The role of industry influence in sinus balloon dilation: Trends over time.

OBJECTIVE: Balloon dilation (BD) is a controversial alternative to conventional sinus surgery. The role of industry on practice patterns remains unknown. The aim of this study was to determine whether industry payments from BD manufacturers influence practice patterns for otolaryngologists and evaluate how these payments change over time. METHODS: Retrospective cohort study using Medicare Provider Utilization and Payment (PUP) Data and Center for Medicare and Medicaid Services Open Payments (OP) general payment datasets. A total of 294 otolaryngologists identified in the PUP dataset who performed BD procedures from January 1, 2013, to December 31, 2015, were cross-referenced in the OP dataset from January 1, 2014, to December 31, 2016, for BD manufacturer payments. Payments to surgeons performing BD stratified by amount, type, and number of procedures performed were primary outcome measures. RESULTS: Of the 294 otolaryngologists reporting BD procedures, 223 (76%) received payments from a company that manufactures BD devices. Receipt of $2,500 in BD payments was associated with performance of one additional BD procedure, and consulting fees were most positively associated with performing additional BD procedures (P = 0.006). The providers receiving the most in BD payments were more likely to continue to receive the most in payments, regardless of number of BD procedures performed. Performing more BD procedures did not correlate with decrease in other sinus procedures. CONCLUSION: Payments to otolaryngologists from manufacturers of sinus BD devices are associated with the performance of an increased number of such procedures. Surgeons should consider the impact of interactions with industry when evaluating patients for BD procedures. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:1540-1545, 2018.

Evolving trends in sinus surgery: What is the impact of balloon sinus dilation?

OBJECTIVES/HYPOTHESIS: Balloon dilation (BD) represents a minimally invasive alternative to endoscopic sinus surgery (ESS). Although BD was introduced in 2006, distinct Current Procedural Terminology (CPT) codes were not available until 2011, making prior analysis of population-based trends difficult. Our objectives were to evaluate these trends and compare any changes to the use of traditional ESS techniques. Geographic trends also were evaluated. METHODS: Medicare Part B national datasets encompassing procedures from 2011 to 2015 were obtained. ESS CPT codes (frontal sinusotomy, maxillary antrostomy with/without tissue removal, sphenoidotomy) and BD codes were searched to determine temporal trends in their use. Additionally, state carriers were individually evaluated for geographic trends. RESULTS: National use of BD increased greater than five-fold (39,193 from 7,496 among Medicare patients), whereas the use of ESS increased by only 5.9%. This increase in BD was observed across all sites, including the sphenoid (7.0x), maxillary (5.1x), and frontal (4.7x) sinuses. In the most recent year for which data was available (2015), a significantly greater portion of sinus procedures in these sites utilized BD in the South (42.1%) compared to the Northeast (30.6%), West (29.5%), and Midwest (25.3%) regions (P < 0.0001). CONCLUSION: The performance of BD has increased markedly in recent years. Because the use of ESS codes remain stable, observed BD trends are unlikely to be due simply to greater familiarity with newer CPT coding. The reasons for the striking increase in BD popularity are speculative and beyond the scope of this analysis, but further study may be needed. LEVEL OF EVIDENCE: NA. Laryngoscope, 128:1299-1303, 2018.

Experience with vertebral artery origin stenting and ostium dilatation: results of treatment and clinical outcomes.

BACKGROUND: The vertebral artery (VA) ostium (VAO) is a common stenosis site. Most patients with VAO stenosis refractory to medical treatment are treated endovascularly using stenting. To optimally cover the ostial plaque, which frequently extends into the adjacent subclavian artery, part of the stent must overhang in the subclavian artery. This configuration makes subsequent VA access very challenging in cases of in-stent or distal vertebrobasilar pathology; it also obstructs the distal subclavian artery. OBJECTIVE: To determine whether angioplasty at the ostium with a dual balloon (Flash Ostial) specially designed to allow the subclavian end of the stent to flare might circumvent these problems and, most importantly, provide optimal plaque coverage around the vertebral ostium. METHODS: Between June 2012 and July 2014, 11 patients with symptomatic VAO stenosis refractory to best medical therapy were treated with stenting and dual balloon Flash angioplasty. Demographics, results, and outcomes were reviewed. RESULTS: A total of 12 VAO stenting-dual balloon angioplasty procedures were performed (mean stenosis, 83.6%; range, 78-90%). Nine patients had mild-to-moderate (40-60%) contralateral VAO stenosis. The initial average modified Rankin Scale (mRS) score was 1.25. In all cases, immediate postangioplasty angiography showed excellent stent apposition against the VA and around the ostium in the subclavian artery. No permanent perioperative complications or deaths occurred. At a mean follow-up of 10.8 months (range 2-24), all patients had symptom resolution and no evidence of symptomatic restenosis on neuroimaging/Doppler studies; the average mRS score was 0.66. Three patients continued to have previously diagnosed mid-cervical VA stenosis; one of them had postprocedure dissection and an asymptomatic in-stent stenosis at 8 months. CONCLUSIONS: Safety and feasibility were demonstrated using the Ostial Flash system for VAO stenting and angioplasty. No permanent perioperative complications were seen.

Trends in the management of male urethral stricture disease in the veteran population.

OBJECTIVE: To evaluate the relative use of urethral dilation, urethrotomy, and urethroplasty for male stricture disease in the Veterans Affairs (VA) population and examine trends over time in this cohort. METHODS: A retrospective chart review was performed using the VA Informatics and Computing Infrastructure database to access the Corporate Data Warehouse. The current procedural terminology codes were used to define a cohort of all men who underwent procedures for urethral stricture disease between October 1999 and August 2013. RESULTS: A total of 92,448 procedures were performed: 50,875 urethral dilations (55.03%), 39,785 urethrotomies (43.03%), and 1788 urethroplasties (0.19%). Over the course of the study, there was a shift in the management of male stricture disease. The relative percentage of urethral dilations performed decreased in each quintile (71.27, 58.03, 45.61, 44.39, and 38.67). The relative percentage of urethrotomies increased in each quintile (27.89, 40.80, 52.18, 53.04, and 56.95) as did the relative percentage of urethroplasties performed (0.85, 1.17, 2.21, 2.57, and 4.38). A total of 80.4% of these urethroplasties were performed in locations with a residency program. CONCLUSION: Although urethroplasty is still underused, there is a trend toward increased use of urethroplasty for male urethral stricture disease in the VA population. The majority of urethroplasties were performed at VA medical centers in locations with a residency program. We predict continued increases in utilization of urethroplasty for male urethral stricture disease as the number of fellowship-trained reconstructive urologists increases.

[Therapy of chronic obstructive eustachian tube dysfunction: evolution of applied therapies]. / Therapie chronisch obstruktiver Funktionsstörungen der Tuba Eustachii: Konzepte im Wandel der Zeit.

This paper reviews the past and present developments in the treatment of chronic obstructive eustachian tube dysfunction. Alongside tube catheterization and bougie insertion, modern approaches such as laser eustachian tuboplasty and balloon eustachian tuboplasty (BET) are described. In BET, transnasal endoscopic insertion via the pharyngeal ostium places a balloon catheter in the cartilaginous portion of the eustachian tube. This is then dilated to a pressure of 10 bar for 2 min. Up until January 2013, 351 chronic obstructive eustachian tube dysfunction patients had been treated in our department using BET. The average preoperative eustachian tube score was 2.1 (± 1.8 standard deviation, SD); 12 months postoperatively it was 6.1 (± 2.6 SD). Of these patients, 87% expressed satisfaction with the improvement in chronic obstructive dysfunction. These results demonstrate that BET is a safe and effective treatment for improving eustachian tube function and ear ventilation.

[Percutaneous tracheostomy in intensive care medicine - Update 2012]. / Punktionstracheotomie in der Intensivmedizin - Update 2012.

Percutaneous tracheostomy has become an established procedure in airway management of critically ill patients. It offers advantages over prolonged tracheal intubation. To date, there is no evidence of the optimal timing of the procedure. The Ciaglia Blue Rhino technique is the most common technique and, as any other techniques of percutaneous tracheostomy, is performed under general anaesthesia and with continuous bronchoscopic control. The recently introduced Ciaglia Blue Dolphin technique is based on radial dilatation with a fluid-filled high pressure balloon. Provided that specific contraindications are observed (e.g. difficult tracheal intubation, inability to identify anatomic landmarks, severe coagulopathy etc.), all techniques have low complication rates. The use of ultrasound may further enhance perioperative safety. Finally it must be noted that percutaneous tracheostomy is an elective procedure that requires informed consent from the patient or an attorney of law.

Tratamiento médico de la gestación ectópica cervical: nuevos avances / Medical management of cervical ectopic pregnancies: new developments

Presentamos un caso de gestación ectópica cervical con tratamiento conservador satisfactorio. Se trató mediante inyecciones sistémicas de metotrexato, que resultaron inicialmente efectivas, aunque posteriormente apareció cuadro hemorrágico genital severo que precisó dilatación y legrado cervical para su resolución, no siendo necesario ningún tipo de actitud terapéutica radical (AU)

We report a case of cervical ectopic pregnancy with successful conservative treatment. The patient was treated with systemic methotrexate injections, which initially proved effective. However, severe genital bleeding subsequently developed, requiring cervical dilation and curettage for resolution. A radical change in the therapeutic approach was not required (AU)

¿Cuál es el momento idóneo para la medición por ultrasonidos de la dilatación braquial mediada por flujo? / What is the ideal moment for ultrasound measurement of brachial artery flow-mediated dilation?

Introducción y objetivo. Las guías técnicas de medición de la dilatación braquial mediada por flujo (DBMF) recomiendan su medida en diástole para evitar la influencia de la distensibilidad (complianza) arterial en los resultados. Sin embargo, no existen estudios que corroboren esta hipótesis, por lo que éste es el objetivo primordial de nuestro trabajo. Sujetos y métodos. Se reclutaron dos grupos de sujetos con estos criterios: grupo I, sujetos sanos con índice tobillo/brazo (ITB) > 0,9 y menores de 30 años, y grupo II, pacientes con arteriopatía periférica sintomática definida por un ITB < 0,9. Se les realizó la medición de la dilatación de la arteria braquial mediada por flujo (DBMF) en el brazo derecho en sístole (S) y diástole (D). Se midió en el mismo acto el ITB y se recogieron los factores de riesgo y los tratamientos. Además, se determinó la dilatación mediada por flujo en ambas arterias femorales (DFMF). Resultados. Se reclutaron 36 y 33 sujetos de los grupos I y II, respectivamente. Se compararon los valores de dilatación en S y D y se representaron como grupo: S / D (valor p). DBMF: I + II: 8,1 ± 4,6% / 7,6 ± 4,9% (p = 0,3); I: 10,8 ± 2,9% / 9,9 ± 3,8% (p = 0,055); II: 5,2 ± 4,3% / 5,16 ± 4,8% (p = 0,3). DFMF: I + II: 3,13 ± 3,6% / 2,8 ± 3,6% (p = 0,35); I: 5,3 ± 2,9% / 4,8 ± 2,6% (p = 0,02); II: 0,6 ± 2,5% / 0,6 ± 3,4% (p = 0,9). Conclusiones. Si se asume la influencia de la complianza en la dilatación arterial, se observa que la dilatación mediada por flujo en sístole es superior a la diastólica en los sujetos sanos, mientras que en los enfermos esta diferencia es prácticamente inexistente. Aunque la diferencia en la arteria braquial de sujetos sanos no llega a la significación (p = 0,055), sí que lo hace en la femoral (p = 0,02), por lo que, al valorar los datos en conjunto, recomendamos utilizar la medición en diástole para evitar sesgos a la hora de realizar comparaciones entre sanos y enfermos

Introduction and aims. The technical guides to measuring the brachial artery flow-mediated dilation (BFMD) recommend that it should be measured in the diastolic phase in order to prevent results from being influenced by arterial distensibility (compliance). No studies have been conducted, however, to confirm this hypothesis and this is therefore the main purpose of our research. Subjects and methods. Two groups of subjects were recruited on the basis of the following criteria: group I, healthy subjects with an ankle-brachial index (ABI) > 0.9 and below 30 years of age, and group II, composed of patients with symptomatic peripheral arterial disease that was defined by an ABI < 0.9. Brachial artery flow-mediated dilation was measured in the right arm in both the systolic (S) and diastolic (D) phases. The ABI was measured at the same time and the risk factors and treatments were collected. Flow-mediated dilation was also determined in both femoral arteries (FFMD). Results. Groups I and II consisted of 36 and 33 subjects respectively. The dilation values in the S and D phases were compared and represented as a group: S / D (value p). BFMD: I + II: 8.1 ± 4.6% / 7.6 ± 4.9% (p = 0.3); I: 10.8 ± 2.9% / 9.9 ± 3.8% (p = 0.055); II: 5.2 ± 4.3% / 5.16 ± 4.8% (p = 0.3). FFMD: I + II: 3.13 ± 3.6% / 2.8 ± 3.6% (p = 0.35); I: 5.3 ± 2.9% / 4.8 ± 2.6% (p = 0.02); II: 0.6 ± 2.5% / 0.6 ± 3.4% (p = 0.9). Conclusions. If it is assumed that compliance influences arterial dilation, systolic flow-mediated dilation is seen to be higher than in the diastolic phase in healthy subjects, whereas this difference is practically inexistent in patients. Although the difference in the brachial artery of healthy subjects does not reach significance (p = 0.055), it does in the femoral artery (p = 0.02). Therefore, on appraising the data as a whole, we recommend measurement in the diastolic phase in order to avoid the occurrence of biases when comparing between healthy and sick subject

Conservative treatment of caustic esophageal injuries in children: 20 years of experience.

The authors present their experience in the medical treatment of 1, 296 caustic esophageal injuries in children over the last 20 years in two study groups, one comprising the period up to 1989 and the other 1990 to 1996, comparing the different treatments used in each group. The treatment was based fundamentally on dilatations with anterograde mercury bougies, Savary bougies, or retrograde thread-guided bougies with gastrostomy. Pneumatic balloons or stenting procedures have also been employed in the last 3 years. Early fiberendoscopy was used systematically in the second group, which provides a more accurate evaluation of the esophageal lesions. Antibiotic coverage was done systematically during the first 10 days in all serious cases, while steroids were employed routinely only in the last 3 years. The results were similar in both groups, with a dilatation average of 32 in the first and 30 in the second group and an initial dilatation interval of 3 to 4 weeks in both. Using updated exploration and dilatation techniques, we drastically reduced the number of gastrostomies needed for retrograde thread-guided dilatations from 51 in the first group to 5 in the second, consequently improving the patients' life quality. There was no mortality and only five esophageal perforations, which did not require surgical treatment.