Epidemiology of pediatric parapneumonic pleural effusion during 13-valent pneumococcal conjugate vaccine implementation.

INTRODUCTION: The reported incidence of parapneumonic pleural effusion, including empyema, has shown fluctuations in the last decades. It has been related to the implementation of different types of conjugate pneumococcal vaccines. METHODS: We have retrospectively reviewed data from all 10 public hospitals in Alicante Province (Spain) covering a population of 279,000 children under 15 years of age, between 2010 and 2018. Effusions less than 10 mm (PE-) and those of 10 mm or more (PE+) were separated. RESULTS: A total of 366 episodes of parapneumonic pleural effusion have been analyzed, 178 PE- (48.6%) and 188 PE+ (51.4%), with a median age of 4 years (interquartile range: 2-7 years) and marked seasonality with the maximum in winter and the minimum in summer. A culture proven bacterial agent was identified in 34 patients (9.3%), mainly Streptococcus pneumoniae (24 patients) followed by Streptococcus pyogenes (7 patients). The most frequent S. pneumoniae serotype was 19A (6 patients) and 3 vaccine failures were observed. The mean annual incidence rate was 14.3 cases per 100,000 children under 15 years of age (7.0 for PE- and 7.3 for PE+). No significant changes were observed in incidence over time, but noticeable differences in incidence were observed in different health departments. CONCLUSIONS: We have not found temporal variations in incidence of parapneumonic effusion despite the implementation of the 13-valent pneumococcal conjugate vaccine. The unexplained disparity in incidence between close departments is noteworthy.

Surgical removal of orbital tumors by orbital approach using ultrasonic surgical system SONOPET®.

PURPOSE: Orbital tumor surgery can be challenging when the tumor is located in a very narrow surgical field and close to important structures, such as nerves or extraocular muscles that can be damaged during surgery. Advances in technology and special surgical techniques help to avoid such damage. We describe our experience using SONOPET® ultrasonic surgical aspirator to remove 12 different orbital tumors that were difficult to treat due to their poorly defined borders, adhesions, or location. METHODS: This is a retrospective case series that describes 12 operations that occurred between March 2016 to December 2018 using an ultrasonic device to debulk or remove orbital tumors. Different approaches and handpieces were used for each case depending on the location and consistency of the tumor. RESULTS: All patients experienced an improvement in preoperative signs and symptoms, pain, proptosis, diplopia, or lagophthalmos. Visual acuity, which had been reduced due to the tumor, was also recovered. There were no intraoperative or postoperative complications due to the use of the device. CONCLUSIONS: The ultrasonic aspirator is a safe, useful device that can successfully remove or debulk infiltrating orbital masses through any orbital access, regardless of their consistency. It is helpful in cases of difficult anatomical access or difficult extraction due to size or adhesions to the surrounding tissues.

Population-Based Cohort of Children With Parapneumonic Effusion and Empyema Managed With Low Rates of Pleural Drainage.

Introduction: The most appropriate treatment for parapneumonic effusion (PPE), including empyema, is controversial. We analyzed the experience of our center and the hospitals in its reference area after adopting a more conservative approach that reduced the use of chest tube pleural drainage (CTPD). Methods: Review of the clinical documentation of all PPE patients in nine hospitals from 2010 to 2018. Results: A total of 318 episodes of PPE were reviewed; 157 had a thickness of <10 mm. The remaining 161 were 10 mm or thicker and were subdivided into three increasing sizes: PE+1, PE+2, and PE+3. There was a strong relationship between the size of the effusion and complicated effusion/empyema, defined by its appearance on imaging studies or by the physical or bacteriological characteristics of the pleural fluid. The size of effusion was also strongly related to the duration of fever and intravenous treatment and was the best independent predictor of the length of hospital stay (LHS) (p < 0.001). CTPD was placed in 2.9% of PE+1 patients, 19.3% of PE+2, and 63.9% of PE+3 (p < 0.001). The referral of patients with PE+1 decreased over time (p = 0.033), as did the use of CTPD in the combined PE+1/PE+2 group (p = 0.018), without affecting LHS (p = 0.814). There were no changes in the use of CTPD in the PE+3 group (p = 0.721). Conclusions: The size of the PPE is strongly correlated with its severity and with LHS. Most patients can be treated with antibiotics alone.

Localized Bilateral Superior and Inferior Orbital Neurofibroma in the Absence of Neurofibromatosis.

Localized or isolated neurofibromas are peripheral nerve sheath tumors. They are rare in the orbit and occur without a systemic neurofibromatosis. There are few cases of bilateral tumors reported but none affecting both supraorbital and infraorbital nerves. We report a 45-year-old female who presented an extraconal mass in the right orbit as an incidental finding in a head computer tomography, without ocular symptoms. Magnetic resonance image showed a well-defined oval mass in the right supraorbital and infraorbital nerves, of similar characteristics, as well as smaller masses in the left supraorbital and infraorbital nerves. A progressive increase in size of the left supraorbital and infraorbital tumor motivated their surgical excision. The histological result was compatible with a neurofibroma. These uncommon orbital tumors are slow growing and affect the sensory nerves of the trigeminal nerve. Neurofibromas usually present progressive symptoms due to the orbital mass, proptosis, or visual changes although not in this case. Surgical removal is the only definitive treatment.

Deep lateral rim-sparing orbital wall decompression in spontaneous globe subluxation associated with shallow orbits and eyelids laxity.

Purpose: To share our experience on deep lateral wall rim-sparing orbital decompression for the prevention of further spontaneous globe subluxation, in patients with shallow orbits and eyelid laxity.Methods: This is a retrospective, interventional case series review. We report the results of deep lateral wall rim-sparing orbital decompression in 7 patients with recurrent spontaneous globe subluxation, operated in our department between 2010 and 2016. The orbital morphology was established by computed tomography scan images, and all patients with shallow orbit configuration and who in addition had eyelid laxity were included. Patients with thyroid eye disease were excluded.Results: No significant intraoperative and postoperative complications were encountered. In all cases, the patients were satisfied with the aesthetic result and none reported further episodes of globe subluxation.Conclusions: Deep lateral wall rim-sparing orbital decompression is a safe and effective decompressive procedure associated with minimal complications, which can be performed successfully in patients with spontaneous globe subluxation associated with shallow orbits with enough eyelid laxity.

Deep Lateral Wall Partial Rim-Sparing Orbital Decompression with Ultrasonic Bone Removal for Treatment of Thyroid-Related Orbitopathy.

PURPOSE: To describe the results of thyroid-related orbitopathy (TRO) treated by ultrasonic deep lateral wall bony decompression with partial rim sparing (DLW-PRS). METHODS: A review was carried out, from January 2015 to September 2017, of all patients treated with ultrasonic DLW-PRS decompression using a SONOPET® (Stryker, Kalamazoo, MI, USA) ultrasonic aspirator, using a lateral, small triangle flap incision for access. The primary outcome was the change in proptosis (measured by the difference in Hertel exophthalmometry measurements). Other secondary outcomes were changes in visual acuity (VA) (using Snellen scale, decimal fraction), presence of lagophthalmos, eyelid retraction (measured by upper eyelid margin distance to the corneal reflex (MRD1) and lower eyelid margin distance to the corneal reflex (MRD2), and presence of exposure keratopathy). RESULTS: A total of 58 orbital decompressions in 35 patients were reviewed, with 23 patients (65.7%) having bilateral decompressions. There was a female preponderance with 26 patients (74.2%), and the mean age ± standard deviation was 52.6 ± 13.9 years. Mean proptosis was 24.51 ± 1.76 mm preoperatively, reduced to 19.61 ± 1.27 mm in final follow-up. The mean reduction was 4.9 ± 1.54 mm. VA improved from 0.8 ± 0.14 to 0.9 ± 0.12, p=0.039. 5 of 13 patients (38.4%) with preoperative diplopia reported improvement or complete resolution after surgery. MRD1 was reduced from 5.25 ± 0.88 mm to 4.49 ± 0.7 mm. MRD2 was also reduced from 6.3 ± 0.88 mm to 5.0 ± 0.17 mm. Presence of lagophthalmos was reduced from 35 eyes (60.3%) to five (8.6%); the presence of epiphora was also reduced from 20 patients (57.1%) to 3 (8.5%) following decompression. Complications of the surgery included zygomatic hypoaesthesia in 14 (40%) patients in the early postoperative period and chewing alterations in 10 (28.5%) of the patients. All of these complications were resolved at the 6-month follow-up visit. We noted no surgical complications such as ocular or soft tissue damage, infection, inflammation, or visual loss. CONCLUSIONS: The SONOPET® ultrasonic bone curette can be used safely and effectively for DLW orbital decompression surgery. The main benefits were good visualization and handling of tissues and speed and ease of use of the equipment. This trial is registered with ClinicalTrials.gov identifier: NCT04025034.

Reconstruction of Upper Eyelid Defects Secondary to Malignant Tumors with a Newly Modified Cutler-Beard Technique with Tarsoconjunctival Graft.

PURPOSE: We describe a modification of Cutler-Beard's technique, using a contralateral tarsoconjunctival graft, in patients who underwent excision of large malignant tumors of the upper eyelid. METHODS: This is an interventional retrospective review (clinical study) of ten cases, with age range from 64 to 86 years (mean: 71.2 years ± 6.49) with malignant upper eyelid tumors, operated by the same surgeon (AB-G), between 2011 and 2016. The resulting defects were reconstructed using a modification of Cutler-Beard's technique. A tarsoconjunctival graft was harvested from the contralateral upper eyelid, with an extra 3 mm of conjunctiva from the superior edge of tarsus and was attached to the upper eyelid defect, different from that previously described. Follow-up ranged between 24 and 60 months (mean: 41.6 ± 9.87). Functional, cosmetic outcomes and postoperative complications were evaluated. RESULTS: No upper eyelid retraction, eyelid margin entropion, or graft retraction was observed in any of the cases. All of the patients were satisfied with the aesthetic result. CONCLUSION: This technique allows us to safely inset a suitable graft on the ocular surface, with sufficient blood supply, resulting in a stable margin and good contour.

Epidemiological and clinical features of visceral leishmaniasis in children in Alicante Province, Spain.

BACKGROUND: Visceral leishmaniasis (VL) is endemic to the Mediterranean basin. In children, VL often presents with non-specific symptoms and can be life-threatening without proper treatment. AIM: To describe the epidemiological and clinical features of pediatric VL in children in Alicante, Spain. METHODS: The study included all paediatric (<15 years) cases admitted to three hospitals in the province of Alicante from May 1992 to May 2015 with diagnosis of VL (detection was either by anti-Leishmania antibodies in serology or Leishmania in blood and/or bone marrow aspirates). RESULTS: There were 38 cases of pediatric VL (18 aged <24 months, 15 aged 24-59 months and 5 aged ≥5 years). The main symptoms were fever (97.4%), followed by pallor (75.0%) and loss of appetite (46.4%). Eighty-seven per cent of patients were anaemic (haemoglobin < 9 g/dL), 73.7% had neutropenia and 68.4% had thrombocytopenia. Before 2004, 92.3% of patients were treated with meglumine antimoniate (MA) and 7.7% with liposomal amphotericin B (LAmB); after 2004, 84% were treated with LAmB and just one (16%) with MA (p < 0.001). LAmB performed better than MA in terms of mean treatment length (7.4 days vs 25.9 days, p < 0.001), time to becoming afebrile (1.7 vs 13.7 days, p < 0.001), and length of hospital stay (10.9 vs 19.4 days, p = 0.001). CONCLUSION: Paediatric VL in Alicante mainly affects children under five. Children aged ≤24 months present with a lower haemoglobin and white blood cell count. Treatment with LAmB reduces treatment length, time to becoming afebrile and length of hospital stay.

The use of autologous dermis grafts for the reconstruction of the anophthalmic socket.

PURPOSE: The main objectives of enucleation, evisceration or secondary orbital implants are to replace orbital volume and obtain good motility and adaptation of the implant and the external prosthesis. We describe our experience using autologous dermis graft sutured to Tenon and conjunctiva following evisceration, enucleation and any reconstruction requiring either a primary or secondary orbital implant, even those with large tissue loss. MATERIALS AND METHODS: A retrospective case series of patients who received an autologous dermis graft to assist in closure of a Tenon's capsule and conjunctiva at the time of placement of secondary orbital implants or evisceration or enucleation with fornices retraction or tension in tissues. We also describe how and from where to take the dermis graft. RESULTS: 72 patients were included and all received orbital porous polyethylene implants: 28 patients had secondary orbital implants, 36 patients had evisceration and 8 patients had enucleation. Implant size was 20 mm in most cases, but went to 22 mm. Follow-up ranged from 3 to 36 months. No intraoperative complications were observed in donor or receptor area. 8 cases had incipient ischemia of the dermis graft, but were treated and resolved with autologous serum. CONCLUSIONS: Implant exposure is due to bad surgical technique, an inadequate implant size or excessive tension on the suture. Dermis autologous graft allows moving the orbital implant anteriorly because it replaces surface to suture Tenon and conjunctiva without tension, so a good adaptation of a thinner external prosthesis is possible, resulting in better motility.

Melanoma histopathology reporting: are we complying with the National Minimum Dataset?

BACKGROUND: The Royal College of Pathologists introduced the National Minimum Dataset (NMDS) for the histopathological reporting of cutaneous melanoma in February 2002. AIM: To determine if histological reporting of invasive primary cutaneous melanoma in the West Midlands region of the UK was compliant with the NMDS. METHODS: Reports were identified from March 2002 to March 2003 via the regional Cancer Intelligence Unit, and compared with the NMDS. If all items of the NMDS were adhered to, the report was considered compliant. If not compliant, the report was checked to see if it included selected clinical and staging parameters. RESULTS: 543 cases of invasive cutaneous melanoma were identified, but only 407 reports were analysed. 69/407 (17%) (95% CI 14% to 20%) reports were fully compliant with the NMDS. Of the non-complaint reports, 45/361 (12%) (95% CI 9% to 16%) reported all staging and clinically relevant parameters; 62/361 (17%) (95% CI 59% to 65%) reported all staging parameters. Breslow thickness was reported in all but one of the reports (99.7%), Clark's level was reported in 344/407 (85%), ulceration in 280/407 (69%), and microsatellites in 146/407 (36%). CONCLUSION: There was slow uptake of the NMDS in this region in the year following its introduction. Although major parameters required for staging were more consistently reported, ulceration and microsatellites were less frequently reported.