Michelle T. Sun

Factors Associated With the Epidemic of Hospitalizations Due to Atrial Fibrillation

Recent reports have described that hospitalizations for atrial fibrillation (AF) are continuing to increase. Given that hospitalizations are responsible for most of the economic burden associated with AF, the aim of this study was to characterize the impact of age and how changing procedural practices may be contributing to the increasing rates of AF hospitalizations. The annual age- and gender-specific incidence of hospitalizations for AF, electrical cardioversions, electrophysiologic studies, and radiofrequency ablation procedures in Australia were determined from 1993 to 2007 inclusive. Over this 15-year follow-up period spanning almost 300 million person-years, a total of 473,501 hospitalizations for AF were identified. There was a relative increase in AF hospitalizations of 203% over the study period, in contrast to an increase for all hospitalizations of only 71%. Whereas the gender-specific incidence of hospitalizations remained stable, the age-specific incidence increased significantly over the study period, particularly in older age groups. AF hospitalizations associated with electrical cardioversions decreased from 27% to 14% over the study period. Electrophysiologic studies and radiofrequency ablation procedures contributed minimally to the overall increase in AF hospitalizations observed. In conclusion, in addition to the growing prevalence of AF because of the aging population, there is an increasing age-specific incidence of hospitalizations for AF, particularly in older age groups. In contrast, changing procedural trends have contributed minimally to the increasing number of AF-associated hospitalizations. Greater attention to older patients with AF is required to develop strategies to prevent hospitalizations and contain the growing burden on health care systems.

Associations of Epicardial, Abdominal, and Overall Adiposity with Atrial Fibrillation

Background—Although adiposity is increasingly recognized as a risk factor for atrial fibrillation (AF), the importance of epicardial fat compared with other adipose tissue depots remains uncertain. We sought to characterize and compare the associations of AF with epicardial fat and measures of abdominal and overall adiposity. Methods and Results—We conducted a meta-analysis of 63 observational studies including 352 275 individuals, comparing AF risk for 1-SD increases in epicardial fat, waist circumference, waist/hip ratio, and body mass index. A 1-SD higher epicardial fat volume was associated with a 2.6-fold higher odds of AF (odds ratio, 2.61; 95% confidence interval [CI], 1.89–3.60), 2.1-fold higher odds of paroxysmal AF (odds ratio, 2.14; 95% CI, 1.45–3.16) and, 5.4-fold higher odds of persistent AF (odds ratio, 5.43; 95% CI, 3.24–9.12) compared with sinus rhythm. Likewise, a 1-SD higher epicardial fat volume was associated with 2.2-fold higher odds of persistent compared with paroxysmal AF (odds ratio, 2.19; 95% CI, 1.66–2.88). Similar associations existed for postablation, postoperative, and postcardioversion AF. In contrast, associations of abdominal and overall adiposity with AF were less extreme, with relative risks per 1-SD higher values of 1.32 (95% CI, 1.25–1.41) for waist circumference, 1.11 (95% CI, 1.08–1.14) for waist/hip ratio, and 1.22 (95% CI, 1.17–1.27) for body mass index. Conclusions—Strong and graded associations were observed between increasing epicardial fat and AF. Moreover, the strength of associations of AF with epicardial fat is greater than for measures of abdominal or overall adiposity. Further studies are needed to assess the mechanisms and clinical relevance of epicardial fat.

Endoscopic Transethmoidal Approach with or without Medial Rectus Detachment for Orbital Apical Cavernous Hemangiomas

PURPOSE To determine the indications for the addition of a transcaruncular approach along with detachment of the medial rectus muscle during the removal of small apical cavernous hemangiomas using an endoscopic transethmoidal approach. DESIGN Retrospective, noncomparative case series. METHODS Multicenter study of 12 patients with apical orbital tumors removed using an endoscopic transethmoidal approach. The decision to detach the medial rectus muscle with the addition of a transcaruncular approach was made during surgery for tumors largely lateral to the medial rectus muscle. Tumors adjacent to the medial orbital wall were removed via an endoscopic transethmoidal approach alone. RESULTS Seven tumors were removed via an endoscopic transethmoidal approach combined with medial rectus muscle detachment, whereas 5 patients underwent removal without detachment of the medial rectus. All patients had visual impairment. Complete excision of the hemangiomas was achieved in all patients and tumor size ranged from 6 × 5 mm to 20 × 12 mm. The mean postoperative follow-up time was 11.8 ± 4.3 months. At final follow-up, the best-corrected visual acuity improved in 11 patients. Three patients had transient horizontal diplopia resulting from partial paralysis of the medial rectus muscle after detachment during surgery. CONCLUSIONS The endoscopic transethmoidal approach with or without medial rectus detachment is a promising approach for selected small cavernous hemangiomas located at the deep medial orbital apex. Detachment of the medial rectus muscle can be a useful technique for tumors located largely lateral to the medial rectus muscle. Further studies will be required to demonstrate the safety and efficacy of this technique.

Sebaceous carcinoma in Japanese patients: clinical presentation, staging and outcomes

Aim To describe the clinical features, management and correlation of the American Joint Committee on Cancer tumour node metastasis (TNM) staging for eyelid carcinoma with outcomes in Japanese patients with sebaceous carcinoma. Methods Multicentre retrospective review of 63 Japanese patients. Tumours were staged using the American Joint Committee on Cancer 7th edition TNM criteria. Results A distinct mass was the initial presentation in 94% and correct initial diagnosis made in 57% patients. Most tumours (60%) presented at stage T2aN0M0. The remaining TNM stages were: T2bN0M0 (25%); T3aN0M0 (9%); T3bN0M0 (2%); T2bN1M0 (2%); T3bN1M1 (2%). Frozen section controlled excision was performed in 81%. One patient required an orbital exenteration. Median follow-up was 4.2 years. Local recurrence occurred in four patients treated with frozen section controlled excision. Five patients had regional nodal metastases, two of which had T2aN0M0 lesions. T3a tumours and greater were significantly associated with local recurrence but not regional nodal metastasis. One patient died due to disease. One patient is alive with disease, and remaining patients were alive without disease at last follow-up. Conclusions In this Japanese cohort, an eyelid mass was the main clinical presentation of sebaceous carcinoma. Contrary to previous reports, T2a tumours smaller than 10 mm were associated with regional nodal metastases.

Merkel Cell Carcinoma of the Eyelid: Management and Prognosis

IMPORTANCE The literature on Merkel cell carcinoma (MCC) of the eyelid remains scarce, and there has yet to be a study using the most up-to-date TNM staging system for this rare but aggressive tumor. OBJECTIVE To analyze the TNM stage, management, and outcomes of patients with MCC of the eyelid. DESIGN, SETTING, AND PARTICIPANTS Retrospective case series of 21 patients from 5 tertiary referral centers in the United Kingdom and Australia with primary MCC of the eyelid presenting at a median age of 77 years, with median follow-up of 54 months. Tumors were staged according to the American Joint Committee on Cancer, 7th edition, TNM criteria for eyelid carcinoma and MCC. MAIN OUTCOMES AND MEASURES TNM stage, treatment modalities, and clinical outcome. RESULTS The eyelid carcinoma TNM stages were T2aN0M0 for 5 patients, T2bN0M0 for 7 patients, T3aN0M0 for 4 patients, T3bN0M0 for 3 patients, T2bN1M0 for 1 patient, and T3aN1M0 for 1 patient. The MCC TNM stages were T1N0M0 for 12 patients, T2N0M0 for 7 patients, T1N1M0 for 1 patient, and T2N1M0 for 1 patient. One patient had a sentinel lymph node biopsy, and 8 patients underwent head/neck imaging. Eighteen patients underwent a wide local excision, 12 with a paraffin section and 6 with a frozen section. Two patients underwent Mohs surgery, 1 of whom required an orbital exenteration. Twelve patients (57%) received adjuvant radiotherapy, and 2 patients received chemotherapy. The local recurrence rate was 10%, the regional nodal recurrence rate was 10%, and the distant metastatic recurrence rate was 19%. The lowest T category tumor metastasizing to both regional nodes and distant locations was a T2a (eyelid TNM)/T1 (Merkel TNM) tumor measuring 8 mm. Two patients with T3a (eyelid TNM)/T2 (Merkel TNM) tumors died of metastatic MCC. CONCLUSIONS AND RELEVANCE The majority of patients with MCC of the eyelid present with localized eyelid disease of T category T2 (eyelid TNM)/T1 (Merkel TNM). A wide local excision with margin control remains the mainstay of treatment, whereas the use of radiotherapy is institution specific. Tumors with a low T category are associated with regional nodal and distant metastatic disease. It may therefore be reasonable to consider a sentinel lymph node biopsy or strict regional lymph node surveillance for all MCCs of the eyelid, regardless of T category or size.

Endoscopic medial orbital fat decompression for proptosis in type 1 graves orbitopathy.

PURPOSE To describe the surgical technique for endoscopic medial orbital fat decompression in type 1 (lipogenic) Graves orbitopathy and report outcomes. DESIGN Retrospective interventional case review. METHODS We reviewed 108 patients (206 orbits) with inactive, type 1 Graves orbitopathy without diplopia, who underwent endoscopic medial orbital fat decompression solely for proptosis reduction. Following endoscopic transethmoid medial orbital wall decompression, extraconal and intraconal orbital fat was removed with a low-suction cutting instrument. All patients were followed up for at least 12 months. Surgical time, preoperative and postoperative Hertel exophthalmometry, incidence of postoperative diplopia within 30-degree visual field in the primary gaze, and other complications were analyzed. RESULTS The mean surgical time was 97.7 ± 16.7 minutes (67-136 minutes). The mean follow-up was 16.0 ± 4.2 months (12-24 months). Preoperative and postoperative proptosis values at final review were 21.1 ± 2.3 mm (17-26 mm) and 13.0 ± 0.9 mm (12-15 mm), respectively (P < .001). Median reduction in proptosis was 8.0 mm with mean of 8.2 ± 1.8 mm (4-11 mm). Symmetry to within 2 mm was achieved in 106 of 108 patients (98.1%). Twenty-five of 108 patients (23.1%) had diplopia within 30-degree visual field of the gaze, and 23 of these had complete resolution within 3 months, while the remaining 2 patients required squint surgery. CONCLUSIONS Endoscopic medial orbital fat decompression may be an effective technique for proptosis in selected patients with type 1 Graves orbitopathy and is associated with a low rate of surgically induced diplopia.

Traumatic orbital compartment syndrome: Importance of the lateral canthomy and cantholysis

Orbital compartment syndrome (OCS) is an ophthalmic emergency that requires urgent surgical decompression to preserve vision.

Histological subtypes of periocular basal cell carcinoma

To determine the proportion of different subtypes of periocular BCC in South Australia.

Impact of research presentations at the annual scientific sessions of the Heart Rhythm Society

BACKGROUND Abstract presentation at conferences provides the opportunity to rapidly communicate research findings. The outcome and impact of publications arising from cardiac electrophysiology abstracts are not known. OBJECTIVE The purpose of this study was to examine the characteristics of abstracts presented at the annual scientific sessions of Heart Rhythm Society (HRS), their publication rate, and the indexed impact of subsequent publications. METHODS Two independent database searches (MEDLINE and EMBASE) were performed by cross-referencing authors and keywords from abstracts originally presented at HRS in 2003. ISI Web of Knowledge was accessed for impact factors and citation rates. RESULTS A total of 790 abstracts were presented, of which 377 (47.7%) resulted in publication of an original article. Median time to publication was 1.39 years (interquartile range [IQR] 0.88-2.30 years), and the median impact factor and citation rate of published articles was 4.14 (IQR 3.48-11.05) and 10 (IQR 4-25), respectively. Experimental research abstract category (odds ratio [OR] 2.03, P <.001), randomized study design (OR 0.53, P = .02), and positive findings (OR 0.80, P = .06) were independently predictive of publication by stepwise logistic regression. Independent predictors of higher citation rates were randomized study design (P = .03) and impact factor of the publishing journal (P <.001). CONCLUSION Almost half of all abstracts presented at HRS resulted in publication in journals with a high impact factor. Experimental research abstracts, those with a randomized study design, and those demonstrating positive findings were predictors of subsequent publication. Randomized study design and greater impact factor of the publishing journal were found to predict higher citation rates.

Accuracy of Biopsy in Subtyping Periocular Basal Cell Carcinoma.

Purpose: To determine the accuracy of initial biopsy in the diagnosis of basal cell carcinoma (BCC) histologic subtype. Methods: Retrospective histopathologic review of patients with a diagnosis of primary periocular BCC from 2006 to 2013 inclusive. Results: A total of 174 primary BCCs were identified. BCCs were classified as nodular, superficial, or aggressive (including mixed cases with an aggressive component). Punch biopsies were used in 41% of cases, while the remaining patients underwent shave or incision biopsies. The final histologic subtypes at excision were nodular (59%), superficial (7%), nodular and superficial (7%), and aggressive (51%). The overall concordance between the BCC subtype identified in the biopsy specimen and the subsequent excision specimen was 54%. In total, there were 51 cases (29%) of BCC, which included aggressive subtypes, of which 52% of initial biopsies failed to detect an aggressive component. There were 45 cases (26%) of mixed BCC, and an aggressive histologic subtype was present in 73% of these cases. Conclusions: The accuracy of initial biopsy for BCC histologic subtype at excision is highest for nodular BCC. For aggressive BCC, biopsy was able to detect the aggressive component in only 48% of cases. This may have implications for choice of treatment modality.