Endoscopy Unit Level Interventions to Improve Adenoma Detection Rate: A Systematic Review and Meta-Analysis.

BACKGROUND & AIMS: Adenoma detection rate (ADR) is inversely correlated with the risk of interval colon cancer and is a key target for quality improvement in endoscopy units. We conducted a systematic review and meta-analysis to identify and evaluate the effectiveness of interventions that can be implemented at the endoscopy unit level to improve ADRs. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search was conducted in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases between January 1990 and December 2022 to identify relevant studies. Both randomized controlled trials and observational studies were eligible. Data for the primary outcome of ADR were analyzed and reported on the log-odds scale with 95% CIs using a random-effects meta-analysis model using the empiric Bayes estimator. RESULTS: From 10,778 initial citations, 34 studies were included in the meta-analysis comprising 371,041 procedures and 1501 endoscopists. The provision of report cards (odds ratio [OR], 1.28; 95% CI, 1.13-1.45; P < .001) and the presence of an additional observer to identify polyps (OR, 1.25; 95% CI, 1.09-1.43; P = .002) were associated with significant increases in ADRs whereas multimodal interventions were borderline significant (OR, 1.18; 95% CI, 1.00-1.40; P = .05) and withdrawal time monitoring was not associated significantly with an increase in ADRs (OR, 1.35; 95% CI, 0.93-1.96; P = .11). CONCLUSIONS: The provision of report cards and the presence of an additional observer to identify polyps are associated with improved ADRs and should be considered for implementation in endoscopy facilities.

[EVIVO program adapted for the labor sector†: a help for managing chronic condition and professional life]. / Adaptation du cours EVIVO au secteur du travail : concilier maladie chronique et vie professionnelle.

EVIVO is a well-established chronic disease self-management program, having been successfully implemented during the last decade in Switzerland. The program has shown positive results in facilitation of self-management competences for patients living with chronic diseases and their relatives. EVIVO was designed to run for 6 weeks with weekly sessions of 2 and a half hour each. We tested the effectiveness of a shortened version of EVIVO, running it over five half days in order to make it more focused for patients who are challenged by managing their chronic illness within the context of their professional life. Participants in the five-session version showed comparable self-efficacy levels compared with those who had attended the standard six-week six-session courses. Overall, the five-session version was well accepted, considered very useful, met the participants' needs and changed their perception of their own expectations towards self-management of their illness.

Le cours EVIVO «â€…Devenir acteur de sa santé avec une maladie chronique ¼ a été implémenté en Suisse et s'est montré utile pour aider les personnes concernées et/ou leurs proches à renforcer leurs capacités à gérer la maladie et vivre le quotidien de manière plus positive. Structuré sur 6 semaines à raison d'une session de 2 h 30 par semaine, il a été reformaté sur 5 demi-journées afin d'être implémenté dans le monde du travail. L'évaluation d'EVIVO sur 5 sessions montre des résultats comparables dans l'évolution du sentiment d'autoefficacité comparable au cours sur 6 sessions. De plus, la version en 5 sessions ciblant les enjeux liés au travail s'est globalement révélée acceptable, utile et répondant aux besoins des participant·e·s qui ont exprimé avoir changé leurs attentes envers l'autogestion de leur maladie.

Management of colonoscopic perforation: a systematic review and treatment algorithm.

BACKGROUND: The aim of this review is to evaluate and summarize the current strategies used in the management of colonoscopic perforations as well as propose a modern treatment algorithm. METHODS: Articles published between January 2004 and January 2019 were screened. A total of 167 reports were identified in combined literature search, of which 61 articles were selected after exclusion of duplicate and unrelated articles. Only studies that reported on the management of endoscopic perforation in an adult population were retrieved for review. Case reports and case series of 8 patients or less were not considered. Ultimately, 19 articles were considered eligible for review. RESULTS: A total of 744 cases of colonoscopic perforations were reported in 19 major articles. The cause of perforation was mentioned in 16 articles. Colonoscopic perforations were reported as a consequence of diagnostic colonoscopies in 222 cases and therapeutic colonoscopies in 248 cases. The site of perforation was mentioned in 486 cases. Sigmoid colon was the predominant site followed by the cecum. The management of colonoscopic perforations was reported in a total of 741 patients. Surgical intervention was employed in 75% of the patients, of these 15% were laparoscopic and 85% required laparotomy. The predominant surgical intervention was primary repair. CONCLUSION: Management strategies of colon perforations depend upon the etiology, size, severity, location, available expertise, and general health status. Usually, peritonitis, sepsis, or hemodynamic compromise requires immediate surgical management. Endoscopic techniques are under continuous evolution. Newer developments have offered high success rate with least amount of post-procedure complications. However, there is a need for further studies to compare the newer endoscopic techniques in terms of success rate, cost, complications, and the affected part of colon.

A prospective comparison of live and video-based assessments of colonoscopy performance.

BACKGROUND AND AIMS: Colonoscopy performance is typically assessed by a supervisor in the clinical setting. There are limitations of this approach, however, because it allows for rater bias and increases supervisor workload demand during the procedure. Video-based assessment of recorded procedures has been proposed as a complementary means by which to assess colonoscopy performance. This study sought to investigate the reliability, validity, and feasibility of video-based assessments of competence in performing colonoscopy compared with live assessment. METHODS: Novice (<50 previous colonoscopies), intermediate (50-500), and experienced (>1000) endoscopists from 5 hospitals participated. Two views of each colonoscopy were videotaped: an endoscopic (intraluminal) view and a recording of the endoscopist's hand movements. Recorded procedures were independently assessed by 2 blinded experts using the Gastrointestinal Endoscopy Competency Assessment Tool (GiECAT), a validated procedure-specific assessment tool comprising a global rating scale (GRS) and checklist (CL). Live ratings were conducted by a non-blinded expert endoscopist. Outcomes included agreement between live and blinded video-based ratings of clinical colonoscopies, intra-rater reliability, inter-rater reliability and discriminative validity of video-based assessments, and perceived ease of assessment. RESULTS: Forty endoscopists participated (20 novices, 10 intermediates, and 10 experienced). There was good agreement between the live and video-based ratings (total, intra-class correlation [ICC] = 0.847; GRS, ICC = 0.868; CL, ICC = 0.749). Intra-rater reliability was excellent (total, ICC = 0.99; GRS, ICC = 0.99; CL, ICC = 0.98). Inter-rater reliability between the 2 blinded video-based raters was high (total, ICC = 0.91; GRS, ICC = 0.918; CL, ICC = 0.862). GiECAT total, GRS, and CL scores differed significantly among novice, intermediate, and experienced endoscopists (P < .001). Video-based assessments were perceived as "fairly easy," although live assessments were rated as significantly easier (P < .001). CONCLUSIONS: Video-based assessments of colonoscopy procedures using the GiECAT have strong evidence of reliability and validity. In addition, assessments using videos were feasible, although live assessments were easier.

Impact of experience on self-assessment accuracy of clinical colonoscopy competence.

BACKGROUND AND AIMS: Self-assessment is important for life-long learning and a recommended assessment method for endoscopy skills. Prior literature has not investigated self-assessment accuracy of colonoscopic competence in the clinical setting. This study aimed to determine the self-assessment accuracy of novice, intermediate, and experienced endoscopists. METHODS: Novice (performed <50 previous colonoscopies), intermediate (50-500), and experienced (>1000) endoscopists from 5 hospitals each performed a clinical colonoscopy. Video recordings of procedures were independently assessed by 2 blinded expert endoscopists by using the Gastrointestinal Endoscopy Competency Assessment Tool (GiECAT). Externally assessed and self-assessed GiECAT scores were defined as the mean of the 2 video-based ratings and as participants' own assigned ratings, respectively. Self-assessment accuracy between the externally assessed and self-assessed scores was evaluated by using absolute difference scores, intraclass correlation coefficients, and the Bland-Altman analysis. RESULTS: Twenty novice, 10 intermediate, and 10 experienced endoscopists participated. There was moderate agreement of externally assessed and self-assessed GiECAT scores, with an intraclass correlation coefficient of 0.65 (95% confidence interval, 0.44-0.80). The absolute difference scores among the 3 groups were significantly different (P = .002), with experienced endoscopists demonstrating a more accurate self-assessment ability compared with novices (P = .002). Bland-Altman plots suggest that novice and experienced endoscopists tend to overrate and underrate their clinical competence, respectively; no specific trends were associated with intermediates. CONCLUSION: Participants demonstrated moderate self-assessment accuracy of clinical competence. Endoscopist experience was positively associated with self-assessment accuracy; novices demonstrated lower self-assessment accuracy compared with experienced endoscopists. Moreover, novices tended to overestimate their performances. Novice endoscopists may benefit from targeted interventions to improve self-assessment accuracy.

The effect of small solar powered 'Bͻkͻͻ' net fans on mosquito net use: results from a randomized controlled cross-over trial in southern Ghana.

BACKGROUND: Long-lasting insecticidal nets (LLINs) are ineffective malaria transmission prevention tools if they are unused. Discomfort due to heat is the most commonly reported reason for not using nets, but this problem is largely unaddressed. With increasing rural electrification and the dropping price of solar power, fans could improve comfort inside nets and be affordable to populations in malaria endemic areas. Here, results are presented from a pilot randomized controlled cross-over study testing the effect of fans on LLIN use. METHODS: Eighty-three households from two rural communities in Greater Accra, Ghana, randomized into three groups, participated in a 10-month cross-over trial. After a screening survey to identify eligible households, all households received new LLINs. BÍ»kͻͻ net fan systems (one fan per member) were given to households in Group 1 and water filters were given to households in Group 2. At mid-point, Group 1 and 2 crossed over interventions. Households in Group 1 and 2 participated in fortnightly surveys on households' practices related to nets, fans and water filters, while households in Group 3 were surveyed only at screening, mid-point and study end. Entomological and weather data were collected throughout the study. Analysis took both 'per protocol' (PP) and 'intention to treat' (ITT) approaches. The mid- and end-point survey data from Group 1 and 2 were analysed using Firth logistic regressions. Fortnightly survey data from all groups were analysed using logistic regressions with random effects. RESULTS: Provision of fans to households appeared to increase net use in this study. Although the increase in net use explained by fans was not significant in the primary analyses (ITT odds ratio 3.24, p > 0.01; PP odds ratio = 1.17, p > 0.01), it was significant in secondary PP analysis (odds ratio = 1.95, p < 0.01). Net use was high at screening and even higher after provision of new LLINs and with follow up. Fan use was 90-100% depending on the fortnightly visit. CONCLUSIONS: This pilot study could not provide definitive evidence that fans increase net use. A larger study with additional statistical power is needed to assess this association across communities with diverse environmental and socio-demographic characteristics.

Gastrointestinal Endoscopy Competency Assessment Tool: reliability and validity evidence.

BACKGROUND: Rigorously developed and validated direct observational assessment tools are required to support competency-based colonoscopy training to facilitate skill acquisition, optimize learning, and ensure readiness for unsupervised practice. OBJECTIVE: To examine reliability and validity evidence of the Gastrointestinal Endoscopy Competency Assessment Tool (GiECAT) for colonoscopy for use within the clinical setting. DESIGN: Prospective, observational, multicenter validation study. Sixty-one endoscopists performing 116 colonoscopies were assessed using the GiECAT, which consists of a 7-item global rating scale (GRS) and 19-item checklist (CL). A second rater assessed procedures to determine interrater reliability by using intraclass correlation coefficients (ICCs). Endoscopists' first and second procedure scores were compared to determine test-retest reliability by using ICCs. Discriminative validity was examined by comparing novice, intermediate, and experienced endoscopists' scores. Concurrent validity was measured by correlating scores with colonoscopy experience, cecal and terminal ileal intubation rates, and physician global assessment. SETTING: A total of 116 colonoscopies performed by 33 novice (<50 previous procedures), 18 intermediate (50-500 previous procedures), and 10 experienced (>1000 previous procedures) endoscopists from 6 Canadian hospitals. MAIN OUTCOME MEASUREMENTS: Interrater and test-retest reliability, discriminative, and concurrent validity. RESULTS: Interrater reliability was high (total: ICC=0.85; GRS: ICC=0.85; CL: ICC=0.81). Test-retest reliability was excellent (total: ICC=0.91; GRS: ICC=0.93; CL: ICC=0.80). Significant differences in GiECAT scores among novice, intermediate, and experienced endoscopists were noted (P<.001). There was a significant positive correlation (P<.001) between scores and number of previous colonoscopies (total: ρ=0.78, GRS: ρ=0.80, CL: Spearman's ρ=0.71); cecal intubation rate (total: ρ=0.81, GRS: Spearman's ρ=0.82, CL: Spearman's ρ=0.75); ileal intubation rate (total: Spearman's ρ=0.82, GRS: Spearman's ρ=0.82, CL: Spearman's ρ=0.77); and physician global assessment (total: Spearman's ρ=0.90, GRS: Spearman's ρ=0.94, CL: Spearman's ρ=0.77). LIMITATIONS: Nonblinded assessments. CONCLUSION: This study provides evidence supporting the reliability and validity of the GiECAT for use in assessing the performance of live colonoscopies in the clinical setting.

Gastrointestinal Endoscopy Competency Assessment Tool: development of a procedure-specific assessment tool for colonoscopy.

BACKGROUND: Ensuring competence remains a seminal objective of endoscopy training programs, professional organizations, and accreditation bodies; however, no widely accepted measure of endoscopic competence currently exists. OBJECTIVE: By using Delphi methodology, we aimed to develop and establish the content validity of the Gastrointestinal Endoscopy Competency Assessment Tool for colonoscopy. DESIGN: An international panel of endoscopy experts rated potential checklist and global rating items for their importance as indicators of the competence of trainees learning to perform colonoscopy. After each round, responses were analyzed and sent back to the experts for further ratings until consensus was reached. MAIN OUTCOME MEASUREMENTS: Consensus was defined a priori as ≥80% of experts, in a given round, scoring ≥4 of 5 on all remaining items. RESULTS: Fifty-five experts agreed to be part of the Delphi panel: 43 gastroenterologists, 10 surgeons, and 2 endoscopy managers. Seventy-three checklist and 34 global rating items were generated through a systematic literature review and survey of committee members. An additional 2 checklist and 4 global rating items were added by Delphi panelists. Five rounds of surveys were completed before consensus was achieved, with response rates ranging from 67% to 100%. Seven global ratings and 19 checklist items reached consensus as good indicators of the competence of clinicians performing colonoscopy. LIMITATIONS: Further validation required. CONCLUSION: Delphi methodology allowed for the rigorous development and content validation of a new measure of endoscopic competence, reflective of practice across institutions. Although further evaluation is required, it is a promising step toward the objective assessment of competency for use in colonoscopy training, practice, and research.

Wait times for diagnostic colonoscopy among outpatients with colorectal cancer: a comparison with Canadian Association of Gastroenterology targets.

BACKGROUND: Timely access to colonoscopy is a nationally recognized issue in Canada, with previous studies documenting significant wait times for a variety of indications. However, specific wait times for colonoscopy among patients diagnosed with colorectal cancer remain unknown. METHODS: A review of all outpatient cases of colorectal cancer diagnosed at colonoscopy in London, Ontario, in 2010 was performed. Wait times from the date of referral to colonoscopy were reviewed and compared with maximal wait times established by the Canadian Association of Gastroenterology (CAG) stratified according to indication. Cancer stage at the time of diagnosis was compared with colonoscopy wait times. RESULTS: A total of 106 colorectal cancer patients meeting the inclusion and exclusion criteria were included in the study. Forty-six per cent of patients waited longer than CAG targets, with a mean (± SD) wait time of 79 ± 101 days. Higher cancer stage was associated with shorter wait time, likely as a result of triaging. CONCLUSION: Long wait times for diagnostic colonoscopy among patients with colorectal cancer remain an issue, with a significant proportion of cases not meeting maximal CAG wait time targets.

VIBe Scale: Validation of the Intraoperative Bleeding Severity Scale by Spine Surgeons.

BACKGROUND: The Validated Intraoperative Bleeding Scale (VIBe Scale) was initially validated with surgeons who operate on cardiothoracic, abdominal, and pelvic cavities and fulfilled criteria for a clinician-reported scale. However, there is a need for a tool to aid in intraoperative blood management during spine surgeries. The purpose of the present study was to establish the reliability and consistency of the VIBe Scale as a tool for spine surgeons to assess intraoperative bleeding. METHODS: Orthopedic (n = 16) and neurological (n = 9) spine surgeons scored videos depicting surgical bleeding and assessed the VIBe Scale's relevance and clarity. Inter- and intraobserver agreement (Kendall's W) were calculated for all surgeons and pooled with responses from the original study to establish agreement across specialties. RESULTS: All of the spine surgeons indicated that the scale was clinically relevant for evaluating hemostasis and could be implemented in a clinical study. Twenty-two spine surgeons (88%) reported that the scale represents the range of bleeding site sizes and severities expected in their practice. Twenty-four spine surgeons (96%) indicated that the scale would be useful in communicating bleeding severity with other members of the surgical team. Interobserver agreement was acceptable (0.79) for orthopedic specialists, appreciable (0.88) for neurological specialists, and appreciable (0.88) for the combined specialists. Intraobserver agreement was excellent for orthopedic (0.91) and neurological (0.91) spine surgeons and excellent (0.96) for the combined specialists. CONCLUSIONS: The results highlight the reliability of the VIBe Scale and potential utility for quantifying intraoperative blood loss in spine surgery. CLINICAL RELEVANCE: The VIBe Scale may be useful for evaluating the efficacy of untested intraoperative hemostatic agents and for comparing the relative efficacy of 2 or more analogous agents. It may also prove useful for intraoperative staff by quantifying ongoing intraoperative blood loss and correlating losses with the potential transfusion and intraoperative hemostatic agent requirements.

Association of Trainee Participation in Colonoscopy Procedures With Quality Metrics.

Importance: Trainees routinely participate in colonoscopy procedures, yet whether their involvement is positively or negatively associated with procedural quality is unknown because prior studies involved small number of trainees and/or supervisors, lacked generalizability, and/or failed to adjust for potential confounders. Objective: To assess the association between trainee participation and colonoscopy quality metrics. Design, Setting, and Participants: This multicenter population-based cohort study was conducted at 21 academic and community hospitals between April 1, 2017, and October 31, 2018, among consecutive adult patients undergoing colonoscopy. Procedures performed by endoscopists who did not supervise trainees were excluded. Statistical analysis was performed from April 3, 2017, to October 31, 2018. Exposure: Participation by a trainee, defined as a resident or fellow enrolled in a gastroenterology or general surgery training program. Main Outcomes and Measures: The primary outcome was the adenoma detection rate (ADR), and secondary outcomes were sessile serrated polyp detection rate (ssPDR), polyp detection rate (PDR), cecal intubation rate (CIR), and perforation rate. Results: A total of 35 499 colonoscopies (18 989 women [53.5%]; mean [SD] patient age, 60.0 [14.1] years) were performed by 71 physicians (mean [SD] time in practice, 14.0 [9.3] years); 5941 colonoscopies (16.7%) involved trainees. There were no significant differences in the ADR (26.4% vs 27.3%; P = .19), CIR (96.7% vs 97.2%; P = .07), and perforation rate (0.05% vs 0.06%; P = .82) when trainees participated vs when they did not participate, whereas the the ssPDR (4.4% vs 5.2%; P = .009) and PDR (39.2% vs 42.0%; P < .001) were significantly lower when trainees participated vs when they did not. After adjustment for potential confounders, the ADR (risk ratio [RR], 0.97; 95% CI, 0.91-1.03; P = .30), PDR (RR, 0.98; 95% CI, 0.93-1.04; P = .47), and CIR (RR, 0.93; 95% CI, 0.78-1.10; P = .38) were not associated with trainee participation, although the ssPDR remained significantly lower (RR, 0.79; 95% CI, 0.64-0.98; P = .03). Conclusions and Relevance: This study suggests that trainee involvement during colonoscopy was associated with reduced ssPDR but not other colonoscopy outcome measures. Extra care should be exercised when examining the right colon when trainees are involved.

Investigating the Effect of Vibrotactile Feedback in Transfemoral Amputee With and Without Movable Ankle Joint.

The loss of somatosensory feedback after transfemoral amputation imposes a serious challenge in achieving postural stability. In the recent past, weight shifting exercises with fixed ankle joint have been reported useful in boosting the limit of stability (LOS) only in the sound limb; the LOS on the prosthetic limb did not improve. A fixed ankle joint restricts movement in the anterior-posterior direction at the ankle level. Thus, it may suppress the ability to move forward LOS despite awareness of center of pressure (COP) due to vibrotactile feedback. Therefore, it could have limited the improvement in the LOS of a prosthetic limb in previous studies. This article investigates this hypothesis by evaluating the effect of vibrotactile feedback in the LOS of transfemoral amputees with fixed as well as movable ankle joints. This evaluation is done during weight shifting exercises. Firstly, we developed an in-house COP guided vibrotactile sensory feedback system. Next, we recruited five transfemoral amputees to perform a weight-shifting exercise with a) fixed ankle joint (single-axis cushion heel (SACH) foot) and b) movable ankle joint (single-axis foot). Finally, we analyzed the recorded center of pressure trajectory signals for the limit of stability. The findings of repeated measures ANOVA showed a marginally significant interaction ( [Formula: see text], [Formula: see text], [Formula: see text]) between ankle joint and feedback conditions during backward shifting in weight shifting exercise. Further analysis showed that during the backward shifting fixed ankle joint did not improve in the presence of vibrotactile feedback, while a marginally significant ( [Formula: see text]) improved LOS was observed in the movable ankle joint with feedback. The findings conclude that the vibrotactile feedback is more effective in transfemoral amputees with movable ankle joint compared with fixed ankle joint.

Postprocedural interpretation of endoscopic retrograde cholangiopancreatography by radiology.

BACKGROUND: With the increase in the use of endoscopic retrograde cholangiopancreatography (ERCP) (necessitating real-time interpretation), it is unknown whether post-ERCP radiologist reporting is still necessary or helpful. OBJECTIVES: To determine the rate of discrepancy of results, and the rate of clinically relevant misses and additions, by the radiology report in a blinded setting. METHODS: A retrospective analysis of the procedure and blinded postprocedure radiology reports of 100 consecutive ERCP cases was performed. A list of clinically relevant pathology and subgroups was made a priori. Discrepancies are described as proportions, with 95% CIs. The radiology yield regarding pathology that was clearly demonstrated at ERCP (bile leaks and stones removed) was calculated. Clinical follow-up was used to clarify additional abnormalities reported by radiology. RESULTS: Clinically relevant discrepancies in report pairs occurred in 29.0% of cases (95% CI 20% to 39%), or 40.0% if discrepancies regarding bile duct dilation are considered (95% CI 30% to 50%). In 15 of 30 cases (50.0% [95% CI 31% to 69%]) in which bile duct stones were removed, the radiologist did not report a stone. The radiologist did not report five of eight bile leaks (62.5% [95% CI 24% to 91%]). In seven cases (7.0% [95% CI 2.9% to 13.9%]), an additional abnormality was noted by radiology, including a biliary stricture, bile duct and pancreatic duct stones, as well as sclerosing cholangitis. However, during a mean follow-up period of 5.6 months, it appeared that these radiology interpretations were likely incorrect. Discrepancy rates did not vary among the ERCP attendings or by radiology volume. CONCLUSIONS: Discrepancies between endoscopists' and radiologists' ERCP reports are common. Blinded radiology interpretation frequently misses important pathology, and falsely positive additional diagnoses may be made.

Floseal only versus in combination in spine surgery: a comparative, retrospective hospital database evaluation of clinical and healthcare resource outcomes.

OBJECTIVE: Flowable agents such as Floseal® (F) are often reserved as adjuncts to non-flowable agents (i.e. gelatin (G) sponges and thrombin (T)) when bleeding is not sufficiently controlled. Based on their perceived positive impact, it is postulated that flowable agents alone may result in better clinical and resource utilization outcomes. Clinical and health-care utilization outcomes were compared in this retrospective analysis of spine surgery cases with charges for Floseal only (FO) and F + G/T. METHODS: The United States Premier Hospital Database was searched for adult spine surgeries performed between October 2010 and September 2015 with FO or F and G/T charges. To obtain an unbiased treatment estimate, 1:1 propensity-score matching was used to identify FO and F + G/T cohorts. The cohorts were compared for rates of intraoperative, perioperative, postoperative and transfusion; blood loss-related, serious and other complications; hospital length-of-stay (LOS), surgical time, and volume of hemostat charged. RESULTS: Among 40,335 spine surgeries, 15,105 FO and F + G/T matched pairs were compared. Significantly (p < 0.0001) lower percentages of FO than F + G/T cases received intraoperative (1.4% vs. 2.5%), perioperative (1.6% vs. 2.8%), postoperative (1.6% vs 3.0%), and any transfusion (2.3% vs. 4.3%). FO cases had significantly less blood loss complications than F + G/T cases (0.5% vs. 0.8%, p = 0.0022) and significantly (p < 0.0001) shorter hospital LOS (-0.45 days), surgical time (-39.0 min), and used less hemostat (-12.5 mL). CONCLUSIONS: Results from this observational hospital database analyses indicate that FO use in spine surgery is associated with lower blood transfusion use and blood loss complications compared to its use with adjunct non-flowable hemostatic agents. The shorter hospital stay, reduced surgical time, and less hemostat volume health-care utilization outcomes that favored FO versus combination use may translate to health system cost savings. Further validation of these findings using controlled clinical trials and cost-consequence studies is warranted. CLINICAL RELEVANCE: The use of flowable hemostatic agents alone may result in better clinical and possibly economic outcomes in spine surgery.

A Multicenter Radiographic Evaluation of the Rates of Preoperative and Postoperative Malalignment in Degenerative Spinal Fusions.

STUDY DESIGN: Multicenter, retrospective, institutional-review-board -approved study at 18 institutions in the United States with 24 treating investigators. OBJECTIVE: This study was designed to retrospectively assess the prevalence of spinopelvic malalignment in patients who underwent one- or two-level lumbar fusions for degenerative (nondeformity) indications and to assess the incidence of malalignment after fusion surgery as well as the rate of alignment preservation and/or correction in this population. SUMMARY OF BACKGROUND DATA: Spinopelvic malalignment after lumbar fusion has been associated with lower postoperative health-related quality of life and elevated risk of adjacent segment failure. The prevalence of spinopelvic malalignment in short-segment degenerative lumbar fusion procedures from a large sample of patients is heretofore unreported and may lead to an under-appreciation of these factors in surgical planning and ultimate preservation or correction of alignment. METHODS: Lateral preoperative and postoperative lumbar radiographs were retrospectively acquired from 578 one- or two-level lumbar fusion patients and newly measured for lumbar lordosis (LL), pelvic incidence (PI), and pelvic tilt. Patients were categorized at preop and postop time points as aligned if PI-LL < 10° or malaligned if PI-LL≥10°. Patients were grouped into categories based on their alignment progression from pre- to postoperative, with preserved (aligned to aligned), restored (malaligned to aligned), not corrected (malaligned to malaligned), and worsened (aligned to malaligned) designations. RESULTS: Preoperatively, 173 (30%) patients exhibited malalignment. Postoperatively, 161 (28%) of patients were malaligned. Alignment was preserved in 63%, restored in 9%, not corrected in 21%, and worsened in 7% of patients. CONCLUSION: This is the first multicenter study to evaluate the preoperative prevalence and postoperative incidence of spinopelvic malalignment in a large series of short-segment degenerative lumbar fusions, finding over 25% of patients out of alignment at both time points, suggesting that alignment preservation/restoration considerations should be incorporated into the decision-making of even degenerative lumbar spinal fusions. LEVEL OF EVIDENCE: 3.

Text extraction and document image segmentation using matched wavelets and MRF model.

In this paper, we have proposed a novel scheme for the extraction of textual areas of an image using globally matched wavelet filters. A clustering-based technique has been devised for estim ating globally matched wavelet filters using a collection of groundtruth images. We have extended our text extraction scheme for the segmentation of document images into text, background, and picture components (which include graphics and continuous tone images). Multiple, two-class Fisher classifiers have been used for this purpose. We also exploit contextual information by using a Markov random field formulation-based pixel labeling scheme for refinement of the segmentation results. Experimental results have established effectiveness of our approach.

Effect of PEGylation on performance of protein microbubbles and its comparison with lipid microbubbles.

Aqueous suspensions of microbubbles are being used in various biomedical applications such as contrast imaging, targeted drug and gene delivery, delivery of drugs through blood brain barrier (BBB) and IV O2 delivery etc. Major microbubble formulations use either proteins or lipids as their shell material. Protein microbubble formulations mainly consist of serum albumin, lysozyme etc., while lipid microbubble formulations consist of phospholipids like 1,2-Distearoyl-sn-glycero-3-phosphocholine (DSPC), 1,2-dipalmitoyl-sn-glycero-3 phosphocholine (DPPC), etc. This work focuses on comparing performance of protein and lipid microbubbles in terms of their shelf life and in vitro performance. Protein microbubbles were produced using Bovine serum albumin (BSA) as main ingredient and N-acetyl-dl-tryptophan (Tryp) as an additive. Lipid microbubbles were produced using a mixture of DSPC as main ingredient and PEG40S (90:10molar ratio) as emulsifier. A narrow sized range (3-5µm) microbubble suspension was produced using sonication method followed by size isolation using centrifugation. These microbubbles were stored in a (PGO) solution containing 10% 1,2 propanediol (P), 10% glycerol (G) and 80% original solution used to make microbubbles (O) and were studied for their shelf stability, in vitro stability, immunogenicity and ability to produce contrast. For a 4weeks of observation period, a least reduction in concentration of around 18% was observed for PEGylated BSA microbubbles whereas highest reduction of 38% was observed for DSPC-PEG40S microbubbles. In-vitro persistence performance for PEGylated BSA microbubbles was found to be better than non-PEGylated BSA microbubbles as well as DSPC-PEG40S microbubbles. Non-PEGylated BSA microbubbles were found to be immunogenic whereas PEGylated BSA and DSPC-PEG40S microbubles were found to be non-immunogenic.

Medialized, Muscle-Splitting Approach for Posterior Lumbar Interbody Fusion: Technique and Multicenter Perioperative Results.

STUDY DESIGN: Retrospective, multicenter study of perioperative results OBJECTIVE.: The purpose of this study was to describe the surgical technique for medialized posterior lumbar fusion as well as present preliminary complication and treatment results from a multicenter retrospective study. SUMMARY OF BACKGROUND DATA: Posterior exposures remain the most commonly performed approaches for spinal fusion. Conventional open posterior exposures, however, have relatively high exposure-related morbidity and postoperative infection rates. Less invasive exposures for transforaminal and anterior (lateral) interbody fusion have been widely used over the past decade, but the need for bilateral posterior exposure has challenged the development of less invasive exposures for direct posterior approaches for lumbar fusion. METHODS: Consecutive patients treated with minimally invasive spine (MIS) posterior lumbar interbody fusion with medialized cortical bone trajectory pedicle screw and rod fixation were identified from four sites in the United States. Of the 138 patients identified, 61% of patients were treated for degenerative spondylolisthesis at 167 levels, most commonly at L4-5 (62%). Perioperative treatment, complication, and reoperation data were collected to describe early feasibility of the approach. RESULTS: Mean total operative time was 135 minutes with an average of 236  mL of blood loss. Mean total postoperative length of hospital stay was 2.6 days, with 25% of patients discharged on the same day or within 23 hours of surgery. Total perioperative complication rate in 138 patients was 10.1% (14/138) with three related reoperations. Intraoperative complications included five (3.6%) instances of incidental durotomy, without any progression to persistent cerebrospinal fluid leaks. Nine (6.5%) postoperative complications occurred, including one L5 vertebral body fracture, two pulmonary embolisms, one deep vein thrombosis, one urinary tract infection one instance of urinary retention, two superficial surgical site infections, and one patient with persistent pain at 6 months postoperative. Three (2.2%) reoperations were performed, one for revision of the L5 vertebral body fracture, and two for wound debridement. No instances of postoperative radiculitis or neurological injury were observed. CONCLUSION: Medialized, muscle-sparing posterior exposures with specialized instrumentation can be performed in patients with degenerative lumbar pathology with low surgical morbidity and blood loss and a short length of postoperative hospital stay. LEVEL OF EVIDENCE: 4.

Efficiency and patient experience with propofol vs conventional sedation: A prospective study.

AIM: To determine whether anaesthesiologist-administered sedation with propofol (AAP) or endoscopist-administered conscious sedation (EAC) with fentanyl/midazolam shortens colonoscopy duration/total room time. METHODS: This is a prospective, non-randomized, comparative study that enrolled patients greater than 18 years of age undergoing colonoscopy in a single Canadian academic outpatient endoscopy unit over a three-month consecutive period. Colonoscopies in this unit are performed both with AAP and EAC. Patient demographics, procedure-related data and adverse events were documented. Additionally, the level of procedure difficulty, and whether a staff endoscopist, trainee with assistance, or independent trainee, performed the procedure were documented. A validated modified 4-question, 5-point Likert scale telephone survey was used to assess patient satisfaction with colonoscopy. The telephone patient satisfaction survey was conducted 24-72 h following the procedure. RESULTS: Two hundred and thirty patients were enrolled during the study period with 126 patients in the AAP group and 104 patients in the EAC group. Mean procedure time was 18.3 ± 10.1 min in the AAP group and 14.7 ± 7.1 min in the EAC group (P = 0.002). Mean total room time was 36.8 ± 13.7 with AAP and 30.1 ± 11 min with EAC (P < 0.001). Multivariate analysis revealed the use of AAP (P = 0.002), resident participation (P < 0.001), diagnostic interventions (P = 0.033), therapeutic interventions (P < 0.001), lower body mass index (P = 0.008) and American Society of Anaesthesiologist class (P = 0.016), to be predictors of longer total room time. Patient age and gender were not significant predictors. After excluding cases in which trainees were involved, there was no significant difference in procedure time between the two groups (P = 0.941), however total room time was still prolonged in the AAP group (P = 0.019). The amount of pain experienced was lower with AAP (P = 0.02), with a trend toward overall higher patient satisfaction (P = 0.074). There were 2 sedation-related adverse events, both in the AAP group involving a patient with aspiration requiring hospitalization and a patient with hypoxia managed with bronchodilators. CONCLUSION: EAC results in reduced total room time compared to AAP. Resident participation doubles procedure time regardless of sedation type.