Need For Repeat Procedures Research Articles

Repair of Large Traumatic Tympanic Membrane Perforation with a Steri‐Strips Patch

To investigate the effects of the Steri-Strips patch (3M) on the treatment of large traumatic tympanic membrane perforations (TMP). Prospective, randomized, controlled. Tertiary university hospital. A randomized prospective analysis was performed between February 2009 and January 2011 for the treatment of traumatic TMP larger than 50% of the entire tympanic membrane. The results of closure rate, closure time, hearing gain, and rate of otorrhea between conservative observation, paper patching, and Steri-Strips patching groups were compared. In total, 87 patients were analyzed in this study. The closure rates of the perforations in the Steri-Strips patching, paper patching, and observation groups were 93.3%, 84.2%, and 78.9%, respectively. There was no statistically significant difference in tympanic membrane closure rate between the 3 groups. The Steri-Strips technique decreased the need for repeat procedures. Overall, the Steri-Strips and paper patching groups showed shorter healing times compared with the observation group. However, there was an increased rate of otorrhea in the Steri-Strips group compared with the observation group. Steri-Strips patching reduced the healing time and need for repeat procedures in patients with large traumatic TMPs. However, the occurrence of otorrhea was significantly more common in patients treated with the Steri-Strips technique.

Catheter ablation of atrial fibrillation as first-line therapy--a single-centre experience

The aims of the study were (i) to assess the characteristics of patients selected for atrial fibrillation (AF) ablation as first-line therapy, (ii) to identify current clinical criteria for such a strategy, and (iii) to analyse the outcome compared with patients who had failure of antiarrhythmic drug (AAD) therapy prior to ablation. Consecutive patients undergoing ablation of AF were included in a prospective registry. Serial long-term electrocardiogram monitoring and clinical follow-up were performed after 3, 6, and 12 months. Out of 434 patients, 17% underwent AF catheter ablation as first-line therapy (AAD-), and 83% had undergone at least one AAD trial (AAD+). In AAD- patients, the reasons for this strategy were: (i) patient preference, n= 51 (71%); (ii) contra-indication to AAD, n= 21 (29%). Atrial fibrillation duration prior to ablation was shorter (52 ± 54 vs. 78 ± 81 months, P= 0.005), and the percentage of patients hospitalized for AF (32% vs. 48%, P= 0.01) was lower in AAD- patients. Long-term multiple procedure success rate (78% vs. 64%, P= 0.03) was higher in the AAD- group, and there were less repeat ablations in this group (21% vs. 38%, P= 0.01). Catheter ablation was first-line therapy of AF in a significant number of patients, according either to patient preference or to medical factors, and this had important implications. Ablative therapy was performed at an earlier stage of the disease, and was associated with a significantly higher success rate and with a decreased need for repeat procedures.

Prevalence and Predictors of Complications of Radiofrequency Catheter Ablation for Atrial Fibrillation

Up to 6% of patients experience complications after radiofrequency catheter ablation (RFA) of atrial fibrillation (AF). The purpose of this study is to determine the prevalence and predictors of periprocedural complications after RFA for AF. The subjects were 1,295 consecutive patients (age = 60 ± 10 years) who underwent RFA (n = 1,642) for paroxysmal (53%) or persistent AF (47%) from January 2007 to January 2010. A complication occurred in 57 patients (3.5%); a vascular access complication in 31 (1.9%); pericardial tamponade in 20 (1.2%); a thromboembolic event in 4 (0.2%); deep venous thrombosis in 1 (<0.01%); and pulmonary vein stenosis in 1 patient (<0.01%). There were no procedure-related deaths. On multivariate analysis, female gender (OR = 2.27; ±95% CI: 1.31-2.57, P < 0.01) and procedures performed in July or August (OR = 2.10; ±95% CI: 1.16-3.80, P = 0.01) were independent predictors of any complication. For vascular complications, treatment with clopidogrel (OR = 4.40; ±95% CI: 1.43-13.53, P = 0.01), female gender (OR = 3.65; ±95% CI: 1.72-7.75, P < 0.01) and performing RFA in July or August (OR = 2.71; ±95% CI: 1.25-5.87, P = 0.01) were independent predictors. The only predictor of cardiac tamponade was prior RFA (OR = 3.32; ±95% CI: 0.95-11.61; P < 0.05). Prevalence of perioperative complications for RFA of AF is 3.5% and vascular access complications constitute the majority. The need for clopidogrel therapy should be carefully considered prior to RFA. At teaching institutions close supervision should be exercised during vascular access early in the year. Improvements in ablation technology and elimination of the need for repeat procedures may decrease the risk of pericardial tamponade.

Measuring Value From the Patient's Perspective

With growing calls for scaling back medical spending in the United States, cardiac treatments in general, and revascularization procedures in particular, are receiving scrutiny. The American Heart Association estimates that in 2009, $93 billion in direct cost of care was attributed to ischemic heart disease in the United States.1 Much of this expense was due to an estimated 7 million cardiac procedures performed in the United States in 2006. These procedures include >1.3 million percutaneous coronary interventions (PCIs), and when coupled with a typical hospital charge of $45 000, it is clear that spending on PCI is a significant financial burden for the US healthcare system. Article see p 46 One of the drawbacks of PCI as a method of revascularization is the need for repeat procedures due to restenosis. This process is gradual and rarely life threatening, but often leads to symptoms of worsening angina, reduced quality of life, and significant expense for evaluation and treatment. The development of drug-eluting stents (DES) has been a major advance in the quest to reduce the restenosis rate, and they are now used in >70% of PCI procedures despite their higher initial cost of $1600 to $3200 compared with a bare-metal stent procedure.2 This rush to use a new technology, though not uncommon in United States, has led many to wonder whether this gain in quality of life is worth the added expense. A recently publicized case of overutilization of stenting has highlighted the skepticism that these procedures are appropriately used.3 To determine value of eliminating restenosis (eg, with DES), we have …

A New Rotary Powered Device for Bone Marrow Aspiration and Biopsy Yields Superior Specimens with Less Pain: Results of a Randomized Clinical Study

AbstractAbstract 1529▪ Introduction:The importance of bone marrow aspiration and biopsy in the evaluation of hematopoietic and non-hematopoietic disorders is well established. However, this technique is associated with morbidity and mortality risks.1 Recently, a battery-powered bone marrow biopsy system was developed to allow operators to safely, quickly and efficiently access the marrow space. We previously evaluated this device in swine models and in patients needing routine hematology outpatient evaluation.2 In the current study we compared the powered device to the traditional manual technique by relatively assessing pain scores, procedure times, biopsy capture rates, quality of material retrieved, safety and operator satisfaction. Methods:Two large academic medical centers participated in this trial (San Antonio, TX and Madrid, Spain). The study protocol was approved by each center's institutional review board. Adult patients requiring bone marrow biopsies were considered for the study. Following informed consent, patients were randomized to have procedures using a manual biopsy device (T-handle Jamshidi bone marrow biopsy and aspiration set, Cardinal Health, Dublin, OH) or the Powered device (OnControl 11 gauge/102mm Bone Marrow Biopsy System, Vidacare Corporation, Shavano Park, TX). After infiltration of the skin and medullary bone with local anesthesia, a visual analog scale (VAS) pain score was recorded immediately following skin puncture and once again at the end of the procedure for each patient. Procedure time was measured from skin puncture to core specimen ejection from the needle. Pathologic assessment of 30 randomized samples was carried out. Operator satisfaction with devices was measured on a scale of 0–10, with 10 as the highest rating. Statistics were calculated using t-test and chi-square, with an alpha-level of 0.05. Results:Five operators from 2 sites enrolled 50 patients (Powered, n=25; Manual, n=25). Of those patients, 58% were male and 42% were female; and had a mean age of 56.0±18.0 years. The mean height was 167.5 ± 10.5cm and the mean weight was 78.7 ± 22.7kg. Forty percent were lymphoma patients—the largest diagnostic group. Between patient groups, there were no significant differences in the means for these variables. See Table below for quantitative results, including pathology analysis. For the pathology qualitative analysis, there was no difference between groups for hemorrhage, clot/particle spicules, or smear spicules.PoweredManualp-valueMean VAS score, needle insertion2.6 ± 2.04.1 ± 2.50.022Mean VAS score, overall procedure3.2 ± 2.23.8 ± 3.00.438Mean biopsy procedure time (seconds)100.0 ± 72.8224.1 ± 79.0<0.001First pass biopsy core capture success88%88%1.000Mean core biopsy length (mm)13.1 ± 4.88.2 ± 3.60.005Mean core biopsy width (mm)1.9 ± 0.31.6 ± 0.150.001Mean core biopsy usable area (mm2)25.4 ± 12.311.9 ± 5.60.001Mean core biopsy volume (mm3)36.8 ± 20.215.3 ± 6.20.001Mean core biopsy cohesiveness score2.1 ± 1.31.9 ± 0.70.597Mean core biopsy, percent cortex material5.1 ± 9.236.9 ± 28.3<0.001Mean core biopsy, percent crush artifact18.4 ± 14.52.7 ± 5.30.001Mean operator satisfaction score9.5 ± 0.57.0 ± 1.6<0.001 Conclusions:Results of this trial suggest that the use of a Powered bone marrow biopsy device significantly reduces needle insertion pain. While not reflected in the results, overall pain may be better tolerated due to the important difference in procedure time. Moreover, the superior size and overall quality of core specimens retrieved by the Powered device provides more material for pathologic evaluation, thereby increasing diagnostic yield and reducing the need for repeat procedures. Cohesiveness of the medullary bone sampled was comparable for both techniques; however, the Powered system was less likely to recover non-hematopoietic tissue (e.g. cortical bone and soft tissue). Artifact was slightly more common with the Powered device (aspiration, hemorrhage and crush) but this did not impact on the diagnostic quality of the sample. No differences in safety data were noted for either technique and operator satisfaction favored the Powered device.1. Bain BJ. Bone marrow biopsy morbidity and mortality. British Journal of Haematology 2003;121:949-51.2. Swords RT, Kelly KR, Cohen SC et al. Rotary powered device for bone marrow aspiration and biopsy yields excellent specimens quickly and efficiently. J Clin Pathol 2010;63:562-5. [Display omitted] Disclosures:Swords:Vidacare Corporation: Research Funding. Anguita:Vidacare Corporation: Research Funding. Kelly:Vidacare Corporation: Research Funding. Philbeck:Vidacare Corporation: Employment. Miller:Vidacare Corporation: Employment, Equity Ownership. Brenner:Vidacare Corporation: Research Funding.

Bowel Preparation for Pediatric Colonoscopy Procedures

Colonoscopy is a routinely performed procedure in children and adolescents. Proper visualization of the intestinal mucosa, completion of the procedure, including examination of the terminal ileum, detection of pathological lesions, and therapeutic maneuvers, all are highly dependent on the quality of the bowel preparation. A significant proportion of patients, in some reports up to one third, are inadequately prepared for the examination, which leads to extended procedure time, incomplete examination, or need for repeat procedure. Aside from efficacy and safety, the most important aspects of colon preparation in pediatrics are ease of administration, palatability, dietary restriction, and minimization of disruption of daily routine. An ideal preparation does not exist and a wide variety of regimens are being used. Several of these have been investigated in pediatric clinical trials. This article reviews the published literature with an emphasis on the most commonly used agents, their mechanism of action, efficacy and ease of use, and safety.

Short Communication: Pig islet xenotransplantation acceptance in a Latin-American diabetic population

Progress in porcine islet xenotransplantation has been accompanied by studies on acceptance of this new procedure by patients, health professionals or the general public. Such studies have not been done in the Latin-American population. We conducted a questionnaire in 108 diabetes patients (insulin-dependent, n = 53; insulin-independent, n = 55) in a public hospital in Argentina. The questions addressed the general perception of the xenotransplant procedure and specific items related to the outcome (achieving insulin independence, improvement in metabolic control, delay in emergence of diabetic complications, need for repeat procedures, potential of transfer of infectious viruses, association with psychological problems, and anticipated success in relation to achieving a cure). Eighty-six (79%) of the patients accepted islet xenotransplantation; this incidence was not different for insulin-dependent or insulin-independent patients, patients with or without complications, or patients with good or poor metabolic control. Also, over 75% of patients accepted the procedure if this is only associated with a reduction in insulin requirement, if the procedure just delays but not prevents the onset of complications, or if the procedure needs to be performed every 6 months. Fifty-seven percent of patients indicated acceptance even if the potential transmission of a virus infection cannot be completely ruled out: this outcome was not affected by the outbreak of the H1N1 flu epidemic during the conduct of this study. Forty percent of patients indicated that living with porcine cells in their body could give psychological problems. We conclude that this population of Latin-American diabetic patients shows a high acceptance rate of a porcine islet xenotransplantation product.

Cortical mastoidectomy in surgery of tubotympanic disease. Are we overdoing it?

Background and purpose of the study The role of cortical mastoidectomy in the surgical treatment of tubotympanic type of otitis media has remained controversial especially when there is no evidence of active infection. Though literature is replete with studies for and against the requirement of mastoidectomy, there is a paucity of prospective studies in this regard. A randomized controlled trial was conducted to assess the impact of mastoidectomy in the management of mucosal chronic otitis media. Methods 62 patients with uncomplicated mucosal chronic otitis media were randomly allotted to two groups of 31 each. Patients in group A underwent tympanoplasty with mastoidectomy and group B underwent tympanoplasty without mastoidectomy. All the patients were followed up for a minimum of three months and results were assessed in terms of graft uptake, hearing improvement and need for repeat procedure. Results No significant difference in outcome was observed between the two groups in all parameters compared. The residual air-bone gap was 12.55 ± 12.98 in group A and 12.71 ± 11.54 in group B. Graft uptake rate was 93.55% in group A and 96.775% in group B. 2 patients in group A and one patient in group B underwent repeat procedures. Conclusions There is little evidence in favour of cortical mastoidectomy in surgery of tubotympanic disease.

1807 PREDICTORS FOR NEGATIVE URETEROSCOPY IN THE MANAGEMENT OF UPPER URINARY TRACT STONE DISEASE

You have accessJournal of UrologyStone Disease: SWL, Ureteroscopic or Percutaneous Stone Removal III1 Apr 20101807 PREDICTORS FOR NEGATIVE URETEROSCOPY IN THE MANAGEMENT OF UPPER URINARY TRACT STONE DISEASE Jessica Kreshover, Rian Dickstein, Courtney Rowe, Richard Babayan, and David Wang Jessica KreshoverJessica Kreshover More articles by this author , Rian DicksteinRian Dickstein More articles by this author , Courtney RoweCourtney Rowe More articles by this author , Richard BabayanRichard Babayan More articles by this author , and David WangDavid Wang More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1732AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Although computed tomography (CT) scans are extremely accurate in assessing ureteral and renal calculi, there is an increased effort by urologists to limit CT scans and minimize radiation exposure. On occasion, patients undergo a planned ureteroscopy with laser lithotripsy and it is discovered that the stone has already passed. We sought to identify predictive factors of negative ureteroscopies from a large cohort of patients. METHODS A retrospective chart review was performed on all ureteroscopies performed by a single surgeon from August 2003 to May 2008 for renal and ureteral stones. Renal units were examined separately to include bilateral cases. Renal units were excluded for stone size greater than 10mm (given a low probability of spontaneous passage), staged procedures, and with previously placed ureteral stents given the need for repeat procedure. Negative ureteroscopies were then compared with those where stones were identified and treated. Factors including stone size, stone location, presence of pre-operative pain, time interval since CT, presence of hydronephrosis, and use of alpha-blockers as medical expulsive therapy (MET) were compared between the two cohorts using student's t-test, test of proportions, and analysis of variance. RESULTS A total of 256 ureteroscopies (97 bilateral) were identified (Table 1). Twenty five of 256 renal units (9.7%) did not have stones upon direct visualization. Comparing negative and positive cohorts, there was a significant difference in stone size (4.48 vs 6.78mm, p<0.001) and stone location (p=0.04). There were no significant differences between the two cohorts with respect to time interval from CT to surgery (p=0.65), presence of hydronephrosis (p=0.74), use of MET (p=0.21), or pre-operative pain (p=0.83). CONCLUSIONS Negative ureteroscopies were performed in almost 10% of renal units with a reasonable chance of stone passage. Our data suggest that smaller stone size and distal location are useful predictors for a negative ureteroscopy. Pre-operative pain, presence of hydronephosis, time interval until surgery, and use of MET did not correlate with negative ureteroscopy. Thus, patients who elect to undergo ureteroscopy with laser lithotripsy should be given informed consent about the possibility of undergoing a negative ureteroscopy. In addition, repeat imaging may be considered before surgery in patients with smaller and more distal ureteral stones. Boston, MA© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e701 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jessica Kreshover More articles by this author Rian Dickstein More articles by this author Courtney Rowe More articles by this author Richard Babayan More articles by this author David Wang More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Balloon Aortic Valvuloplasty (BAV) for Severe Symptomatic Aortic Stenosis (AS) in the Current ERA

Background: BAV fell out of favour due to poor survival benefit, perceived procedural complexity and the need for repeat procedure in short duration. It has been used as a bridge to aortic valve replacement (AVR) or transcatheter aortic valve insertion (TAVI) and as a palliative procedure for patients who have been denied valve replacement.

Successful Treatment of Unicameral Bone Cyst by Single Percutaneous Injection of α-BSM

Unicameral bone cyst (UBC) is a benign bone lesion, recognized for its high rate of recurrence and need for repeat procedures to achieve healing. We hypothesized that the osteoconductive material apatitic calcium phosphate (alpha-BSM) could be effective in filling and stimulating resolution of UBC. The purpose of this study was to evaluate clinical and radiographic outcomes of UBC treated by a single injection of alpha-BSM. Thirteen patients (6 male, 7 female) with a mean age of 10.5 years, underwent single percutaneous injection of alpha-BSM for presumed UBC. The aspiration of the cysts was followed by vigorous saline lavage using 2 wide bore needles to disrupt the cyst walls. alpha-BSM "paste" was then injected under fluoroscopic guidance. Radiographs were digitized to measure cystic area (millimeter squares) on 2 orthogonal views. Healing was rated according to a modified Neer outcome grading system. Nine of the 13 patients had had pathologic fractures in the past. Eleven of the 13 patients had had past unsuccessful treatment: multiple steroid injections in 6, curettage and bone grafting in 3, and bone marrow and demineralized bone matrix (Grafton) injection in 2. Five cysts were grade 1 (healed 100%), 6 grade 2 (healed >50%), 2 grade 3 (healed <50% with increased cortical thickness), and none grade 4 (recurrence/enlargement). The average resolution of cystic area in 11/13 cysts was 85.7% at final follow-up of 35.8 months (P=0.0001) with 2.8 mm of average gain in cortical thickness (P=0.0018). None of the 13 lesions required an additional procedure or repeat injection. All patients were clinically asymptomatic at latest follow-up. This is the first study quantifying cyst resolution objectively according to actual decrease in area (millimeter squares). A single injection of alpha-BSM is a safe, minimally invasive and efficacious method to treat UBC in the pediatric population.

Poor Bowel Preparation in Colonoscopy Is a Costly Problem

Purpose: Poor colonic preparation (prep) is a major limitation on the quality of colonoscopy (colon). Inpatient (IP) status has previously been shown to be a significant predictor of poor prep. No prospective trials evaluated the effect of education (edu) on IP prep outcomes. The aims of the study are: 1. To prospectively identify predictors of poor prep in IP's. 2. To determine if enhanced patient (pt) edu can significantly improve the quality of prep in IP's undergoing colon. Methods: The study was done as a single-blinded, prospective, randomized, concealed allocation, multicenter study. IP's scheduled for colon in 2 urban hospitals were included. Factors previously shown to influence prep outcome in outpts and other potential risk factors (RF) were documented. Pt compliance with prep ingestion was obtained from nursing staff blinded to the pt allocation. Endoscopists blinded to the randomization rated the prep using a visual analog scale ranging from 0–4 (0 = poor, 4 = excellent). Pts were randomized to one of two groups. The edu group received a 15 min verbal session by a health care worker and a pictorial brochure in addition to the standard instructions by the registered nurse (RN). Standard of care (SOC) group received instructions from the RN alone. Results: Of the 73 pt's enrolled, 68 were included in the study, 5 were excluded as the procedure was not done the next day as planned. Of the 68 included, N = 38 in the edu group and N = 30 in the SOC group. The mean age of all pt's was 60.2 years, 45.6% were women, 54.4% were nonwhite and 22% had less than high school edu. Poor prep was seen in 23.5%. In 47.1% the prep was inadequate for screening purposes. Due to poor prep, 11.8% of the pt's had repeat colon, extending hospital stay. Consuming > 75% of the prep (P= 0.009) and prep given before 3:00 pm (P= 0.01) were the only significant predictors of adequate bowel prep. Other RF including demographics, edu level, concurrent illness, ability to ambulate, presence/absence of GI symptoms on admission, family history of colon cancer/polyps and prep type were similar in good and poor prep pts. Poor prep was seen in 23.7% of pts in the edu group (<2 score) compared to 23.3% in the SOC group (P= ns). Poor preps increased the average cost of a colon by $400 due to need for repeat procedure and by $863 due to the prolonged IP stay leading to a total increase by $1263/case. Conclusion: 1. Poor bowel prep in IP's remains a costly problem in U.S. hospitals. 2. Inadequate prep resulted in a prolonged hospital stay in 11.8% of pts. 3. Pre-procedural edu alone does not appear to impact the quality of the bowel prep in IP's. 4. Newer strategies need to be developed that place emphasis on increasing compliance and early administration of the bowel prep in IP's.

Late adverse events after drug-eluting stent implantation

Stents that elute antiproliferative drugs prevent restenosis after percutaneous coronary artery revascularization, reducing the need for repeat procedures. Randomized trials in low-risk patients supported initial regulatory approval for drug-eluting stents (DES). In 2006, meta-analyses of long-term outcomes from these trials associated DES use with adverse events, believed to be attributable to late stent thrombosis, occurring more than 9 months after the initial procedure. This article appraises these late adverse effects and illustrates the power and shortcomings of large national registries, focused, well-conducted clinical trials, and meta-analyses of clinical trial data. This timely, robust evidence base reflects an alignment of academic, industry, and public health priorities.

Variability of Acetylcholinesterase Hyperinnervation Patterns in Distal Rectal Suction Biopsy Specimens in Hirschsprung Disease

Variability in cholinergic innervation may contribute to false-negative and false-positive evaluations for Hirschsprung disease (HD). We compared intraspecimen variability of histochemical acetylcholinesterase (ACE) activity in 62 distal rectal mucosal biopsy specimens from 33 patients with short-segment HD (SSHD), 14 patients with short-segment HD/Down syndrome (SSHD/DS), 10 patients with total colonic aganglionosis (HDTC), and 45 ganglionated control specimens obtained because of clinical suspicion for HD. Specimens were evaluated in 1-mm linear segments for abnormal distribution and abnormal intensity of staining reaction in the lamina propria (LP), muscularis mucosae (MM), numerical excess of small submucosal nerves (SSN), and presence or absence of large submucosal nerves (LSN) defined as >35 microns in diameter. Patients with HD and controls were predominantly infant males. Aggregate length of specimens was 186 mm in HD and 136 mm in controls. We defined multiple patterns and relative frequencies of normal and abnormal ACE reactivity in the muscularis mucosae, submucosal nerves, and innervation in the lamina propria. We verified a hyperinnervation pattern more common in neonates within each subset of HD. Large submucosal nerves >35 microns in diameter are relatively less common in SSHD/DS and HDTC. Eleven of 57 patients with HD had at least 1 mm of normal muscularis mucosae accounting for 19/186 mm examined. Ten percent of control mm had at least 1 submucosal nerve >35 microns in diameter. Intraspecimen variability in ACE patterns, when extreme, can usually be resolved by findings elsewhere in an adequate specimen, minimizing the need for repeat procedures.

Studies of Drug-Eluting Stents

All technology has limitations, some of which are not recognized at the time of introduction. Once adopted, technology may be challenged as to whether the initial promise of patient benefit demonstrated in clinical trials has been achieved in the setting of routine practice. This challenge is the objective of observational studies. Among interventional cardiologists, the jury on drug-eluting stents is still out. Article p 2071 Progress has not been linear for coronary stenting technology. The introduction of 2 new stents that largely prevented the problem of restenosis1,2 was met by an explosive adoption of these techniques by physicians and requests by patients. Within the first 8 months of introduction in Massachusetts, the rate of drug-eluting stents (DES) as a proportion of total stent procedures reached 90%.3 However, reports of late adverse events and stent thrombosis, a rare but morbid event, raised alarm in patients and prompted caution from regulators and physicians. The net outcome has been a return to increased use of bare-metal stents, with DES use decreasing to 64% in the United States (Millenium Research Group, Waltham, Mass, written communication, 2007). The benefits of restenosis prevention observed in randomized trials comparing DES to bare-metal stents were far greater in magnitude than many other incremental changes in medicine. Relative reductions in the need for repeat procedures to treat restenosis reached 75% to 80%,1,2 a larger jump forward than that achieved with the introduction of bare-metal stents to replace balloon angioplasty.4,5 Although the composite end points in the pivotal trials of drug-eluting stents included myocardial infarction and death and patients were followed for 5 years after stenting, the trials were not powered to detect harm in these important end points.6,7 Some have voiced concern that the trials leading to DES approval did not anticipate the broad …

Frequency and Indications for Performance of Repeat Colonoscopy within Sixty Days

Purpose: Overuse of colonoscopy affects the availability, quality, and cost of care. We sought to evaluate the frequency and indications for repeat colonoscopy within 60 days, and to evaluate whether baseline patient characteristics or the course during the first colonoscopy predicted the need for repeat procedures. Methods: We identified 781 patients who had more than one colonoscopy within 60 days, among 51559 patients (1.5%) who underwent colonoscopy during Jan 2004 to Dec 2006. Control patients who did not have repeat exams were matched with the study population with respect to procedure date and location. Medical records were reviewed for patient demographic and historical data and numerous procedural characteristics. Univariate and multivariate logistic regressions were performed to assess the association between the repeat colonoscopy and patient age, gender, BMI, history of abdominal surgery, procedure tolerance, size of largest polyp, endoscopist experience, inpatient vs. outpatient status, and use of anticoagulants, narcotics or benzodiazepines. Results: The most common reasons for repeat colonoscopy included poor bowel preparation (32%), “Need for Complex Therapy” (21%), bleeding management (13%), pathology follow-up (12%), stricture therapy (6%), failure due to intolerance (4%), failure due to anatomy (4%), and anticoagulant or antiplatelet agent mgmt (2%). Multivariate logistic regression showed statistically significant differences between the study and control populations in regard to age (OR = 1.01; 95% CI 1.003–1.017; P < 0.005), history of abdominal surgery (OR = 1.68; 95% CI 1.34–2.11; P < 0.0001), procedural tolerance level (OR = 4.01; 95% CI 2.20–7.30; P < 0.0001), inpatient versus outpatient status (OR = 1.78; 95% CI 1.31–2.41; P < 0.001), largest polyp size ≥ 2 cm (OR = 10.70; 95% CI 5.08–22.56; P < 0.0001), and use of anticoagulants (OR = 1.58; 95% CI 1.12–2.22; P < 0001). Endoscopist experience, and patient gender, BMI, or use of narcotics or benzodiazepines did not correlate with repeat procedures. Conclusion: Poor bowel preparation and referral for complex therapies are the dominant indications for repeating colonoscopy within 2 months. Variables associated with performance of repeat colonoscopy included older age, history of previous abdominal surgery, inpatient status, poor procedure tolerance, largest polyp size more than 2 cm, and use of anticoagulants at the time of the first colonoscopy.

Combined Partial Endoscopic Biliary Sphincterotomy and Endoscopic Balloon Sphincteroplasty in the Management of Difficult Bile Duct Stones

Background: Endoscopic biliary sphincterotomy (EBS) is currently the standard procedure for removal of bile duct stones. Endoscopic balloon dilation (EBD) can be a valuable adjunct to sphincterotomy when difficult extraction is anticipated (e.g., large stones, small native papilla, non-dilated distal duct, etc). EBD dilates the intraduodenal and intrapancreatic portion of the distal bile duct, which may theoretically facilitate stone extraction in these cases. However, EBD alone is associated with an increased risk of pancreatitis. A combined approach of performing a partial EBS (pEBS) followed by EBD has been used to minimize this risk. Aim: To report our experience with this combined method for removing bile duct stones. Methods: We retrospectively identified all patients who underwent combined pEBS and EBD between January 2005 and September 2006. Patient demographics, clinical information, size and number of bile duct stones, and procedural variables (balloon size, need for additional extraction modalities (e.g., lithotripsy)), successful rate of stone extraction, need for repeat procedure(s), and complications were reviewed. Results: Combined pEBS and EBD was performed in 13 patients (M: F 8:5; mean age: 68.6 years, 27-91 years). Mean stone diameter was 11.6 mm (5-18). Stone number ranged from 1-10; 6 patients had one, 6 had 3-5, and one had 10 stones. Three patients had BII gastrectomy, 4 had large periampullary diverticulae, and 3 had a small papilla limiting the achievable sphincterotomy length. One patient had Glanzmann thrombasthenia, and 2 were referred after failed stone extraction elsewhere. All patients underwent pEBS with an average size of 6.2 mm (3-10 mm); pEBS was defined as an EBS length of 25-50% of the distance between the papillary orifice and the duodenal wall. CRE balloon diameter was influenced by stone size and individual anatomy, and ranged from 8-18 mm. Endoscopic removal of all stones was achieved in all 13 patients (100%); 9 (70%) required only one session, 3 (23%) required two sessions, and one (7%) required 3 sessions. Removal was accomplished by retrieval balloon only in 6 patients (46%), a balloon plus a basket in 6 (39%), and mechanical lithotripsy in 2 (19%). There were no immediate or short-term complications, including perforation or pancreatitis. Conclusion: EBD after partial EBS appears to be a safe and effective option when difficult stone extraction is anticipated. The incidence of EBD-induced pancreatitis appears low following a partial EBS, suggesting a partial EBS may have a protective effect. Larger trials comparing this approach to other techniques for managing challenging stone cases are warranted.

Changing outcomes of coronary revascularization in British Columbia, 1995–2001

To examine outcomes following all first coronary revascularization procedures, isolated coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) on British Columbia (BC) resident adults from 1995 to 2001. CABG and PCI data were obtained from the BC Cardiac Registry, and mortality data were obtained from the BC Vital Statistics Agency. Analysis was performed by annual cohorts, and the rates reported are unadjusted. An increasing percentage of revascularization procedures was performed with PCI (62% in 1995 to 73% in 2001; P<0.001) due to the increased use of PCI procedures. Except in emergent cases, 30-day mortality improved after PCI (1.8% to 1.1%; P=0.02) and CABG (1.8% to 1.2%; P=0.01). Emergent cases accounted for 9.0% of PCIs and 2.7% of CABGs, the percentage treated by CABG decreasing from 14.5% in 1995 to 7.5% by 2001 (P<0.001). Mortality rates among emergent cases was higher at 30 days, with no trend in PCI mortality (12%) but a substantial reduction in 30-day mortality after CABG (28% to 10%; P=0.003). One-year survival free from repeat revascularization following PCI increased from 73% in 1995 to 83% in 2001 (P<0.001) and from 94% to 95% (P<0.005) following CABG. Improvements in procedure-related mortality observed in trials have extended to clinical practice. With respect to emergent cases, an increasing proportion were treated by PCI with no change in PCI mortality but associated with a drop in surgical mortality. There has been a consistent and substantial drop in the need for repeat procedures within one year for patients selected for PCI.

Management of detrusor–external sphincter dyssynergia

Detrusor-external sphincter dyssynergia (DSD) is a debilitating problem in patients with spinal cord injury. DSD carries a high risk of complications, and even life expectancy can be affected. The mainstay of treatment is the use of antimuscarinic medication and catheterization, but in those for whom this is not possible external sphincterotomy has been the traditional management route. External sphincterotomy, however, is associated with significant risks, including hemorrhage, erectile dysfunction and the need for repeat procedures, and over the last decade alternatives have been investigated, such as urethral stents and botulinum toxin injection. We present a review of DSD, including the current management strategies and prospects for future treatment.

Decision models for assessing the cost effectiveness of drug-eluting stents

Percutaneous coronary intervention is an increasingly common treatment for many people with coronary disease. Randomised trials using antiproliferative, drug-eluting stents (DES) have shown important reductions in the need for repeat procedures after initial percutaneous coronary intervention. These trials indicate that the growing use of DES has the potential to create major clinical benefits for patients; however, in actual practice, the associated costs may cause financial crises for hospital systems. This paper reviews previously published DES economic decision models from both societal and hospital perspectives. From a social perspective, additional spending for new technologies may be acceptable if these technologies convincingly improve the lives of patients. The models reviewed suggest that DES incurs large costs to both society and hospitals, and currently offers uncertain clinical benefits. More research is recommended to identify high-risk patients who stand to gain significant health benefits from this therapy.