Comment on: Insurance coverage decisions for pediatric proton therapy

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Evaluation of a fever-management algorithm in a pediatric cancer center in a low-resource setting

Abstract

Background

In low- and middle-income countries (LMICs), inconsistent or delayed management of fever contributes to poor outcomes among pediatric patients with cancer. We hypothesized that standardizing practice with a clinical algorithm adapted to local resources would improve outcomes. Therefore, we developed a resource-specific algorithm for fever management in Davao City, Philippines. The primary objective of this study was to evaluate adherence to the algorithm.

Procedure

This was a prospective cohort study of algorithm adherence to assess the types of deviation, reasons for deviation, and pathogens isolated. All pediatric oncology patients who were admitted with fever (defined as an axillary temperature  >37.7°C on one occasion or ≥37.4°C on two occasions 1 hr apart) or who developed fever within 48 hr of admission were included. Univariate and multiple linear regression analyses were used to determine the relation between clinical predictors and length of hospitalization.

Results

During the study, 93 patients had 141 qualifying febrile episodes. Even though the algorithm was designed locally, deviations occurred in 70 (50%) of 141 febrile episodes on day 0, reflecting implementation barriers at the patient, provider, and institutional levels. There were 259 deviations during the first 7 days of admission in 92 (65%) of 141 patient episodes. Failure to identify high-risk patients, missed antimicrobial doses, and pathogen isolation were associated with prolonged hospitalization.

Conclusions

Monitoring algorithm adherence helps in assessing the quality of pediatric oncology care in LMICs and identifying opportunities for improvement. Measures that decrease high-frequency/high-impact algorithm deviations may shorten hospitalizations and improve healthcare use in LMICs.

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Pathology and genomics of pediatric melanoma: A critical reexamination and new insights

Abstract

The clinicopathologic features of pediatric melanoma are distinct from those of the adult counterpart. For example, most childhood melanomas exhibit a uniquely favorable biologic behavior, save for those arising in large/giant congenital nevi. Recent studies suggest that the characteristically favorable biologic behavior of childhood melanoma may be related to extreme telomere shortening and dysfunction in the cancer cells. Herein, we review the genomic profiles that have been defined for the different subtypes of pediatric melanoma and particularly emphasize the potential prognostic value of telomerase reverse transcriptase alterations for these tumors.

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Addition of oral iron to plasma transfusion in human congenital hypotransferrinemia: A 10-year observational follow-up with the effects on hematological parameters and growth

Abstract

Congenital hypotransferrinemia (OMIM 209300) is an extremely rare disorder of inherited iron metabolism. Since its description in 1961, only 16 cases have been reported. The defective gene and molecular defect causing this disorder and clinicolaboratory findings seen in the homozygous and heterozygous states have been documented in both humans and mice. However, due to the lack of follow-up studies of the described cases, the long-term prognosis remains unknown. We present a 10-year observational follow-up of a patient previously diagnosed on a molecular basis who was treated with a unique therapy of plasma transfusion fortified with oral iron, with satisfactory clinicolaboratory responses.

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Posttransplantation relapse of pediatric chronic myelomonocytic leukemia cured using donor lymphocyte infusion

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Ovarioleukodystrophy in Chinese Han: A case report

Publication date: November 2017
Source:Clinical Neurology and Neurosurgery, Volume 162
Author(s): Dao Pei Zhang, Qian Kun Ma, Shu Ling Zhang, Jian Zhang Li




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Editorial Board

Publication date: October 2017
Source:Clinical Neurology and Neurosurgery, Volume 161





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Endocrine Mucin-Producing Sweat Gland Carcinoma of the Eyelid Associated With Mucinous Adenocarcinoma.

Endocrine mucin-producing sweat gland carcinoma, a rare, low-grade neoplasm with predilection for the eyelids, has been posited as a precursor to invasive mucinous adenocarcinoma. Endocrine mucin-producing sweat gland carcinoma and its concurrence with mucinous adenocarcinoma have received little attention in the ophthalmic literature. The combination of the 2 histologic patterns parallels endocrine ductal carcinoma in situ of the breast and its transition to Type B invasive mucinous carcinoma. The authors describe a 59-year-old man who developed a tumor of the right upper eyelid showing endocrine mucin-producing sweat gland carcinoma in the outer dermis and extensive mucinous carcinoma in the deeper tissue. Immunohistochemical analysis showed positivity for endocrine markers chromogranin, synaptophysin, CD56, estrogen, and progesterone in each histologic component of the tumor. This research was conducted in conformity with the Helsinki Declaration and HIPPA regulations. (C) 2017 by The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc., All rights reserved.

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Epidemiology of Youth Boys' and Girls' Lacrosse Injuries in the 2015-2016 Seasons.

Purpose: Examinations of injury among younger populations of lacrosse players that are beginning their development is limited. This study describes the epidemiology of youth boys' and girls' lacrosse injuries during the 2015-2016 seasons. Methods: Surveillance data originated from a convenience sample of 10 leagues in five states with 1090 boys' and 480 girls' lacrosse players from the U9-U15 divisions. Athletic trainers reported injury and exposure data at games and practices. Time-loss (TL) injuries were defined as resulting in >=24 hours of participation restriction time. Injury counts and rates per 1000 athlete-games/practices were calculated. Injury rate ratios (IRR) with 95% confidence intervals (CI) compared rates by sex and age division. Results: Overall, 241 and 59 injuries were reported in boys' and girls' youth lacrosse, respectively, of which 17.0% and 18.6% were TL. Compared to girls, boys had a higher overall injury rate (12.7 vs. 8.7/1000 athlete-games/practices; IRR=1.5; 95%CI: 1.1-1.9). U13/U15 boys had a higher TL injury rate than U9/U11 boys (2.6 vs. 1.0/1000 athlete-game/practices; IRR=2.6; 95%CI: 1.1-6.1). Most injuries were diagnosed as contusions (boys: 53.7%; girls: 47.2%) and resulted from stick contact (boys: 34.1%; girls: 30.6%) and ball contact (boys: 17.1%; girls: 25.0%). Among girls, ball contact contributed to 75.0% (n=9) of all head/face injuries. Among the 14 concussions reported in boys, player contact was the most common injury mechanism (50.0%, n=7), followed by stick contact (35.7%, n=5). Conclusion: Boys' lacrosse has a higher injury incidence than girls' lacrosse, reflecting the contact nature of the boys' game. The high incidence of stick- and ball-related injuries suggests the need for youth specific rules to better protect youth players. (C) 2017 American College of Sports Medicine

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Work Rate during Self-paced Exercise is not Mediated by the Rate of Heat Storage.

PURPOSE: To date, there have been mixed findings on whether greater anticipatory reductions in self-paced exercise intensity in the heat are mediated by early differences in rate of body heat storage. The disparity may be due to an inability to accurately measure minute-to-minute changes in whole-body heat loss. Thus, we evaluated whether early differences in rate of heat storage can mediate exercise intensity during self-paced cycling at a fixed rate of perceived exertion (RPE of 16; hard-to-very-hard work effort) in COOL (15[degrees]C), NORMAL (25[degrees]C) and HOT (35[degrees]C) ambient conditions. METHODS: On separate days, nine endurance-trained cyclists exercised in COOL, NORMAL and HOT conditions at a fixed RPE until work rate (measured after first 5-min of exercise) decreased to 70% of starting values. Whole-body heat loss and metabolic heat production were measured by direct and indirect calorimetry respectively. RESULTS: Total exercise time was shorter in HOT (57+/-20 min) relative to both NORMAL (72+/-23 min, P=0.004) and COOL (70+/-26 min, P=0.045). Starting work rate was lower in HOT (153+/-31 W) compared to NORMAL (166+/-27 W, P=0.024) and COOL (170+/-33 W, P=0.037). Rate of heat storage was similar between conditions during the first 4 min of exercise (all P>0.05). Thereafter, rate of heat storage was lower in HOT relative to NORMAL and COOL until 30-min of exercise (last common time-point between conditions; all P

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Ocular Dysfunctions Presenting in Tacrolimus-Induced Posterior Reversible Encephalopathy Syndrome: A Case Presentation

The constellation of ocular symptoms, known as Balint's syndrome, is a rare disorder seen in bilateral parieto-occipital lesions and is most frequently due to arterial occlusive disease or acute hypertension. Here we present a case of a patient with tacrolimus-induced posterior reversible encephalopathy syndrome (PRES) who presented with optic ataxia, simultanagnosia, and ocular apraxia. These ocular findings, consistent with Balint's syndrome, are rarely the initial presentation of PRES. This case highlights the importance of early recognition of this unusual phenomenon as well as the importance of an individualized rehabilitation plan to maximize functional independence in these patients.

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Radiographic evaluation of condylar positioning in patients undergoing orthognathic surgery

Abstract

Objective

The aim of this study was to evaluate alterations in condylar positioning through submentovertex projection (Hirtz Radiographic Technique) in patients who underwent orthognathic surgery for maxillary advancement and mandibular setback with stable internal fixation.

Methods

A prospective longitudinal clinical study of 40 surgical patients presenting dentofacial deformity admitted in the Oral and Maxillofacial Surgery Department of Federal University of Paraná (UFPR) in the period between March 2013 and December 2015. We performed two submentovertex digital radiographs, one 7 days before surgery and the other one 30 days after the procedure. Cephalometric tracings were made using Radiocef® Studio 2 Software and measured the intercondylar and condylar angles (right and left).

Results

There was a decrease in the intercondylar angle (p < 0.001) and an increase in condylar angles both the right and the left side (p < 0.001) when compared with the pre and postoperative period. There was a larger increase in condylar angle on the right side in males (p = 0.007).

Conclusion

There is a tendency of decreasing of the intercondylar angle after orthognathic surgery, regardless of the alteration in the condylar angles, creating a new position of the condyle in the glenoid fossa. Patients with asymmetry may present greater alterations in the positioning of the opposite condylar to the deviation of the mandibular midline.

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Shrinkage in oral squamous cell carcinoma: An analysis of tumor and margin measurements in vivo, post-resection, and post-formalin fixation

To quantify changes in tumor size and tumor-free margins following surgical resection and formalin fixation of oral cavity squamous cell carcinoma.

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Radiographic evaluation of condylar positioning in patients undergoing orthognathic surgery

Abstract

Objective

The aim of this study was to evaluate alterations in condylar positioning through submentovertex projection (Hirtz Radiographic Technique) in patients who underwent orthognathic surgery for maxillary advancement and mandibular setback with stable internal fixation.

Methods

A prospective longitudinal clinical study of 40 surgical patients presenting dentofacial deformity admitted in the Oral and Maxillofacial Surgery Department of Federal University of Paraná (UFPR) in the period between March 2013 and December 2015. We performed two submentovertex digital radiographs, one 7 days before surgery and the other one 30 days after the procedure. Cephalometric tracings were made using Radiocef® Studio 2 Software and measured the intercondylar and condylar angles (right and left).

Results

There was a decrease in the intercondylar angle (p < 0.001) and an increase in condylar angles both the right and the left side (p < 0.001) when compared with the pre and postoperative period. There was a larger increase in condylar angle on the right side in males (p = 0.007).

Conclusion

There is a tendency of decreasing of the intercondylar angle after orthognathic surgery, regardless of the alteration in the condylar angles, creating a new position of the condyle in the glenoid fossa. Patients with asymmetry may present greater alterations in the positioning of the opposite condylar to the deviation of the mandibular midline.

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p53-Dependent PUMA to DRAM antagonistic interplay as a key molecular switch in cell-fate decision in normal/high glucose conditions

As an important cellular stress sensor phosphoprotein p53 can trigger cell cycle arrest and apoptosis and regulate autophagy. The p53 activity mainly depends on its transactivating function, however, how p53 c...

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Sophoridine induces apoptosis and S phase arrest via ROS-dependent JNK and ERK activation in human pancreatic cancer cells

Pancreatic cancer is generally acknowledged as the most common primary malignant tumor, and it is known to be resistant to conventional chemotherapy. Novel, selective antitumor agents are pressingly needed.

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ICG-001 suppresses growth of gastric cancer cells and reduces chemoresistance of cancer stem cell-like population

ICG-001, a small molecule, binds CREB-binding protein (CBP) to disrupt its interaction with β-catenin and inhibits CBP function as a co-activator of Wnt/β-catenin-mediated transcription. Given its ability to i...

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Erratum to “Extramammary Paget's disease of the oral mucosa and perioral skin” [Oral Surg Oral Med Oral Pathol Oral Radiol 2017; 124 (2):e157-e163.]

Publication date: Available online 11 September 2017
Source:Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
Author(s): Xiangjian Wang, Lanyan Wu, Xueke Shi, Xin He, Wei Li, Hongmei Zhou




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Expression of PD-L1 in Hormone-naïve and Treated Prostate Cancer Patients Receiving Neoadjuvant Abiraterone Acetate plus Prednisone and Leuprolide

Purpose: Programmed cell death ligand-1 (PD-L1)/programmed cell death-1 (PD-1) blockade has been unsuccessful in prostate cancer (PCa), with poor immunogenicity and subsequent low PD-L1 expression in PCa being proposed as an explanation. However, recent studies indicate that a subset of PCa may express significant levels of PD-L1. Further, the androgen antagonist enzalutamide has been shown to up-regulate PD-L1 expression in PCa preclinical models. In this study, we evaluated the effect of neoadjuvant androgen deprivation therapy with abiraterone acetate plus prednisone and leuprolide (Neo-AAPL) on PD-L1 expression in PCa. Experimental Design: Radical prostatectomy (RP) tissues were collected from 44 patients with intermediate-to-high risk PCa who underwent RP after Neo-AAPL treatment. Untreated PCa tissues were collected from 130 patients, including 44 matched controls for the Neo-AAPL cases. Tumor PD-L1 expression was detected by immunohistochemistry using validated anti-PD-L1 antibodies. Tumor-infiltrating CD8+ cells were analyzed in trial cases and matched controls. Expression of DNA mismatch repair genes was examined in PD-L1-positive tumors. Results: Neo-AAPL-treated tumors showed a trend toward decreased PD-L1 positivity compared to matched controls (7% vs 21% having ≥1% positive tumor cells; p = 0.062). Treated tumors also harbored significantly less tumor-infiltrating CD8+ cells (p = 0.029). In 130 untreated PCas, African American, elevated serum PSA, and small prostate independently predicted tumor PD-L1 positivity. Loss of MSH2 expression was observed in one of twenty-one PD-L1-positive tumors. Conclusions: A subset of PCa expresses PD-L1, which is not increased by Neo-AAPL treatment, indicating that combining Neo-AAPL treatment with PD-L1/PD-1 blockade may not be synergistic.

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Preoperative Panel Testing for Hereditary Cancer Syndromes Does Not Significantly Impact Time to Surgery for Newly Diagnosed Breast Cancer Patients Compared with BRCA1/2 Testing

Abstract

Background

This study seeks to determine whether there is a delay in time to surgery in breast cancer patients with panel tests compared with traditional BRCA testing.

Methods

This study was a retrospective review of women diagnosed with breast cancer who underwent genetic evaluation from our institution's Genetic Counselor Database from January 2013 to August 2015. Patients were excluded if they were male, clinical information was unavailable, the patient underwent neoadjuvant chemotherapy, had a diagnosis of recurrent breast cancer during time of study, or had postoperative genetics evaluation.

Results

Included in the study were 138 patients. The time from diagnosis to surgery for BRCA1/2 tested patients was 43.5 days compared with 51.0 days in the panel group (p = 0.186). Turnaround time for genetic testing decreased during the period studied and was approximately 6 days longer for panel testing than BRCA testing. It took 12.2 days for BRCA results and 18.9 days for the panel results (p < 0.01). Turnaround time for BRCA1/2 testing in 2014 and 2015 was 12.4 and 10.5 days respectively, whereas panel testing was 20.5 and 18.2 days (p ≤ 0.001). Of the variables included in multivariable linear regression, only mastectomy significantly contributed to time to surgery (p < 0.001).

Discussion

Panel genetic testing did not delay time to surgery compared with BRCA testing alone. The use of panel testing has increased over time, and lab turnaround time has decreased. Mastectomy was the only clinical variable contributing to longer time to surgery.

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The Androgen Receptor: Is It a Promising Target?

Abstract

A growing body of literature supports the conclusion that the androgen receptor (AR) plays an important role in breast cancer pathogenesis and may prove to be a relevant therapeutic target for patients with AR-driven breast cancer. This has been most apparent in the subset of patients with triple-negative breast cancer (TNBC), in whom approximately 50% of tumors may have androgen dependence. Recent phase 2 clinical trials of agents that antagonize AR or reduce androgen production have shown clinical benefit and efficacy to varying degrees. This review highlights three of these recent trials of AR⁺ TNBC and acknowledge ongoing research in this exciting area.

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Presidential Address: The Road Ahead—Challenges and Opportunities

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Factors Influencing Management and Outcome in Patients with Occult Breast Cancer with Axillary Lymph Node Involvement: Analysis of the National Cancer Database

Abstract

Background

Occult breast cancer (OBC) is rare and optimal local–regional (LR) management has not been defined. Using a patient registry database, we examine factors associated with treatment and outcomes in OBC.

Methods

Female patients with cT0 N1/2 M0 BC were selected from the National Cancer Database (2004–2013) and categorized into four treatment groups: MAST = mastectomy with axillary lymph node dissection (ALND) ± radiation (RT); RT + ALND = RT with ALND, no breast surgery; ALND = ALND alone; OBS = no breast surgery, RT, or ALND. Patient characteristics and overall survival (OS) were compared between groups, and multivariable analysis was used to identify factors associated with treatment and OS.

Results

Among 2.03 million BC cases, 1853 females (0.09%) with cT0 N1/2 M0 disease were identified and 1231 patients were categorized into a treatment group: MAST = 592, RT + ALND = 342, ALND = 106, OBS = 191. On logistic regression, care at an academic center was associated with a higher likelihood of RT + ALND compared with MAST (odds ratio 2.03, 95% confidence interval [CI] 1.50–2.74, p < 0.001). Patients treated with RT + ALND had significantly better OS on univariate survival analysis compared with patients treated with MAST (hazard ratio [HR] 0.475, 95% CI 0.306–0.736, p = 0.001). RT + ALND was independently associated with OS on multivariable survival analysis (HR 0.509, 95% CI 0.321–0.808, p = 0.004), after adjusting for covariates.

Conclusions

Patients with OBC were more likely to undergo RT + ALND if they received care at an academic center. Patients treated with RT + ALND had significantly better OS compared with patients treated with MAST, after adjusting for covariates. This supports the use of RT + ALND as LR treatment for patients with OBC.

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Expanded Gene Panel Use for Women With Breast Cancer: Identification and Intervention Beyond Breast Cancer Risk

Abstract

Background

Clinicians ordering multi-gene next-generation sequencing panels for hereditary breast cancer risk have a variety of test panel options. Many panels include lesser known breast cancer genes or genes associated with other cancers. The authors hypothesized that using broader gene panels increases the identification of clinically significant findings, some relevant and others incidental to the testing indication. They examined clinician ordering patterns and compared the yield of pathogenic or likely pathogenic (P/LP) variants in non-BRCA genes of female breast cancer patients.

Methods

This study analyzed de-identified personal and family histories in 1085 breast cancer cases with P/LP multi-gene panel findings in non-BRCA cancer genes and sorted them into three groups by the panel used for testing: group A (breast cancer genes only), group B (commonly assessed cancers: breast, gynecologic, and gastrointestinal), and group C (a more expanded set of tumors). The frequency of P/LP variants in genes with established management guidelines was compared and evaluated for consistency with personal and family histories.

Results

This study identified 1131 P/LP variants and compared variants in clinically actionable genes for breast and non-breast cancers. Overall, 91.5% of these variants were in genes with management guidelines. Nearly 12% were unrelated to personal or family history.

Conclusion

Broader panels were used for 85.6% of our cohort (groups B and C). Although pathogenic variants in non-BRCA genes are reportedly rare, the study found that most were in clinically actionable genes. Expanded panel testing improved the identification of hereditary cancer risk. Small, breast-limited panels may miss clinically relevant findings in genes associated with other heritable cancers.

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Breast Cancer-Related Lymphedema Risk is Related to Multidisciplinary Treatment and Not Surgery Alone: Results from a Large Cohort Study

Abstract

Background

Breast cancer-related lymphedema (BCRL) is a significant complication for women undergoing treatment. We assessed BCRL incidence and risk factors in a large population-based cohort.

Methods

We utilized the Olmsted County Rochester Epidemiology Project Breast Cancer Cohort from 1990–2010 and ascertained BCRL and risk factors. The cumulative incidence estimator was used to estimate the rate of BCRL; competing risks regression was used for multivariable analysis.

Results

A total of 1794 patients with stage 0–3 breast cancer with a median of 10 years follow-up were included. The cumulative incidence of BCRL diagnosis within 5 years was 9.1% [95% confidence interval (CI) 7.8–10.5%]. No BCRL events occurred among patients without axillary surgery. In the axillary surgery subset (n = 1512), the 5-year incidence of BCRL was 5.3% in sentinel lymph node (SLN) surgery and 15.9% in axillary dissection (ALND) patients (p < 0.001). In patients treated with surgery only, BCRL rates were not different between ALND versus SLN (3.5 and 4.1% at 5 years, p = 0.36). Addition of breast or chest wall radiation more than doubled the BCRL rate in ALND patients (3.5 vs. 9.5% at 5 years, p = 0.01). The groups with highest risk (>25% at 5 years) all involved ALND with nodal RT and/or anthracycline/cytoxan + taxane chemotherapy. In multivariable analysis of patients with any axillary surgery factors significantly associated with BCRL were ALND, chemotherapy, radiation, and obesity.

Conclusions

BCRL is a sequelae of multimodal breast cancer treatment and risk is multifactorial. BCRL rates are higher in patients receiving chemotherapy, radiation, ALND, more advanced disease stage, and higher body mass index.

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Clinical Decision-Making in Patients with Variant of Uncertain Significance in BRCA1 or BRCA2 Genes

Abstract

Background

How diagnosis with a variant of uncertain significance (VUS) in a BRCA gene impacts clinical decision-making is not well known.

Methods

We queried for all patients attending Mayo Clinic Rochester from 2004 to 2016 who tested positive for BRCA1 or BRCA2 VUS and reviewed patient management choices. Groups were compared by using Wilcoxon rank-sum and Chi-square tests.

Results

We identified 97 patients (95 females, 2 males) with BRCA VUS. For patients without cancer history (n = 20), 80% had a mother or sister with breast cancer, and median Tyrer-Cuzick (IBIS) lifetime breast cancer risk score was 27% (range 16–62%). Management included bilateral prophylactic mastectomy (BPM) in 39%, where choice for BPM was significantly associated with IBIS score (median 32 vs. 24%, p = 0.02) and first-degree family history of breast cancer (100 vs. 64%, p = 0.03) but not Gail score or total number of family members with cancer. For patients with breast cancer who had known VUS status prior to surgery (n = 9), the rate of contralateral prophylactic mastectomy (CPM) was 22% compared with 25% without known VUS and 83% with known BRCA pathogenic mutation. In 21 of 97 (22%) patients, the BRCA VUS has been reclassified (95% benign, 5% deleterious).

Conclusions

BRCA VUS carriers with cancer elected surgical choices similar to average-risk breast cancer patients. However, VUS carriers without cancer had high rates of BPM, associated with first-degree family history and IBIS score. Over time, a significant proportion of BRCA VUS were reclassified, illustrating the importance of appropriate counseling regarding VUS.

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Contralateral Prophylactic Mastectomy with Immediate Breast Reconstruction Increases Healthcare Utilization and Cost

Abstract

Background

The rates of contralateral prophylactic mastectomy (CPM) in women with unilateral breast cancer continue to rise, especially in women undergoing immediate breast reconstruction (IBR).

Methods

We utilized administrative claims data from a large US commercial insurance database (OptumLabs) to identify women age 18–64 years who underwent IBR between January 2004 and December 2013. We compared 2-year unadjusted utilization rates and total costs of care between unilateral mastectomy (UM) and bilateral mastectomy (BM) for implant-based and autologous reconstruction. Comparisons were tested using t-test and differences in cost were estimated using the Wilcoxon rank-sum test.

Results

Overall, 11,235 women undergoing mastectomy with IBR were identified; 7319 with implant reconstruction [1923 UM (26%) and 5396 BM (74%)] and 3916 with autologous reconstruction [1687 UM (43%) and 2229 BM (57%)]. The overall rate of office visits (2386 vs. 2391 per 100 women, p = 0.42) and hospital readmission rate (29.1 per 100 women vs. 27.4, p = 0.06) were similar between BM + IBR and UM + IBR. Women undergoing BM + IBR had a higher emergency room (ER) visit rate (34.1 per 100 women vs. 29.8, p < 0.0001). The total 2-year cost of care was higher for BM + IBR than UM + IBR for implant reconstruction ($106,711 vs. $97,218, p < 0.0001) and for autologous reconstruction ($114,725 vs. $87,874, p < 0.0001).

Conclusions

BM + IBR (autologous or implant) was associated with increased ER visits and higher total cost of care over 2 years compared with UM + IBR. Patients considering CPM should be counseled on the additional risks and costs associated with BM + IBR.

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Evaluating the Risk of Upstaging HER2-Positive DCIS to Invasive Breast Cancer

Abstract

Background

Overexpression of human epidermal growth factor 2 (HER2) in invasive breast cancer (IBC) is an independent poor prognostic factor. However, the significance of HER2 overexpression in ductal carcinoma in situ (DCIS) is not well defined. The current study assessed the correlation of HER2⁺ DCIS with the rate of upstaging to IBC on the final pathology.

Methods

The study retrospectively analyzed patients with the diagnosis of DCIS on core needle biopsy (CNB) at the authors' institution from 2009 to 2016. Data were analyzed using two-sample t tests. Multivariate analysis was performed using logistic regression.

Results

The study found that HER2⁺ DCIS had significantly higher rates of upstaging to IBC than HER2⁻ DCIS (odds ratio [OR] 1.89; p = 0.012). In addition, triple-positive disease was more than two times more likely to be upstaged (OR 2.5; p = 0.01), whereas patients with estrogen (ER)-positive, progesterone (PR)-positive, and HER2⁻ diseases were half as likely to be upstaged (OR 0.5; p = 0.04). Upstaging did not differ for patients with triple-negative disease (OR 0.89; p = 0.8). Additionally, patients with HER2⁺ DCIS were significantly younger regardless of ER/PR status (p = 0.03). The overexpression of HER2 in patients with an initial diagnosis of DCIS on CNB were twice as likely to have IBC on the final pathology as those who did not.

Conclusion

The results suggest that overexpression of HER2 may serve as a biomarker for risk stratification of patients with DCIS and may help to guide treatment strategies in the future. For institutions in which HER2 testing may be performed on DCIS, patients should be counseled appropriately about the risk of upgrade to IBC.

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A 10-Year Experience with Mastectomy and Tissue Expander Placement to Facilitate Subsequent Radiation and Reconstruction

Abstract

Background

An integrated approach to skin sparing mastectomy with tissue expander placement followed by radiotherapy and delayed reconstruction was initiated in our institution in 2002. The purpose of this study was to assess the surgical outcomes of this strategy.

Methods

Between September 2002 and August 2013, a total of 384 reconstructions had a tissue expander placed at the time of mastectomy and subsequently underwent radiotherapy. Rates and causes of tissue expander explantation before, during, and after radiotherapy, as well as tumor specific outcomes and reconstruction approaches, were collected.

Results

Median follow-up after diagnosis was 5.6 (range 1.3–13.4) years. In the study cohort, 364 patients (94.8%) had stage II–III breast cancer, and 7 patients (1.8%) had locally recurrent disease. The 5-year rates of actuarial locoregional control, disease-free survival, and overall survival were 99.2, 86.1, and 92.4%, respectively. The intended delayed-immediate reconstruction was subsequently completed in 325 of 384 mastectomies (84.6% of the study cohort). Of the remaining 59 tissue expanders, 1 was explanted before radiotherapy, 1 during radiotherapy, and 7 patients (1.8%) were lost to follow-up. Fifty patients (13.0%) required tissue expander explantation after radiation and before their planned final reconstruction, primarily due to cellulitis. Nonetheless, the cumulative rate of completed reconstructions was 89.6%. The median time from placement of the tissue expander until reconstruction was 12 (interquartile range 9–15) months.

Conclusions

Tissue expander placement at skin-sparing mastectomy in patients who require radiotherapy appears to be a viable strategy for combining reconstruction and radiotherapy.

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Lobular Neoplasia and Atypical Ductal Hyperplasia on Core Biopsy: Current Surgical Management Recommendations

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Predicting Nodal Positivity in Women 70 Years of Age and Older with Hormone Receptor-Positive Breast Cancer to Aid Incorporation of a Society of Surgical Oncology Choosing Wisely Guideline into Clinical Practice

Abstract

Purpose

One of the Society of Surgical Oncology Choosing Wisely guidelines recommends avoiding routine sentinel lymph node (SLN) surgery in clinically node-negative women ≥70 years of age with hormone receptor-positive (HR+) breast cancer. We sought to assess the impact of tumor stage and grade on nodal positivity, and to develop a model to identify patients at low-risk of nodal positivity to aid adoption of the guideline.

Methods

We identified women ≥70 years of age with HR+ cN0 invasive breast cancer in the National Cancer Database (NCDB; 2010–2013) and examined the impact of tumor stage and grade on nodal positivity to identify low-risk combinations. A multivariable logistic regression model was developed to incorporate additional factors. The area under the curve (AUC) and relative risks (RR) were used to assess performance.

Results

Among 71,834 cases, the pathologic nodal positivity (pN+) rate was 15.3%. We identified low-risk criteria as grade 1, cT1mi-T1c (≤2.0 cm), or grade 2, cT1mi-T1b (≤1.0 cm), with pN+ rates of 7.8% compared with 22.3% in patients not meeting these criteria (RR 2.86, p < 0.001). On multivariable analysis, factors associated with pN+ status included clinical T stage, grade, and histology (each p < 0.001). The resulting model had AUC 0.70 and identified women with low predicted probability (<10%) of positive nodes, of whom 6.3% were pN+, versus 21.2% in those with predicted probability ≥10% (RR 3.34, p < 0.001).

Conclusion

The simple clinical rule (grade 1, cT1mi-T1c, or grade 2, cT1mi-T1b), as well as the predictive model, both identify women at low risk of nodal positivity where SLN surgery can be omitted.

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Influence of Distance to Hospital and Insurance Status on the Rates of Contralateral Prophylactic Mastectomy, a National Cancer Data Base study

Abstract

Introduction

We evaluated the impact of travel distance and insurance status on contralateral prophylactic mastectomy (CPM) rates in breast cancer.

Methods

We queried the National Cancer Data Base (NCDB) for women >18 years of age with a nonmetastatic primary breast cancer of ductal, lobular, or mixed histology. Patient- and facility-specific CPM rates were calculated based on insurance, race, and distance to treatment center. Standard univariable and multivariable regression analysis was performed.

Results

Overall, the CPM rate was 6.5% for the 864,105 patients identified. Most patients traveled <20 miles to a treatment center (79.5%) and had private insurance or Medicare (58.3 and 33.4%, respectively). In general, younger, White, non-Hispanic, and privately insured patients residing further from a treatment center was associated with increased rates of CPM. However, distance to the treatment center and insurance type had a greater absolute impact on rates of CPM for Black and Hispanic patients. Absolute CPM rate increases for patients >100 miles from a treatment center compared with those <20 miles from a treatment center were observed to be greater for Black and Hispanic patients (3.5 and 3.9%, respectively) compared with White and non-Hispanic patients (2.5 and 2.6%). Additionally, further patient travel distance was associated with higher treatment center-specific CPM rates.

Conclusion

Increased travel distance is independently associated with increased rates of CPM for all patients and increased facility-specific rates of CPM. Black and Hispanic patients were found to be more vulnerable to the impact of travel distance and insurance status on rates of CPM.

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Challenging Atypical Breast Lesions Including Flat Epithelial Atypia, Radial Scar, and Intraductal Papilloma

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Intraoperative Radiation Using Low-Kilovoltage X-Rays for Early Breast Cancer: A Single Site Trial

Abstract

Introduction

Two prospective, randomized trials, TARGIT-A and ELIOT, have shown intraoperative radiation therapy (IORT) to be a safe alternative to whole breast radiation therapy following breast-conserving surgery for selected low-risk patients. However, minimal data are available about the clinical effectiveness of this modality of treatment using the Xoft^® Axxent^® Electronic Brachytherapy (eBx^®) System^®.

Methods

A total of 201 patients with 204 early-stage breast cancers were enrolled in a prospective X-ray IORT trial from June 2010 to September 2013. All tumors were treated with breast-conserving surgery and IORT. Data were collected at 1 week, 1 month, 6 months, 1 year, and yearly thereafter.

Results

With a median follow-up of 50 months, there have been seven ipsilateral breast tumor events (IBTE), no regional or distant recurrences, and no breast cancer-related deaths. One IBTE was within the IORT field, four outside of the IORT field but within the same quadrant as the index cancer, and two were new biologically different cancers in different quadrants. Three events were in patients who deviated from the protocol criteria. Kaplan–Meier analysis projects that 2.9% of patients will recur locally at 4 years.

Conclusions

Recurrence rates observed in this trial were comparable to those of the TARGIT-A and ELIOT trials as well as the retrospective TARGIT-R trial. The low complication rates previously reported by our group as well as the low recurrence rates reported in this study support the cautious use and continued study of IORT in selected women with low-risk breast cancer.

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Differences Among a Modern Cohort of BRCA Mutation Carriers Choosing Bilateral Prophylactic Mastectomies Compared to Breast Surveillance

Abstract

Background

Women with a BRCA mutation have significantly elevated breast cancer risk, which can be reduced by >90% with bilateral prophylactic mastectomy (BPM). We sought to compare a cohort of BRCA mutation carriers choosing BPM versus breast surveillance to better elucidate factors that may impact decision making.

Methods

Women with a BRCA mutation were retrospectively identified from a prospectively maintained database. The surveillance cohort (n = 313) consisted of women seen in a high-risk clinic between 2014 and 2016, while the surgery cohort (n = 142) consisted of women who underwent BPM between 2010 and 2016. Clinical and familial factors were compared between the groups.

Results

Women choosing BPM were more likely to have a BRCA1 than BRCA2 mutation compared with the surveillance group (57 vs. 45%, p = 0.02) and were less likely to have a personal history of ovarian cancer (10 vs. 20%, p = 0.01). Furthermore, women undergoing BPM were more likely to be married (78 vs. 62%, p = 0.01), to have more children (median 2 vs. 1, p < 0.001), and to have undergone a prophylactic oophorectomy (61 vs. 37%, p < 0.001). Women choosing BPM had more first-degree relatives (63 vs. 48%, p = 0.01) or a sister (23 vs. 14%, p = 0.02) with a history of breast cancer and were more likely to have a family member with ovarian cancer under the age of 40 years (9 vs. 4%, p = 0.03). There was no difference in the number of prior breast biopsies or history of atypia/lobular carcinoma in situ.

Conclusion

The decision to undergo BPM appears multifactorial, with gene mutation, family history, and relationships appearing to have the strongest influence on decision making.

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MACRA and the Changing Medicare Payment Landscape

Abstract

Background

The Medicare Access and CHIP Reauthorization Act (MACRA) is being implemented in 2017 by the Centers for Medicare and Medicaid Services (CMS) as the Quality Payment Program (QPP) and will have important and far reaching effects on how physicians are reimbursed and on how they practice. The QPP modifies the Medicare physician payment system by eliminating the Sustainable Growth Rate formula and incorporating the existing Physician Quality Reporting System, EHR Incentive Program, and the Value Modifier into a single new Merit-based Incentive Payment System (MIPS).

Methods

The authors reviewed the MACRA legislation as well as the CMS resources on the QPP and other sources to summarize the regulations pertaining to the new program, particularly for the first performance period.

Results

CMS has taken great care to create a smooth transition for Medicare physicians. Clinicians can avoid any penalty for performance in 2017 by submitting a minimal amount of quality data, attesting to a single improvement activity, or successfully attaining the base score for the advancing care information portion of MIPS. The reduced reporting period also makes it possible for participants to begin collecting data as late as October 2nd and still achieve the full possible score in the program.

Conclusions

Surgeons should be taking steps now to ensure that they are prepared to succeed in the QPP. The transition period creates a clear pathway for avoiding penalties while providing an opportunity to test one's ability to participate and improve performance.

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Prospective Study Comparing Surgeons’ Pain and Fatigue Associated with Nipple-Sparing versus Skin-Sparing Mastectomy

Abstract

Background

Nipple-sparing mastectomy (NSM) is more technically challenging than skin-sparing mastectomy (SSM) but offers quality-of-life and cosmetic advantages. However, surgeon physical symptoms related to NSM workload have not been documented.

Methods

This was a prospective study using questionnaires to compare surgeon-reported physical symptoms before, during, and after NSM versus SSM. Surgeons also answered general questions about each mastectomy. Bilateral cases were performed simultaneously by two surgeons, who completed independent questionnaires.

Results

Questionnaires were completed after 82 SSMs and 44 NSMs. On a 0–10 scale, surgeons reported NSM was more physically demanding than SSM (7.0 vs. 4.5, p < 0.001). Mean visualization was more difficult (5.7 vs. 3.2, p < 0.001) and mean fatigue score was greater (5.6 vs. 3.1, p < 0.001) after NSM than SSM. The mean increase in neck pain (on a 0–4 scale) was greater for NSM than SSM, both from before-to-during surgery (0.8 vs. 0.2, p = 0.003) and before-to-after surgery (0.9 vs. 0.2, p = 0.002). The mean increase in lower back pain was greater for NSM than SSM, both from before-to-during surgery (0.7 vs. 0.2, p = 0.008) and before-to-after surgery (0.9 vs. 0.2, p = 0.003). Surgeons reported that NSM was more mentally demanding (p < 0.001), complex (p = 0.01), and difficult (p < 0.001) than SSM.

Conclusion

Surgeons experienced greater physical symptoms, mental strain, and fatigue with NSM than SSM. This raises concern that mild but repetitive pain over the course of a breast surgeon's career may lead to repetitive stress injury.

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Selective Use of Sentinel Lymph Node Surgery in Patients Undergoing Prophylactic Mastectomy Using Intraoperative Pathology

Abstract

Background

Routine sentinel lymph node (SLN) surgery during prophylactic mastectomy (PM) is unnecessary, because most PMs do not contain cancer. Our institution utilizes intraoperative pathology to guide the surgical decision for resection of SLNs in PM. The purpose of this study was to review the effectiveness of this approach.

Methods

We identified all women aged ≥18 years who underwent bilateral PM (BPM) or contralateral PM (CPM) at our institution from January 2008 to July 2016. We evaluated the frequency of SLN resection and rate of occult breast cancer (DCIS or invasive disease) in the PM. We used the following definitions: over-treatment—SLN surgery in patients without cancer; under-treatment—no SLN surgery in patients with cancer; appropriate treatment—no SLN in patients without cancer or SLN surgery in patients with cancer.

Results

PM was performed on 1900 breasts: 1410 (74.2%) CPMs and 490 (25.8%) BPMs. Cancer was identified in 58 (3.0%) cases (32 invasive disease and 26 DCIS) and concurrent SLN surgery was performed in 44 (75.9%) of those cases. Overall, SLN surgery guided by intraoperative pathology resulted in appropriate treatment of 1787 (94.1%) cases: 1319 (93.5%) CPMs and 468 (95.5%) BPMs, by avoiding SLN in 1743/1842 cases without cancer (94.6%), and performing SLN surgery in 44/58 cases with cancer (75.9%).

Conclusions

Use of intraoperative pathology to direct SLN surgery in patients undergoing PM minimizes over-treatment from routine SLN in PM and minimizes under-treatment from avoiding SLN in PM, demonstrating the value of intraoperative pathology in this era of focus on appropriateness of care.

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Positive Ultrasound-guided Lymph Node Needle Biopsy in Breast Cancer may not Mandate Axillary Lymph Node Dissection

Abstract

Background

The ACOSOG Z0011 (Z11) trial demonstrated that in patients with nonpalpable axillary lymph nodes (LN) and one to two positive sentinel LN (SLN), axillary LN dissection (ALND) is unnecessary.JAMA 305:569–575, [2011], Ann Surg 264:413–42, [2016] The Z11 trial did not require preoperative axillary ultrasound (axUS). In many centers, preoperative axUS is part of the standard workup of a newly diagnosed breast cancer patient, but in light of the Z11 results, its role is now questioned.

Methods

We retrospectively analyzed newly diagnosed breast cancer patients at two institutions. Inclusion criteria were patients with (1) no palpable lymphadenopathy, (2) abnormal axUS, (3) axillary LN metastasis confirmed preoperatively by axUS-lymph node needle biopsy, (4) no neoadjuvant therapy, and (5) ALND. LN disease burden was dichotomized as N1 versus N2-3. We examined relationships between clinicopathologic factors, including axUS characteristics, and LN disease burden.

Results

Of 129 included cases, 67 had N1 disease (51.9%) and 62 had N2-3 disease (48.1%). Factors significantly associated with N1 disease were tumor size ≤2 cm (p = 0.012), nonlobular histology (p = 0.013), and one suspicious LN on axUS (p = 0.008). For patients with both tumor size on imaging ≤2 cm and one abnormal LN on axUS, only 27% had N2-3 disease (p = 0.007).

Conclusions

More than half of patients without palpable adenopathy but with preoperative US-guided biopsy proven axillary LN metastases had N1 disease. For patients with both tumor size ≤2 cm and only 1 abnormal LN on axUS, 73% had N1 disease. This suggests that such patients, if they are otherwise analogous to Z11 patients, may undergo attempt at SLNB.

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Israel rake retractor modification to improve exposure during oropharyngeal surgery on patients with larger body habitus

Abstract

Purpose

Elective oropharyngeal surgery including tonsillectomy and uvulopalatopharyngoplasty performed for obstructive sleep apnea is increasingly performed on patients of larger body habitus. The use of the Crowe-Davis retractor in such patients may be complicated by a large barrel-chest making it difficult to anchor the retractor to the Mayo stand for suspension limiting oropharyngeal exposure. Here, we present a simple modification using the Israel Retractor to facilitate suspension of the Crowe-Davis mouth gag.

Methods

Operational instructions were followed for Israel retractor modification in oropharyngeal surgery.

Results

The Crowe-Davis retractor is able to anchor to the Israel retractor, whose prongs articulate on the Mayo Stand for suspension. This extension allows suspension of patients with larger body habitus in oropharyngeal surgery.

Conclusions

Use of the Israel retractor as an extension of the Crowe-Davis retractor handle provides an easy, quick, safe, and reliable method for placing patients of larger body habitus into suspension.

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Israel rake retractor modification to improve exposure during oropharyngeal surgery on patients with larger body habitus

Abstract

Purpose

Elective oropharyngeal surgery including tonsillectomy and uvulopalatopharyngoplasty performed for obstructive sleep apnea is increasingly performed on patients of larger body habitus. The use of the Crowe-Davis retractor in such patients may be complicated by a large barrel-chest making it difficult to anchor the retractor to the Mayo stand for suspension limiting oropharyngeal exposure. Here, we present a simple modification using the Israel Retractor to facilitate suspension of the Crowe-Davis mouth gag.

Methods

Operational instructions were followed for Israel retractor modification in oropharyngeal surgery.

Results

The Crowe-Davis retractor is able to anchor to the Israel retractor, whose prongs articulate on the Mayo Stand for suspension. This extension allows suspension of patients with larger body habitus in oropharyngeal surgery.

Conclusions

Use of the Israel retractor as an extension of the Crowe-Davis retractor handle provides an easy, quick, safe, and reliable method for placing patients of larger body habitus into suspension.

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Bloody Epiphora (Hemolacria) Years After Repair of Orbital Floor Fracture

Surgical repair of orbital fractures with implants is a widely used treatment modality. While a variety of established complications are associated with this technique, most are directly understood and treated. Bloody epiphora is a finding with potentially ominous causes. The authors present a unique case of bloody epiphora, accompanied by orbital hemorrhage arising several years after orbital floor fracture repair, due to erosion of the nasolacrimal drainage system by a displaced implant combined with anticoagulation. The collection and evaluation of all protected patient health information was compliant with the regulations and conditions set forth in the Health Insurance Portability and Availability Act of 1996.

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Marcus Gunn Jaw-Winking Syndrome: A Comprehensive Review and Report of Four Novel Cases

Purpose: To report 4 cases of Marcus Gunn jaw-winking synkinesis (MGJWS) in the absence of ptosis. Methods: A retrospective review of patients with MGJWS and congenital ptosis was compiled from the public and private subspecialty adult and pediatric oculoplastic practices of the 2 senior authors (AAM, TGH). Clinical data collected on patients with MGJWS included visual acuity, stereopsis, ocular motility, side of jaw-wink, presence or absence of ptosis, levator function, clinical photographs and videos, and any management undertaken. Results: A total of 848 cases of congenital ptosis were seen. Of these, there were 72 consecutive patients with MGJWS, of which 4 cases (5.6%) had no ptosis. One patient had bilateral MGJWS, with ptosis on one side only. The authors found the incidence of MGJWS in our study population to be 8.5% of all congenital ptosis cases. When the authors excluded syndromic, neurogenic, and myopathic causes of congenital ptosis, the incidence was 12.1%. In addition, the authors found a trend toward females with simple congenital ptosis and MGJWS being affected on the left side, however this was not statistically significant. Conclusions: The authors report the first case series of MGJWS in the absence of ptosis within the second largest series ever reported. These findings may help further our understanding of the etiology behind MGJWS.

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An Alternative for Permanent Punctal Occlusion: Labial Mucous Membrane Graft in the Management of Severe Dry Eye

No abstract available

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A Single- Versus Double-Layered Closure Technique in Anophthalmic Surgery

Purpose: To compare the frequency of orbital implant exposure and extrusion following eye removal with a simplified closure technique, closing Tenon's capsule and conjunctiva in 1 layer versus the classic technique of closure in 2 separate layers. Methods: The authors conducted a retrospective case note review of patients who underwent evisceration or enucleation treated by 1 surgeon between 2001 and 2013. Between 2001 and 2004, Tenon's capsule and conjunctiva were closed in separate layers; after 2004, a simplified 1-layer closure following eye removal was used. The primary outcome parameters were presence or absence of implant exposure or extrusion. Results: One hundred fifty-seven patients who underwent evisceration and 172 patients who underwent enucleation were included. Following evisceration, 2.5% developed exposure or extrusion of the implant, this was 2.5% in the 1-layer closure technique and 2.7% in the 2-layer closure technique (p = 0.95). Following enucleation, 1.7% developed exposure or extrusion of the implant, this was 1.8% in the 1-layer closure technique and 1.7% in the 2-layer closure technique (p = 0.96). Overall implant exposure and extrusion was 2.1%, this was 2.2% in the 1-layer closure technique and 2.1% in the 2-layer closure technique (p = 0.96). Conclusions: No difference was found in the frequency of spheric acrylic implant exposure or extrusion in patients who underwent eye removal with single-layer closure of Tenon's capsule and conjunctiva compared with patients treated with separate closure of these layers.

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Prognostic Value of the Staging System for Eyelid Tumors in the 7th Edition of the American Joint Committee on Cancer Staging Manual

Purpose: To determine the prognostic value of the staging criteria for eyelid tumors in the 7th edition of the American Joint Committee on Cancer (AJCC) staging manual and to determine, for each type of eyelid tumor, which AJCC T categories are associated with increased risk of nodal metastasis and thus potential usefulness of sentinel lymph node biopsy. Methods: Systematic review and analysis of articles found by searching PubMed and Google Scholar using the search terms "AJCC," "eyelid," "carcinoma," and "melanoma." Results: Rates of local recurrence, regional nodal metastasis, and distant metastasis were approximately 7% to 10%, 1% to 9%, and 0% to 0.8%, respectively, for eyelid squamous cell carcinoma; 5% to 6%, 8% to 23%, and 2% and 14%, respectively, for eyelid sebaceous carcinoma; 10%, 10% to 22%, and 19% to 22%, respectively, for eyelid Merkel cell carcinoma (when staged according to the criteria for eyelid carcinoma as opposed to Merkel cell carcinoma), 14%, 5%, and 0%, respectively, for eyelid sweat gland carcinoma; and 2%, 9%, and 6%, respectively, for eyelid melanoma. Overall, the risks of local recurrence and regional nodal and distant metastasis appeared to increase with increasing AJCC T category, although not statistically significant in all studies. Clinical T2b or greater T category was significantly associated with increased risk of nodal metastasis for eyelid squamous cell carcinomas, sebaceous carcinomas, Merkel cell carcinomas (staged with eyelid carcinoma criteria), sweat gland carcinomas, and melanomas. Clinical T3 or greater T category was significantly associated with distant metastasis for eyelid carcinomas and melanomas. Conclusion: For eyelid carcinomas and eyelid melanomas, AJCC 7th edition T category correlates with the risks of nodal and distant metastasis, with T2b and larger tumors associated with highest risk of nodal metastasis. Patients with T2b or larger tumors may be candidates for sentinel lymph node biopsy or close nodal surveillance.

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A Retrospective Review of Orbital Decompression for Thyroid Orbitopathy with Endoscopic Preservation of the Inferomedial Orbital Bone Strut

Purpose: To determine incidence of new-onset diplopia, resolution of preexisting diplopia, and impact on proptosis resulting from endoscopic orbital decompression with and without preservation of the inferomedial orbital strut for thyroid orbitopathy. Methods: Retrospective review of all patients undergoing endoscopic 2- or 3-wall decompression with or without preservation of the strut for thyroid orbitopathy from January 2012 to June 2015. Results: Twenty-six patients (45 orbits) were included and divided into 4 primary categories: 2-wall decompression with strut preservation (4 orbits, 8%), 2-wall decompression with strut removal (7 orbits, 16%), 3-wall decompression with strut preservation (27 orbits, 60%), and 3-wall decompression with strut removal (7 orbits, 16%). The incidence of new-onset diplopia was 20% (2/10 patients without preoperative diplopia) overall and 16% in the strut preservation group (1/6 patients without preoperative diplopia). Resolution of diplopia occurred in 4 of 16 patients (25%) with preoperative diplopia, and all 4 had been treated with a 3-wall decompression with strut preservation. Resolution of diplopia in the group treated with strut preservation was 36% (4/11 patients with preoperative diplopia), and 0% of the 5 diplopic patients treated without strut preservation. Reduction in proptosis was statistically greater in those treated with strut removal (p = 0.003). Conclusions: This study demonstrates that endoscopic orbital decompression with preservation of the inferomedial bone strut results in a comparable to lower rate of new-onset diplopia compared with other reported techniques. When combined with 3-wall balanced decompression, this technique demonstrates a high rate of resolution of preexisting diplopia.

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Endovascular Management of a Traumatic Infraorbital Pseudoaneurysm Causing Orbital Compartment Syndrome

An 89-year-old woman presented after blunt injury to the left orbit from a fall. Examination findings were suggestive of left-sided orbital compartment syndrome, unresponsive to emergent lateral canthotomy and cantholysis. CT revealed a left-sided orbital floor blowout fracture involving the infraorbital canal, with a large maxillary and infraorbital hematoma. Angiography revealed a pseudoaneurysm supplied by the infraorbital artery. Interventional neuroradiology successfully achieved hemorrhage control by endovascular obliteration of the parent artery close to the pseudoaneurysm. To our knowledge, this is the first reported case of successfully managing active intraorbital hemorrhage causing orbital compartment syndrome by endovascular vessel sacrifice of an infraorbital artery pseudoaneurysm.

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Efficacy of Orbital Color Doppler Imaging and Neuroimaging in the Diagnosis of Carotid Cavernous Fistulas

Purpose: To evaluate the diagnostic sensitivity and specificity of orbital color Doppler imaging (CDI) and conventional neuroimaging (CT/MRI) compared with cerebral angiography in patients with carotid-cavernous fistulas (CCFs). Methods: The study design was a retrospective patient chart and imaging review. The authors reviewed 655 charts of all patients who underwent CDI and neuroimaging (CT/MRI) between 2006 and 2015 at one institution. Sixty patients had a presumptive diagnosis of CCF without thrombosis. Thirty-seven patients with 43 events met the inclusion criteria of the study. The diagnostic sensitivity of the 3 noninvasive imaging modalities (CDI, CT, MRI) for CCF was compared with the gold standard 6-vessel cerebral angiography. Significance testing was performed using the 2-tailed Fisher test. Results: Color Doppler imaging had high sensitivity (96.8%) but low specificity (41.7%) for the diagnosis of CCFs with anterior orbital findings. A negative CDI had more diagnostic value than a positive CDI. While an arterial wave form in the superior ophthalmic vein was the most common finding of CCF on CDI, enlargement of the superior ophthalmic vein was the only statistically significant finding. Posterior cortical venous drainage was noted in about 10% of the patients with indirect (low-flow) fistulas, who presented with unilateral orbital signs and symptoms, a finding not previously reported in the literature. Conclusion: Color Doppler imaging is a useful noninvasive, radiation-free modality for diagnosis of CCF with anterior drainage, with higher sensitivity than CT or MRI, but equivalent specificity. A significant limitation of CDI is the lack of usefulness in diagnosing fistulas with posterior cortical venous drainage, which carry a risk of intracerebral hemorrhage and stroke. In this series, 10% of unilateral CCFs with anterior orbital signs and symptoms showed angiographic evidence of posterior cortical venous drainage.

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Lacrimal Drainage System Involvement in Linear Scleroderma

Linear scleroderma is a localized variety of scleroderma characterized by fibrotic areas of the dermis involving head region without systemic features. Ocular involvement has been sparsely reported in the form of episcleritis, dry eye, and uveitis. We describe a 42-year-old man with linear scleroderma, en coup de sabre type with associated nasolacrimal duct obstruction and prolonged dacryocystitis.

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Comparative Evaluation of the Ostium After External and Nonendoscopic Endonasal Dacryocystorhinostomy Using Image Processing (Matlabs and Image J) Softwares

Purpose: The purpose of this study was to compare the characteristics of the ostium after external dacryocystorhinostomy and nonendoscopic endonasal dacryocystorhinostomy (NEN-DCR). Methods: This cross-sectional study included patients who underwent a successful external dacryocystorhinostomy or NEN-DCR and had ≥1 month follow up. Pictures of the ostium were captured with a nasal endoscope (4 mm, 30°) after inserting a lacrimal probe premarked at 2 mm. Image analyses were performed using Image J and Contour softwares. Results: Of the 113 patients included, external dacryocystorhinostomy group had 53 patients and NEN-DCR group had 60 patients. The mean age of patients in the NEN-DCR group (38 years) was significantly (p 0.05) in mean follow up (6 vs. 4 months), maximum diameter of ostium (8 vs. 7 mm), perpendicular drawn to it (4 vs. 4 mm), area of ostium (43 vs. 36 mm2), and the minimum distance between common internal punctum and edge of the ostium (1 vs. 1 mm) between the external and NEN-DCR groups. Conclusions: Image processing softwares offer simple and objective method to measure the ostium. While ostia are comparable in size, their relative position differs with posteriorly placed ostia in external compared with inferior in NEN-DCR.

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Re: “Lateral Rectus and Medial Rectus Expansion Following Orbital Decompression”

No abstract available

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A Novel One-Stage Obstruction-Based Endoscopic Approach to Congenital Nasolacrimal Duct Obstruction

Purpose: To report 10-year results of a 1-stage, obstruction-based, endoscopic approach in children with congenital nasolacrimal duct obstruction (CNLDO) with and without prior failed probing/intubation. Methods: In a retrospective study, children with primary CNLDO of >6 months old previously failed probing/intubation, acute dacryocystitis or dacryocele at any age, and at least 6 months follow up. Diagnosis was based on history of tearing and dye disappearance test. Excluded were patients with complete puncto-canalicular obstruction and craniofacial anomaly. Type of CNLDO was confirmed using endonasal endoscopic guided probing. An endoscopic probing was performed for membranous, intubation for incomplete complex, and dacryocystorhinostomy for complete complex CNLDO. They were followed at 1 week, 1, 3, and 6 months, and then after. Success was defined as no or occasional tearing related to noxious stimulus at least 6 months after the procedure. Results: There were 226 eyes (200 patients). Mean age was 26.72 months. Previous failed probing/intubation was in 34.1%. Inferior turbinate impaction in 73.5% and septal deviation in 2.7% were noted. Membranous CNLDO was found in 38.9%, incomplete complex in 57.9%, and complete complex in 3.1%. Mean time of tube removal was 11.9 weeks and last follow-up time was 24.3 months. There was no significant effect of any variables on the final success rates (probing: 96.5%, intubation: 95.4%, dacryocystorhinostomy: 100%). Conclusions: One-stage, obstruction-based endoscopic approach to CNLDO resulted in a high success rate for different types of CNLDO (membranous, incomplete complex, and complete complex). No variable significantly affected the success rates.

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Orbitocutaneous Fistula Secondary to Buried Polyethylene Mesh Implant 12 Years After Injury

Fabric monofilament polyethylene mesh is an implant primarily used in the repair of abdominal and chest walls. However, there have been isolated reports of using this implant in facial reconstruction. The authors describe a patient who underwent prior orbital floor fracture repair with polyethylene mesh and subsequently developed a recurrent orbital abscess 12 years later. Despite incorporation of the fabric monofilament polyethylene mesh within healed bone, an orbitocutaneous fistula developed after a secondary injury, causing hyperglobus and cicatricial lower eyelid retraction.

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Rates of Positive Findings on Positron Emission Tomography and Bone Marrow Biopsy in Patients With Ocular Adnexal Lymphoma

Purpose: The aim of this study was to determine rates of positive findings on positron emission tomography (PET) and bone marrow biopsy performed during staging workup for ocular adnexal lymphoma (OAL). Methods: A retrospective review of OAL patients was conducted. Demographics, primary versus secondary OAL, histologic subtype, and findings on PET and bone marrow biopsy performed as part of the initial staging workup for OAL were recorded. Results: The study included 119 patients with OAL. There were 85 primary and 34 secondary OALs. The main histologic subtypes of lymphoma were mucosa-associated lymphoid tissue (n = 61), follicular (n = 26), diffuse large B-cell (n = 17), and mantle cell (n = 10). Positive PET findings were seen in 42 of 68 patients (62%) with primary OAL and 19 of 24 (79%) with secondary OAL. Positive PET findings were seen in 24 of 47 patients (51%) with mucosa-associated lymphoid tissue, 13 of 17 (76%) with follicular, 14 of 15 (93%) with diffuse large B-cell, and 9 of 10 (90%) with mantle cell lymphoma. Positive findings on bone marrow biopsy were seen in 7 of 59 patients (12%) with mucosa-associated lymphoid tissue, 4 of 23 (17%) with follicular, 1 of 17 (6%) with diffuse large B-cell, and 2 of 9 (22%) with mantle cell lymphoma. Conclusions: Our findings suggest that a significant proportion of patients with primary and secondary OAL have positive findings on PET and bone marrow biopsy at initial diagnosis, suggesting a reasonable yield for these tests as part of the initial staging workup in patients with a new diagnosis of OAL.

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Conjunctival Melanoma Responsive to Combined Systemic BRAF/MEK Inhibitors

This report demonstrates a unique case of conjunctival melanoma harboring a BRAF V600E mutation responsive to systemic therapy with BRAF and MEK inhibitors. While systemic therapy would not be appropriate in patients with local disease alone, it may act therapeutically in cases of higher stage ocular surface and eyelid melanoma.

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Periocular Breast Carcinoma Metastases: Predominant Origin From the Lobular Variant

Purpose: To further define the histopathologic features of breast carcinoma conducive to orbital metastasis. Methods: Ten new female patients with orbital or eyelid breast cancer metastases encountered between 2011 and 2016 had their medical records reviewed for determining their clinical characteristics. Microscopic glass slides from biopsies and immunohistochemical test results were also analyzed. Biomarkers studied included cytokeratin 7, nuclear estrogen and progesterone receptors, HER2, and E-cadherin. Results: All orbital metastatic lesions were lobular (nonductal) carcinomas that could arise as late as 24 years after the diagnosis of the primary breast tumors. The average age of patients at the time or orbital presentation was 64 years. Metastases were composed of small tumor cells with round, orthochromatic nuclei, and a small amount of cytoplasm. The cells were disposed in a variably fibrotic tumor-associated stroma. Two lesions were variants of lobular carcinoma—namely, alveolar and pleomorphic (the latter displaying cellular crowding, with some degree of nuclear atypia and less stroma). Three of the 9 orbital metastases presented with enophthalmos and 2 displayed euphthalmos despite variably sized orbital masses. In 2 cases, synchronous bilateral orbital metastases prevented any relative difference in globe position. Estrogen and progesterone receptors were usually detectable whereas E-cadherin could not be demonstrated. Conclusions: Breast pathologists no longer refer to primary breast carcinomas and their orbital metastases as "scirrhous." It has been determined that the majority of orbital breast metastases are lobular carcinomas. This may be due to their lack of intercellular cohesiveness and the absence of E-cadherin which normally is expressed in many neoplastic cell types including ductal breast carcinomas, limiting their dispersion. In contrast, the majority of primary breast carcinomas are ductal. The ubiquitous collagenous matrix in breast metastases retracts, partially accounting for enophthalmos. The presence of euphthalmos despite an orbital mass additionally suggests some retraction of fibrous tissue (with or without fat atrophy) that suppresses relative proptosis. Metastatic lobular breast carcinoma is further implicated if there is a concomitant limitation in extraocular motility or vision decline.

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Amelanotic Cellular Blue Nevus of the Eyelid

The authors describe an isolated, yellowish papular lesion of the upper eyelid in a 63-year-old man. Following excision, histopathologic analysis showed the features of a benign hypopigmented cellular blue nevus, the first and only case involving the eyelid skin.

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An Anatomical Murine Model of Heterotopic Periorbital Subunit Transplantation

Background: Conventional reconstructive methods fail to achieve satisfactory results in total eyelid defect cases. Vascularized composite tissue allotransplantation might provide both good appearance and function for these patients. The structure of the eyelid is exceptional because it simultaneously consists of skin, connective tissue, the striated muscle, fiber structure, aponeuroses, and mucosa. Thus, before clinical application of eyelid allotransplantation, more experiments are needed to clarify the impact of ischemia, immunal suppressive agents, and deinnervation effects on these sophisticated structures. We developed an heterotopic periorbital transplantation model in rats to facilitate further experiment in this field. Methods: Twenty-five inbred male Lewis rats were used for anatomy study (n=10), and as donors or recipients of the operations (n=10). In the anatomy study, the vascular distribution and innervation to the periorbital unit was identified and recorded. Then, according to the anatomy study, 10 heterotopic transplantations and 2 transplantations with pedicle ligated were performed. The posterior facial vein and the external carotid artery are selected as the graft pedicle. All transplanted eyelids were assessed daily. Micro-CT scanning and hematoxylin and eosin staining of the grafts were performed 60 days after the operation. Results: All recipients tolerated the operation well. All grafts without pedicles ligated survived and new hair growth was observed. All of the transplanted eyelids were pink and pliable during the entire observation period, and we did not observe any signs of arterial or venous occlusion. In the recipients with graft pedicle ligated, the grafts were necrosed and mummified within 4 to 5 days. MicroCT of the survived grafts showed good blood supply and histologic staining revealed normal histologic morphologies. Conclusions: Our study proved the anatomical feasibility of periorbital transplantation by establishing a heterotopic transplantation model, which might facilitate future eyelid allotransplantation-related experiments.

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Pott’s Puffy Tumor: A Rare Presentation

No abstract available

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Clinical Presentation and Bacteriology of Eyebrow Infections: The Massachusetts Eye and Ear Infirmary Experience (2008–2015)

Purpose: This study retrospectively reviews preseptal cellulitis and abscesses involving the eyebrow to elucidate the bacteriology and potential causative factors. Methods: A retrospective chart review was conducted to identify patients who had been diagnosed with preseptal cellulitis or abscess involving the eyebrow at the Massachusetts Eye and Ear Infirmary between 2008 and 2015. Demographic, clinical, and microbiological data were collected. Results: Eighty patients with eyebrow infections were identified, of whom 49 (61.3%) were female and 31 (38.7%) were male. The median age was 37 years (range 14–67 years). Eyebrow abscess was present in 54 cases (67.5%), while 26 cases (32.5%) were limited to preseptal cellulitis without abscess formation. Methicillin-resistant Staphylococcus aureus was found in 20 abscesses (39.2% of culture results), and methicillin-sensitive S. aureus was found in 12 abscesses (23.5% of culture results). Coagulase-negative staphylococci were present in 7 eyebrow abscesses (13.7% of culture results). Clinical history was remarkable for eyebrow hair removal (tweezing, waxing, threading, or shaving) in 17 cases (21.3%), manipulation of acne lesions ("popping," "picking," or "squeezing") in 6 cases (7.5%), and both brow hair removal and acne manipulation in 1 case (1.3%). Conclusions: There is a high incidence of methicillin-resistant Staphylococcus aureus in the bacteriology of eyebrow infections. Empirical antibiotic coverage for methicillin-resistant Staphylococcus aureus should be strongly considered in any patient with an eyebrow area abscess or preseptal cellulitis. Individuals who practice cosmetic eyebrow grooming should be encouraged to consider hygiene practices, which could reduce the risk of infection.

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The meta‐analysis

Fernando de Andrade Quintanilha Ribeiro
Braz J Otorhinolaryngol.2017;83:497

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First Clinical Consensus and National Recommendations on Tracheostomized Children of the Brazilian Academy of Pediatric Otorhinolaryngology (ABOPe) and Brazilian Society of Pediatrics (SBP)

Melissa A.G. Avelino, Rebecca Maunsell, Fabiana Cardoso Pereira Valera, José Faibes Lubianca Neto, Cláudia Schweiger, Carolina Sponchiado Miura, Vitor Guo Chen, Dayse Manrique, Raquel Oliveira, Fabiano Gavazzoni, Isabela Furtado de Mendonça Picinin, Paulo Bittencourt, Paulo Camargos, Fernanda Peixoto, Marcelo Barciela Brandão, Tania Maria Sih, Wilma Terezinha Anselmo‐Lima
Braz J Otorhinolaryngol.2017;83:498-506

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Impact of cartilage graft size on success of tympanoplasty

Waleed Abdelhameed, Ibrahim Rezk, Alhussein Awad
Braz J Otorhinolaryngol.2017;83:507-11

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Encoding of speech sounds at auditory brainstem level in good and poor hearing aid performers

Hemanth Narayan Shetty, Manjula Puttabasappa
Braz J Otorhinolaryngol.2017;83:512-22

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Profile and prevalence of hearing complaints in the elderly

Magda Aline Bauer, Ângela Kemel Zanella, Irênio Gomes Filho, Geraldo de Carli, Adriane Ribeiro Teixeira, Ângelo José Gonçalves Bós
Braz J Otorhinolaryngol.2017;83:523-9

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Preoperative vestibular assessment protocol of cochlear implant surgery: an analytical descriptive study

Roseli Saraiva Moreira Bittar, Eduardo Setsuo Sato, Douglas Jósimo Silva Ribeiro, Robinson Koji Tsuji
Braz J Otorhinolaryngol.2017;83:530-5

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Treatment of large persistent tracheoesophageal peristomal fistulas using silicon rings

Ibrahim Erdim, Ali Ahmet Sirin, Bahadir Baykal, Fatih Oghan, Ali Guvey, Fatma Tulin Kayhan
Braz J Otorhinolaryngol.2017;83:536-40

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The effect of melatonin and vitamin C treatment on the experimentally induced tympanosclerosis: study in rats

Sema Koc, Halil Kıyıcı, Aysun Toker, Harun Soyalıç, Huseyin Aslan, Hakan Kesici, Zafer I. Karaca
Braz J Otorhinolaryngol.2017;83:541-5

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Efficacy of syringe‐irrigation topical therapy and the influence of the middle turbinate in sinus penetration of solutions

Guilherme Henrique Wawginiak, Leonardo Balsalobre, Eduardo Macoto Kosugi, João Paulo Mangussi‐Gomes, Raul Ernesto Samaniego, Aldo Cassol Stamm
Braz J Otorhinolaryngol.2017;83:546-51

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Evaluation of aesthetic and functional outcomes in rhinoplasty surgery: a prospective study

Sara Sena Esteves, Miguel Gonçalves Ferreira, João Carvalho Almeida, José Abrunhosa, Cecília Almeida e Sousa
Braz J Otorhinolaryngol.2017;83:552-7

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Medical adherence to intranasal corticosteroids in adult patients

Emre Ocak, Baran Acar, Deniz Kocaöz
Braz J Otorhinolaryngol.2017;83:558-62

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An often neglected area in crooked nose: middle turbinate pneumatization

Fatih Özdoğan, Halil Erdem Özel, Erkan Esen, Erdem Altıparmak, Selahattin Genç, Adin Selçuk
Braz J Otorhinolaryngol.2017;83:563-7

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Does stapes surgery improve tinnitus in patients with otosclerosis?

Onur Ismi, Osman Erdogan, Mesut Yesilova, Cengiz Ozcan, Didem Ovla, Kemal Gorur
Braz J Otorhinolaryngol.2017;83:568-73

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Speech perception performance of subjects with type I diabetes mellitus of noise

Bárbara Cristiane Sordi Silva, Erika Barioni Mantello, Maria Cristina Foss Freitas, Milton César Foss, Myriam de Lima Isaac, Adriana Ribeiro Tavares Anastasio
Braz J Otorhinolaryngol.2017;83:574-9

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Hearing handicap in patients with chronic kidney disease: a study of the different classifications of the degree of hearing loss

Klinger Vagner Teixeira da Costa, Sonia Maria Soares Ferreira, Pedro de Lemos Menezes
Braz J Otorhinolaryngol.2017;83:580-4

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Proliferative verrucous leukoplakia: diagnosis, management and current advances

Diogo Lenzi Capella, Jussara Maria Gonçalves, Adelino Antônio Artur Abrantes, Liliane Janete Grando, Filipe Ivan Daniel
Braz J Otorhinolaryngol.2017;83:585-93

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Canine fossa puncture in endoscopic sinus surgery: report of two cases

Federico Sireci, Matteo Nicolotti, Paolo Battaglia, Raffaele Sorrentino, Paolo Castelnuovo, Frank Rikki Canevari
Braz J Otorhinolaryngol.2017;83:594-9

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Postauricular neurofibroma – a rare occurrence

Tan Shi Nee, Mazita Ami, Kong Min Han, Primuharsa Putra Sabir Husin Athar
Braz J Otorhinolaryngol.2017;83:600-1

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Thyroid compressive mass, a metastasis of femur chondrosarcoma after 14 years: case report and literature review

François Simon, Marion Classe, Pierre Vironneau, Michel Wassef, Philippe Herman, Nicolas Le Clerc
Braz J Otorhinolaryngol.2017;83:602-4

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Oral manifestations of dengue viral infection

Beuy Joob, Viroj Wiwanitkit
Braz J Otorhinolaryngol.2017;83:605

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“The Use Of Bone Grafts Or Modified BSSO Technique In Large Mandibular Advancements Reduces The Risk Of Persisting Mandibular Inferior Border Defects”

Publication date: Available online 11 September 2017
Source:Journal of Oral and Maxillofacial Surgery
Author(s): Julio Cifuentes, Nicolás Yanine, Daniel Jerez, Ariel Barrera, Jimoh Olubanwo Agbaje, Constantinus Politis
PurposeHealing of the inferior border of the mandible may be compromised in large advancements, leaving an unaesthetic defect at the inferior border. The objective of this article is to compare different bilateral sagittal split osteotomy (BSSO) techniques in order to prevent the incidence of lower border mandibular defects.Patients and MethodsThe authors undertook a retrospective multicenter cohort study comparing three BSSO techniques for advancements greater than 5 millimeters: Traditional Non-Grafted BSSO Technique (group A), Traditional Grafted BSSO Technique (group B) and Modified BSSO Technique (group C). The space created by the mandibular advancement was measured. The presence or absence of a defect was determined one year post-surgery by clinical and radiographic assessment. The bone defect outcome was associated with potential risk predictors (age, sex, side of sagittal split osteotomy, and magnitude of mandibular advancement) by logistic regression analysis.ResultsA total of 1002 operative sites in 501 patients were included in the study. Age 26,8 SD (11), sex (310 female, 191 male) and mandibular advancement (9,3mm right side, 10mm left side) were similar between the groups. (p>.05) The proportion of post-surgical lower border mandibular defects were: group A 54,5%, group B 1,3% and group C 10,6%. The Traditional Grafted BSSO Technique, and Modified BSSO Technique were significantly more effective in preventing the incidence of mandibular lower border defects compared with Traditional Non-Grafted BSSO Technique. (p<.05)ConclusionSurgeons are advised that there is a significant proportion of mandibular lower border defects with the Traditional Non-Grafted BSSO Technique.The use of bone grafts or the modified BSSO technique in mandibular advancements greater than 10 mm significantly reduces the risk of persisting mandibular inferior border defects.



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Management of Head and Neck Burns – a 15 year review

Publication date: Available online 11 September 2017
Source:Journal of Oral and Maxillofacial Surgery
Author(s): Travis J. Hamilton, Jeromy Patterson, Rachael Y. Williams, Walter L. Ingram, Juvonda S. Hodge, Shelly Abramowicz
PurposeThe purpose of this project was to characterize isolated head and neck burns admitted to Grady Memorial Hospital (GMH) Burn Center.Materials and MethodsThis was a retrospective case series of patients admitted to GMH Burn Center with primary diagnosis of head and neck burns from 2000-2015. Demographic data (gender and age) were recorded. Burn details (etiology, mechanism, percent of burned total body surface area [TBSA], depth, and associated injuries) was summarized. Patient management and hospital course were documented. The data were collected using a standardized collection form. Descriptive statistics were computed.ResultsThere were 5,938 patients admitted to burn unit at GMH during the study period. Of them, 2,547 patients had head and neck burns. 205 patients met inclusion criteria. Majority (n=136, 66%) were male with a mean age of 40 years old. The most common burn depth was superficial partial thickness. Flame burns were the most likely mechanism related to full thickness injury. About a quarter of patients had an associated injury such as inhalation or ocular injury. Surgical interventions consisted of tangential excision and split thickness skin grafting, contracture release, excision of hypertrophic scars, and rotational flaps. The mean LOS for isolated head and neck burns was 4.4 days. Overall mortality was 2%.ConclusionThe results of this study show that superficial partial thickness head and neck burns were more likely to occur due to accidental exposure to flames in men older than 55 years. Due to an increase in risk and mortality of inhalation injury associated with head and neck burns, airway protection and respiratory management are critical considerations of head and neck burn management.



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Immediate reconstruction of failed implants in the esthetic zone using a flapless technique and autogenous composite tuberosity graft

Publication date: Available online 11 September 2017
Source:Journal of Oral and Maxillofacial Surgery
Author(s): Gerry M. Raghoebar, Henny J.A. Meijer, Baucke van Minnen, Arjan Vissink
We describe a technique for immediate reconstruction of bone after removal of failed dental implants in the aesthetic region in order to optimize the aesthetic outcome of retreatment. We conducted a study in 16 consecutive patients in which the bony defect resulting from implant removal was immediately reconstructed with a combined autogenous bone and soft tissue graft harvested from the maxillary tuberosity. After a healing period of 3 months, implants were inserted. One year after placement of the definitive restoration, no implants were lost, the peri-implant tissues were healthy, the aesthetics scored with the pink aesthetic score were favorable and the patients were satisfied. With this technique, it appears that immediate reconstruction of the hard and soft tissue components with a combined bone-soft tissue graft after removal of an implant is a feasible treatment option, both from the perspective of the patient and professional. It expedites rehabilitation, reduces morbidity and is accompanied by a favorable aesthetic outcome.



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Periorbital necrotizing fasciitis induced by streptococcus pyogenes: a case report and clarification.

Publication date: Available online 11 September 2017
Source:Journal of Oral and Maxillofacial Surgery
Author(s): D. Deneubourg, Z. Catherine, P. Lejuste, P. Breton
IntroductionPeriorbital necrotizing fasciitis (PONF) is a rare condition of the face. PONF can lead to blindness, functionnal and aesthetic sequellae, multiple organ failure and death. The aim of this article is, through a case report, to raise the awereness of maxillofacial surgeons on this severe disease.Case reportWe report a case of a 30-year-old woman who presented with a bilateral palpebral oedema and pain three days after a jugal wound was sutured. Necrosis of the skin of the left palpebral unit was extending rapidly. The patient had signs of sepsis. Surgical debridement was performed promptly and associated with intravenous broad-spectrum empiric antibiotics. The patient recovered slowly with no complication other than residual skin defect of both eyelids which was later corrected by fullthickness skin graft.ConclusionSpecial attention should be payed to signs of preseptal cellulitis as they can, in some cases, rapidly turn into a PONF. Early diagnosis and treatment are the keys to favorable outcome.



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“Silent” Sleep Apnea in Dentofacial Deformities and Prevalence of Daytime Sleepiness after Orthognathic/Intranasal Surgery

Publication date: Available online 11 September 2017
Source:Journal of Oral and Maxillofacial Surgery
Author(s): Jeffrey C. Posnick, Anayo Adachie, Neeru Singh, Elbert Choi
PurposeThe purposes of this study were to: determine the occurrence of undiagnosed "silent" obstructive sleep apnea (OSA) in dentofacial deformity (DFD) subjects at initial surgical presentation; and to report on the level of daytime sleepiness in DFD subjects with OSA and chronic obstructed nasal breathing (CONB) after undergoing bimaxillary, chin, and intranasal surgery.MethodsA retrospective cohort study of subjects with a bimaxillary DFD and CONB was implemented. Subjects were divided into Group I (no OSA) and Group II (OSA). Group II was further subdivided into Group IIa (referred with polysomnogram [PSG] confirmed OSA) and Group IIb (diagnosis of OSA only after surgical consultation/airway evaluation and positive PSG). Group II subjects were analyzed > 1 year after surgery (range 1-10 years) for daytime sleepiness using the Epworth Sleepiness Survey (ESS). Subjects with postoperative excessive daytime sleepiness (EDS) were assessed for risk factors and continued need for OSA treatment. Subjects in Group II were studied to determine which DFD patterns were most associated with OSA. We compared the prevalence of OSA between our study population and the general population.ResultsTwo-hundred and sixty-two subjects met the inclusion criteria. Twenty-three percent (60/262) had PSG confirmed OSA (Group II). This was much higher than found in the general population. Seven percent (19/262) were known to have OSA at initial surgical consultation (Group IIa). An additional 16% (41/262) were later confirmed by PSG to have OSA (Group IIb). Primary mandibular deficiency and short face DFDs were most likely to have OSA (p=0.000 and 0.001, respectively). In Group II, 91% (55/60) rated their daytime sleepiness as "Not Sleepy" at a minimum of 1 year after surgery. A significant association was found between Group II subjects with post-operative EDS ("sleepy" or "very sleepy") and a preoperative BMI level of overweight (p=0.026).ConclusionOur study found "silent" OSA to be frequent in the DFD population. The prevalence of OSA in DFD subjects exceeded that estimated in the general population, with retrusive jaw patterns most affected. In DFD subjects also presenting with OSA and CONB, we confirmed low levels of daytime sleepiness long-term after simultaneous bimaxillary orthognathic, chin, and intranasal surgery.



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Efficacy and safety of controlled-release oxycodone/naloxone versus controlled-release oxycodone in Korean patients with cancer-related pain: a randomized controlled trial

Controlled-release oxycodone/naloxone (OXN-CR) maintains the effect of opioid-induced analgesia through oxycodone while reducing the occurrence rate of opioid-induced constipation through naloxone. The present...

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Antiinflammatory strategies in intrahepatic islet transplantation: a comparative study in preclinical models.

Background: The identification of pathway(s) playing a pivotal role in peritransplant detrimental inflammatory events represents the crucial step towards a better management and outcome of pancreatic islet transplanted patients. Recently, we candidate the CXCR1/2 inhibition as a relevant strategy in enhancing pancreatic islet survival after transplantation. Methods: Here, the most clinically used antiinflammatory compounds (IL1-receptor antagonist, steroids and TNF-[alpha] inhibitor) alone or in combination with a CXCR1/2 inhibitor were evaluated in their ability to improve engraftment or delay graft rejection. To rule out bias related to transplantation site, we used well-established preclinical syngeneic (250 C57BL/6 equivalent islets in C57BL/6) and allogeneic (400 Balb/c equivalent islets in C57BL6) intrahepatic islet transplantation platforms. Results: In mice, we confirmed that targeting the CXCR1/2 pathway is crucial in preserving islet function and improving engraftment. In the allogeneic setting, CXCR1/2 inhibitor alone could reduce the overall recruitment of transplant-induced leukocytes and significantly prolong the time to graft rejection both as single agent and in combination with immunosuppression. No other antiinflammatory compounds tested (IL1-receptor antagonist, steroids and TNF-[alpha] inhibitor) alone or in combination with CXCR1/2 inhibitor, improve islet engraftment and significantly delay graft rejection in the presence of MMF+FK-506 immunosuppressive treatment. Conclusions: These findings indicate that only the CXCR1/2-mediated axis plays a crucial role in controlling the islet damage and should be a target for intervention to improve the efficiency of islet transplantation. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Endocrine Mucin-Producing Sweat Gland Carcinoma of the Eyelid Associated With Mucinous Adenocarcinoma.

Endocrine mucin-producing sweat gland carcinoma, a rare, low-grade neoplasm with predilection for the eyelids, has been posited as a precursor to invasive mucinous adenocarcinoma. Endocrine mucin-producing sweat gland carcinoma and its concurrence with mucinous adenocarcinoma have received little attention in the ophthalmic literature. The combination of the 2 histologic patterns parallels endocrine ductal carcinoma in situ of the breast and its transition to Type B invasive mucinous carcinoma. The authors describe a 59-year-old man who developed a tumor of the right upper eyelid showing endocrine mucin-producing sweat gland carcinoma in the outer dermis and extensive mucinous carcinoma in the deeper tissue. Immunohistochemical analysis showed positivity for endocrine markers chromogranin, synaptophysin, CD56, estrogen, and progesterone in each histologic component of the tumor. This research was conducted in conformity with the Helsinki Declaration and HIPPA regulations. (C) 2017 by The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc., All rights reserved.

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Efficacy and safety of controlled-release oxycodone/naloxone versus controlled-release oxycodone in Korean patients with cancer-related pain: a randomized controlled trial

Abstract

Background

Controlled-release oxycodone/naloxone (OXN-CR) maintains the effect of opioid-induced analgesia through oxycodone while reducing the occurrence rate of opioid-induced constipation through naloxone. The present study was designed to assess the non-inferiority of OXN-CR to controlled-release oxycodone (OX-CR) for the control of cancer-related pain in Korean patients.

Methods

In this randomized, open-labeled, parallel-group, phase IV study, we enrolled patients aged 20 years or older with moderate to severe cancer-related pain [numeric rating scale (NRS) pain score ≥4] from seven Korean oncology/hematology centers. Patients in the intention-to-treat (ITT) population were randomized (1:1) to OXN-CR or OX-CR groups. OXN-CR was administered starting at 20 mg/10 mg per day and up-titrated to a maximum of 80 mg/40 mg per day for 4 weeks, and OX-CR was administered starting at 20 mg/day and up-titrated to a maximum of 80 mg/day for 4 weeks. The primary efficacy endpoint was the change in NRS pain score from baseline to week 4, with non-inferiority margin of −1.5. Secondary endpoints included analgesic rescue medication intake, patient-reported change in bowel habits, laxative intake, quality of life (QoL), and safety assessments.

Results

Of the ITT population comprising 128 patients, 7 with missing primary efficacy data and 4 who violated the eligibility criteria were excluded from the efficacy analysis. At week 4, the mean change in NRS pain scores was not significantly different between the OXN-CR group (n = 58) and the OX-CR group (n = 59) (−1.586 vs. −1.559, P = 0.948). The lower limit of the one-sided 95% confidence interval (−0.776 to 0.830) for the difference exceeded the non-inferiority margin (P < 0.001). The OXN-CR and OX-CR groups did not differ significantly in terms of analgesic rescue medication intake, change in bowel habits, laxative intake, QoL, and safety assessments.

Conclusions

OXN-CR was non-inferior to OX-CR in terms of pain reduction after 4 weeks of treatment and had a similar safety profile. Studies in larger populations of Korean patients with cancer-related pain are needed to further investigate the effectiveness of OXN-CR for long-term pain control and constipation alleviation.

Trial registration ClinicalTrials.gov NCT01313780, registered March 8, 2011

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