Promoting Strategies to Increase HPV Vaccination in the Pediatric Primary Care Setting.

INTRODUCTION: Evaluation of a quality improvement project designed to improve HPV vaccine uptake in a pediatric primary care setting for young adolescents. METHOD: Three strategies were implemented in one private pediatric practice to promote HPV vaccine uptake for 11- and 12-year-old adolescents. 1) a standardized vaccine policy change was made to include HPV vaccine with other adolescent vaccines, 2) a pre-visit email was sent to parents of teens to provide factual vaccine information in preparation for the visit, and 3) a provider communication initiative was implemented to ensure all providers communicated consistent messages and delivered an effective cancer prevention recommendation for HPV vaccination. A pre/post design was used to compare vaccine rates. Data was obtained via the electronic health records. RESULTS: The post-intervention group demonstrated HPV vaccine rates increased substantially from 17.8% to 63.6%. DISCUSSION: Strategically implementing standardized clinical vaccine policies and presumprive provider communication practices has implications for significantly increasing HPV vaccine uptake among teens and may be key to preventing cancer among future generations.

Airway Autoimmune Inflammatory Response (AAIR) Syndrome: An Asthma-Autoimmune Overlap Disorder?

Asthma encompasses numerous phenotypes that may require alternate approaches to diagnosis and therapy, particularly for patients whose symptoms remain poorly controlled despite escalating treatment. We describe 3 patients with apparent asthma who demonstrated unusual findings on cryobiopsy by flexible bronchoscopy and responded to therapy directed against autoimmune disease.

Endoscopic ultrasound-guided biliary drainage versus percutaneous transhepatic biliary drainage: predictors of successful outcome in patients who fail endoscopic retrograde cholangiopancreatography.

BACKGROUND: Patients with failed endoscopic retrograde cholangiopancreatography (ERCP) are conventionally offered percutaneous transhepatic biliary drainage (PTBD). While PTBD is effective, it is associated with catheter-related complications, pain, and poor quality of life. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is a minimally invasive endoscopic option increasingly offered as an alternative to PTBD. We compare outcomes of EUS-BD and PTBD in patients with biliary obstruction at a single tertiary care center. METHODS: A retrospective review was performed in patients with biliary obstruction who underwent EUS-BD or PTBD after failed ERCP from June 2010 through December 2014 at a single tertiary care center. Patient demographics, procedural data, and clinical outcomes were documented for each group. The aim was to compare efficacy and safety of EUS-BD and PTBD and evaluate predictors of success. RESULTS: A total of 60 patients were included (mean age 67.5 years, 65 % male). Forty-seven underwent EUS-BD, and thirteen underwent PTBD. Technical success rates of PTBD and EUS-BD were similar (91.6 vs. 93.3 %, p = 1.0). PTBD patients underwent significantly more re-interventions than EUS-BD patients (mean 4.9 versus 1.3, p < 0.0001), had more late (>24-h) adverse events (53.8 % vs. 6.6 %, p = 0.001) and experienced more pain (4.1 vs. 1.9, p = 0.016) post-procedure. In univariate analysis, clinical success was lower in the PTBD group (25 vs. 62.2 %, p = 0.03). In multivariable logistic regression analysis, EUS-BD was the sole predictor of clinical success and long-term resolution (OR 21.8, p = 0.009). CONCLUSION: Despite similar technical success rates compared to PTBD, EUS-BD results in a lower need for re-intervention, decreased rate of late adverse events, and lower pain scores, and is the sole predictor for clinical success and long-term resolution. EUS-BD should be the treatment of choice after a failed ERCP.

Endoscopic Gallbladder Drainage for Acute Cholecystitis.

BACKGROUND/AIMS: Surgery is the mainstay of treatment for cholecystitis. However, gallbladder stenting (GBS) has shown promise in debilitated or high-risk patients. Endoscopic transpapillary GBS and endoscopic ultrasound-guided GBS (EUS-GBS) have been proposed as safe and effective modalities for gallbladder drainage. METHODS: Data from patients with cholecystitis were prospectively collected from August 2004 to May 2013 from two United States academic university hospitals and analyzed retrospectively. The following treatment algorithm was adopted. Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and cystic duct stenting was initially attempted. If deemed feasible by the endoscopist, EUS-GBS was then pursued. RESULTS: During the study period, 139 patients underwent endoscopic gallbladder drainage. Among these, drainage was performed in 94 and 45 cases for benign and malignant indications, respectively. Successful endoscopic gallbladder drainage was defined as decompression of the gallbladder without incidence of cholecystitis, and was achieved with ERCP and cystic duct stenting in 117 of 128 cases (91%). Successful endoscopic gallbladder drainage was also achieved with EUS-guided gallbladder drainage using transmural stent placement in 11 of 11 cases (100%). Complications occurred in 11 cases (8%). CONCLUSIONS: Endoscopic gallbladder drainage techniques are safe and efficacious methods for gallbladder decompression in non-surgical patients with comorbidities.

Endoscopic gallbladder drainage compared with percutaneous drainage.

BACKGROUND: High-risk patients with cholecystitis have conventionally been offered percutaneous gallbladder drainage (PGBD) for treatment. A growing experience of endoscopic gallbladder drainage (EGBD) has been reported to be effective and safe. OBJECTIVE: To compare the short- and long-term outcomes of EGBD and PGBD. DESIGN: A retrospective review. SETTING: Single academic tertiary care center. PATIENTS: Inpatients diagnosed with cholecystitis. INTERVENTIONS: Any patient deemed a nonsurgical candidate and who has undergone either PGBD or EGBD was included in the analysis. MAIN OUTCOME MEASUREMENTS: Patient demographics along with procedural and clinical outcomes were recorded for each group. RESULTS: Forty-three patients underwent PGBD and 30 underwent EGBD (24 transpapillary, 6 transmural). Technical (97.6% vs 100%) and clinical (97.6% vs 86.7%) success rates of PGBD and EGBD were similar. However, postprocedure hospital length of stay (16.3 vs 7.6 days), time to clinical resolution (4.6 vs 3.0 days), adverse event rate (39.5% vs 13.3%), number of sessions (2.0 vs 1.0), number of repeat interventions (53.4% vs 13.3%), and postprocedure pain scores (3.8 vs 2.1) were significantly higher for PGBD than EGBD. LIMITATIONS: Retrospective analysis. CONCLUSION: Although EGBD has similar technical and clinical success compared with PGBD, it uses fewer hospital resources and results in fewer adverse events, improved pain scores, and decreased need for repeat gallbladder drainage. EGBD may provide a less-invasive, safer, cost-effective option for gallbladder drainage than PGBD with improved clinical outcomes.

Probe-based confocal laser endomicroscopy in the pancreatic duct provides direct visualization of ductal structures and aids in clinical management.

BACKGROUND: Confocal endomicroscopy provides real-time evaluation of various sites and has been used to provide detailed endomicroscopic imaging of the biliary tree. We aimed to evaluate the feasibility and utility of probe-based confocal laser endomicroscopy of the pancreatic duct as compared to cytologic and histologic results in patients with indeterminate pancreatic duct strictures. METHODS: Retrospective data on patients with indeterminate pancreatic strictures undergoing endoscopic retrograde cholangiopancreatography (ERCP) and confocal endomicroscopy were collected from two tertiary care centres. Real-time confocal endomicroscopy images were obtained during ERCP and immediate interpretation according to the Miami Classification was performed. RESULTS: 18 patients underwent confocal endomicroscopy for evaluation of pancreatic strictures from July 2011 to December 2012. Mean pancreatic duct size was 4.2mm (range 2.2-8mm). Eight cases were interpreted as benign, 4 as malignant, 4 suggestive of intraductal papillary mucinous neoplasms, and 2 appeared normal. Cytology/histopathology for 15/16 cases showed similar results to confocal endomicroscopy interpretation. Kappa coefficient of agreement between cyto/histopathology and confocal endomicroscopy was 0.8 (p=0.0001). Pancreatic confocal endomicroscopy changed management in four patients, changing the type of surgery from total pancreatectomy to whipple. CONCLUSIONS: Confocal endomicroscopy is effective in assisting with diagnosis of indeterminate pancreatic duct strictures as well as mapping of abnormal pancreatic ducts prior to surgery.

Safety and efficacy of radiofrequency ablation in the management of unresectable bile duct and pancreatic cancer: a novel palliation technique.

UNLABELLED: Objectives. Radiofrequency ablation (RFA) has replaced photodynamic therapy for premalignant and malignant lesions of the esophagus. However, there is limited experience in the bile duct. The objective of this pilot study was to assess the safety and efficacy of RFA in malignant biliary strictures. METHODS: Twenty patients with unresectable malignant biliary strictures underwent RFA with stenting between June 2010 and July 2012. Diameters of the stricture before and after RFA, immediate and 30 day complications and stent patency were recorded prospectively. Results. A total of 25 strictures were treated. Mean stricture length treated was 15.2 mm (SD = 8.7 mm, Range = 3.5-33 mm). Mean stricture diameter before RFA was 1.7 mm (SD = 0.9 mm, Range = 0.5-3.4 mm) while the mean diameter after RFA was 5.2 mm (SD = 2 mm, Range = 2.6-9 mm). There was a significant increase of 3.5 mm (t = 10.8, DF = 24, P value = <.0001) in the bile duct diameter post RFA. Five patients presented with pain after the procedure, but only one developed mild post-ERCP pancreatitis and cholecystitis. CONCLUSIONS: Radiofrequency ablation can be a safe palliation option for unresectable malignant biliary strictures. A multicenter randomized controlled trial is required to confirm the long term benefits of RFA and stenting compared to stenting alone.

Regional dissemination of a trimethoprim-resistance gene cassette via a successful transposable element.

BACKGROUND: Antimicrobial resistance is a growing international problem. We observed a 50% increase in the prevalence of trimethoprim resistance among fecal Escherichia coli from healthy Nigerian students between 1998 and 2005, a trend to increase that continued in 2009. METHODS AND FINDINGS: A PCR-based screen revealed that 131 (43.1%) of isolates obtained in Nigeria in 2005 and 2009 carried integron-borne dfrA cassettes. In the case of 67 (51.1%) of these isolates, the cassette was a class 1-integron-borne dfrA7 gene, which has been reported at high prevalence from E. coli isolates from other parts of Africa. Complete sequencing of a 27 Kb dfrA7-bearing plasmid from one isolate located the dfrA7 gene within a Tn21-type transposon. The transposon also contained an IS26-derived bla/sul/str element, encoding resistance to ß-lactams, sulphonamides and streptomycin, and mercury resistance genes. Although the plasmid backbone was only found in 12 (5.8%) of trimethoprim-resistant isolates, dfrA7 and other transposon-borne genes were detected in 14 (16.3%) and 32 (26.3%) of trimethoprim resistant isolates collected in Nigeria in 2005 and 2009, respectively. Additionally, 37 (19.3%) of trimethoprim-resistant E. coli isolates collected between 2006 and 2008 from Ghana were positive for the dfrA7 and a transposon marker, but only 4 (2.1%) harbored the plasmid backbone. CONCLUSIONS: Our data point to transposition as a principal mechanism for disseminating dfrA7 among E. coli from Nigeria and Ghana. On-going intensive use of the affordable broad-spectrum antibacterials is likely to promote selective success of a highly prevalent transposable element in West Africa.

Oblique posterior trochanteric osteotomy in revision total hip arthroplasty.

Modular polyethylene failure and attendant revision play an increasing role in hip arthroplasty. In spite of well-fixed, well-aligned components, bearing exchange has a high risk of chronic instability, which may be attributed to the resection of stabilizing soft tissue structures to gain exposure. This creates a difficult situation for the surgeon and an inexplicable one for the patient with a previously well-functioning implant. The senior author modified a technique previously described by Shaw that included an osteotomy of the posterior one third of the greater trochanter and preservation of posterior soft tissues. Thirty-five patients underwent 47 revision procedures utilizing this approach, including 16 modular component and 31 more extensive procedures. There were no dislocations or significant complications and no loss of reduction or nonunion. The approach offers excellent exposure while preserving stabilizing soft tissues.

Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study.

BACKGROUND: Distinguishing septic arthritis from transient synovitis of the hip in children can be challenging. Authors of recent retrospective studies have used presenting factors to establish algorithms for predicting septic arthritis of the hip in children. This study differs from previous work in three ways: data were collected prospectively, C-reactive protein levels were recorded, and the focus was on children in whom the findings were so suspicious for septic arthritis that hip aspiration was performed. METHODS: Over four years, we prospectively collected data on every child (a total of fifty-three) who underwent hip aspiration because of a suspicion of septic arthritis at our institution. Diagnoses of confirmed septic arthritis, presumed septic arthritis, and transient synovitis were determined on the basis of the results of Gram staining, culture, and a cell count of the hip aspirate. Presenting factors and laboratory values were recorded. To evaluate the strength of predictors, we performed univariate and multivariate analysis on data from forty-eight patients who met the inclusion criteria. RESULTS: Univariate analysis showed that fever, the C-reactive protein level, and the erythrocyte sedimentation rate were strongly associated with the final diagnosis (p < 0.05). On multivariate analysis, the C-reactive protein level and erythrocyte sedimentation rate were found to be significant predictors. However, the erythrocyte sedimentation rate was not independent of the C-reactive protein level on backward elimination, and the C-reactive protein level was the only risk factor that was strongly associated with the outcome at a 5% significance level. Patients with five predictive factors had a 98% chance of having septic arthritis, those with four factors had a 93% chance, and those with three factors had an 83% chance. CONCLUSIONS: This prospective study of children who presented with findings that were highly suspicious for septic arthritis of the hip builds on the work of previous authors. We found fever (an oral temperature >38.5 degrees C) was the best predictor of septic arthritis followed by an elevated C-reactive protein level, an elevated erythrocyte sedimentation rate, refusal to bear weight, and an elevated serum white blood-cell count. In our study group, a C-reactive protein level of >2.0 mg/dL (>20 mg/L) was a strong independent risk factor and a valuable tool for assessing and diagnosing children suspected of having septic arthritis of the hip.