In-office Procedure Research Articles

Behavioral Strategies to Minimize Procedural Distress During In-Office Pediatric Tympanostomy Tube Placement Without Sedation or Restraint

The purpose of this study was to evaluate behavioral strategies to minimize procedural distress associated with in-office tympanostomy tube placement for children without general anesthesia, sedation, or papoose-board restraints. 120 6-month- to 4-year-olds and 102 5- to 12-year-olds were treated at 16 otolaryngology practices. Mean age of children was 4.7 years old (SD = 3.18 years), with more boys (58.1%) than girls (41.9%). The cohort included 14% Hispanic or Latinx, 84.2% White, 12.6% Black, 1.8% Asian and 4.1% ‘Other’ race and ethnicity classifications. The in-office tube placement procedure included local anesthesia via lidocaine/epinephrine iontophoresis and tube placement using an integrated and automated myringotomy and tube delivery system. Behavioral strategies were used to minimize procedural distress. Anxiolytics, sedation, or papoose board were not used. Pain was measured via the faces pain scale-revised (FPS-R) self-reported by the children ages 5 through 12 years. Independent coders supervised by a psychologist completed the face, legs, activity, cry, consolability (FLACC) behavior observational rating scale to quantify children’s distress. Mean FPS-R score for tube placement was 3.30, in the “mild’ pain range, and decreased to 1.69 at 5-min post-procedure. Mean tube placement FLACC score was 4.0 (out of a maximum score of 10) for children ages 6 months to 4 years and was 0.4 for children age 5–12 years. Mean FLACC score 3-min post-tube placement was 1.3 for children ages 6 months to 4 years and was 0.2 for children age 5–12 years. FLACC scores were inversely correlated with age, with older children displaying lower distress. The iontophoresis, tube delivery system and behavioral program were associated with generally low behavioral distress. These data suggest that pediatric tympanostomy and tube placement can be achieved in the outpatient setting without anxiolytics, sedatives, or mechanical restraints.

O-025 Value of hysteroscopy

Abstract text The 3 main characters in any ART are the uterus, the endometrium, and the embryo. With the rutinary use of 2D US and especially 3D US in infertile patients we are able to assess most of the uterine anomalies and intrauterine pathologies. Until recently, the assessment of the endometrial cavity with hysteroscopy was reserved only for cases of IVF failure, as a complementary evaluation to ensure that nothing was missed during the ultrasound scan. We also need to remember how hysteroscopy was performed in the past and, unfortunately, in some cases even today. In the old days, to assess the endometrial cavity, it was required to take the patient to the operating room and under general anesthesia, dilate the cervix to then introduce a large diameter hysteroscope only for diagnostic purposes. The prevalent working model in ART today is in close collaboration between Fertility specialists, Ultrasound and Hysteroscopy units in order to improve patient’s outcome. In our center, a diagnostic hysteroscopy is performed as part of the diagnostic workup of the infertility patient. It is performed in office setting and without anesthesia, by the staff of the reproduction and infertility unit. When we look at hysteroscopy as an in-office procedure and no longer as a procedure performed in operating room, we appreciate that it is something that all infertility patients can benefit from. The right question to ask now would be “Is there a benefit in performing a hysteroscopy to all our patients?”. Ultrasound is not perfect, especially when evaluating the endometrium. The gold standard and the only modality that we have to assess the endometrium with direct visualization is hysteroscopy. Chronic endometritis, adhesions and adenomyosis are only a few examples of what can be assessed by direct vision of the endometrial cavity. The advantages of a simple, inexpensive, office procedure such as hysteroscopy outweigh any other consideration against it. During my talk all these points will be presented helping to understand why hysteroscopy is becoming an indispensable tool in every assisted fertility unit.

Acupuncture

Many patients with chronic pain turn to alternative, complementary therapy as part of their pain management. Acupuncture has been gaining legitimacy for decades and was approved as a medical therapy in the United States in the 1990s. Numerous studies have assessed acupuncture’s therapeutic potential for a variety of diseases and disorders, with mixed results. While there is positive evidence of acupuncture’s beneficial effects for knee and low back pain, as well as migraines, research also shows the placebo effect may play an equally important role in the efficacy of acupuncture. Acupuncture is based on the principal of applied pressure through the insertion of thin needles into specific points of the body serving as channels of connection to specific organs. The ideology of acupuncture defines health as the interconnection of wellness, not just the absence of disease. Acupuncture aims to restore and align one’s qi, or vital energy, by resolving blockages or excessive buildup of qi in the body. One of the oldest therapies in traditional Chinese medicine, this nonpharmacological option has been studied for the treatment of multiple diseases and symptoms, including insomnia, pain, allergies, hot flashes, respiratory issues, mood disorders, tobacco use, and GI symptoms. In recent years, acupuncture has become more popular and moved out of the category of fringe treatments. Acupuncture is now an in-office procedure covered by many insurance providers. During the procedure, a practitioner inserts 5 to 20 single-use, stainless steel, flexible needles ranging from 10 mm to 100 mm into identified acupuncture points, where they remain for 10 to 20 minutes while the patient is relaxed and lying down. Quick introduction of the needle by a skillful practitioner minimizes any anticipated pain. The mechanisms of acupuncture’s action and efficacy are still under study. Proposed explanations include vagal nerve stimulation that alleviates chronic inflammation, hormonal changes influenced by needle insertion, and immunomodulation caused by pressure on major neural bundles. Another potential mechanism is that analgesia may result from spinal or supraspinal release of natural opioids. Many high-quality randomized controlled trials have addressed acupuncture’s effectiveness in the treatment of acute or chronic back pain, knee pain, and headaches. Multiple studies show both acupuncture treatment and simulated therapies provide superior pain relief compared with no treatment at all. A 2020 Cochrane Database Systematic Review meta-analysis reviewed 33 randomized controlled trials of acupuncture use for chronic lower back pain in adults. The studies compared acupuncture with sham intervention, usual care, or no treatment in 8,270 participants. The review authors determined that while acupuncture was more effective than no treatment in improving pain and function, acupuncture did not play a more clinically meaningful role than simulated intervention in relieving pain or improving quality of life. A 2006 randomized controlled trial in Annals of Internal Medicine assessed the efficacy and safety of acupuncture compared with sham acupuncture and conservative therapy. More than 1,000 patients with chronic pain for at least 6 months due to osteoarthritis of the knee were allocated up to 6 physiotherapy sessions and as-needed NSAIDs, plus either 10 sessions of acupuncture, 10 sessions of sham acupuncture, or 10 physician visits over the course of 6 weeks. Researchers found success rates of 53.1% for acupuncture, 51.0% for sham acupuncture, and 29.1% for conservative therapy, with no significant difference between acupuncture and sham acupuncture. A randomized controlled trial published in JAMA in 2005 investigated the effectiveness of acupuncture, sham acupuncture, or waiting list control in 302 patients with migraine. No significant difference was detected between the acupuncture (51% reduction in headache days) and the sham acupuncture (53% reduction in headache days) groups in reducing migraine headaches, but researchers did find a significant difference compared with the control (15% reduction). Acupuncture is considered generally safe when performed by an experienced, well-trained practitioner. As a complementary therapy, acupuncture offers an overall positive response with limited adverse effects and a nonpharmacologic treatment option to address pain. Consider letting your patients know that believing in the efficacy of acupuncture is just as important to treatment as the therapy itself.

Comparison of Complication Risk Following Trigger Digit Release Performed in the Office Versus the Operating Room: A Population-Based Assessment

Trigger digit release (TDR) performed in an office-based procedure room (PR) setting minimizes surgical costs compared with that performed in an operating room (OR); yet, it remains unclear whether the rates of major complications differ by setting. We hypothesized that surgical setting does not have an impact on the rate of major complications after TDR. Adult patients who underwent isolated TDR from 2006 to 2015 were identified from the MarketScan commercial database (IBM) using the provider current procedural terminology code 26055 with a concordant diagnosis on the same claim line (International Classification of Diseases, ninth revision, clinical modification 727.03). The PR cohort was defined by presence of a place-of-service code for an in-office procedure without OR or ambulatory center revenue codes, or anesthesiologist claims, on the day of the surgery. The OR cohort was defined by presence of an OR revenue code. We identified major medical complications, surgical site complications, as well as iatrogenic neurovascular and tendon complications within 90 days of the surgery using International Classification of Diseases, ninth revision, clinical modification diagnosis and/or current procedural terminology codes. Multivariable logistic regression was used to compare the risk of complications between the PR and OR groups while controlling for Elixhauser comorbidities, smoking, and demographics. For 7,640 PR and 29,962 OR cases, the pooled rate of major medical complications was 0.99% (76/7,640) and 1.47% (440/29,962), respectively. The PR setting was associated with a significantly lower risk of major medical complications in the multivariable analysis (adjusted odds ratio 0.76; 95% confidence interval 0.60-0.98). The pooled rate of surgical site complications was 0.67% (51/7,640) and 0.88% (265/29,962) for the PR and OR cases, respectively, with no difference between the surgical settings in the multivariable analysis (adjusted odds ratio 0.81; 95% confidence interval 0.60-1.10). Iatrogenic complications were infrequently observed (PR 5/7,640 [0.07%]; OR 26/29,962 [0.09%]). Compared with performing TDR in the OR using a spectrum of commonly used anesthesia types, performing TDR in the PR using local-only anesthesia was associated with a comparably low risk of major medical complications, surgical complications, and iatrogenic complications. Prognostic II.

A comparative analysis of in-office vital 6% hydrogen peroxide activated charcoal tooth whitening treatment enhanced with an 810nm diode laser, compared to 35% hydrogen peroxide bleaching

Laser dental bleaching is considered to be a contemporary approach to enhancing the in-office power bleaching procedure.
 Objective
 Investigate if laser enhanced 6% Hydrogen Peroxide (HP) solution is equivalent to 35% HP solution over a two-visit power bleaching treatment protocol. In a randomised double-blinded clinical trial, 43 patients were assigned to a group that received either the laser-enhanced 6% Hydrogen Peroxide (n=21) treatment, or the standard 35% Hydrogen Peroxide (n=22) treatment, over two visits, with a one-week interval. Activated charcoal HP paste was prepared for both groups. The laser enhanced 6% HP group received a dosage of 90 J/cm² per bleaching cycle using 810nm diode laser. Tooth colour was measured at the beginning and end of each session registering parameters L*, a* and b*, and tooth sensitivity. The calculated difference between these Parameters, ∆E, was the primary data focus. The mean ∆E over the treatment duration was used to answer the research question by a t-test to evaluate group differences at 5% significance level. The analysis revealed that the null hypothesis could not be rejected and the results were inconclusive. The observations expound the idea of an absorption enhancement mechanism, rather than a free radical activation, as the technique for improving bleaching outcomes.

Feasibility and Safety of Office-Based Transnasal Balloon Dilation for Neopharyngeal and Proximal Esophageal Strictures in Patients with a History of Head and Neck Carcinoma

The aim of this study was to assess feasibility and safety of office-based transnasal balloon dilation of neopharyngeal and proximal esophageal strictures in patients with a history of head and neck carcinoma. The secondary objective was to explore its effectiveness. This prospective case series included patients previously treated for head and neck carcinoma with neopharyngeal or proximal esophageal strictures who underwent transnasal balloon dilation under topical anesthesia. The target dilation diameter was 15 mm; if necessary dilation procedures were repeated every 2–4 weeks until this target was reached. Completion rates, adverse events, and patient experiences measured by VAS scores (0 = no complaints – 10 = unbearable complaints), dysphagia scores based on food consistency (0 = no dysphagia – 5 = unable to swallow liquids/saliva), and self-reported changes in swallowing symptoms were recorded. Follow-up was 2 months. Twenty-six procedures were performed in 12 patients, with a completion rate of 92%. One minor complication occurred, i.e. an infection of the dilation site. Tolerance of the procedure was good (median VAS = 2). The dysphagia score improved after a mean of 2.2 procedures per patient, however not significantly. Eight patients reported improvement in dysphagia, of whom 3 had recurrence of dysphagia within 1 month post-treatment. Office-based transnasal balloon dilation is a feasible and safe in-office procedure which is well-tolerated by patients. The dilations can improve dysphagia, although effects might be transient.

Abstract PO035: Identification and validation of endometrial cancer specific miRNA biomarkers in endometrial fluid collected using saline infused sonohysterography techniques

Abstract Abnormal uterine bleeding is a common benign gynecologic complaint around the time of menopause, and is also the most common symptom of endometrial cancer. This complaint prompts in-office endometrial biopsy to exclude malignancy. Unfortunately, because only a limited portion of the lining tissue is sampled, the endometrial biopsy is not always accurate which can lead to delays in diagnosis and the potential for worsening of the disease and prognosis. Biomolecules have proven to be useful tools in cancer screening and early diagnosis. Liquid biopsy has been widely accepted as a less- or non-invasive way to obtain samples from patients, including blood, urine, saliva and other types of body fluids. However, no circulating biomarkers have been easily identified in the patient blood of endometrial cancer. MicroRNA are a class of small molecules and has shown promise in cancer detection. MicroRNAs may be detected in the biopsy tissue or by testing the fluid that cells secrete. Endometrial tissue is inherently difficult to sample in the office. Although direct sampling from the endometrium has limitations, but the fluid secreted by the lining endometrial epithelial cells can be easily sampled using a technique adapted from an in-office procedure known as a sonohysterography. This procedure is used in the evaluation of abnormal uterine bleeding by introducing saline solution into the endometrial cavity as a contrast material during transvaginal ultrasound. The infused saline is normally discarded, but can be collected for microRNA analysis. In this study, we report the preliminary results of potential miRNA biomarkers identified in 60 patient endometrial fluid collected using sonohystography technique. Patients were recruited who planned to undergo hysterectomy for either benign indication or for a known endometrial cancer diagnosis. The endometrial fluid was collected prior to surgery using a technique similar to that used in sonohysterography. The miRNA was extracted and quantitated. Following the reverse transcription, each sample was amplified on a customized microarray plate with known specific miRNA target primer printed in each well (miScrpt miRNA PCR Array). Patient demographic and health information was collected to be used in the final analysis along with the final pathology results of their surgery. In total, 60 patient samples have been collected and processed (30 cancer and 30 controls). Significant variations in expression were identified in several miRNA markers. Markers with at least a two-fold increase (e.g. miR-429, miR-146a-5p, miR-34b-3p) or decrease (e.g. miR-296-5p, miR-204-5p) in expression were considered candidates for validation. Twelve miRNA markers with the greatest variation in expression were chosen to be used on an additional set of patients to further validate the results. The results will be presented. The method developed here will provide a non-invasive way in early diagnosis and screening for endometrial cancer and therefore impact on improvement of women’s health. Citation Format: Jianing Yang, Joel Barkley, Kameron Firouzi, Bikash Bhattarai, Dean Coonrod, Frederic Zenhausern. Identification and validation of endometrial cancer specific miRNA biomarkers in endometrial fluid collected using saline infused sonohysterography techniques [abstract]. In: Proceedings of the AACR Virtual Special Conference: Endometrial Cancer: New Biology Driving Research and Treatment; 2020 Nov 9-10. Philadelphia (PA): AACR; Clin Cancer Res 2021;27(3_Suppl):Abstract nr PO035.

Efficacy and Safety of Electromyography‐Guided Injection of Botulinum Toxin to Treat Retrograde Cricopharyngeus Dysfunction

ObjectiveTo report the efficacy and safety of electromyography-guided percutaneous botulinum toxin injection into the cricopharyngeus muscle in an office setting for treatment of the inability to belch and associated symptoms caused by retrograde cricopharyngeus dysfunction (R-CPD).Study DesignRetrospective case series of treated patients.SettingTertiary care laryngology clinic.MethodsA retrospective review was performed on 18 consecutive patients who were diagnosed syndromically with R-CPD. The combined diagnostic test and treatment—specifically, botulinum toxin injection into the cricopharyngeus muscle—was accomplished in an office setting by a single surgeon using electromyography guidance. Items assessed are efficacy, safety, complications, and duration of benefit.ResultsAll 18 patients (100%) treated in the in-office setting gained the ability to burp with improvement in the associated symptoms of R-CPD at initial follow-up. Of those who had the in-office procedure performed initially, 80% maintained the ability to burp at 6 months with relief of all the associated symptoms of R-CPD. No patients experienced permanent complications from the injection, but 7 patients experienced varying degrees of noisy breathing within 1 week after the procedure, which was managed with breathing techniques and resolved.ConclusionIn a case series of 18 patients with R-CPD, all patients gained the ability to burp with improvement in the majority of their symptoms of R-CPD at the time of their initial follow-up at 1 week. None experienced severe complications, and 7 experienced transient noisy breathing, which resolved.

Recommended Imaging for Salivary Gland Disorders

Imaging modalities useful in the contemporary evaluation of salivary gland disorders are discussed. Salivary gland ultrasound—due to its wide applicability, versatility, availability, and low cost—is supported as a frontline evaluation and is frequently done as an in-office procedure by the treating surgeon. Contrast-enhanced CT may be as accurate as non-contrast CT in detecting sialolithiasis. Although conventional sialography (fluoroscopic salivary gland evaluation with ductal dilation and radiocontrast insufflation) was initially designed as a diagnostic procedure, more recently, reported experience has demonstrated it to result in improved salivary function for several disorders—including its use as treatment of juvenile recurrent parotitis. Conventional sialography remains the most accurate method to assess the full ductal anatomy and is superior to MRI sialography which fails to adequately image the more proximal ducts. For benign salivary tumors, US may obviate the need for further imaging and provide reliable estimation of tumor location. Salivary gland disorders are most efficiently imaged with in-office ultrasound. In settings where US cannot be performed, CT (with or without contrast) remains a reliable initial method to detect salivary gland abnormalities including sialolithiasis. MR sialography has become a useful modality for evaluating stenosis and may be considered when conventional sialography is not available.

The novel corona virus and rhinology: Impact on practice patterns and future directions.

ObjectivesTo evaluate the impact of the novel coronavirus pandemic on practice patterns, clinical behavior, personal health, and emotional/psychological concerns of rhinologists.MethodsA 15-question survey was sent out to the American Rhinologic Society's (ARS) membership to determine the impact of COVID-19 during the crisis. Demographic factors and practice patterns were collected and evaluated.ResultsThere were 224 total respondents out of 835 ARS members queried (26.8% response rate). Study queries were sent in April 2020. Notably, 17.8% reported illness in themselves or their staff and 74.4% noted a psychological/emotional impact. A plurality of rhinologists noted their practice volume and in-office procedure volume has become 20.0% and 0.0% of their prior volumes, respectively. In addition, 96.2% were noted to be using telemedicine in our subspecialty.ConclusionIn addition to severely impacting volume and the perception of future decreases in patients and revenue, the COVID-19 pandemic has had a physical and emotional impact on rhinologists in ways that need to be further studied. These data include significantly novel and objective information. The COVID-19 crisis also reveals the important role of telemedicine in rhinology. Guidelines regarding personal protective equipment for in-office visits, nasal endoscopy, and other in-office and operating room procedures would be particularly helpful as future waves are expected.

Analysis of Emergent Nonhospital-Based Retina Consultation Requests in an Academic Nonhospital-Associated Retina Practice

To evaluate the outcomes of after-hour encounters concerning patients referred by eye physicians to on-call retina services for emergent evaluation not seen in or referred by an emergency department. Retrospective study. Patients seeking treatment at 3 private practice institutions over a 2-year period between 2017 and2018. A retrospective chart review was conducted comprising all patients who sought treatment emergently and after clinic hours from 3 academic nonhospital-associated retina-only private practice institutions over a 2-year period. Patient presenting symptoms, diagnosis given at time of after-hours appointment, duration of symptoms, source of after-hours consultation (patient or provider), procedure performed at appointment, and appointments that led to surgery. Nine hundred eighty-seven charts were reviewed. Provider referrals accounted for 49.13% (n= 485) and patient-derived referrals accounted for 50% (n= 493) of appointments. New patients accounted for 27.6% (n= 146) of patient-derived and 85.2% (n= 413) of provider-derived referrals. The most common presenting symptoms were flashes and floaters (42.5%; n= 420), decrease in visual acuity (32.1%; n= 317), generalized eye pain (7.4%; n= 73), visual field disturbance (4.3%; n= 42), and postoperative ocular pain (3.4%; n= 34). An in-office procedure was performed at the time of examination in 18% of encounters (n= 178), with most of these being laser retinopexy. Surgery was performed within 24 hours in 18% (n= 180), within 48 hours in 20.6% (n=203), within 72 hours in 21.7% (n= 214), and within 96 hours in 22.6% (n= 223) of the appointment. When combined with procedures, 36.2% (n= 358) of encounters led to urgent intervention within 24 hours. If a provider called about an existing patient, 37.5% of these appointments (n= 27) led to surgery versus 12.8% (n=49) if an existing patient self-referred. If a provider called about a new patient, 31.7% of these appointments (n= 131) led to surgery versus 10% (n= 14) if a new patient self-referred. At these 3 private practice retinal specialty clinics, 41% of after-hours appointment requests resulted in an intervention within 96 hours, and 36% of these patients underwent an intervention within 24 hours.

Management Non-healing Trophic Ulcer in a Leprosy Patient with Combination of Injection and Topical Platelet Rich Plasma

Introduction: Trophic ulcer is one of the leprosy sequelae due to peripheral neuropathy. Trophic ulcers in leprosy patients can pose a significant stigma to the patients and remain challenging to clinicians due to the low response to treatment. Recent studies have reported the effectiveness of Platelet-rich plasma (PRP) in the management of chronic ulcers. This study reports a case of non-healing trophic ulcers in leprosy patients treated with a combination of injection and topical PRP. Case Presentation: A 61-year-old female patient referred to complaining of a non-healing wound in her right foot since two months ago. She was a leprosy patient with already finished medication since 19 years ago. She treated the wound with sodium chloride compress and gentamycin ointment without any improvement. The general status was in normal condition. Skin examination on the right plantar pedis showed a solitary ulcer sized 1 × 0.5 × 0.3 cm and linear ulcer sized 2.5 × 3 × 0.3 cm with callus in the surrounding. The sensoric test with Semmes-Weinstein Monofilaments (SWM) showed decreased sensory in magenta monofilament (300 g). The whole blood test, blood glucose, renal function, and kidney function showed no abnormality. Gram examination from the base of the ulcer showed no bacteria. We diagnosed a trophic ulcer and treated it with a combination of injection and topical PRP every week. The clinical result showed that the ulcer completely healed in four weeks of PRP treatment and no side effect appeared during treatment. Conclusions: A combination of injection and topical PRP showed to be promising in the management of non-healing trophic ulcers in leprosy patients. It is a simple, safe, and cost-effective in-office procedure and can improve the patient’s quality of life.

Bleaching Gigi Vital pada Gigi Anterior sampai Premolar Pertama Maksila dan Mandibula (Laporan Kasus)

Background: The discoloration of teeth is a common aesthetic concern for many patients. It can have a profound effect on their self-esteem, interaction with others and employability. Dental bleaching can be used as a treatment for teeth that are discolored due to intrinsic and extrinsic staining. Vital bleaching is an in-office procedure which utilize 25-40% hydrogen peroxides. Home-bleaching with gels containing 10%, 15%, or 20% carbamide peroxide is recommended after in-office procedure. Objective: To overview planning and treatment of vital discoloration teeth with combination in-office and home-bleaching procedure. Case: A 31 year old patient complained about her lack of confidence due to yellow looking teeth. The patient told the dentist she used to consume coffee at least twice a day. Measuring teeth color with Vitapan shade guide (VITA Zahnfabrik) resulted in A3 color for maxillary teeth and A3,5 for mandibular teeth as well as shade guide opalescence results in A3,5 color. The teeth were fully cleaned with brush. Gingiva area was isolated using opaldam, and it was activated using light curing unit for 10 seconds in each servikal area. Bleaching material was applied to six anterior teeth and first maxillary and mandibular premolar in 20 minutes, it was activated every 5 minute by stirring bleaching material with tip brush. After done with the procedure, bleaching material was cleaned with suction, whipped by using cotton pellet. Color matching was done after in-office bleaching process using Vitapan shade guide (VITA Zahnfabrik), it was attained A1 color for maxillary teeth and A2 for mandibular teeth. Color matching using shade guide opalescence resulted in W3 color. The patient was instructed to use individual tray through gel containing carbamide peroxide 10% for 8 hours on each day for 1 full week. Conclusion: In-office and home-bleaching procedure is the treatment of choice in vital discoloration of teeth.

Feasibility of freehand MRI/US cognitive fusion transperineal biopsy of the prostate in local anaesthesia as in-office procedure-experience with 400 patients.

Transrectal (TR) ultrasound-guided prostate biopsy is one of the most commonly performed urologic procedures worldwide. The major drawback of this approach is the associated risk for infectious complications. Sepsis rates are increasing due to rising antibiotic resistance, representing a global issue. The transperineal (TP) approach for prostate biopsy has recently been adopted at many centres as an alternative to the TR biopsy, and it was shown to be associated with a lower risk for sepsis. The aim of this study was to assess safety and tolerability of TP prostate biopsy performed in local anaesthesia. We retrospectively analysed data of patients who had undergone office-based TP prostate biopsy in local anaesthesia, performed by a single surgeon between January 2015 and May 2019. We evaluated the patients' acceptance of the procedure by a pain score, as well as its safety and diagnostic performance. Four hundred patients were included. Median age was 66 years [range, 49-86]. Median prostate-specific antigen (PSA) concentration was 6.4 ng/ml [range, 0.3-1400], median PSA density was 0.15 ng/ml2 [range, 0-31.1] and median prostate volume was 40 ml [range, 6-150]. A total of 118 (29.5%) and 105 (26.2%) patients had orally received two and one doses of 500 mg fluoroquinolone, respectively, and 177 (44.3%) patients did not receive any antibiotic prophylaxis. No infectious complications occurred. Median pain score was 2.0 (range, 0-8). Overall cancer detection rate was 64.5% (258/400). Freehand TP prostate biopsy in local anaesthesia is a safe, effective and well-tolerated outpatient procedure with a high cancer detection rate. The elimination of infectious complications and its high accuracy make this technique a feasible alternative to the TR approach for the urological office. We assume that the single puncture and our trocar-like access sheath introduction technique diminish tissue trauma and bacterial exposition, and thus contribute to these promising results.

1817 is Paracervical Block Useful to Decrease Pain During in Office?

Study Objective To determine if paracervical block significantly decreases pain during in-office hysteroscopy. Design Retrospective chart review. Setting Gynecologic in-office procedure room in an academic medical center. Patients or Participants Patient undergoing in office hysteroscopy. Interventions In office hysteroscopy was performed using a STORZ Bettocchi hysteroscope with continuous flow using a 5 mm external sheet and a 30o 2.9 mm optic. All the procedures were performed by the same physician. Measurements and Main Results 50 patient's charts were reviewed, 21 received a paracervical block and 29 did not receive any local anesthesia. Of the 21 that received the block, mean age was 46.1 years, 27.6% were nulliparous, 24.1% were postmenopausal. Of the 29 patients who received no local anesthesia, mean age was 46.9 years (p=0.783), 48.3% were nulliparous, 27.6% were postmenopausal. In both groups, the most common reasons for hysteroscopy were abnormal uterine bleeding (AUB). Pain was recorded for all patients immediately after finalizing the procedure using a Likert-like scale from 1 to 10. The average pain score for the patients who received the paracervical block was 3.48 compared to 4.07 in those not having the block (p=0.348). Neither obesity nor nulliparity were found to be associated with increased pain, however postmenopausal women overall were found to have higher reported pain (p=0.013.). If given a paracervical block, mean pain in postmenopausal women was 4.29 compared to 6.00 without block (p=.215.). Conclusion Hysteroscopy as a safe and relatively low pain procedure. Local anesthetic in the form of a paracervical block has been used historically to decrease pain during the procedure. Paracervical block does not significantly decrease pain during procedure, even in menopausal women who were found to have higher pain scales on average. Therefore, future studies should further investigate strategies to decrease pain during office hysteroscopy especially for postmenopausal women.

In-office shoulder arthroscopy and tenotomy of the long head of the biceps tendon-a cadaveric feasibility study.

Studies have shown that isolated tenotomy of the long head of the biceps (LHB) improves significantly pain scores, active range of motion and Constant score in elderly patients with massive and irreparable cuff tears with no osteoarthritis. This cadaveric study was performed to assess the feasibility of a tenotomy of the LHB and subacromial corticosteroid injection using a minimally invasive in-office setting under local anaesthesia on awake patients. Twenty scare-free shoulders were included in the study. We performed the procedure in an in-office setting using a wrist arthroscope with no fluid, connected to wireless camera and light source. A standard shoulder arthroscopy was finally performed in order to analyse the tenotomy quality and detect possible iatrogenic lesions. The LHB tendon was cut fully in all cases, the mean length of the proximal stump of the LHB was 0.4cm (range, 0.3-0.7mm) and the mean duration of the surgery was 3.5 minutes (range, 2.43-3.86min). No iatrogenic lesion occurred during the in-office procedure. This cadaveric study suggests that it is feasible and safe to perform, under local anaesthesia, a minimally invasive arthroscopic tenotomy of the LHB and subacromial injection using an in-office setting. Further clinical studies are needed to confirm the reliability, indication and effectiveness of this technique.

Thread-Lifts: A Double-Edged Suture? A Comprehensive Review of the Literature.

Thread-lifting has experienced a recent surge in popularity as interest in minimally invasive techniques for facial rejuvenation continues to grow. By placing barbed sutures along specific trajectories to lift the superficial musculoaponeurotic system to address facial ptosis, thread-lifting carries several advantages over the traditional facelift. Over the past few decades, there have been ongoing advances in the implementation of thread-lifting using barbed sutures. To review the current evidence regarding the safety and efficacy of thread-lifting for facial rejuvenation. An analysis was conducted of PubMed indexed English language literature regarding thread-lifting using barbed sutures. Early studies using nonabsorbable barbed sutures described high revision and complication rates. Newer techniques implementing absorbable sutures have fewer adverse events, although the long-term efficacy of these procedures remains unclear. Thread-lifts play a substantial role in minimally invasive techniques for facial rejuvenation. Additional studies are needed to better evaluate the safety and long-term efficacy of this quick, in-office procedure.

The Effect of Microblepharon Exfoliation on Clinical Correlates of Contact Lens Discomfort.

Microblepharon exfoliation improved eyelid signs and tear film characteristics after a single in-office treatment in symptomatic contact lens wearers. The purpose of this study was to assess the effect of two eyelid hygiene treatments-microblepharon exfoliation and a hypoallergenic foam cleanser (LidHygenix)-on clinical signs of the eyelids, meibomian glands, and tear film in contact lens discomfort. A randomized, interventional, unmasked, crossover trial was conducted on 30 experienced daily-wear soft contact lens wearers. Assessment of clinical signs of the eyelid margin, meibomian gland morphology and secretion, and tear film biophysical properties was performed (baseline 1), and participants were randomly assigned to receive one of the two treatments (microblepharon exfoliation or foam cleansing using LidHygenix) as a single in-office procedure. Symptoms were evaluated using the Contact Lens Dry Eye Questionnaire-8 immediately after treatment, and assessment of all the study variables was repeated at the follow-up visit 7 to 10 days after treatment. After 28 to 30 days of washout, participants returned for reassessment of the study variables (baseline 2) and were crossed over to receive the alternate treatment. Follow-up was repeated 7 to 10 days after the second treatment. Seven to 10 days after treatment with microblepharon exfoliation, symptomatic wearers showed significant improvement in anterior blepharitis (mean difference, 0.60; P = .04), lid wiper staining (0.50; P = .06), and lid-parallel conjunctival folds (0.68, P = .02) along with orifice capping (median difference, 0.65; P < .001), foam (0.90; P < .001), secretion volume (0.69; P < .001), quality (0.74; P < .001), and expressibility (0.49; P = .002), which were also clinically significant changes. However, in tear properties, significant improvements were observed in tear volume (LidHygenix, -1.25 mm; microblepharon exfoliation, -1.62 mm), break-up time (-0.14 seconds; -0.14 seconds), tear evaporation rate without contact lenses (21.52 g m h; 45.43 g m h), and lipid layer thickness (-20.61 nm; -25.13 nm) after both treatments but in symptomatic lens wearers only (P < .05). Microblepharon exfoliation improved eyelid signs and tear film characteristics in symptomatic contact lens wearers after a single in-office treatment.

Using anxiolytics in a pediatric otolaryngology clinic to avoid the operating room

IntroductionThere is increasing concern regarding the risks associated with the use of general anesthesia in pediatric patients. Many otolaryngologic procedures performed under general anesthesia can also be performed in clinic. We hypothesize that anxiolytics can aid in performing common procedures in clinic thus avoiding the need to undergo general anesthesia in the OR. MethodsWe performed a retrospective review of patients undergoing inoffice procedures with anxiolytics in our pediatric otolaryngology outpatient clinic between February 2013 and January 2017. Charts were reviewed for age, past medical history, procedure type/duration, and outcome. These results were then compared to a cohort undergoing similar procedures in the OR. ResultsA total of 34 patients underwent an in-office procedure with an anxiolytic. The success rate was 97% (33/34). The average age was 6.2 years. Six children (17%) had a known history of chromosomal abnormalities and 2 children (6%) had autism. The four most common procedures performed were cerumen impaction removal (8), flexible laryngoscopy (6), ear canal foreign body removal (5), and septal cautery (4). Performing similar procedures in the OR resulted in an average additional cost of $822. ConclusionsPerforming procedures with anxiolytics in a pediatric otolaryngology clinic is safe, expeditious, and cost-effective. Anxiolytics can provide an effective alternative to general anesthesia.

Selective laser sintered mould for orbital cavity reconstruction

PurposeOrbital fractures are the most commonly encountered midfacial fractures, and usually, the fracture involves the floor and/or the medial wall of the orbit. This paper aims to present an innovative approach for primary and secondary reconstructions of fractured orbital walls through the use of computer-assisted techniques and additive manufacturing.Design/methodology/approachFirst, through the 3D anatomical modelling, the geometry of the implant is shaped to fill the orbital defect and recover the facial symmetry. Subsequently, starting from the modelled implant, a customised mould is designed taking into account medical and technological requirements.FindingsThe selective laser sintered mould is able to model and form several kind of prosthetic materials (e.g. titanium meshes and demineralised bone tissue), resulting in customised implants and allowing accurate orbital cavity reconstructions. The case study proved that this procedure, at the same time, reduces the morbidity on the patients, the duration of surgery and the related costs.Originality/valueThis innovative approach has great potential, as it is an easy and in-office procedure, and it offers several advantages over other existing methods.