Citations

Abstract Introduction The transbasal approach traditionally uses a bicoronal scalp incision with bifrontal craniotomy to establish an extradural midline skull base working corridor. Depending on additional craniofacial osteotomies, this approach can expand its reach to the nasal cavity and paranasal sinuses and may be employed for the resection of particularly complex sinonasal and midline skull base tumors. Given its discrepancy in nomenclature and differences in interoperator technique, we propose a practical, operatively oriented guide for trainees performing this approach. Methods Three formalin-fixed, latex-injected specimens were dissected under microscopic magnification and endoscopic-assisted visualization. Stepwise dissections of the transcranial-transbasal approach with common modifications were performed, documented with three-dimensional photography, and supplemented with representative case applications. Results The traditional transbasal approach via bifrontal craniotomy affords wide extradural access to the anterior cranial fossa and central skull base. The addition of craniofacial osteotomies further expands access into the sinonasal cavities, clivus, and craniocervical junction. Key steps described include patient positioning, bicoronal skin incision, pericranial graft harvest, bifrontal craniotomy, orbital rim osteotomy, sphenoidotomy, bilateral ethmoidectomies, and microsurgical dissection of the sellar region. Basal superior sagittal sinus ligation and durotomy allow for intradural exposure. Reconstruction techniques are also discussed. Conclusion While the transbasal approach is rich with historical descriptions, illustrations, and modifications, its stepwise performance may be relatively unknown and unclear to younger generations of trainees. We present a comprehensive guide to optimize familiarity with the transbasal approach and its indications in the surgical anatomy laboratory, mastery of the relevant microsurgical anatomy, and simultaneous preparation for learning and participation in the operating room.

Abstract Background and study aims Adequacy of endoscope disinfection in resource-limited settings is unknown. Adenosine triphosphate (ATP) testing is useful for evaluation of endoscope reprocessing, and ATP <200 relative light units (RLUs) after manual endoscope cleaning has been associated with adequacy of endoscope disinfection. Methods Consecutive endoscopes undergoing reprocessing at five World Gastroenterology Organisation (WGO) training centers underwent ATP testing before and after an on-site educational intervention designed to optimize reprocessing practices. Results A total of 343 reprocessing cycles of 65 endoscopes were studied. Mean endoscope age was 5.3 years (range 1–13 years). Educational interventions, based on direct observation of endoscope reprocessing practices at each site, included refinements in pre-cleaning, manual cleaning, high-level disinfection, and endoscope drying and storage. The percentage of reprocessing cycles with post-manual cleaning ATP ≧200 decreased from 21.4% prior to educational intervention to 14.8% post-intervention (P=0.11). In multivariable logistic modelling, gastroscopes were significantly less likely (odds ratio [OR] 0.04, 95% confidence interval [CI] 0.01–0.19; P<0.001) than colonoscopes to achieve post-manual cleaning ATP < 200. No other factor (educational intervention, study site, endoscope age) was significantly associated with improved outcomes. Endoscope ID was not significantly associated with ATP values, and sites that performed manual versus automated HLD did not have significantly different likelihood of post-manual cleaning ATP <200 (OR 1.18, 95% CI 0.56–2.50; P=0.67). Conclusions In resource-limited settings, approximately 20% of endoscope reprocessing cycles may result in inadequate disinfection. This was not significantly improved by a comprehensive educational intervention. Alternative approaches to endoscope reprocessing are needed.

Abstract Background Published data on the risk of venous thromboembolism (VTE) with coronavirus disease 2019 (COVID-19) vaccines are scarce and inconclusive, leading to an unmet need for further studies. Methods A retrospective, multicentered study of adult patients vaccinated for one of the three approved COVID-19 vaccines in the United States of America and a pre-COVID-19 cohort of patients vaccinated for influenza at two institutions: Mayo Clinic Enterprise sites and the Medical College of Wisconsin, looking at rate of VTE over 90 days. VTE was identified by applying validated natural language processing algorithms to relevant imaging studies. Kaplan–Meier curves were used to evaluate rate of VTE and Cox proportional hazard models for incident VTE after vaccinations. Sensitivity analyses were performed for age, sex, outpatient versus inpatient status, and type of COVID-19 vaccine. Results A total of 911,381 study subjects received COVID-19 vaccine (mean age: 56.8 [standard deviation, SD: 18.3] years, 55.3% females) and 442,612 received influenza vaccine (mean age: 56.5 [SD: 18.3] years, 58.7% females). VTE occurred within 90 days in 1,498 (0.11%) of the total 1,353,993 vaccinations: 882 (0.10%) in the COVID-19 and 616 (0.14%) in the influenza vaccination cohort. After adjusting for confounding variables, there was no difference in VTE event rate after COVID-19 vaccination compared with influenza vaccination (adjusted hazard ratio: 0.95 [95% confidence interval: 0.85–1.05]). No significant difference in VTE rates was observed between the two cohorts on sensitivity analyses. Conclusion In this large cohort of COVID-19-vaccinated patients, risk of VTE at 90 days was low and no different than a pre-COVID-19 cohort of influenza-vaccinated patients.

Abstract Introduction The development of endoscopic techniques has made endoscopic endonasal approaches (EEAs) to the anterior cranial fossa (ACF) increasingly popular. Still, the steps and nuances involved in the approach may be difficult to understand for trainees. Thus, we aim to didactically describe the EEAs to the ACF in an anatomically based, step-by-step manner with supplementary clinical cases. Methods Six cadaveric head specimens were dissected. Endoscopic endonasal Draf I, IIA, IIB, and III frontal sinusotomies, endoscopic endonasal superior ethmoidectomy, and endoscopic endonasal transcribriform and transplanum approaches were modularly performed. The specimens were photodocumented with endoscopic techniques. Results Draf I frontal sinusotomy started with the complete removal of the anteromedial portion of the agger nasi cell, exposing the medial orbital wall, cranial base, and anterior cribriform plate. Draf II frontal sinusotomy proceeded with the removal of the floor of the frontal sinus between the lamina papyracea and the middle turbinate (IIa), and the nasal septum (IIb) until the first olfactory filaments were exposed. Draf III proceeded by creating a superior septal window just below the floor of the frontal sinus. The bone of the ACF bounded by the limbus sphenoidale posteriorly, frontal sinus anteriorly, and the medial orbital walls bilaterally was removed; the cribriform plate was removed; and the crista galli was dissected free from the dural leaflets of the falx cerebri and removed. Conclusion We provide a step-by-step dissection describing basic surgical steps and anatomy of the EEAs to the ACF to facilitate the learning process for skull base surgery trainees.

Abstract Introduction The American Association of Neurological Surgeons (AANS), North American Skull Base Society (NASBS), American Rhinologic Society (ARS), and American Neurotology Society (ANS) fellowship directories are important information repositories for skull base surgical fellowship programs. However, there is limited research on the amount and depth of information available through these resources. The objective of the present study is to assess Web site accessibility and information availability for individual fellowship programs listed within the AANS, NASBS, ARS, and ANS fellowship directories. Methods Lists of all accredited skull base surgical programs were obtained from the AANS and NASBS fellowship directories. Duplications in listed programs were removed, and systematic queries via an online search engine were conducted to identify fellowship Web sites. From each available Web site, information pertaining to 24 different variables was collected and organized into two categories—recruitment and education. Differences in the availability of information on recruitment and education were then compared across Web sites and contextualized relative to other surgical specialties. Results After excluding duplicates, 113 fellowship programs were identified, of which 99 (87.6%) had accessible Web sites. Of the 48 listed by the NASBS, direct Web site links were available for 33 (68.8%), email contacts were accessible for 32 (66.7%), and phone numbers were listed for 6 (12.5%). Of the 39 programs listed by the AANS, none included Web site links, 38 (97.4%) provided an email contact, and 39 (100%) listed a departmental contact telephone number. All 28 (100%) programs listed by the ANS provided a phone and email contact in addition to a Web site link to each institutional Web site. Of the 33 programs listed by the ARS, 29 (88%) had a departmental contact telephone number, 31 (94%) had an email contact available, and 4 (12%) had a program Web site link directly available from the database Web site. Of the 99 total programs, fellowship Web sites displayed an average of 5.46 (42.0%) of the 13 recruitment features and 4.80 (42.6%) of the 11 education features. Programs in the geographic Northeast were significantly less likely to present information pertaining to recruitment (p = 0.023). Furthermore, programs in geographic Northeast and West were significantly less likely to present information focused on surgical training and/or education (p = 0.006). Conclusion Although many skull base fellowship programs have maintained comprehensive program Web sites, certain critical aspects remain deficient, and some programs provide little to no information. Providing more detailed information about programs can prove mutually beneficial for fellowship program directors and candidates.

Introduction Hospitalizations, proton-pump inhibitors (PPI), and systemic antibiotics increase the risk of Clostridioides difficile infection (CDI) in cirrhosis. We compare the risk of CDI with hepatic encephalopathy (HE) medications, hypothesizing that rifaximin may decrease CDI risk. Materials and Methods A retrospective study of hospitalized HE patients treated with lactulose and/or rifaximin at Mayo Clinic Minnesota, Florida, and Arizona from 2008 to 2013 was conducted. Data on demographics, hospitalizations, antibiotics, and PPI use and CDI were gathered. Univariate and multivariable cox models were constructed. Results We found 1,112 hospitalizations in 1,055 unique patients (55 had 1 subsequent readmission, 1 patient had 2); 428 (40.6%) patients were women (median age: 58 years [interquartile range: 52–65]). CDI developed after 66/1,112 (5.9%) hospitalizations within 12 months post-discharge. Lactulose was administered in 21 (31.8%), rifaximin in 5 (7.6%), both in 40 (60.6%) hospitalizations. Systemic antibiotics were used in 28 (42.4%) patients and PPIs in 60 (90.9%) patients.Univariate analysis using medication (with lactulose alone as the reference group) showed rifaximin was not significantly associated with CDI compared with lactulose (hazard ratio [HR]: 1.57, 95% confidence interval [CI]: 0.57–4.33, p = 0.39). Use of both medications was not significant compared with lactulose (HR: 1.41, 95% CI: 0.84–2.38, p = 0.19). Results were similar after controlling for confounders. Multivariable analysis based on length of stay, age, and gender showed no differences between rifaximin versus lactulose and both versus lactulose. Conclusion There is no significant difference between lactulose and rifaximin on CDI development in HE patients. However, CDI should still be considered when managing diarrhea in HE patients.

Background Clostridioides difficile infection (CDI) is associated with frequent recurrences. The role of probiotics in preventing CDI remains unclear despite patients frequently using them. Methods We performed a systematic-review and meta-analysis to evaluate the role of Saccharomyces boulardii, a yeast probiotic, in preventing primary or recurrent CDI in patients on systemic antimicrobial therapy. We searched MEDLINE, Embase, and Web of Science up to December 2021 to identify studies (case-control, cohort, or clinical trial studies) reporting the use of systemic antimicrobials with or without S. boulardii and providing information on primary or recurrent CDI. Pooled odds ratios with 95% confidence intervals were calculated using a random effects model. Results Eight studies (six randomized control trials and two cohort studies) were included. Six studies with 9,712 patients evaluated primary prevention. The rate of CDI in patients who received S. boulardii was 0.73% (44/5977) compared to 1.09% (41/3735) in the control group. Meta-analysis showed no difference in the risk of CDI among the two groups (odds ratio [OR], 0.71; 95%CI, 0.46–1.10; p = 0.124) with no significant heterogeneity (I2 = 0%). In two studies with 292 patients evaluating secondary prevention, the rate of recurrent CDI was 36.73% (54/147) on S. boulardii compared to 46.20% (67/145) in controls, with no significant difference (p = 0.19). Subgroup analysis of studies using S. boulardii (250 mg twice daily) showed no difference in the CDI risk with or without S. boulardii. No serious adverse events from S. boulardii were noted. Conclusion The use of S. boulardii appears to have no benefit for preventing either primary or recurrent CDI in patients taking systemic antimicrobials.