Brent B. Pickrell

Endobronchial Ultrasonography-Guided Transbronchial Needle Aspiration Biopsy for Preoperative Nodal Staging of Lung Cancer in a Veteran Population

IMPORTANCE Recently, preoperative lung cancer staging has evolved to include endobronchial ultrasonography-guided transbronchial needle aspiration (EBUS-TBNA) biopsies of the hilar and mediastinal lymph nodes, but the feasibility and usefulness of the procedure have not been well studied in the veteran population. OBJECTIVE To determine the safety and effectiveness of EBUS-TBNA as a key component of a preoperative staging algorithm for lung cancer in veterans. DESIGN, SETTING, AND PARTICIPANTS Review of a prospectively maintained thoracic surgery database that includes patients who underwent lung resection for lung cancer between January 1, 2009, and December 31, 2012, at a single Veterans Affairs medical center among a consecutive cohort of 166 patients with clinically early-stage (I or II) lung cancer who underwent lobectomy with nodal dissection. INTERVENTIONS Endobronchial ultrasonography-guided transbronchial needle aspiration mediastinal staging (EBUS group) in 62 patients (37.3%) was compared with noninvasive nodal staging plus integrated positron emission tomography-computed tomography only (PET/CT-only group) in 104 patients (62.7%). The accuracy of nodal staging was assessed by comparison with the final pathological staging after complete nodal dissection (the gold standard). MAIN OUTCOMES AND MEASURES Primary outcomes were feasibility, safety, accuracy, and negative predictive value of EBUS-TBNA for preoperative nodal staging. A secondary outcome was the rate of nontherapeutic lung resection for occult N2 disease, with comparison between the EBUS group and the PET/CT-only group. RESULTS No significant complications were attributable to the EBUS-TBNA procedure. In the EBUS group, 258 lymph node stations were sampled. N1 hilar metastases were diagnosed in 8 patients (12.9%) before surgery, and the remainder were staged N0. Accuracy and negative predictive value of EBUS-TBNA were 93.5% (58 of 62) and 92.6% (50 of 54), respectively. The overall rate of nontherapeutic lung resection performed in patients with occult N2 disease was 10.8% (18 of 166) (8.1% in the EBUS group and 12.5% in the PET/CT-only group) (P = .37). CONCLUSION AND RELEVANCE A preoperative lung cancer staging strategy that includes EBUS-TBNA seems to be safe and effective in a veteran population, resulting in a low rate of nontherapeutic operations because of occult N2 nodal disease.

Tracheal Cartilaginous Sleeve in Syndromic Craniosynostosis: An Underrecognized Source of Significant Morbidity and Mortality.

Abstract Tracheal cartilaginous sleeve (TCS) is a rare and previously unrecognized source of morbidity and mortality in patients with certain craniosynostosis syndromes. There is a paucity of reporting on this airway anomaly, and the true incidence of TCS is largely unknown. The purpose of this study was to investigate the incidence of TCS among patients with syndromic craniosynostosis at our institution. Patients with syndromic craniosynostosis who underwent direct bronchoscopy and laryngoscopy were evaluated retrospectively by pediatric otolaryngologists for the presence of TCS and associated anomalies. Among patients with a diagnosis of syndromic craniosynostosis in our craniofacial database, 10 (37%) were found to have previous direct bronchoscopy and laryngoscopy reports. Of these 10 patients, 2 had Crouzon syndrome, 3 had Pfeiffer syndrome, 3 had Apert syndrome, 1 had Muenke syndrome, and 1 had Antley–Bixler syndrome. Eighty percent (8/10) of these patients were found to have some evidence of TCS. The most commonly observed associated findings included the following: tracheostomy dependency (7/10; 70%), hearing loss (6/10; 60%), obstructive sleep apnea (5/10; 50%), cervical spine anomalies (5/10; 50%), developmental delay (5/10; 50%), and enlarged cerebral ventricles (4/10; 40%). Larger multicenter studies are required to further characterize this airway anomaly and its impact on this patient population. Our results confirm the importance of thorough airway evaluation at initial presentation and the need for validated screening protocols.Tracheal cartilaginous sleeve (TCS) is a rare and previously unrecognized source of morbidity and mortality in patients with certain craniosynostosis syndromes. There is a paucity of reporting on this airway anomaly, and the true incidence of TCS is largely unknown. The purpose of this study was to investigate the incidence of TCS among patients with syndromic craniosynostosis at our institution. Patients with syndromic craniosynostosis who underwent direct bronchoscopy and laryngoscopy were evaluated retrospectively by pediatric otolaryngologists for the presence of TCS and associated anomalies. Among patients with a diagnosis of syndromic craniosynostosis in our craniofacial database, 10 (37%) were found to have previous direct bronchoscopy and laryngoscopy reports. Of these 10 patients, 2 had Crouzon syndrome, 3 had Pfeiffer syndrome, 3 had Apert syndrome, 1 had Muenke syndrome, and 1 had Antley-Bixler syndrome. Eighty percent (8/10) of these patients were found to have some evidence of TCS. The most commonly observed associated findings included the following: tracheostomy dependency (7/10; 70%), hearing loss (6/10; 60%), obstructive sleep apnea (5/10; 50%), cervical spine anomalies (5/10; 50%), developmental delay (5/10; 50%), and enlarged cerebral ventricles (4/10; 40%). Larger multicenter studies are required to further characterize this airway anomaly and its impact on this patient population. Our results confirm the importance of thorough airway evaluation at initial presentation and the need for validated screening protocols.

Isolated Unilateral Frontosphenoidal Craniosynostosis: A Rare Cause of Anterior Plagiocephaly.

Abstract Isolated unilateral frontosphenoidal synostosis is a rare and often misdiagnosed cause of synostotic frontal plagiocephaly. It is important to distinguish the various synostotic causes of frontal plagiocephaly from deformational frontal plagiocephaly because operative intervention is required in synostotic plagiocephaly to avoid progressive deformity, whereas deformational plagiocephaly typically improves without surgery. This study reports a patient with a unique case of anterior plagiocephaly caused by left-sided frontosphenoidal craniosynostosis. The workup should include a thorough history and clinical examination followed by computed tomography scan with three-dimensional reconstruction. Frontosphenoidal synostosis should be suspected in the absence of a coronal synostosis in a child with anterior unilateral plagiocephaly and treated surgically. Good aesthetic and functional results occur with prompt diagnosis and early surgical correction.

Beta-blockers as therapy for infantile hemangiomas.

Infantile hemangiomas (IH) are common benign vascular tumors seen in children. Although the majority will improve spontaneously without treatment, a small subset will require therapy due to a variety of complications. Less than a decade ago, propranolol replaced corticosteroids as first-line treatment for most IH and it has proven to be a relatively safe, effective therapy. After initiation of propranolol, most hemangiomas show evidence of significant improvement relatively rapidly, often within days. Although propranolol is generally felt to have a more limited side-effect profile than systemic corticosteroids, its use has been infrequently associated with adverse events, including sleep disturbances, acrocyanosis, hypotension, bradycardia, respiratory events, and hypoglycemia. Rarely, hypoglycemic seizures have been reported, usually occurring in the setting of prolonged fasting.

Evidence-Based Medicine: Mandible Fractures

LEARNING OBJECTIVES After reading this article, the participant should be able to: 1. Explain the epidemiology of mandible fractures. 2. Discuss preoperative evaluation of the patient with a mandible fracture. 3. Compare the various modalities of fracture fixation. 4. Identify common complications after fracture repair. SUMMARY In this Maintenance of Certification/Continuing Medical Education article, the reader is provided with a review of the epidemiology, preoperative evaluation, perioperative management, and surgical outcomes of mandible fractures. The objective of this series is to present a review of the literature so that the practicing physician can remain up-to-date on key evidence-based guidelines to enhance management and improve outcomes. The physician can also seek further in-depth study of the topic through the references provided.

Partial Ear Defects

Abstract Reconstruction of partial ear defects represents one of the most challenging areas within reconstructive surgery of the head and neck. Each case of auricular reconstruction is unique and warrants a systematic approach that accounts for defect size and location, the quality of the surrounding skin, patient preference, and operator experience. In this article, the authors outline different reconstructive approaches for defects of the upper‐, middle‐, and lower‐third of the auricle. The relevant anatomy is discussed in detail. Successful outcomes in auricular reconstruction rely on the surgeons careful analysis of the defect as well as knowledge of the different reconstructive options available.

Sternal Wound Salvage in Post-Transplant Adolescents: Omental Flap Reconstruction in Patients With Prior Abdominal Surgery.

AbstractSternal wound infections remain a significant cause of morbidity and mortality in patients undergoing complex cardiothoracic surgery. Heart and lung transplant patients presumably face additional risk secondary to their underlying morbidity, postoperative immunosuppression, and difficulty with primary wound closure over large graft size. These patients present a unique challenge to the reconstructive surgeon, as many have a significant past surgical history, which can limit or alter treatment options. This study reports 2 pediatric transplant patients who underwent use of omental flap for sternal wound reconstruction in the context of significant past abdominal surgery. One patient underwent prior heart transplantation and the other patient underwent previous bilateral lung transplantation. Both had significant abdominal surgery prior to transplantation and suffered from sternal wound complications post-transplantation. Each patient was successfully treated with omental flap reconstruction.

Gorlin-Goltz Syndrome: An Uncommon Cause of Facial Pain and Asymmetry.

AbstractGorlin-Goltz syndrome is an underdiagnosed autosomal dominant disorder with variable expressivity that is characterized by an increased predisposition to tumorigenesis of multiple types. The major clinical features include multiple basal cell carcinomas (BCCs) appearing in early childhood, palmar and plantar pits, odontogenic keratocysts of the oral cavity, skeletal defects, craniofacial dysmorphism, and ectopic intracranial calcification. The authors present the clinical course of a 12-year-old girl presenting with facial asymmetry and pain because of previously undiagnosed Gorlin-Goltz syndrome. Early diagnosis and attentive management by a multidisciplinary team are paramount to improving outcomes in patients with this disorder, and this report serves as a paradigm for maintaining a high clinical suspicion, which must be accompanied by an appropriate radiologic workup.

Distinct gene expression profiles in two cases of Merkel cell polyomavirus‐negative Merkel cell carcinoma: shedding light on an esoteric entity

development of keratin squames, and the retention of melanin in certain areas of the skin. Accumulation of the residues of sweat, scales, sebum, emollients, bath oils, and soaps may also contribute to its pathogenesis. The condition usually manifests as asymptomatic, dirtlike, slightly papillomatous, hyperpigmented patches or plaques primarily on the neck and trunk. It can be seen at any age and in both genders. Lesions are resistant to regular washing with soap but are easily removed by wiping with ethyl or isopropyl alcohol. Cases of TFFD can be both diagnosed and treated using this simple procedure. Recurrence is unusual after treatment. Differential diagnoses include dermatosis neglecta (DN), confluent and reticulate papillomatosus of Gougerot and Carteaud, pityriasis versicolor, and acanthosis nigricans. Whether TFFD and DN are different diseases or diverse types of the same disease is still controversial. In DN, the patient neglects to wash the lesion for any of a number of different reasons, the most common of which is poor hygiene. Both TFFD and DN lesions can be treated completely by wiping with alcohol; however, DN lesions can also be cleared by washing with soap and water. The lesions of any of the other disorders included within the gamut of the differential diagnosis cannot be cleared by wiping with alcohol or by washing. Although both of our patients had regular washing habits, their lesions were gradually growing. We were able to remove the lesions easily with alcohol. To the best of our knowledge, only approximately 60 cases of TFFD have been reported in the literature until now. Lack of awareness of this condition, even among dermatologists, is likely to be the major reason for the under-reporting of the entity. Unnecessary skin biopsies and batteries of blood tests can be avoided if TFFD is retained in the differential diagnosis of such presentations.