Real-world assessment of treatment inertia in the management of patients treated for major depressive disorder in the USA.

Aim: Major depressive disorder (MDD) is a debilitating illness in which depressive symptoms may persist after treatment. Treatment inertia is the continued use of the same pharmacotherapy regimen when treatment goals are not met. This study assessed the frequency of treatment inertia among adult patients with MDD treated in a real-world setting. Patients & methods: This was a retrospective, observational study of patients with MDD identified in the Decision Resources Group Real World Evidence US Data Repository from January 2014 to June 2018. Patients (≥18 years) had an elevated Patient Health Questionnaire-9 (PHQ-9) score (≥5) following 8 weeks of stable baseline antidepressant use with/without mental-health outpatient therapy. Treatment inertia, modification and discontinuation were evaluated over a 16-week follow-up period (timeline based on the APA Practice Guidelines). The primary outcome was the proportion of MDD patients experiencing treatment inertia. Results: 2850 patients (median age, 55 years; 74% female) met the study criteria. Of these patients, 834 (29%) had study-defined treatment inertia, 1534 (54%) received treatment modification and 482 (17%) discontinued treatment. Use of mirtazapine (Odd ratio [OR]: 0.63; 95% confidence interval [CI]: 0.50-0.79), selective serotonin reuptake inhibitors (OR: 0.64; 95% CI: 0.54-0.75) or bupropion (OR: 0.71; 95% CI: 0.60-0.84) in the baseline period was associated with an increased likelihood of treatment modification versus not receiving treatment with these medications. Frequency of treatment inertia may differ among those who do not have a documented PHQ-9 score. Conclusion: Effective symptom management is critical for optimal outcomes in MDD. Results demonstrate that treatment inertia is common in MDD despite guidelines recommending treatment modification in patients not reaching remission.

Anatomic Optical Coherence Tomography (aOCT) for Evaluation of the Internal Nasal Valve.

OBJECTIVES/HYPOTHESIS: To establish the utility of anatomic optical coherence tomography (aOCT) in evaluating internal nasal valve (INV). STUDY DESIGN: Anatomic specimen imaging study. METHODS: Fresh-harvested human specimen heads were evaluated using both computed tomography (CT) imaging as well as using aOCT. Scans were performed at three time points: 1) After septoplasty for cartilage harvest, 2) after placement of butterfly graft (BFG), and 3) after placement of bilateral spreader grafts (SG). Imaging data were then converted into 3D models of the nasal airway. CT- and aOCT-generated models were compared by both static volumetric analysis and computational fluid dynamics (CFD) to predict nasal resistance and pressure. RESULTS: Scans using aOCT showed comparable results to CT in terms of volumetric parameters both before and after intervention. Analysis of aOCT data by CFD demonstrated decrease in pressure after SG or BFG intervention. No statistically significant difference was observed when comparing CT- and aOCT-generated calculations of pressure or resistance. CONCLUSION: The INV can be imaged in a static fashion using aOCT technology. Advantages over traditional CT imaging include lack of exposure to radiation and rapid scan time. In addition, in-office use is possible as aOCT technology develops. Further investigation will be necessary to define the role of aOCT in the dynamic evaluation of this vital component of the nasal airway. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:2148-2156, 2022.

All-fiber probes for endoscopic optical coherence tomography of the large airways.

Endoscopic optical coherence tomography of large airways poses unique challenges. A hybrid lens is described that consists of a section of coreless fiber and graded index fiber (GIF), followed by a ball lens section. This design produces low numerical aperture beams better suited for large airway imaging. The performance of this lens is compared against conventional GIF and ball lens designs. Forward- and side-viewing probes were modeled, fabricated, and tested. The impact of a sheath on the beam profile was also investigated. Probes with working distances larger than 10 mm and depth-of-focus exceeding 12 mm are demonstrated with the proposed design.

Real-World Evidence of Treatment, Tolerance, Healthcare Utilization, and Costs Among Postacute Care Adult Patients Receiving Enteral Peptide-Based Diets in the United States.

OBJECTIVE: Peptide -based (PB) enteral tube feeding (ETF) formulas have been shown to reduce gastrointestinal (GI) intolerance in patients receiving enteral nutrition. However, limited data exist in relation to their use in the postacute/home care setting. We sought to assess the real-world GI tolerance, healthcare utilization, and resource use costs of 100% whey-protein PB ETF in adults in a postacute care setting and describe their demographic, clinical, and treatment characteristics. METHOD: Using medical claims data from the United States, we analyzed GI intolerance events occurring in adults receiving 100% whey-protein PB ETF (Peptamen® adult formulas) for one year before and after initiation of ETF. Resource use costs were subsequently estimated using a multivariate general linearized model and adjusted for age, gender, and Charlson Comorbidity Index score. RESULTS: The proportion of adults experiencing no GI intolerance events increased from 41% (418/1022) to 59% (601/1022) in the one-year period after initiation of 100% whey PB ETF (P < .001). The proportion of patients with at least one hospital inpatient visit also decreased from 100% (1022/1022) to 72% (737/1022) over the same period, and the mean number of inpatient visits per patient decreased from 15.6 to 13.0. Cost modeling revealed that outpatient visits accounted for 42% ($1174/$2820) of total estimated healthcare resource costs in the first 30 days after 100% whey PB ETF initiation, with only 9% ($255/$2820) due to emergency room visits. CONCLUSION: These 100% whey-protein PB ETF formulas are a valuable nutrition treatment option for patients with or at risk of malnutrition who show intolerance to standard ETF formulas and may reduce hospital inpatient visits and associated costs.

Sensing Inhalation Injury-Associated Changes in Airway Wall Compliance by Anatomic Optical Coherence Elastography.

Quantitative methods for assessing the severity of inhalation (burn) injury are needed to aid in treatment decisions. We hypothesize that it is possible to assess the severity of injuries on the basis of differences in the compliance of the airway wall. Here, we demonstrate the use of a custom-built, endoscopic, anatomic optical coherence elastography (aOCE) system to measure airway wall compliance. The method was first validated using airway phantoms, then performed on ex vivo porcine tracheas under varying degrees of inhalation (steam) injury. A negative correlation between aOCE-derived compliance and severity of steam injuries is found, and spatially-resolved compliance maps reveal regional heterogeneity in airway properties.

Utility of endoscopic anatomical optical coherence tomography in functional rhinoplasty.

Objective measurement of the nasal valve region is valuable for the assessment of functional rhinoplasty surgical outcomes. Anatomical optical coherence tomography (aOCT) is an imaging modality that may be used to obtain real-time, quantitative, and volumetric scans of the nasal airway. We aim to evaluate if volumetric aOCT imaging is useful for the examination of the nasal valve region before and after functional rhinoplasty procedures. aOCT scans of the nasal valves were performed on four cadaveric heads before and after spreader graft and butterfly graft procedures. The resulting aOCT images were compared against video endoscopy images, and the segmented volumes of the nasal airway obtained from aOCT scans were compared with computed tomography (CT) derived volumes acquired under the same conditions. The aOCT-derived volumes match the CT volumes closely, with a mean Dice similarity coefficient of 0.88 and a mean Hausdorff distance of 2.3 mm. Furthermore, the aOCT images were found to represent the shape of the nasal cavity accurately. Due to its ability to perform real-time, quantitative, and accurate evaluation of the nasal airway, aOCT imaging is a promising modality for the objective assessment of the nasal valves before and after functional rhinoplasty procedures.

Localized compliance measurement of the airway wall using anatomic optical coherence elastography.

We describe an elastographic method to circumferentially-resolve airway wall compliance using endoscopic, anatomic optical coherence tomography (aOCT) combined with an intraluminal pressure catheter. The method was first demonstrated on notched silicone phantoms of known elastic modulus under respiratory ventilation, where localized compliance measurements were validated against those predicted by finite element modeling. Then, ex vivo porcine tracheas were scanned, and the pattern of compliance was found to be consistent with histological identification of the locations of (stiff) cartilage and (soft) muscle. This quantitative method may aid in diagnosis and monitoring of collapsible airway wall tissues in obstructive respiratory disorders.

Combined anatomical optical coherence tomography and intraluminal pressure reveal viscoelasticity of the in vivo airway.

It is hypothesized that the local, viscoelastic (time-dependent) properties of the airway are important to accurately model and ultimately predict dynamic airway collapse in airway obstruction. Toward this end, we present a portable, endoscopic, swept-source anatomical optical coherence tomography (aOCT) system combined with a pressure catheter to capture local airway dynamics in vivo during respiration. aOCT scans were performed in the airways of a mechanically ventilated pig under paralysis with dynamic and static ventilation protocols. Validation of dynamic aOCT luminal cross-sectional area (CSA) measurements against Cine CT, obtained during the same exam, showed an aggregate difference of 15 % ± 3 % . aOCT-derived CSA obtained in the in vivo trachea also exhibited hysteresis as a function of pressure, depicting the viscoelastic nature of the airway wall. The volumetric imaging capabilities were validated by comparing aOCT- and CT-derived geometries of the porcine airway spanning nine generations from the trachea to the bronchioles. The ability to delineate regional differences in airway viscoelastic properties, by measuring airway deformation using aOCT combined with intraluminal pressure, paves the way to patient-specific models of dynamic airway collapse.

Multi-modal anatomical Optical Coherence Tomography and CT for in vivo Dynamic Upper Airway Imaging.

We describe a novel, multi-modal imaging protocol for validating quantitative dynamic airway imaging performed using anatomical Optical Coherence Tomography (aOCT). The aOCT system consists of a catheter-based aOCT probe that is deployed via a bronchoscope, while a programmable ventilator is used to control airway pressure. This setup is employed on the bed of a Siemens Biograph CT system capable of performing respiratory-gated acquisitions. In this arrangement the position of the aOCT catheter may be visualized with CT to aid in co-registration. Utilizing this setup we investigate multiple respiratory pressure parameters with aOCT, and respiratory-gated CT, on both ex vivo porcine trachea and live, anesthetized pigs. This acquisition protocol has enabled real-time measurement of airway deformation with simultaneous measurement of pressure under physiologically relevant static and dynamic conditions- inspiratory peak or peak positive airway pressures of 10-40 cm H2O, and 20-30 breaths per minute for dynamic studies. We subsequently compare the airway cross sectional areas (CSA) obtained from aOCT and CT, including the change in CSA at different stages of the breathing cycle for dynamic studies, and the CSA at different peak positive airway pressures for static studies. This approach has allowed us to improve our acquisition methodology and to validate aOCT measurements of the dynamic airway for the first time. We believe that this protocol will prove invaluable for aOCT system development and greatly facilitate translation of OCT systems for airway imaging into the clinical setting.

Airway compliance measured by anatomic optical coherence tomography.

Quantification of airway compliance can aid in the diagnosis and treatment of obstructive airway disorders by detecting regions vulnerable to collapse. Here we evaluate the ability of a swept-source anatomic optical coherence tomography (SSaOCT) system to quantify airway cross-sectional compliance (CC) by measuring changes in the luminal cross-sectional area (CSA) under physiologically relevant pressures of 10-40 cmH2O. The accuracy and precision of CC measurements are determined using simulations of non-uniform rotation distortion (NURD) endemic to endoscopic scanning, and experiments performed in a simplified tube phantom and ex vivo porcine tracheas. NURD simulations show that CC measurements are typically more accurate than that of the CSAs from which they are derived. Phantom measurements of CSA versus pressure exhibit high linearity (R2>0.99), validating the dynamic range of the SSaOCT system. Tracheas also exhibited high linearity (R2 = 0.98) suggestive of linear elasticity, while CC measurements were obtained with typically ± 12% standard error.

Every wheeze does not merit a puffer! Case of an overnight cure of chronic asthma.

The peril of incorrect diagnostic labelling is highlighted by this case of acute respiratory distress caused by a retrosternal recurrent goitre. An initial clinical diagnosis which cannot be fully validated on investigation with unexpected or poor response to treatment should prompt consideration and investigation for an alternative explanation.

Long-term study of port-site incisional hernia after laparoscopic procedures.

BACKGROUND: Laparoscopic surgery is widely practiced and offers realistic benefits over conventional surgery. There is considerable variation in results between surgeons, concerning port-site complications. The aim of this study was to evaluate the laparoscopic port closure technique and to explore the factors associated with port-site incisional hernia. METHODS: Between January 2000 and January 2007, 5541 laparoscopic operations were performed by a single consultant surgeon for different indications. The ports were closed by the classical method using a J-shaped needle after release of pneumoperitoneum. The incidence of port-site incisional hernias was calculated. All patients were followed up by outpatient clinic visits and by their general practitioners. RESULTS: During a 6-year period, 5541 laparoscopic operations were performed. Eight patients (0.14%) developed port-site hernia during a mean follow-up period of 43 months (range, 25 to 96) and required elective surgery to repair their hernias. No major complications or mortality was reported. CONCLUSION: Laparoscopic port closure using the classical method was associated with an acceptable incidence of port-site hernia. Modification of the current methods of closure may lead to a new technique to prevent or reduce the incidence of port-site incisional hernias.

Management of complications after laparoscopic Nissen's fundoplication: a surgeon's perspective.

INTRODUCTION: Gastro-oesophageal reflux disease (GORD) is a common problem in the Western countries, and the interest in the minimal access surgical approaches to treat GORD is increasing. In this study, we would like to discuss the presentations and management of complications we encountered after Laparoscopic Nissen's fundoplication in our District General NHS Hospital. The aim is to recognise these complications at the earliest stage for effective management to minimise the morbidity and mortality. METHODS: 301 patients underwent laparoscopic treatment for GORD by a single consultant surgeon in our NHS Trust from September 1999. The data was prospectively collected and entered into a database. The data was retrospectively analysed for presentations for complications and their management. RESULTS: Surgery was completed laparoscopically in all patients, except in five, where the operation was technically difficult due to pre-existing conditions. The complications we encountered during surgery and follow-up period were major intra-operative bleeding (n = 1, 0.33%), severe post-operative nausea and vomiting (n = 1, 0.33%), wound infection (n = 3, 1%), port-site herniation (n = 1, 0.33%), wrap-migration (n = 2, 0.66%), wrap-ischaemia (n = 1, 0.33%), recurrent regurgitation (n = 4, 1.32%), recurrent heartburn (n = 29, 9.63%), tension pneumothorax (n = 2, 0.66%), surgical emphysema (n = 8, 2.66%), and port-site pain (n = 4, 1.33%). CONCLUSION: Minimal access approach to treat GORD has presented with some specific and unique complications. It is important to recognise these complications at the earliest possible stage as some of these patients may present in an acute setting requiring emergency surgery. All members of the department, and not just the members of the specialised team, should be aware about these complications to minimise the morbidity and mortality.

Laparoscopic surgery for chronic groin pain in the general population: a prospective study.

BACKGROUND: Chronic groin pain is a challenging problem among not only athletes but also the general population. The aim of this study was to evaluate the role of laparoscopic surgery in the management of these patients. PATIENTS AND METHODS: Prospective data including the outcomes were collected and analyzed for 43 patients who had groin pain without clinical or radiologic evidence of hernia. All patients had magnetic resonance imaging scan and had consulted an orthopedic surgeon when appropriate. All patients were followed in clinic 2 weeks after operation and 6 months after the operation by phone call, and all were asked to call our unit in case of partial or no improvement. RESULTS: From September 1999 to August 2006, we performed 1617 laparoscopic groin hernia repairs in 1209 patients using the transabdominal preperitoneal approach. Forty-three patients (3 women and 40 men) with variable life activities and employment were included in this study. Only five patients played football at a professional level. The mean age of these patients was 38 years (range, 17-74 years), and the mean follow-up was 43 months (range, 14-72 months).The clinical invagination test showed wide external inguinal ring in 27 (62.7%) patients and tender inguinal canal in another 6 (13.95%) patients. Negative laparoscopy was reported in 7 (16.27%) patients. All patients had mesh insertion. The operation cured groin pain in 30 (69.76%) patients, and the pain improved in another 9 (20.93%) patients. Three (6.97%) patients had no change in their symptoms, and the pain became worse in 1 (2.32%) patient. CONCLUSION: We suggest offering laparoscopic groin exploration and mesh insertion for any adult patient presenting with chronic groin pain without clinical evidence of groin hernia or radiologic abnormality regardless of age, life activities, and employment.

Laparoscopic appendectomy in a district hospital: does the technique influence the outcome?

BACKGROUND: Laparoscopic appendicectomy (LA) has proved to be a safe, effective procedure for appendicitis. However, its application in the current surgical practice is still far less than the laparoscopic cholecystectomy. Therefore, its role as a gold standard operation for acute appendicitis (AA) is less well established. METHODS: Between September 1999 and January 2007, a series of 200 patients (112 female, 88 male) with AA underwent LA in our surgical unit. A single consultant surgeon performed all the cases. Outcomes, including the length of stay, operative time, and complications, were evaluated. Follow-up assessment of patients was performed by outpatient appointment. RESULTS: The indications for LA were clinical diagnosis of AA for 177 patients (85%) and interval appendicectomy for 23 patients (15%). The mean age of these patients was 18.8 years (range, 8-83). Operative diagnosis of inflamed appendix, including perforated appendicitis in 9 patients (7.5%), was made in 139 patients (69.5%), and the appendix was macroscopically normal in 40 patients (20%). Different pathologies were found in 21 patients (11.5%). Of the 40 (20%) macroscopically normal appendices, 10 (5%) appendices were reported as inflamed by histopathology examination. The operative time ranged from 13 to 62 minutes, with a mean of 18 minutes. Minor morbidity was reported in 11 patients (5.5%) CONCLUSION: In experienced hands using a meticulous technique, LA provides diagnostic and therapeutic options, decreased operative time, rapid recovery, short hospital stay, fewer postoperative complications, and no intra-abdominal abscesses. Appendicectomy has cured right iliac fossa pain in almost all the patients.

Patient experience with gallstone disease in a national health service district hospital.

BACKGROUND: The prevalence of gallstone disease in the community makes it an important area of service in district general hospitals. Laparoscopic surgical techniques in synergy with modern imaging and endoscopic and interventional techniques have revolutionized the treatment of gallstone disease, making it possible to provide prompt and definitive care to patients. METHODS: Patients with gallstone disease were treated based on a predetermined protocol by a special-interest team depending on the patient's mode of presentation. Data were collected and analyzed prospectively. RESULTS: Our team treated 1332 patients with gallstone disease between September 1999 and December 2007. Patients (249) with acute symptoms presented through Accident and Emergency (A&E). Despite varied presentations, laparoscopic treatment was possible in all but 8 patients. The study comprised 696 patients who underwent laparoscopic cholecystectomy (LC) as in-hospital (23 hour) cases in a stand-alone center, and 257 outpatients and 379 inpatients. Sixty-seven patients with acute cholecystitis had their surgery within 96 hours of acute presentation. Seventy patients had laparoscopic subtotal cholecystectomy. The overall morbidity was 2.33% with 3 patients having residual common bile duct stones; 3 patients had biliary leak from cystic or accessory duct stumps and one had idiopathic right segmental liver atrophy; 19 had wound infections, 5 had port-site hernia. No mortalities occurred during the 30-day follow-up. CONCLUSION: We believe that prompt investigation with imaging and endoscopic intervention if needed along with LC at the earliest safe opportunity by a specialized dedicated team represents an effective method for treating gallstone disease in district general hospitals. Our experience with over 1000 patients has offered us the courage of conviction to say that justice is finally here for gallstone sufferers.

An apricot story: view through a keyhole.

BACKGROUND: Very few cases of small bowel obstruction due to ingested fruits have been described in literature, and most of these have managed by a laparotomy. Laparoscopic assisted surgery can effectively deal with such impacted foreign bodies, thereby avoiding a formal laparotomy. CASE PRESENTATION: A 75 years old lady was admitted via the Accident and Emergency to the surgical ward with a three-day history of abdominal pain and vomiting. Investigations were suggestive of acute small bowel obstruction. On laparoscopy, there was an area of sudden change in calibre of small bowel with dilated proximal and collapsed distal segment in distal jejunum. A foreign body, dried undigested apricot, was extracted by mini-laparotomy. DISCUSSION: Small bowel obstruction is a frequent cause of emergency surgery, and aetiology may include food bolus obstruction. Diagnosis is usually confirmed intra-operatively. Foreign body impacted in small bowel can be removed by open or laparoscopic methods. CONCLUSION: Generally, laparotomy is performed for diagnosis and management in acute bowel obstruction, but with increasing expertise, laparoscopy can be equally effective with all the other advantages of minimal access approach.

Acute transhiatal migration and herniation of fundic wrap following laparoscopic nissen fundoplication.

Acute transhiatal wrap herniation can occur in the early postoperative period following laparoscopic Nissen fundoplication due to events which can raise intra-abdominal pressure. Of a total of 264 patients who underwent laparoscopic Nissen fundoplication in our series, two developed acute transhiatal wrap herniation, 8 and 12 weeks after the procedure, respectively. Prompt referral to our unit with early diagnosis and laparoscopic reduction of the hernia resulted in an uneventful recovery in one patient. Delay in recognition and referral for the other patient resulted in strangulation and perforation of the stomach in the posterior mediastinum, necessitating laparotomy and resection of the gastric fundus. Awareness and a high index of suspicion are necessary to detect and treat the condition early, thereby averting a potentially life-threatening clinical situation. Herniation, if detected early, can be treated by the laparoscopic approach. Satisfactory outcomes in the management of wrap migration following laparoscopic Nissen fundoplication hinge on early recognition and prompt surgical intervention. It is important to recognize and prevent factors that lead to anatomical failure of the operation. Methods to fix the fundic wrap and the benefits of using prosthetic material for crural repair need to be considered.

Gallstones: best served hot.

BACKGROUND: Acute episodes of gallstone-related diseases have traditionally been managed conservatively. In the event of gallstones obstructing the common bile duct, patients had endoscopic extraction of calculi with interval cholecystectomy after 4 weeks to 6 weeks when acute inflammatory changes have subsided. This placed the patient at risk of recurrent cholecystitis, pancreatitis, or other complications of cholelithiasis. METHODS: Patients presenting with acute gallstone-related diseases were investigated and underwent laparoscopic cholecystectomy during the same admission according to a predetermined treatment protocol. RESULTS: All patients (119) treated according to the study protocol had good results, with no 30-day mortality and no biliary tract injuries. One patient had bleeding from the cystic artery, and 6 patients required conversion to open cholecystectomy. CONCLUSION: Growing expertise in laparoscopic cholecystectomy has made it possible for surgeons to perform safe cholecystectomy in the presence of acute gallstone-related disease. Our experience of managing gallstone disease with prompt cholecystectomy during the index admission shows that this approach provides better, safer, and more cost-effective patient care.