Ali Izadpanah

Propranolol versus corticosteroids in the treatment of infantile hemangioma: a systematic review and meta-analysis.

Background: Infantile hemangiomas are benign vascular neoplasms that can cause numerous functional or cosmetic problems. The authors reviewed the pathogenesis of hemangioma and compared the efficacy and complications related to therapy with propranolol versus corticosteroids. Methods: A comprehensive review of the literature was conducted from 1965 to March of 2012 using MEDLINE, PubMed, Ovid, Cochrane Review database, and Google Scholar. All articles were reviewed for reports of clinical cases, reported side effects, doses, duration of treatment, number of patients, and response rate to treatment. Results: A total of 1162 studies were identified. Of those, only 56 articles met inclusion criteria after review by two independent reviewers (A.I. and J.K.). For the meta-analysis, 16 studies comprising 2629 patients and 25 studies comprising 795 patients were included. Less than 90 percent of patients treated with corticosteroids responded to therapy, compared with 99 percent of patients treated with propranolol after 12 months of follow-up. Meta-analysis demonstrated the corticosteroid studies to have a pooled response rate of 69 percent versus the propranolol response rate of 97 percent (p < 0.001). Conclusions: Propranolol is a relatively recent therapy of hemangiomas with fewer side effects, a different mechanism of action, and greater efficacy than current first-line corticosteroid therapy. Many of these studies do not have the same patient population or duration/regimen of treatment for hemangiomas; however, based on available data in the literature, it appears that propranolol could be an emerging and effective treatment for infantile hemangiomas. Further randomized controlled trials are recommended. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Utility outcome scores for unilateral facial paralysis.

BackgroundFacial paralysis is a debilitating condition. Dynamic and static facial reanimation remains a challenge for plastic surgeons and requires important resources. Our objective was to quantify the health state utility assessment (ie, utility score outcomes) of living with unilateral facial paralysis. MethodsUtility assessments using visual analog scale, time trade-off, and standard gamble were used to obtain utility outcome scores for unilateral facial paralysis from a prospective sample of the general population and medical students. ResultsA total number of 123 individuals prospectively participated in the study. All measures (visual analog scale, time trade-off, and standard gamble) for unilateral facial paralysis [0.56 ± 0.18, 0.78 ± 0.21, and 0.79 ± 0.21 respectively] were significantly different (P < 0.0001) from the corresponding outcome scores for monocular blindness [0.61 ± 0.21, 0.83 ± 0.21, and 0.85 ± 0.18, respectively] and binocular blindness [0.33 ± 0.18, 0.65 ± 0.28, and 0.65 ± 0.29, respectively]. Linear regression analysis using age, race, income, and education as predictors of each of the utility scores for facial paralysis showed no statistical significance. ConclusionsIn samples of the general population and medical students, all utility score outcome measures for facial paralysis were lower than those for monocular blindness. Our sample population, if faced with unilateral facial paralysis, would theoretically undergo facial reanimation procedures with a willingness to sacrifice 8 years of life and be willing to undergo a procedure with a 21% chance of mortality to attain perfect health, respectively.

The impact of living with a functional and aesthetic nasal deformity after primary rhinoplasty: a utility outcomes score assessment.

BackgroundRevision rhinoplasty for functional deformities can be both an aesthetic and reconstructive surgical challenge. We set out to quantify the health state utility assessment of living with the physical appearance of nasal asymmetry along with having nasal obstruction. The use of utility scores has helped to establish the health burden of living with various medical conditions. We sought to quantify living with a health state of nasal asymmetry with nasal obstruction after primary rhinoplasty using utility outcome scores. MethodsWe used previously validated utility outcome measures to quantify the health burden of this clinical scenario in 128 prospective subjects. These subjects were from a sample of the population and medical students recruited to complete a survey to determine the utility outcome score of revision rhinoplasty using visual analog scale (VAS), time trade-off (TTO), and standard gamble (SG) tests to obtain utility scores for revision rhinoplasty. Linear regression and Student t test were used for statistical analysis. ResultsAll measures (VAS, TTO, and SG) for functional nasal deformity (0.80 ± 0.13, 0.90 ± 0.12, and 0.91 ± 0.13, respectively) of the 128 prospective subjects participating in this online study were significantly different (P < 0.005) from the corresponding scores for monocular blindness (0.63 ± 0.15, 0.85 ± 0.16, and 0.85 ± 0.19, respectively) and binocular blindness (0.38 ± 0.18, 0.66 ± 0.25, and 0.69 ± 0.24, respectively). Being white was inversely related to the VAS utility scores for rhinoplasty (P < 0.05). Additionally, female sex was positively correlated to the TTO score. Age, income, and education were not predictors of utility scores. ConclusionsIn a sample of the population and medical students, VAS, TTO, and SG utility scores for revision rhinoplasty were determined and can be compared objectively with other health states and diseases with known utility scores. In a preoperative setting, women were objectively willing to potentially “trade” more years of life to treat a functional nasal deformity. If faced with a deformed nose after primary rhinoplasty, our sample population would consent to undergo a revision rhinoplasty procedure with a theoretical 9% chance of mortality and were willing to trade 3.6 years of their remaining life.

Quantitative analysis of the orbital floor defect after zygoma fracture repair.

PURPOSE Moderate-energy zygoma fractures result frequently in a posteromedially displaced bone fragment. Closed reduction using a force vector directed in an anterolateral direction frequently produces stable repair of these injuries. Exploration of the orbital floor (OF) is not routinely undertaken. However, as the zygoma forms a significant portion of the OF, realignment may create an unrecognized OF defect. Routine OF exploration may be unnecessary and carries the risks of eyelid malposition, scarring, and extraocular muscle injury. Our goal was to quantitatively describe the effect of zygoma reduction on OF defect size and identify predictors for floor exploration. PATIENTS AND METHODS Retrospectively, patients with moderate energy zygoma fractures were identified. Fractures inadequately reduced on the postoperative computed tomography (CT) scan or those which underwent OF exploration were excluded. The sizes of preoperative and postoperative floor defects from CT scans were measured. Globe projection was measured. Statistical analysis was carried out using Students t test. RESULTS Of 102 identified patients, 15 satisfied the inclusion criteria. The average pre- and postoperative OF defects measured 0.3 and 0.6 cm(2), respectively. This difference approached statistical significance, but was clinically insignificant except in 1 patient. Similarly, globe projection was clinically similar between the repaired and unaffected sides, except in the same patient. CONCLUSION In majority, repair of moderate energy zygoma fractures does not clinically significantly increase OF defect or produce enophthalmos. In patients with significant displacement of the zygoma at the level of OF with comminution of floor fragments, the reduction maneuver may create a critical size defect and we believe should be followed by floor exploration.

A comparison and cost analysis of cranioplasty techniques: autologous bone versus custom computer-generated implants.

BackgroundCranioplasty can be performed either with gold-standard, autologous bone grafts and osteotomies or alloplastic materials in skeletally mature patients. Recently, custom computer-generated implants (CCGIs) have gained popularity with surgeons because of potential advantages, which include preoperatively planned contour, obviated donor-site morbidity, and operative time savings. A remaining concern is the cost of CCGI production. The purpose of the present study was to objectively compare the operative time and relative cost of cranioplasties performed with autologous versus CCGI techniques at our center. MethodsA review of all autologous and CCGI cranioplasties performed at our institution over the last 7 years was performed. The following operative variables and associated costs were tabulated: length of operating room, length of ward/intensive care unit (ICU) stay, hardware/implants utilized, and need for transfusion. ResultsTotal average cost did not differ statistically between the autologous group (n = 15;

Utility Outcome Assessment of the Aging Neck following Massive Weight Loss

25,797.43) and the CCGI cohort (n = 12;

The impact of living with severe lower extremity lymphedema: a utility outcomes score assessment.

28,560.58). Operative time (P = 0.004), need for ICU admission (P < 0.001), and number of complications (P = 0.008) were all statistically significantly less in the CCGI group. The length of hospital stayand number of cases needing transfusion were fewer in the CCGI group but did not reach statistical significance. ConclusionThe results of the present study demonstrated no significant increase in overall treatment cost associated with the use of the CCGI cranioplasty technique. In addition, the latter was associated with a statistically significant decrease in operative time and need for ICU admission when compared with those patients who underwent autologous bone cranioplasty.Level of evidence: IV, therapeutic

Living with a Unilateral Mastectomy Defect: A Utility Assessment and Outcomes Study

Objective The authors set out to quantify the health state utility assessment of living with the physical appearance of the aging neck following massive weight loss. Described utility scores may help to establish the health burden of the aging neck in the growing bariatric patient population. Study Design Prospective cohort observational study. Setting Tertiary referral medical center. Subjects and Methods Three validated tools were used to determine utility scores for living with an aging neck: visual analog scale (VAS), time trade-off (TTO), and standard gamble (SG). A 5-point Likert scale was used to evaluate the subjects’ ease of understanding. A prospective sample of volunteers from the general population and medical students was used for this assessment. Results In total, 118 prospective volunteers were included in the survey. All measures (VAS, TTO, SG); (0.89 ± 0.07, 0.94 ± 0.08, and 0.95 ± 0.10, respectively) varied (P < .0001) from the corresponding ones for monocular blindness (0.62 ± 0.18, 0.87 ± 0.15, and 0.85 ± 0.20, respectively) and binocular blindness (0.32 ± 0.18, 0.66 ± 0.25, and 0.64 ± 0.28, respectively). Conclusion The authors objectified the health state of living with an aging neck in the massive weight loss patient with utility scores (TTO, 0.94) comparable with those living with obstructive sleep apnea. This sample population, if faced with an aging neck following massive weight loss, would undertake a neck rejuvenation procedure with a theoretical 5% chance of mortality and would be willing to trade 2.1 years of remaining life-years to attain this procedure.

Nipple-areolar Complex Reconstruction following Postmastectomy Breast Reconstruction: A Comparative Utility Assessment Study

BackgroundDebilitating lower extremity lymphedema can be either congenital or acquired. Utility scores are an objective measure used in medicine to quantify degrees of impact on an individual’s life. Using standardized utility outcome measures, we aimed to quantify the health state of living with severe unilateral lower extremity lymphedema. MethodsA utility outcomes assessment using visual analog scale, time trade-off, and standard gamble was used for lower extremity lymphedema, monocular blindness, and binocular blindness from a sample of the general population and medical students. Average utility scores were compared using a paired t test. Linear regression was performed using age, race, and education as independent predictors. ResultsA total of 144 prospective participants were included. All measures [visual analog scale, time trade-off, and standard gamble; expressed as mean (SD)] for unilateral lower extremity lymphedema (0.50 ± 0.18, 0.76 ± 0.22, and 0.76 ± 0.21, respectively) were significantly different (P < 0.001) from the corresponding scores for monocular blindness (0.64 ± 0.18, 0.84 ± 0.16, and 0.83 ± 0.17, respectively) and binocular blindness (0.35 ± 0.17, 0.61 ± 0.28, and 0.62 ± 0.26, respectively). ConclusionsWe found that a sample of the general population and medical students, if faced with severe lymphedema, is willing to theoretically trade 8.64 life-years and undergo a procedure with a 24% risk of mortality to restore limb appearance and function to normal. These findings provide a frame of reference regarding the meaning of a diagnosis of severe lower extremity lymphedema to a patient and will allow objective comparison with other health states.

Thigh laxity after massive weight loss: a utilities outcomes assessment.

BACKGROUND The gold standard for the treatment of breast cancer includes mastectomy surgery. Our goal was to quantify the health state utility assessment of living with unilateral mastectomy. METHODS The visual analogue scale (VAS), time trade-off (TTO), and standard gamble (SG) were used to obtain utilities for unilateral mastectomy, monocular blindness and binocular blindness from a prospective sample of the general population and medical students. RESULTS All measures (VAS, TTO, SG) for unilateral mastectomy (0.75 SD 0.17, 0.87 SD 0.14, and 0.86 SD 0.18, respectively) of the 140 volunteers were significantly different from the corresponding scores for monocular (0.61 SD 0.18, 0.84 SD 0.17, and 0.84 SD 0.18, respectively) and binocular blindness (0.38 SD 0.17, 0.67 SD 0.24, and 0.69 SD 0.23, respectively). Age, gender, race, education, and income were not statistically significant independent predictors of utility scores. CONCLUSION In a sample of the general population and medical students, utility assessments for living with unilateral mastectomy were comparable with those of living with bilateral mastectomy and severe breast hypertrophy. Our sample population, if faced living with unilateral mastectomy was willing to gamble a theoretical 14% chance of death and willing to trade 4.2 years of existing life-years.