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Background: The placebo effect observed in clinical trials evaluating medical treatments for chronic rhinosinusitis (CRS) is not well understood. This systematic review and meta‐analysis sought to characterize the placebo effect present within CRS outcomes. Methods: A systematic review of PubMed, Scopus, and Cumulated Index in Nursing and Allied Health Nursing (CINAHL) was performed. Randomized controlled trials (RCTs) evaluating medical treatments for CRS versus placebo were included. We assessed patient‐reported (sino‐nasal outcome test 22 [SNOT‐22], nasal obstruction, sense of smell, nasal obstruction visual analogue score [VAS], sense of smell VAS, anterior rhinorrhea, and postnasal drip) and objective (Lund–Mackay Computed tomography (CT) score, peak nasal inspiratory flow [PNIF], nasal polyp scores, 40‐item Smell Identification Test, serum IgE, and blood eosinophil levels) outcomes. Results: Twenty‐one RCTs were included, comprising 1437 patients (mean age 49.2 years). Biologics were the most common treatment investigated (n = 9). Eleven studies administered background steroids along with placebo. Following placebo administration, multiple patient‐reported outcomes significantly decreased, including SNOT‐22 (mean difference −9.49, 95% confidence interval [CI] [−11.26, −7.73]), nasal obstruction (−0.33 [−0.54, −0.13]), sense of smell (−0.22 [−0.33, −0.11]), nasal obstruction VAS (−2.47 [−2.87, −2.06]), and loss of smell VAS (−2.31 [−4.14, −0.47]) scores. For objective measures, significant changes occurred in Lund–Mackay CT score (−0.82, [−1.48, −0.16]) and PNIF (4.70, [4.76, 24.64]) with placebo. Placebo arms had the greatest impact when no background medications were used. Conclusions: Placebo treatments have a statistically and potentially clinically significant effect on patient‐reported and some objective CRS outcomes. Further investigation is required to fully understand placebo effect, which could improve assessment of RCTs and impact patient care. [ABSTRACT FROM AUTHOR]

CONCLUSION Patients with CRSwNP and comorbid ETD are likely to experience improvement in ETD symptoms on dupilumab, at a similar magnitude as sinus surgery. Keywords: chronic rhinosinusitis; quality of life; therapeutics EN chronic rhinosinusitis quality of life therapeutics 1561 1563 3 07/26/23 20230801 NES 230801 INTRODUCTION Eustachian tube dysfunction (ETD) occurs in ~50% of patients with chronic rhinosinusitis with nasal polyposis (CRSwNP).[1] While treatment of CRSwNP with endoscopic sinus surgery (ESS) has been shown to improve comorbid ETD,[2] little is currently understood about the impact of biologics on ETD in CRSwNP. A baseline ETDQ-7 score of >14.5 was considered clinically significant ETD, or "ETD-positive", and a ETDQ7 value of >3.5 was considered the minimal clinically important difference (MCID).[[4]] Pre- and post-treatment ETDQ-7 were compared using I t i -tests. [Extracted from the article]

Objective: Acromegaly is a condition characterized by an overproduction of growth hormone which infers high morbidity and mortality if left untreated. The objective of this review is to analyse and appraise the current evidence for the generalized use of preoperative medications and the various surgical approaches as described in the literature. Design: A thorough search from MEDLINE via PubMed, EMBASE, and Cochrane Library has been performed which identified a total of 37 papers. Conclusion: The preoperative use of somatostatin receptor agonists (SAs) in acromegaly is a controversial topic with current guidelines suggesting against their generalized routine use. Most authors noticed an insignificant long‐term remission of acromegaly when given SAs compared with nil preoperative therapy, except for invasive macroadenomas as SAs have been found to reduce the tumour volume and aid towards the total resection of the adenoma. Furthermore, according to the evidence available, endoscopic transsphenoidal surgery is the optimum method for hypophysectomy in terms of its remission and safety profile. [ABSTRACT FROM AUTHOR]

In six of the nine patients who underwent localized resection, follow-up was performed, and two of these patients (33%) exhibited metachronous cancers.14 In these two patients, residual Barrett's mucosa was >=3 cm in length, and in the remaining four patients who did not have metachronous cancers, residual Barrett's mucosa was short (<3 cm). In the remaining three patients who underwent localized resection, stepwise ESD was performed for the residual Barrett's mucosa to prevent metachronous cancers. The incidence of Barrett's esophageal adenocarcinoma (EAC) is reported to be 50% or more in Western countries.1 It is rare in Japan. [Extracted from the article]

In six of the nine patients who underwent localized resection, follow-up was performed, and two of these patients (33%) exhibited metachronous cancers.14 In these two patients, residual Barrett's mucosa was >=3 cm in length, and in the remaining four patients who did not have metachronous cancers, residual Barrett's mucosa was short (<3 cm). The incidence of Barrett's esophageal adenocarcinoma (EAC) is reported to be 50% or more in Western countries.1 It is rare in Japan. In the remaining three patients who underwent localized resection, stepwise ESD was performed for the residual Barrett's mucosa to prevent metachronous cancers. [Extracted from the article]

Mepolizumab for chronic rhinosinusitis with nasal polyps: treatment efficacy by comorbidity and blood eosinophil count. Knowledge gaps in using type 2 biologics for real-world treatment of chronic rhinosinusitis with nasal polyps By translating scientific results into an integrated care strategy, biologics targeting T2 inflammation have achieved major progress in treating severe uncontrolled chronic rhinosinusitis with nasal polyps (CRSwNP) during the last decade. In RCTs, discontinuation of biologics caused a slow bounce of nasal polyp scores and nasal symptoms, indicating that continued treatment is necessary to sustain positive outcomes. [Extracted from the article]

Consequently, expert endoscopic diagnosis of SNADETs must not only achieve tumor detection but also incorporate optical biopsy to ensure selection of an appropriate treatment strategy based on the risk of malignancy. Endoscopic submucosal dissection (ESD) was developed in the late 20th century as a treatment for early gastrointestinal cancer. However, endoscopic diagnosis and treatment of superficial non-ampullary duodenal epithelial tumors (SNADETs) has lagged far behind compared with other gastrointestinal tumors because SNADETs are rare and little progress has been made in understanding their clinicopathological characteristics. [Extracted from the article]

Endoscopic submucosal dissection (ESD) was developed in the late 20th century as a treatment for early gastrointestinal cancer. However, endoscopic diagnosis and treatment of superficial non-ampullary duodenal epithelial tumors (SNADETs) has lagged far behind compared with other gastrointestinal tumors because SNADETs are rare and little progress has been made in understanding their clinicopathological characteristics. Consequently, expert endoscopic diagnosis of SNADETs must not only achieve tumor detection but also incorporate optical biopsy to ensure selection of an appropriate treatment strategy based on the risk of malignancy. [Extracted from the article]

Barrett's esophagus (BE) is a precursor to esophageal adenocarcinoma and current practice is to establish endoscopic surveillance once diagnosed, in order to identify early dysplasia and neoplasia that has the potential to undergo endoscopic eradication therapy (EET). Before embarking upon EET the clinical team has a duty to consider all viable options and come to a plan based on recent evidence. The therapeutic approach varies greatly but largely adheres to the mantra of 'Detect–Resect–Ablate', in which high‐quality endoscopy identifies BE associated pathology, associated lesions (if present) undergo safe endoscopic resection and remaining intestinal metaplasia in the esophagus is ablated to prevent recurrence of dysplasia. In this review, current practice, pitfalls, complications, and the future perspectives on practice in this field are discussed. The Western perspective is focused on here, with an outline of the differences in clinical practice with Asian nations and attempts to bridge these differences. [ABSTRACT FROM AUTHOR]

Background: Chronic rhinosinusitis with nasal polyps (CRSwNP) is a type 2 inflammatory disease treated with sinus surgery when refractory to medical intervention. However, recurrence postsurgery is common. Dupilumab, a fully human monoclonal antibody, blocks the shared receptor for interleukin 4 (IL‐4) and IL‐13, key and central drivers of type 2 inflammation. We report the efficacy of dupilumab in patients with CRSwNP from the SINUS‐24/SINUS‐52 trials (NCT02912468/NCT02898454), by number of prior surgeries and time since last surgery. Methods: Patients were randomized to placebo or dupilumab 300 mg every 2 weeks. Post hoc subgroup analyses were performed for patients with 0, ≥1, 1/2, or ≥3 prior surgeries, and for patients who had surgery within <3, 3 to <5, 5 to <10, or ≥10 years. Efficacy outcomes at 24 weeks included co‐primary endpoints nasal polyp score (NPS) and nasal congestion (NC), and Lund‐Mackay (LMK), 22‐item Sino‐Nasal Outcome Test (SNOT‐22), and smell scores. Results: Of 724 patients randomized, 459 (63.4%) had ≥1 prior surgery. Baseline sinus disease (NPS, NC, LMK) and olfactory dysfunction (University of Pennsylvania Smell Identification Test [UPSIT] and loss of smell) scores were worse for patients with ≥3 prior surgeries vs no surgery. Baseline NPS and LMK were worse in patients with <3 years since last surgery than in patients with ≥5 years since last surgery. Dupilumab significantly improved all outcome measures vs placebo in all subgroups by number of surgeries and by time since last surgery. Improvements in NPS and LMK were greater in patients with <3 years since last surgery than patients with ≥5 years. Safety results were consistent with the known dupilumab safety profile. Conclusion: Dupilumab improved CRSwNP outcomes irrespective of surgery history, with greater improvements in endoscopic outcomes in patients with shorter duration since last surgery. [ABSTRACT FROM AUTHOR]

Background: Nasal obstruction is a common complaint in patients with sleep‐disordered breathing and obstructive sleep apnea (OSA). Although topical nasal treatments (TNTs) have been shown to reduce nasal resistance and improve nasal obstruction, there is conflicting evidence regarding the role of TNTs in adult OSA. In this systematic review and meta‐analysis we aim to evaluate the role of TNTs in adults with OSA. Data sources used included PubMed, Ovid MEDLINE, and Cochrane Central, from January 2001 to July 2019. Methods: Inclusion criteria were English‐language studies containing original data on TNTs in adults (≥18 years) with OSA (apnea‐hypopnea index [AHI] ≥5). Exclusion criteria were case reports, studies without outcome measures, and concurrent non‐TNT treatment for OSA. Two investigators independently reviewed all articles and performed quality assessment using validated tools. Meta‐analysis and quality assessment were performed. Results: Of the 2180 abstracts identified, 8 studies met inclusion criteria. TNTs included decongestants (4 of 8 studies), corticosteroids (3 of 8), and antihistamines (1 of 8). Outcome measures included AHI (8 of 8), respiratory distress index (RDI; 1 of 8), oxygen‐desaturation index (ODI; 3 of 8), minimum SaO2 (MinSaO2; 4 of 8), nasal resistance (4 of 8), endoscopic sinus surgery (4 of 8 studies) and standardized rhinoconjunctivitis quality of life questionnaire scores (1 of 8 studies). Qualitatively, all studies showed trends toward improving objective and subjective measures of OSA, although the significance of these improvements varied across studies. A meta‐analysis was performed in 5 studies, but TNTs did not reveal a significant change in AHI (p > 0.05). Conclusion: TNTs may improve minimum oxygen saturation, ODI, RDI, and subjective/quality‐of‐life measures. Allergic patients may have more improvement in OSA measures compared with nonallergic patients. Future studies are indicated to accurately determine the efficacy of TNTs. [ABSTRACT FROM AUTHOR]

Keywords: cerebrospinal fluid rhinorrhea; natural orifice endoscopic surgery; skull base; therapeutics EN cerebrospinal fluid rhinorrhea natural orifice endoscopic surgery skull base therapeutics 321 323 3 02/22/22 20220301 NES 220301 INTRODUCTION The last decade has seen the utilization of endoscopic endonasal approach (EEA) in resection of tumors with intradural components.1 EEA for intracranial masses is both possible and effective.2-4 When compared to transcranial approach, EEA has demonstrated superior vision outcomes, equivalent rates of total resection and complication, and stable quality of life outcomes.5,6 Successful EEA requires adequate skull base closure to prevent cerebrospinal fluid (CSF) leaks. There was no significant difference in postoperative CSF leak rates between pediatric and adult groups, underscoring EEA with NSF repair as a successful and safe technique in the surgical resection of pediatric anterior skull base tumors. One recent study examined NSF skull base reconstruction in a cohort of 12 post-EEA pediatric patients.9 Complications included one CSF leak, with a leak rate of 8.33%. [Extracted from the article]

Objectives: Aspirin‐exacerbated respiratory disease (AERD) is a chronic respiratory condition characterized by a triad of symptoms: asthma, chronic rhinosinusitis with nasal polyposis, and a respiratory reaction to aspirin and other cyclooxygenase‐1 inhibitors, also known as nonsteroidal anti‐inflammatory drugs. The objective of this review is to provide otolaryngologists with an overview of the pathophysiology, diagnosis, and treatment of this under‐recognized condition. Data sources and methods: Foundational papers on AERD were reviewed, focusing on the clinical otolaryngology and allergy/immunology literature and other high impact journals or trials. Results: AERD results from increased production of pro‐inflammatory leukotrienes and a decrease in production of anti‐inflammatory prostaglandins associated with the dysregulation of multiple enzymes influencing eicosanoid metabolism. Diagnosis hinges on a high index of suspicion, careful history, and confirmatory testing for all three elements. Treatments include endoscopic sinus surgery; topical, inhaled, or oral corticosteroids; aspirin desensitization; leukotriene modifying drugs; and the new class of biologics such as dupilumab. Conclusion: AERD is an under‐recognized disease associated with substantial patient‐reported morbidity. We expect rapid progress in the pathophysiological understanding of this disease and available treatments in the coming decades. Level of evidence: 5 [ABSTRACT FROM AUTHOR]

Objectives: To evaluate whether an ethmoidal drug‐eluting stent (DES) (the Relieva Stratus™ MicroFlow Spacer) could better prevent endoscopic sinus surgery (ESS) than standard non‐invasive therapy using corticosteroid nasal spray in patients suffering from chronic rhinosinusitis (CRS). Design: Prospective, randomised clinical trial. Setting: Tertiary referral centre. Participants: Sixty‐three adult patients with ethmoidal involvement in cone beam computerised tomography (CBCT) whose first‐line medical treatment with topical corticosteroids had failed and who were candidates for ESS were randomised either to a DES group, which received triamcinolone acetonide stents (n = 34), or to a topical intranasal corticosteroid group (n = 29) that used optimally dosed triamcinolone acetonide nasal spray. Outcome measures: Patients were followed up prospectively for 6 months and at 36 months. Freedom from ESS was the primary endpoint. Further, we identified those factors predicting ESS. Results: At 6 months, ESS could be prevented in almost half of the patients in both groups (DES 13/28, 46.4%, nasal spray 14/29, 48.3%). At 36 months, 20/28 (71.4%) patients in the DES group and 18/29 (62.1%) in the nasal spray group had been operated. The differences were not statistically significant at either timepoint. Patients who smoked (14/19, 73.7% vs 16/38, 42.1%) were more likely to be operated at 6 months. Conclusion: Endoscopic sinus surgery can be prevented using both therapies in the medium term in almost half of cases with neither therapy being statistically superior. This effect was somewhat diminished in the long term with a trend towards more patients being operated in the DES group. Considering the additional costs, the need for general anaesthesia and the potential side effects associated with DES, its potential clinical role appears to be limited. Smoking was significantly associated with ESS. [ABSTRACT FROM AUTHOR]

Objective: Osteoradionecrosis (ORN) of the sphenoid is a rare but potentially lethal complication that can occur after irradiation of nasopharyngeal and clival malignancies. The objective of this study was to describe a multimodal treatment strategy tailored to the clinical signs and to the radiological extent of the disease, and to report on its preliminary results. Methods: Retrospective monocentric study at a tertiary skull base center. Patients treated for a sphenoid ORN from January 2014 to August 2018 were identified and charts were retrospectively reviewed for demographics, histologic tumor type, previous treatments of the tumor, clinical signs at presentation, radiological data, treatment, and outcomes. Sphenoid ORN was treated by a combination of medical therapy, endovascular treatment, and/or surgery. The use of each of these therapeutic modalities was based on the extent of ORN and on the presenting signs. Results: Seven patients were included: four patients underwent endovascular treatment with occlusion of the internal carotid artery, five patients underwent surgical debridement, and covering of the exposed bone by a local flap, seven patients received antibiotics (in combination with pentoxyphilline, tocopherol, and clodronate in one case). Three patients died after progression of the ORN. The global survival rate was 57% (4/7) with a mean follow‐up of 24 months. In one case, ORN was treated successfully by medical treatment only, with a combination of antibiotics, pentoxyphilline, tocopherol, and clodronate. Conclusion: This retrospective study describes the results of a management strategy adapted to the extent of the disease in sphenoid ORN and based on medical therapy only, or on a combination of medical therapy, interventional radiology, and/or surgery. Level of evidence: 4 [ABSTRACT FROM AUTHOR]

Background: Chronic rhinosinusitis (CRS) is a frequently observed condition in patients with immunodeficiency secondary to tumor necrosis factor alpha inhibitors (TNFαis). The histologic features of CRS caused by TNFαis have yet to be determined and may have important implications in understanding the pathophysiology of the disease process. Methods: A structured histopathology report was used to analyze sinus tissue removed during functional endoscopic sinus surgery (FESS). These structured histopathology variables were compared among patients with CRS on TNFαi (CRSαi), CRS without nasal polyps (CRSsNP) patients, and CRS with nasal polyps (CRSwNP) patients. Results: Eighteen CRSαi, 91 CRSwNP, and 113 CRSsNP patients undergoing FESS were analyzed. Compared to CRSsNP, CRSαi patients exhibited increased mucosal ulceration (16.7% vs 0.9%, p < 0.008), increased fibrosis (100% vs 34.5%, p < 0.001), and increased presence of Charcot‐Leiden crystals (16.7% vs 0%, p < 0.002). Compared to CRSwNP, CRSαi patients demonstrated increased fibrosis (100% vs 54.9%, p < 0.001), decreased presence of subepithelial edema (44.4% vs 69.2% p < 0.043), decreased eosinophil aggregates (22.2% vs 47.3% p < 0.042), and fewer eosinophils per high‐power field (44.4% vs 73.6%, p < 0.017). Conclusion: CRSαi exhibits structured histopathology more similar to CRSsNP. In the appropriate clinical context, it may be reasonable that the medical regimen for these patients be focused on a more antineutrophilic, macrolide‐based approach. This study provides insight into the inflammatory environment of patients with CRSαi and may have implications for disease management. [ABSTRACT FROM AUTHOR]

Background: We investigated the prevalence of psychiatric referral, frequency of repeat upper gastrointestinal (UGI) contrast studies, and esophagogastroduodenoscopy (EGD) in children with ineffective esophageal motility (IEM) before the confirmation of esophageal dysmotility. Methods: A total of 19 children (nine boys, 10 girls; mean age, 13.80 ± 5.10 years) with symptoms of refractory gastroesophageal reflux (GER) who underwent high‐resolution esophageal impedance manometry (HRIM) were enrolled in this retrospective analysis. Refractory GER symptoms were defined as persistent symptoms even under acid‐suppression therapy for 8 weeks in this study. Clinical data including age, gender, time from symptom onset to diagnosis, and number of UGI contrast studies and EGD before diagnosis were obtained. HRM parameters and the prevalence of psychiatric referral were also analyzed. Results: There are 14 children (73.68%) diagnosed with IEM by HRIM, and another 5 children (26.32%) diagnosed as GER disease (GERD) by EGD. A significant proportion of IEM children were misdiagnosed with psychological problems compared with the GERD children (78.57% vs 20.00%, P = 0.04). Three IEM children (21.43%) received antipsychotic and antidepressant agents before diagnosis of IEM, and all of them discontinued these medications after diagnosis. IEM children underwent a greater number of UGI contrast studies (1.07 ± 0.92 vs 0.20 ± 0.45; P = 0.02) and EGD (2.36 ± 2.50 vs 0.60 ± 0.55; P = 0.03) before HRM than GERD children. Conclusions: Esophageal manometry for the diagnosis of IEM should be considered in children with GER symptoms refractory to acid‐suppression therapy for 8 weeks to avoid repeat UGI contrast studies, EGD, and psychological therapy. [ABSTRACT FROM AUTHOR]

Dupilumab shows improvement in validated disease specific quality of life scores compared with placebo Larger studies are needed to improve the certainty of evidence for Omalizumab and Mepolizumab Further data on longer term outcomes, cost effectiveness and those with less severe disease are needed Chronic rhinosinusitis (CRS) refers to inflammation of the nasal sinuses and mucosa, with persistence of sinus inflammation and clinical manifestations beyond 12 weeks.1 CRS affects between 6 and 12% of adults and is a cause of reduced quality of life (QoL) and high healthcare costs.2 Management consisted of topical and systemic glucocorticoids, antibiotics and often repeated sinus surgery. The review found evidence of improvement in disease-specific health-related quality of life and disease severity for patients with severe CRSwNP treated with all three classes of biologics compared with placebo. [Extracted from the article]

The article presents a case study of a one year-old who ingested water-absorbing balls (WABs), leading to a potential risk of intestinal obstruction (IO). It is reported that the medical team used Amidotrizoic Acid (Gastrografin®) to delay WAB expansion and promote evacuation. It is further reported that Esophagogastroduodenoscopy and small bowel contrast series revealed WABs in the jejunum, allowing successful evacuation without surgery.

Rhinocerebral mucormycosis is a rapidly life‐threatening disease caused by a fungal infection. Every diabetic patient with sinusitis symptoms, headache, and visual changes needs radiological approach and nasal endoscopy to rule out mucormycosis. The mortality rate is 50%‐85%, despite an early diagnosis and a correct treatment. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the fracture resistance and marginal quality of maxillary molars restored using lithium disilicate glass‐ceramic (LDG) occlusal veneers with two preparation designs. Methods: Sixteen extracted maxillary molars were assigned to two groups (n = 8). In group 1 (G1), the teeth received a preparation for a conservative full‐coverage occlusal veneer restoration with a 90° rounded shoulder margin. In group 2 (G2), the teeth underwent a 1‐mm cusp reduction with a marginal chamfer. LDG restorations (IPS e.max CAD) were obtained with the Cerec 3 CAD/CAM system and luted with Variolink II cement. After thermomechanical aging (1 250 000 cycles), the specimens were loaded to fracture. A semiquantitative marginal seal evaluation was performed observing resin replicas of the specimens at the scanning electron microscope. Cement thickness was assessed at the stereomicroscope on sectioned specimens. Collected data were statistically analyzed by parametric and nonparametric tests. Results: The maximum load to fracture was 2395.01 ± 150.96 N in G1 and 2408.39 ± 112.66 N in G2. Most of the observed specimens exhibited restorable fractures and continuous margins. Cement thickness was 132 ± 38 μm in G1 and 150 ± 41 μm in G2. No differences between the groups emerged. Conclusion: This study demonstrated similar satisfactory performance of the two considered preparations designs for occlusal veneer with LDG. Clinical Significance: A new minimally invasive occlusal veneer preparation with marginal chamfer exhibited promising fracture resistance and marginal adaptation that were comparable to those of a standard conservative preparation for the restoration of molars with CAD/CAM lithium disilicate occlusal veneers. [ABSTRACT FROM AUTHOR]

The article presents a case study of an 84-year-old man who suffered headaches induced by chronic subdural hematoma after a fall from standing. It notes the patient became progressively more dependent on narcotic therapy for headache control during his hospitalization while his neurological examination remained intact.

Urothelial carcinoma in the upper tract is rare and often discussed separately. Many established risk factors were identified for the disease, including genetic and external risk factors. Radiographic survey, endoscopic examination and urine cytology remained the most important diagnostic modalities. In localized upper tract urothelial carcinomas, radical nephroureterectomy with bladder cuff excision are the gold standard for large, high‐grade and suspected invasive tumors of the renal pelvis and proximal ureter, whereas kidney‐sparing surgeries should be considered in patients with low‐risk disease. Advances in technology have given endoscopic surgery an important role, not only in diagnosis, but also in treatment. Although platinum‐based combination chemotherapy is efficacious in advanced or metastatic disease, current established chemotherapy regimens are toxic and lack a sustained response. Immune checkpoint inhibitors have led to a new era of treatment for advanced or metastatic urothelial carcinomas. The remarkable results achieved thus far show that immunotherapy will likely be the future treatment paradigm. The combination of immune checkpoint inhibitors and other agents is another inspiring avenue to explore that could benefit even more patients. With respect to the high incidence rate and different clinical appearance of upper tract urothelial carcinomas in Taiwan, a possible correlation exists between exposure to certain external risk factors, such as arsenic in drinking water and aristolochic acid in Chinese herbal medicine. As more gene sequencing differences between upper tract urothelial carcinomas and various disease causes are detailed, this has warranted the era of individualized screening and treatment for the disease. [ABSTRACT FROM AUTHOR]

Congenital hyperinsulinism is a rare disease, but is the most frequent cause of persistent and severe hypoglycaemia in early childhood. Hypoglycaemia caused by excessive and dysregulated insulin secretion (hyperinsulinism) from disordered pancreatic β cells can often lead to irreversible brain damage with lifelong neurodisability. Although congenital hyperinsulinism has a genetic cause in a significant proportion (40%) of children, often being the result of mutations in the genes encoding the KATP channel (ABCC8 and KCNJ11), not all children have severe and persistent forms of the disease. In approximately half of those without a genetic mutation, hyperinsulinism may resolve, although timescales are unpredictable. From a histopathology perspective, congenital hyperinsulinism is broadly grouped into diffuse and focal forms, with surgical lesionectomy being the preferred choice of treatment in the latter. In contrast, in diffuse congenital hyperinsulinism, medical treatment is the best option if conservative management is safe and effective. In such cases, children receiving treatment with drugs, such as diazoxide and octreotide, should be monitored for side effects and for signs of reduction in disease severity. If hypoglycaemia is not safely managed by medical therapy, subtotal pancreatectomy may be required; however, persistent hypoglycaemia may continue after surgery and diabetes is an inevitable consequence in later life. It is important to recognize the negative cognitive impact of early‐life hypoglycaemia which affects half of all children with congenital hyperinsulinism. Treatment options should be individualized to the child/young person with congenital hyperinsulinism, with full discussion regarding efficacy, side effects, outcomes and later life impact. What's new?: Congenital hyperinsulinism is a heterogeneous disorder of hypoglycaemia with high morbidity and few therapeutic options.Investigation and treatment principles have been described in several reviews but there has been little emphasis on medium‐ to long‐term outcomes.In the present review, we describe outcomes of congenital hyperinsulinism to provide a long‐range view of the clinical impact of current therapeutic strategies. [ABSTRACT FROM AUTHOR]

Objective: Dental fluorosis has considerable implications on the patients' quality of life. The present study assesses the comparative effectiveness of the various interventions for the treatment of fluorosed enamel. Materials and Methods: Nine databases were searched from inception to December 2016 for randomized trials. After duplicate study selection, data extraction, and risk of bias assessment, mean differences (MD) or Relative Risks and the corresponding 95% confidence intervals (CIs) were calculated and assessed with the GRADE approach. Results: Six trials with a total of 348 patients (at least 40% male/60% female) with a mean age of 17.7 years treated with bleaching, microabrasion, or resin infiltration were included. Evidence of low quality indicated that microabrasion resulted in smaller esthetic improvement compared to bleaching (MD = −2.9; 95% CI = −3.4 to −2.5). Evidence of moderate quality indicated that compared to bleaching a greater esthetic improvement was seen with resin infiltration (MD = 3.6; 95% CI = 2.7‐4.6) or a combination of bleaching with resin infiltration (MD = 3.5; 2.8‐3.7). However, all comparisons were supported from single trials and therefore caution is warranted. Conclusions: Based on the existing limited evidence, resin infiltration seems to be the most promising treatment for dental fluorosis, followed by bleaching and microabrasion. Clinical Significance: For this systematic review, which was registered beforehand in PROSPERO (CRD42016053492), we synthesized evidence from existing randomized clinical trals on humans to see which treatment is most effective for the esthetic rehabilitation of dental fluorosis, the prevalence of which is seeing a worldwide steady increase. We found that resin infiltration seems to be the most effective treatment approach for lesions of mild to moderate severity, followed by bleaching, and finally microabrasion. Our study's strengths are its a priori registration, wide search, quality check according to Cochrane guidelines, and the use of a new robust analytic method to provide valid clinical recommendations according to the principles of evidence‐based medicine. [ABSTRACT FROM AUTHOR]

Spinal cord stimulation (SCS) is a minimally invasive therapy used for the treatment of chronic neuropathic pain. SCS is a safe and effective alternative to medications such as opioids, and multiple randomized controlled studies have demonstrated efficacy for difficult‐to‐treat neuropathic conditions such as failed back surgery syndrome. Conventional SCS is believed mediate pain relief via activation of dorsal column Aβ fibers, resulting in variable effects on sensory and pain thresholds, and measurable alterations in higher order cortical processing. Although potentiation of inhibition, as suggested by Wall and Melzack's gate control theory, continues to be the leading explanatory model, other segmental and supraspinal mechanisms have been described. Novel, non‐standard, stimulation waveforms such as high‐frequency and burst have been shown in some studies to be clinically superior to conventional SCS, however their mechanisms of action remain to be determined. Additional studies are needed, both mechanistic and clinical, to better understand optimal stimulation strategies for different neuropathic conditions, improve patient selection and optimize efficacy. [ABSTRACT FROM AUTHOR]

Peroral endoscopic myotomy (POEM) is a novel clinical technique developed in Japan used to treat esophageal achalasia and esophageal motility disorders. This technique has been rapidly accepted and widely disseminated throughout our clinical practice because of its low invasiveness, technical novelty, and high efficacy. Since the advent of POEM, there have been no clinical guidelines that clearly indicated its standard of care, and these guidelines have been anticipated both nationally and internationally by clinicians who engage in POEM practice. In 2017, to meet these needs, the Japan Gastroenterological Endoscopy Society (JGES) launched the guideline committee for POEM. Based on the guideline development process proposed by the Medical Information Network Distribution Service (MINDS), the guideline committee initially created research questions on POEM and conducted a systematic review and meta‐analysis on each topic. The clinical research extracted from databases for these clinical questions and the systematic review mainly comprised a few retrospective studies with a small number of participants and short trial periods; hence, the strength of the evidence and recommendations derived from these results was low. Throughout this process, the guideline committee met thrice: once on May 13, 2017, and again on September 17, 2017, to formulate the draft. A consensus meeting was then held on January 14, 2018, in Tokyo to establish the guideline statements and finalize the recommendations using the modified Delphi method. This manuscript presents clinical guidelines regarding current standards of practice and recommendations in terms of the nine chief topics in POEM. [ABSTRACT FROM AUTHOR]

Background and Aim: Esophageal stricture is a serious adverse event secondary to extensive endoscopic submucosal dissection (ESD). The present study aimed to investigate the efficacy of carboxymethyl cellulose (CMC) sheets for the prevention of esophageal stricture after full circumferential ESD in an animal model. Methods: Fourteen porcine models were randomized into a control group (n = 7) and a CMC group (n = 7). Five‐centimeter‐long circumferential esophageal ESD was carried out at a distance of 40 to 45 cm from the incisors in all models. In the CMC group, CMC sheets were placed over the mucosal defect completely after ESD, whereas the control group underwent routine ESD only. Endoscopic examination was conducted after the first and second week post‐ESD. Esophageal specimens were harvested during post‐mortem and were evaluated for macroscopic and histological appearance. Blood serum levels of four pro‐inflammatory or profibrotic cytokines were measured quantitatively. Results: The CMC group had better food tolerability during the second week post‐ESD. The CMC group showed a significantly lower esophageal mucosal stricture rate compared to the control group. Histological assessments showed less fibrosis in the submucosal layer, milder damage to the muscularis propria, and enhanced re‐epithelization in the CMC group. Serum transforming growth factor beta 1 levels were significantly lower in the CMC group post‐ESD. Conclusion: Deployment of CMC sheets on the mucosal defect appears to be a promising method for preventing esophageal strictures after extensive ESD. [ABSTRACT FROM AUTHOR]

Abstract: Aim: To investigate whether complete mesocolic excision (CME) might carry a higher risk of bowel dysfunction and subsequent reduction in quality of life compared with conventional resection. Method: A cross‐sectional questionnaire study based on data from a national survey regarding long‐term bowel function and a population‐based cohort study comparing CME (study group) with conventional resection (control group). A total of 622 patients undergoing elective resection for Stage I–III sigmoid adenocarcinoma at four university colorectal centres between June 2008 and December 2014 were eligible to receive the questionnaire in mid‐November 2015. Primary outcomes were four or more bowel movements daily, nocturnal bowel movements, unproductive call to stool, obstructive sensation and impact of bowel function on quality of life (QOL). Results: One hundred and twenty‐seven (69.0%) and 289 (66.0%) patients in the study and control groups, respectively, responded to the questionnaire after medians of 4.41 [interquartile range (IQR) 2.50, 5.83] and 4.57 (IQR 3.15, 5.82) years, respectively (P = 0.048). CME was not associated with: increased risk of four or more bowel movements daily [adjusted OR 1.14 (95% CI 0.59–2.14; P = 0.68)], nocturnal bowel movements [adjusted OR 1.31 (0.66–2.53; P = 0.43)], unproductive call to stool [adjusted OR 0.99 (0.54–1.77; P = 0.97)] or obstructive sensation [adjusted OR 1.01 (0.56–1.78; P = 0.96)]. While one in five patients in both groups had moderate to severe impact of bowel function on QOL, there was no association with CME. Conclusion: For patients with sigmoid cancer, CME is associated with neither higher risk of bowel dysfunction nor impaired QOL. [ABSTRACT FROM AUTHOR]

Abstract: Aim: Azathioprine can prevent postoperative recurrences in Crohn's disease. We compared the efficacy of azathioprine in preventing surgical recurrence to explore whether immediate prophylaxis after surgery is better than azathioprine started after endoscopic or clinical recurrence. Method: Data of patients with intestinal resection and ileocolic anastomosis for Crohn's disease between 2006 and 2015 were retrieved from a prospectively maintained database. Patients were grouped according to the strategies of postoperative therapy with azathioprine. Univariate and multivariate proportional hazard Cox regression analyses were conducted to identify independent predictive factors for surgical recurrence. Results: Only age equal to or less than 16 years at diagnosis was an independent risk factor for surgical recurrence in all 166 patients (P = 0.005). In patients with high risk of recurrence (27 in the symptom‐driven group, 39 in the endoscopy‐driven group and 69 in the immediate prophylaxis group), both immediate and endoscopy‐driven azathioprine delayed and reduced surgical recurrence compared with symptom‐driven azathioprine (P = 0.035, 0.019). Their efficacy in reducing surgical recurrence was confirmed by Cox regression analyses (hazard ratio 0.465, P = 0.045; hazard ratio 0.352, P = 0.028). Surgical recurrence was similar between the immediate and endoscopy‐driven groups. In addition, age ≤ 16 at diagnosis was still an independent risk factor for surgical recurrence in this subgroup. Conclusions: In patients with high risk of recurrence, both immediate prophylactic azathioprine after surgery and azathioprine started after endoscopic recurrence can delay and reduce surgical recurrence compared with azathioprine started after clinical recurrence. In addition, azathioprine started immediately after surgery was not superior to azathioprine started after discovery of endoscopic recurrence. [ABSTRACT FROM AUTHOR]

Abstract: Aim: The presence of tumour deposits (TDs) in colorectal cancer (CRC) is associated with poor prognosis. The seventh edition of TNM subclassified a new nodal stage, N1c, characterized by the presence of TDs without any concurrent positive lymph node (LN). It is not clear if the N1c category is or is not equal to LN metastasis. We aimed to examine the prevalence, characteristics and prognostic significance of this new subcategory. Method: Consecutive patients who underwent surgery for CRC in two centres (2011–2014) were analysed. N1 cM0 patients were matched against non‐N1 cM0 (N0, N1a and N1b) patients for 3‐year overall survival (OS) and disease‐free survival (DFS). Results: We identified 1122 patients with 648 (57.8%) colonic cancers. In 57 patients (5.1%), N1c status was associated with rectal cancers [rectum = 33/57 (57.9%) vs colon = 24/57 (42.1%); P = 0.029], a higher pathological tumour stage [pT3‐T4 N1c = 55/843 (6.5% vspT3‐T4 non‐N1c = 2/279 (0.7%); P < 0.0001] and vascular emboli [n = 35 (61.4%) vs n = 552 (51.8%); P = 0.0305]. Synchronous metastasis was observed in 23 cases (40%). After a mean follow‐up of 31 months, 3‐year OS for M0 patients, was 89.4%, 89.1%, 86.6% and 81.8% for N0, N1a, N1b and N1c tumours, respectively. DFS was significantly worse for N1c than for N0 (P = 0.0169), with N1c status having a significant effect on DFS in colonic cancers (P = 0.014). The presence of more than one TD was associated with a significantly worse DFS (P = 0.021). Conclusion: Our results indicate that N1c CRC patients should be included among high‐risk patients for whom it is widely accepted that adjuvant chemotherapy should be considered. [ABSTRACT FROM AUTHOR]

Abstract: Aim: The delivery of the Scottish Bowel Screening Programme (SBoSP) is rooted in the provision of a high quality, effective and participant‐centred service. Safe and effective colonoscopy forms an integral part of the process. Additional accreditation as part of a multi‐faceted programme for participating colonoscopists, as in England, does not exist in Scotland. This study aimed to describe the quality of colonoscopy in the SBoSP and compare this to the English national screening standards. Methods: Data were collected from the SBoSP between 2007 and 2014. End‐points for analysis were caecal intubation, cancer, polyp and adenoma detection, and complications. Overall results were compared with 2012 published English national standards for screening and outcomes from 2006 to 2009. Results: During the study period 53 332 participants attended for colonoscopy. The colonoscopy completion rate was 95.6% overall. The mean cancer detection rate was 7.1%, the polyp detection rate was 45.7% and the adenoma detection rate was 35.5%. The overall complication rate was 0.47%. Conclusion: Colonoscopy quality in the SBoSP has exceeded the standard set for screening colonoscopy in England, despite not adopting a multi‐faceted programme for screening colonoscopy. However, the overall adenoma detection rate in Scotland was 9.1% lower than that in England which has implications for colonoscopy quality and may have an impact on cancer prevention rates, a key aim of the SBoSP. [ABSTRACT FROM AUTHOR]

Abstract: Aim: Previous studies have found an increased risk for microscopic colitis (MC) associated with proton pump inhibitors. In patients with ulcerative colitis (UC) or Crohn's disease (CD), proton pump inhibitors have been associated with an increased risk for IBD flares and impaired outcomes. The aim of this study was to test the epidemiological associations between gastro‐oesophageal reflux disease (GERD) and MC, UC or CD in a large database. Method: The Miraca Life Sciences Database is a national electronic repository of histopathological records of patients distributed throughout the entire USA. A case–control study evaluated whether the presence of Barrett's metaplasia, erosive oesophagitis on endoscopy or histological signs of reflux oesophagitis, clinical diagnosis of GERD or any GERD type affected the occurrence of MC, UC or CD among 228 506 subjects undergoing bidirectional endoscopy. Multivariate logistic regression analyses were used to calculate ORs and their 95% CI for the risk of MC, UC or CD associated with various types of GERD and were adjusted for age, sex and presence of Helicobacter pylori. Results: The analysis revealed an inverse relationship between GERD and different types of inflammatory bowel disease. The inverse relationships applied similarly to MC (mean = 0.62, 95% CI: 0.58–0.66), UC (mean = 0.89, 95% CI: 0.81–0.97) and CD (mean = 0.76, 95% CI: 0.69–0.85). It also applied to different forms of GERD, with a trend towards more pronounced inverse relationships associated with Barrett's metaplasia or erosive oesophagitis than clinical diagnosis of GERD. Conclusion: Gastro‐oesophageal reflux disease is inversely associated with all forms of inflammatory bowel disease, such as MC, UC, or CD. [ABSTRACT FROM AUTHOR]

Abstract: Aim: It is still controversial whether the optimal operation for perforated diverticulitis with peritonitis is primary anastomosis (PRA) or nonrestorative resection (NRR). The aim of this systematic review and meta‐analysis was to evaluate mortality and morbidity rates following emergency resection for perforated diverticulitis with peritonitis and ostomy reversal, as well as ostomy nonreversal rates. Method: The Pubmed, EMBASE, Cochrane Library, MEDLINE via Ovid, CINAHL and Web of Science databases were systematically searched. Mortality was the primary end‐point. A subgroup meta‐analysis of randomized controlled trials was performed in addition to a meta‐analysis of all eligible studies. Odds ratios (ORs) and mean difference (MD) were calculated for dichotomous and continuous outcomes, respectively. Results: Seventeen studies, including three randomized controlled trials (RCTs), involving 1016 patients (392 PRA vs 624 NRR) were included. Overall, mortality was significantly lower in patients with PRA compared with patients with NRR [OR (95% CI) = 0.38 (0.24, 0.60), P < 0.0001]. Organ/space surgical site infection (SSI) [OR (95% CI) = 0.25 (0.10, 0.63), P = 0.003], reoperation [OR (95% CI) = 0.48 (0.25, 0.91), P = 0.02] and ostomy nonreversal rates [OR (95% CI) = 0.27 (0.09, 0.84), P = 0.02] were significantly decreased in PRA. In the RCTs, the mortality rate did not differ [OR (95% CI) = 0.46 (0.15, 1.38), P = 0.17]. The mean operating time for PRA was significantly longer than for NRR [MD (95% CI) = 19.96 (7.40, 32.52), P = 0.002]. Organ/space SSI [OR (95% CI) = 0.28 (0.09, 0.82), P = 0.02] was lower after PRA. Ostomy nonreversal rates were lower after PRA. The difference was not statistically significant [OR (95% CI) = 0.26 (0.06, 1.11), P = 0.07]. However, it was clinically significant [number needed to treat/harm (95% CI) = 5 (3.1, 8.9)]. Conclusion: This meta‐analysis found that organ/space SSI rates as well as ostomy nonreversal rates were decreased in PRA at the cost of prolonging the operating time. [ABSTRACT FROM AUTHOR]

Abstract: Aim: A longstanding disparity exists between the approaches to restorative surgery after colectomy for patients with ulcerative colitis (UC) in England and Sweden. This study aims to compare rates of colectomy and restorative surgery in comparable national cohorts. Method: The English Hospital Episode Statistics (HES) and Swedish National Patient Register (NPR) were interrogated between 2002 and April 2012. Patients with two diagnostic episodes for UC (age ≥ 15 years) were included. Patients were excluded if they had an episode of inflammatory bowel disease or colectomy before 2002. The cumulative incidences of colectomy and restorative surgery were calculated using the Kaplan–Meier method. Results: A total of 98 691 patients were included in the study, 76 129 in England and 22 562 in Sweden. The 5‐year cumulative incidence of all restorative surgery after colectomy in England was 33% vs 46% in Sweden (P‐value < 0.001). Of the patients undergoing restorative surgery, 92.3% of English patients had a pouch vs 38.8% in Sweden and 7.7% vs 59.1% respectively had an ileorectal anastomosis (IRA). The 5‐year cumulative incidence of colectomy in this study cohort was 13% in England and 6% in Sweden (P‐value < 0.001). Conclusion: Following colectomy for UC only one‐third of English patients and half of Swedish patients underwent restorative surgery. In England nearly all these patients underwent pouches, in Sweden a less significant majority underwent IRAs. It is surprising to demonstrate this discrepancy in a comparable cohort of patients from similar healthcare systems. The causes and consequences of this international variation in management are not fully understood and require further investigation. [ABSTRACT FROM AUTHOR]

This case was about a 71‐year‐old man presented to our clinic for an anterior mediastinal mass found on routine chest computed tomography (CT). CT scan showed a lobulating contoured mass in the anterior mediastinum. A preliminary diagnosis was thymoma. The patient underwent subxiphoid uniportal video‐assisted thoracoscopic surgery for the extended thymectomy and complete excision of the tumour. The pathological examination showed a micronodular thymoma with lymphoid stroma (MTWLS). In conclusion, this report described an extremely rare tumour, MTWLS, and MTWLS might be considered in the differential diagnosis of mediastinal tumour, especially thymoma. [ABSTRACT FROM AUTHOR]

Summary: Background: Pre‐operative tissue diagnosis for suspected malignant biliary strictures remains challenging. Aim: To develop evidence‐based consensus statements on endoscopic tissue acquisition for biliary strictures. Methods: The initial draft of statements was prepared following a systematic literature review. A committee of 20 experts from Asia‐Pacific region then reviewed, discussed, and modified the statements. Two rounds of independent voting were conducted to reach a final version. Consensus was considered to be achieved when 80% or more of voting members voted “agree completely” or “agree with some reservation.” Results: Eleven statements achieved consensus. The choice of tissue sampling modalities for biliary strictures depends on the clinical setting, the location of lesion, and availability of expertise. Detailed radiological and endoscopic evaluation is useful to guide the selection of appropriate tissue acquisition technique. Standard intraductal biliary brushing and/or forceps biopsy is the first option when endoscopic biliary drainage is required with an overall (range) sensitivity and specificity of 45% (26%‐72%) and 99% (98%‐100%), and 48% (15%‐100%) and 99% (97%‐100%), respectively, in diagnosing malignant biliary strictures. Probe‐based confocal laser endomicroscopy and fluorescence in situ hybridisation using 4 fluorescent‐labelled probes targeting chromosomes 3, 7, 17 and 9p21 locus may be added to improve the diagnostic yield. Cholangioscopy‐guided biopsy and EUS‐guided tissue acquisition can be considered after prior negative conventional tissue sampling with an overall (range) sensitivity and specificity of 60% (38%‐88%) and 98% (83%‐100%), and 80% (46%‐100%) and 97% (92%‐100%), respectively, in diagnosing malignant biliary strictures. Conclusion: These consensus statements provide evidence‐based recommendations for endoscopic tissue acquisition of biliary strictures. [ABSTRACT FROM AUTHOR]

Zenker's diverticulum (ZD), or pharyngeal pouch, is an anatomical defect characterized by herniation of the posterior pharyngeal wall through Killian's dehiscence, and may result in dysphagia and regurgitation. Multiple therapeutic modalities including surgery, rigid and flexible endoscopy have been developed to manage ZD. Although surgical management with open and endoscopically assisted techniques have historically been the mainstay of ZD treatment, minimally invasive flexible endoscopic techniques, carried out under conscious sedation, are increasingly favored. Over the last two decades, the advent of new accessories and techniques have changed the landscape of endotherapy for ZD, with the current armamentarium including, but not limited to, endoscopic stapling, CO2 laser, argon plasma coagulation, needle knife, bipolar forceps, hook knife, clutch cutter, stag beetle knife, and submucosal tunneling endoscopic septum division. We hereby review the latest evidence to support the endoscopic management of ZD. [ABSTRACT FROM AUTHOR]

Abstract: Aim: Transanal transabdominal proctosigmoidectomy (TATA) with a coloanal anastomosis is an alternative to abdominoperineal excision of the rectum (APR) for low rectal cancer. Neorectal prolapse is an unusual complication following TATA. This study aimed to determine the incidence of neorectal prolapse after TATA for low rectal cancer. Method: This cohort study was conducted in a tertiary referral colorectal centre. From a prospectively maintained database including 1093 patients treated for rectal cancer between 1984 and 2016 we identified those who underwent sphincter‐preserving surgery. Data regarding the incidence, management and outcomes of neorectal prolapse were analysed. Results: A total of 409 patients were identified, of whom 185 underwent open surgery and 224 a minimally invasive surgical procedure (MIS). All received neoadjuvant chemoradiation. Neorectal prolapse occurred in 4.6% (n = 19) with an incidence of 2.2% in the open and 6.7% in the MIS group (P = 0.023), with no difference between MIS techniques. There was one recurrence of neorectal prolapse (5.9%). The incidence of neorectal prolapse was higher in women (9.5%) than men (2.5%) (P = 0.011). There were no differences in local recurrence rates between the neorectal prolapse group (5.3%) and our population without prolapse (3.4%) (P = 0.79). Conclusion: Neorectal prolapse is a rare occurrence following minimally invasive sphincter‐saving surgical procedures performed for rectal cancer. It appears to be more frequent in patients who undergo MIS procedures and in women. [ABSTRACT FROM AUTHOR]

Abstract: Aim: The goal of this study was to evaluate if dental pulp stem cells (DPSCs) delivered into intrabony defects in a collagen scaffold would enhance the clinical and radiographic parameters of periodontal regeneration. Materials and Methods: In this randomized controlled trial, 29 chronic periodontitis patients presenting one deep intrabony defect and requiring extraction of one vital tooth were consecutively enrolled. Defects were randomly assigned to test or control treatments which both consisted of the use of minimally invasive surgical technique. The dental pulp of the extracted tooth was mechanically dissociated to obtain micrografts rich in autologous DPSCs. Test sites (n = 15) were filled with micrografts seeded onto collagen sponge, whereas control sites (n = 14) with collagen sponge alone. Clinical and radiographic parameters were recorded at baseline, 6 and 12 months postoperatively. Results: Test sites exhibited significantly more probing depth (PD) reduction (4.9 mm versus 3.4 mm), clinical attachment level (CAL) gain (4.5 versus 2.9 mm) and bone defect fill (3.9 versus 1.6 mm) than controls. Moreover, residual PD < 5 mm (93% versus 50%) and CAL gain ≥4 mm (73% versus 29%) were significantly more frequent in the test group. Conclusions: Application of DPSCs significantly improved clinical parameters of periodontal regeneration 1 year after treatment. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Esophageal injury is a major concern during catheter ablation of atrial fibrillation. Operators avoid radiofrequency applications on the esophagus by changing ablation line; however, it is unavoidable in patients with a dilated esophagus, such as esophageal achalasia. Steerable esophageal thermometer is useful for evaluating precise temperatures to prevent esophageal injury. [ABSTRACT FROM AUTHOR]

Abstract: Background and Aim: Although propofol has been widely used for sedation during esophagogastroduodenoscopy (EGD), adverse events including hypoxia and hypotension may be a concern in the propofol‐based sedation. We aimed to analyze whether administration of midazolam would improve safety and efficacy of propofol‐based sedation in EGD. Methods: One hundred twenty patients who were scheduled to undergo diagnostic EGD were randomly assigned to either midazolam plus propofol (MP) or propofol alone groups. In the MP group, 2 mg of midazolam and 10 mg of propofol were given initially. In the propofol alone group, 40–60 mg of propofol was given initially. In both groups, 20 mg of propofol was given repeatedly to maintain moderate sedation as needed. Vital signs including oxygen saturation were monitored every 2 min. After the patients fully recovered, satisfaction score was investigated from endoscopists, nurses, and patients, respectively. Results: The baseline characteristics did not differ between the MP and propofol alone groups. The mean required doses of propofol was (mean ± standard deviation) 0.3 ± 0.3 and 0.8 ± 0.2 mg/kg in the MP and propofol alone groups, respectively (P < 0.001). In addition, sedation‐related adverse events and recovery time did not differ between the two groups. The proportion of satisfactory did not differ between the two groups (MP vs propofol alone; proportion; patient, 95.0% vs 93.3%, P > 0.999; endoscopist, 73.3% vs 80.0%, P = 0.064; nurse, 73.3% vs 76.7%, P = 0.551). Conclusion: Adding midazolam to propofol did not reduced the safety and efficacy, and sedation using propofol alone could be suitable for sedation during diagnostic EGD. [ABSTRACT FROM AUTHOR]

Background: There is a paucity of data supporting antibiotic use in endoscopic sinus surgery (ESS). The objective of this study is to determine perioperative antibiotic use patterns and factors which influence use in ESS. Methods: An online‐based survey was distributed to members of the American Rhinologic Society (ARS). Outcomes included timing of perioperative antibiotic use, practice environment, years of experience, and patient factors that influenced antibiotic use. Results: There were 204 responses (response rate 18.3%); 36.8% of respondents were in academic positions, 32.8% were in private practice, and 30.4% were in academic‐affiliated private practice; 20.6% routinely gave preoperative antibiotics, most commonly to reduce bacterial burden (59.5%) and mucosal inflammation (59.5%); 54.4% routinely gave intraoperative antibiotics, most commonly to reduce the risk of postoperative infection (63.1%); 62.3% routinely gave postoperative antibiotics, citing the need to reduce the risk of postoperative infection (75.6%). Diagnosis influenced postoperative antibiotic use in 63.0%. Preoperative antibiotics were more likely to be prescribed by respondents with more than 5 years of experience (odds ratio [OR] 2.97; 95% confidence interval [CI], 1.04 to 8.54; p = 0.043). Compared to private practitioners, academicians were more likely to give intraoperative antibiotics (OR 2.68; 95% CI, 1.39 to 5.17; p = 0.003), but not preoperative or postoperative antibiotics. Use of nonabsorbable packing was significantly associated with use of postoperative antibiotics (OR 2.01; 95% CI, 1.07 to 3.77; p = 0.031). Conclusion: This study demonstrates the significant variation in perioperative antibiotic use among otolaryngologists. These results provide support for the establishment of evidence‐based practice guidelines for perioperative antibiotic use in ESS. [ABSTRACT FROM AUTHOR]

Background: Multiple cultures are commonly obtained from different sinuses where purulence is encountered during endoscopic sinus surgery (ESS). This brings into question the utility and necessity of obtaining multiple cultures. The purpose of this study was to evaluate if multiple cultures obtained during a single case is informative in finding additional pathogens or if it is a redundant, cost‐increasing practice. We hypothesized that multiple sinus cultures are necessary to identify the pathogens responsible for an individual's sinus disease. We seek to add information on the utility of performing multiple sinus cultures from a patient care and a health economics standpoint. Methods: This study was a retrospective review of a single rhinologist's surgical database from 2008 to 2016. Patients that underwent ESS for chronic rhinosinusitis (CRS) and had multiple cultures obtained during surgery were included. Culture difference was recorded as a discrepancy of an infectious pathogen between cultures. Results: We identified 231 patients with multiple sinus cultures. Of those, 39.4% had a difference of pathogens noted on culture between different sinuses. Only 5% of the cohort received clinically relevant benefit from the second culture obtained in regard to a change in antibiotics. Conclusion: In this retrospective review we showed that, for the practitioner who obtains sinus cultures intraoperatively, limiting this practice to a single culture rather than multiple is cost‐effective and sufficient for identifying the pathogen to be treated. This study, and the resultant change in practice, has the potential to reduce healthcare costs associated with the surgical care of the patient with CRS. [ABSTRACT FROM AUTHOR]

Objective: To review management options for nontubal ectopic pregnancies.Design: Retrospective cohort study.Setting: Tertiary hospital in Melbourne, Australia.Population: A total of 100 nontubal pregnancies: 1 abdominal, 32 caesarean scar, 14 cervical, 41 cornual-interstitial, 12 ovarian.Methods: Cases were classified according to ectopic site. Management categories were medical, surgical, combination or expectant. Use of minimally invasive approaches (ultrasound-guided intra-sac injections or selective surgical techniques) was identified. Primary management was considered to be successful if no further unplanned interventions were required.Main Outcome Measures: Success of primary management and frequency of unplanned interventions.Results: A high rate of success (82%) was demonstrated for all management regimens, with minimal morbidity and no deaths occurring. A high success rate was shown when the primary management regimen was systemic methotrexate or ultrasound-guided intra-sac injection (88%). The success rate for primary surgical management was 57%. High success rates were reported for both primary management with ultrasound-guided injections or in combination with systemic methotrexate (94%) and for primary management with systemic methotrexate alone (81%). Seventy-five per cent of women managed with minimally invasive surgical approaches avoided the need for more extensive surgery, but required longer follow up and additional interventions.Conclusion: Minimally invasive approaches were found to be safe and effective treatment for women desiring to conserve fertility. Ultrasound-guided intra-sac injection and laparoscopic ectopic removal procedures aimed at preserving reproductive organs should be included as minimally invasive primary management tools in addition to the well-recognised option of systemic methotrexate.Tweetable Abstract: Nontubal ectopics: minimally invasive procedures a safe alternative to surgery in selected cases. [ABSTRACT FROM AUTHOR]

Abstract: Background and Aim: Same‐day bidirectional endoscopy (BDE) is a commonly performed procedure, but the optimal sequence for the procedure with moderate conscious sedation is not well established. This study investigated the optimal sequence for same‐day BDE under moderate conscious sedation and carbon dioxide insufflation in terms of sedation doses, patient discomfort, and colonoscopy performance. Methods: A prospective randomized controlled study of 120 patients who were scheduled for BDE examination was performed. Colonoscopy followed by esophagogastroduodenoscopy (EGD) examination was performed in 60 patients (colonoscopy‐EGD group), and EGD followed by colonoscopy examination was performed in another 60 patients (EGD‐colonoscopy group). Endoscopists and patients completed a questionnaire to assess objective and subjective discomfort. Results: Baseline demographics, procedure indications, bowel preparation quality, cecal intubation rate/time, colonoscopy withdrawal time, endoscopic interventions, BDE procedure time, colon polyp/adenoma detection rates, patient discomfort, and adverse events were similar between the two study groups. The total doses of fentanyl and midazolam were significantly higher for the colonoscopy‐EGD group than for the EGD‐colonoscopy group (83.4 ± 17.7 vs 68.7 ± 18.6 μg and 6.3 ± 1.4 vs 5.2 ± 1.3 mg, P < 0.0001 and P < 0.0001, respectively). The recovery time to discharge was significantly longer for the colonoscopy‐EGD group than for the EGD‐colonoscopy group (43.5 ± 16.2 vs 34.5 ± 8.9 min, P = 0.0003). Conclusions: Esophagogastroduodenoscopy followed by colonoscopy is the optimal sequence for same‐day BDE under moderate conscious sedation and carbon dioxide insufflation. Following this order allows for a reduction of sedation doses and for shorter recovery times. [ABSTRACT FROM AUTHOR]

Abstract: Herein, we described a novel method as the use of AcuBlade robotic microsurgery system to manage idiopathic subglottic stenosis in a 73‐y‐old lady. Compared to traditional CO2 lasers, AcuBlade facilitated the scar resection by the generation of different shape of beams (straight, curved, or disk). The same setting used for phonomicrosurgery (1‐mm beam length, power of 10 W and pulse duration of 0.05‐s) allowed to obtain fast, long, and uniform cuts. In addition, the reduction of the number of laser passes over the same area prevented injury of adjacent tissue and thus reduced the risk of recurrence. [ABSTRACT FROM AUTHOR]

A 61-year-old woman received a diagnosis of undifferentiated non-erosive arthritis in 2010 and assumed methotrexate and steroids in 2014. After 1 year, she experienced watery diarrhea, vomiting, fever, weight loss, and severe hypoalbuminemia, thus being admitted into our Unit. Esophagogastroduodenoscopy showed duodenal lymphangiectasia and duodenal biopsy samples several foamy PAS-positive macrophages and villous subtotal atrophy. Transmission electron microscope demonstrated several extracellular and intracellular rod-shaped bacteria ( Tropheryma whipplei). Therefore, we diagnosed Whipple's disease. Our patient assumed doxycycline/hydroxychloroquine with prompt remission of gastrointestinal symptoms. At 1 year of follow-up, she was symptom-free, histological reassessment showed almost complete mucosal healing and transmission electron microscope demonstrated bacteria breaking/disappearance. The present report demonstrates that: (i) rheumatological manifestations are common onset symptoms of Whipple's disease; (ii) immunosuppressive therapy may delay the diagnosis and worsen clinical presentation; (iii) transmission electron microscopy for specific bacteria detection/disappearance is an helpful diagnostic tool, when available. [ABSTRACT FROM AUTHOR]

Background Treatment for achalasia has traditionally been Heller myotomy (HM). Despite its excellent efficacy rate, a number of patients remain symptomatic post-procedure. Limited data exist as to the best management for recurrence of symptoms post-HM. We present an international, multicenter experience evaluating the efficacy and safety of post-HM peroral endoscopic myotomy (POEM). Methods Patients who underwent POEM post-HM from 13 centers from January 2012 to January 2017 were included as part of a prospective registry. Technical success was defined as successful completion of the myotomy. Clinical success was defined as an Eckardt score of ≤3 on 12-month follow up. Adverse events (AE) including anesthesia-related, operative, and postoperative complications were recorded. Results Fifty-one patients were included in the study (mean age 54.2, 47% male). Technical success was achieved in 100% of patients. Clinical success on long-term follow up was achieved in 48 patients (94%), with a mean change in Eckardt score of 6.25. Seven patients (13%) had AE: six experienced periprocedural mucosal defect treated endoscopically and two patients developed mediastinitis treated conservatively. Conclusion For patients with persistent symptoms after HM, POEM is a safe salvation technique with good short-term efficacy. As a result of the challenge associated with repeat HM, POEM might become the preferred technique in this patient population. Further studies with longer follow up are needed. [ABSTRACT FROM AUTHOR]