety profile. Overall CT-defined complete pancreatic cyst ablation was 33.3%.

A prospective randomized trial of 1 versus 2 injections during EUS-guided celiac plexus block for chronic pancreatitis pain.

BACKGROUND: The efficacy of 1-injection versus a 2-injections method of EUS-guided celiac plexus block (EUS-CPB) in patients with chronic pancreatitis is not known. OBJECTIVE: To compare the clinical effectiveness and safety of EUS-CPB by using 1 versus 2 injections in patients with chronic pancreatitis and pain. The secondary aim is to identify factors that predict responsiveness. DESIGN: A prospective randomized study. INTERVENTIONS: EUS-CPB was performed by using bupivacaine and triamcinolone injected into 1 or 2 sites at the level of the celiac trunk during a single EUS-CPB procedure. MAIN OUTCOME MEASUREMENTS: Duration of pain relief, onset of pain relief, and complications. RESULTS: Fifty [corrected] subjects were enrolled (23 received 1 injection, 27 [corrected] received 2 injections). The median duration of pain relief in the 31 responders was 28 days (range 1-673 days). [corrected] Fifteen [corrected] of 23 (65%) [corrected] subjects who received 1 injection [corrected] had relief from pain compared with 16 of 27 (59%) [corrected] subjects who received 2 injections [corrected] (P = .67). [corrected] The median times to onset in the 1-injection and 2-injections groups were 21 and 14 days, respectively (P = .99). No correlation existed between duration of pain relief and time to onset of pain relief or onset within 24 hours. Age, sex, race, prior EUS-CPB, and smoking or alcohol history did not predict duration of pain relief. LIMITATION: Telephone interviewers were not blinded. CONCLUSIONS: There was no difference in duration of pain relief or onset of pain relief in subjects with chronic pancreatitis and pain when the same total amount of medication was delivered in 1 or 2 injections during a single EUS-CPB procedure. Both methods were safe.

Initial experience with EUS-guided Tru-cut biopsy of benign liver disease.

BACKGROUND: Histologic biopsy of the liver is often essential for diagnosing hepatic parenchymal disease. Tissue acquisition is traditionally obtained by a surgical, transvascular, or percutaneous route. OBJECTIVE: To describe our initial experience with EUS-guided Tru-cut biopsy (EUS-TCB) of benign liver disease. DESIGN: A prospective case series. SETTING: A tertiary-referral hospital in Indianapolis, Indiana. PATIENTS: Consecutive subjects undergoing EUS with suspected hepatic parenchymal disease. INTERVENTIONS: EUS-TCB of the liver. MAIN OUTCOME MEASUREMENTS: Liver biopsy specimen yield, diagnosis, and procedural complications. Specimens were routinely stained with hematoxylin and eosin and with special stains for reticulin, iron, and trichome. Each case was reviewed by a single experienced pathologist for the number of portal spaces, total specimen length, and final diagnosis. An adequate specimen was defined as 6 or more complete portal tracts. RESULTS: Between February 2007 and March 2008, 21 consecutive patients (mean age 45 years; 13 women) were evaluated. The most common indications for liver biopsy were suspected nonalcoholic steatohepatitis (n = 9), intrahepatic cholestasis (n = 4), and suspected cirrhosis (n = 3). Transgastric biopsy (median 3 passes, range 1-4) into the left lobe (n = 18) or both the left and caudate lobe (n = 3) yielded a median total specimen length of 9 mm (range 1-23 mm). The median total number of portal tracts in the specimen was 2 complete (range 0-10) plus 3 partial (range 0-8) tracts. Six or more complete portal tracts were present in 6 of 21 (29%). A histologic diagnosis was obtained in 19 of 21 (90%). There were no complications. LIMITATIONS: The small sample size and low-risk population. CONCLUSIONS: In our initial experience, transgastric EUS-TCB of suspected benign liver disease by using a 19-gauge needle appears safe and feasible. Samples obtained are usually smaller than those traditionally considered adequate for histologic assessment. Further refinement of this technique appears indicated.

Ear Reconstruction Simulation: From Handcrafting to 3D Printing.

Microtia is a congenital malformation affecting one in 5000 individuals and is characterized by physical deformity or absence of the outer ear. Nowadays, surgical reconstruction with autologous tissue is the most common clinical practice. The procedure requires a high level of manual and artistic techniques of a surgeon in carving and sculpting of harvested costal cartilage of the patient to recreate an auricular framework to insert within a skin pocket obtained at the malformed ear region. The aesthetic outcomes of the surgery are highly dependent on the experience of the surgeon performing the surgery. For this reason, surgeons need simulators to acquire adequate technical skills out of the surgery room without compromising the aesthetic appearance of the patient. The current paper aims to describe and analyze the different materials and methods adopted during the history of autologous ear reconstruction (AER) simulation to train surgeons by practice on geometrically and mechanically accurate physical replicas. Recent advances in 3D modelling software and manufacturing technologies to increase the effectiveness of AER simulators are particularly described to provide more recent outcomes.