Radiofrequency ablation of benign thyroid nodules: A prospective, multi-institutional North American experience.

BACKGROUND: Radiofrequency ablation for benign thyroid nodules aims to achieve a volume reduction rate of ≥50%. However, factors that predict treatment success have not been defined in a large-scale study. METHODS: A prospective cohort study of biopsy-proven benign thyroid nodules treated with radiofrequency ablation at 3 institutions was performed. Patient demographics, nodule sonographic features, procedural data, and nodule volume reduction were evaluated. Binary logistic regression analysis was performed to identify features associated with treatment response. RESULTS: A total of 620 nodules were analyzed. The pooled median volume reduction rate at 12 months was 70.9% (interquartile range 52.9-86.6). At 1 year follow-up, 78.4% of nodules reached treatment success with a volume reduction rate ≥50%. The overall complication rate was 3.2% and included temporary voice changes (n = 14), vasovagal episodes (n = 5), nodule rupture (n = 3), and lightheadedness (n = 2). No permanent voice changes occurred. Four patients developed postprocedural hypothyroidism. Large baseline nodule volume (>20 mL) was associated with a lower rate of successful volume reduction (odds ratio 0.60 [0.37-0.976]). Large nodules achieved treatment success by 12-month follow-up at a rate of 64.5%, compared with 81.4% for small nodules and 87.2% for medium nodules. CONCLUSION: To our knowledge, this is the largest North American cohort of patients with benign thyroid nodules treated with radiofrequency ablation. Overall, radiofrequency ablation was an effective treatment option with a low risk of procedural complications. Large volume nodules (>20 mL) may be associated with a lower rate of successful reduction with radiofrequency ablation treatment.

TOETVA parathyroid autofluorescence detection: hANDY-i endoscopy attachment.

Background: Treatment options for thyroid pathologies have expanded to include scarless and remote access methods such as the transoral endoscopic thyroidectomy vestibular approach (TOETVA). Currently, no standardized methods exist for locating parathyroid glands (PGs) in patients undergoing TOETVA, which can lead to parathyroid injury and subsequent hypocalcemia. This early feasibility study describes and evaluates the hANDY-i endoscopic attachment for detecting PGs in transoral thyroidectomy. Methods: We used a prototype parathyroid autofluorescence imager (hANDY-i) that was mounted to a 10-mm 0-degree endoscope. The device delivers a split screen view of Red-green-blue (RGB) and near-infrared autofluorescence (NIRAF) which allows for simultaneous anatomical localization and fluorescence visualization of PGs during endoscopic thyroid dissection. Results: One cadaveric case and two patient cases were included in this study. The endoscopic hANDY-i imaging system successfully visualized PGs during all procedures. Conclusion: The ability to leverage parathyroid autofluorescence during TOETVA may lead to improved PG localization and preservation. Further human studies are needed to assess its effect on postoperative hypocalcemia and hypoparathyroidism.

The Use of Patient-Specific Orbital Reconstruction Implants During Maxillectomy Reconstruction.

Background: Reconstruction of the orbital floor after maxillectomy can result in significant functional and aesthetic morbidity. Study Objective: To measure eyelid position, self-reported visual outcomes, and complications in patients undergoing concurrent maxillectomy and reconstruction with a patient-specific orbital reconstruction implant (PSORI). Design Type: Case series. Materials and Methods: Case series including 12 patients who received PSORI for orbital floor reconstruction after tumor extirpation. Primary outcomes gathered were diplopia, ectropion, and wound healing complications. Results: The majority of patients were men (75%) and the mean age was 53.3 years. Ten patients underwent free flap reconstruction with the majority receiving fibula free flaps (n = 6). Median follow-up was 415.5 days. Three patients (25%) experienced long-term complications, including diplopia (n = 1) and hardware extrusion (n = 3). Each of these occurred in the context of total maxillectomy and radiation. This prompted subsequent use of a modified implant design for the final six patients and the preferential use of a midface-degloving approach. These interventions eliminated extrusions in subsequent patients. Conclusion: PSORIs can be used for orbital floor reconstruction following maxillectomy in combination with free tissue transfer. Implant design is critical to reduce complications. The use of a midface degloving approach and a modified low-profile design was associated with a low rate of complications.

Implementation of a Comprehensive Curriculum in Personal Finance for Medical Fellows.

INTRODUCTION: Many residents and fellows complete graduate medical education having received minimal unbiased financial planning guidance. This places them at risk of making ill-informed financial decisions, which may lead to significant harm to them and their families. Therefore, we sought to provide fellows with comprehensive unbiased financial education and empower them to make timely, constructive financial decisions. METHODS: A self-selected cohort of cardiovascular disease, pulmonary and critical care, and infectious disease fellows (n = 18) at a single institution attended a live, eight-hour interactive course on personal finance. The course consisted of four two-hour sessions delivered over four weeks, facilitated by an unbiased business school faculty member with expertise in personal finance. Prior to the course, all participants completed a demographic survey. After course completion, participants were offered an exit survey evaluating the course, which also asked respondents for any tangible financial decisions made as a result of the course learning.  Results: Participants included 12 women and six men, with a mean age of 33 and varying amounts of debt and financial assets. Twelve respondents completed the exit survey, and all "Strongly Agreed" that courses on financial literacy are important for trainees. In addition, 11 reported that the course helped them make important financial decisions, providing 21 examples. CONCLUSIONS: Fellows derive a significant benefit from objective financial literacy education. Graduate medical education programs should offer comprehensive financial literacy education to all graduating trainees, and that education should be provided by an unbiased expert who has no incentive to sell financial products and services.

Staging of Sinonasal and Ventral Skull Base Malignancies.

Tremendous pathologic diversity among sinonasal and ventral skull base malignancies complicates development of a uniform and prognostically relevant staging system. Because of the comparatively low incidence of these tumors, comprehensive evaluation and comparison of specific staging systems is difficult. The current American Joint Committee on Cancer TNM staging system for sinonasal malignancies is the most common and widely used system in current clinical practice. Alternative systems have been proposed for use with individual histopathologic subtypes. Many of these staging systems are of great utility and accurately predict patient survival. Further research and adjustment of these current staging systems remains an important area of research.

Transfacial and Craniofacial Approaches for Resection of Sinonasal and Ventral Skull Base Malignancies.

Malignancies of the paranasal sinuses and ventral skull base present unique challenges to physicians. A transfacial or craniofacial approach allows for wide, possibly en bloc, resection and is ideal for tumors that involve surrounding soft tissue, the palate, the orbit, anterolateral frontal sinus, and lateral dura. Transfacial approaches include a lateral rhinotomy often combined with a medial, subtotal, or total maxillectomy. Reconstruction is most commonly performed with a pericranial flap to separate the intranasal and intracranial compartments. These approaches have evolved and been refined but now are usually reserved for advanced tumors not amenable to endoscopic resection.

Prognostic significance of non-HPV16 genotypes in oropharyngeal squamous cell carcinoma.

OBJECTIVES: Recent studies have found that cases with oropharyngeal squamous cell carcinoma (OPSCC) positive for HPV16 genotype have better overall survival compared with cases positive for other HPV genotypes. We sought to further replicate these studies and determine if this relationship is modified by expression of p16 tumor suppressor protein. MATERIAL AND METHODS: We identified 238 OPSCC cases from the Carolina Head and Neck Cancer Study (CHANCE) study, a population based case-control study. Tumors that tested positive solely for HPV16 genotype and no other genotypes with PCR were classified as HPV16-positive. Tumors positive for any other high-risk HPV genotype were classified as non-HPV16-positive. Expression of p16 in the tumor was determined with immunohistochemistry. Follow-up time was calculated from the date of diagnosis to date of death or December 31, 2013. Overall survival was compared with the Kaplan-Meier curves and log-rank test. Hazard ratios (HR) adjusted for smoking, alcohol use, sex, race, and age was calculated with the Cox proportional hazard regression. RESULTS: Cases with HPV16-positive OPSCC had better overall survival than cases with non-HPV16-positive OPSCC (log-rank p-value: 0.010). When restricted to OPSCC cases positive for p16 expression, the same trend continued (log-rank p-value: 0.002). In the adjusted model, cases with non-HPV16-positive OPSCC had greater risk of death compared to cases with HPV16-positive tumors (HR: 1.92; 95% CI: 1.03, 3.60). CONCLUSIONS: This finding indicates that HPV genotyping carries valuable prognostic significance in addition to p16 status and future survival studies of OPSCC should take into account differing HPV genotypes.

Management of Frontal Sinus Tumors.

The most common primary tumors of the frontal sinus are osteomas and inverted papillomas, although a variety of other tumors involving this space have been reported. With the advent of new surgical techniques and instrumentation, an endoscopic approach to this region has become feasible. The preoperative assessment and decision making must take into account the complexity of frontal sinus anatomy, tumor type, tumor location, and associated attachments. These procedures allow adequate visualization, tumor removal, and postoperative monitoring, and preserve fairly normal sinus function. Open techniques may also be required and should be in the surgeon's armamentarium.

Recruitment of underserved, high-risk participants to a head and neck cancer screening program.

OBJECTIVES/HYPOTHESIS: Early detection is essential in head and neck cancer treatment as prognosis varies greatly with stage at diagnosis. Underserved populations often present with advanced disease, and individuals with tobacco and heavy alcohol use demonstrate a higher head and neck cancer incidence. This study aims to evaluate whether various promotional methods differentially recruited behavioral risk factor positive and/or underserved populations to our screening event. STUDY DESIGN: Prospective cross-sectional study. METHODS: A hospital-based, medical student-run, free head and neck cancer screening event for 187 participants was held in April 2015. Medical campus-based, community-based, and media-based promotions were implemented to recruit participants. Event participants filled out questionnaires to determine how they were recruited, their risk-factor history, and their socioeconomic status. Prevalence of the higher-risk population across the various promotional methods was analyzed. RESULTS: Community-based promotions were significantly associated with the recruitment of participants in the underserved subgroups, namely uninsured (P = .019), unemployed (P = .006), and those with an annual household income <$20,000 (P < .001). Although not statistically significant, participants with behavioral risk factors reported a higher percentage of recruitment by media-based promotions. Campus-based promotions led to the highest absolute number, but not percentage, of higher-risk participants. CONCLUSIONS: Community-based promotions most efficiently recruit underserved guests to participate in a hospital-based head and neck cancer screening event as compared to media and campus-based promotions. Institutions interested in recruiting higher proportions of underserved guests to these screening events should consider focusing attention and allocation of resources to community-based promotions. LEVEL OF EVIDENCE: 4 Laryngoscope, 126:2699-2704, 2016.

Educational Value of a Medical Student-Led Head and Neck Cancer Screening Event.

OBJECTIVE: To evaluate improvement of medical student knowledge of head and neck cancer (HNC) through participation in HNC screening fairs run by medical students. STUDY DESIGN: Prospective cohort study of surveys assessing medical students' knowledge of HNC before and after volunteering at screening fairs. SETTING: Four screening fairs held at the University of Miami Miller School of Medicine during Oral, Head and Neck Cancer Awareness Week. SUBJECTS: Medical student screening fair volunteers. METHODS: Four HNC screening fairs were organized by medical student volunteers. All students completed a preevent survey assessing baseline knowledge and participated in an otolaryngologist-led training session about HNC and the screening examination. During the screening events, students educated guests about HNC and performed physician-guided history and physical examinations. Finally, students completed identical surveys 1 week and 3 months after the event. RESULTS: Thirty-four (n = 34) students completed the preevent surveys. At baseline, 59%, 44%, and 24% named tobacco, alcohol, and human papilloma virus as risk factors, compared with 84%, 81%, and 69% on 3 month follow-up, respectively. Out of 6 analyzed questions, the median total number of correctly answered questions improved from 2 on pretest to 5 at 3 months (P < .0001). CONCLUSION: Volunteer participation in a HNC screening program improves medical students' knowledge of HNC risk factors and symptoms. This innovative approach to students' education via participation and organization of screening events is a useful method of improving their HNC knowledge.

Brief report: antisynthetase syndrome-associated myocarditis.

BACKGROUND: The antisynthetase (AS) syndrome is characterized by autoimmune myopathy, interstitial lung disease, cutaneous involvement, arthritis, fever, and antibody specificity. We describe 2 patients with AS syndrome who also developed myocarditis, depressed biventricular function, and congestive heart failure. METHODS AND RESULTS: Both patients were diagnosed with AS syndrome based on clinical manifestations, detection of serum AS antibodies, and myositis confirmation with the use of skeletal muscle magnetic resonance imaging and skeletal muscle biopsy. In addition, myocarditis resulting in heart failure was confirmed with the use of cardiac magnetic resonance imaging and from endomyocardial biopsy findings. After treatment for presumed AS syndrome-associated myocarditis, one patient recovered and the other patient died. CONCLUSIONS: AS syndrome is a rare entity with morbidity and mortality typically attributed to myositis and lung involvement. This is the first report of AS syndrome-associated myocarditis leading to congestive heart failure in 2 patients. Given the potentially fatal consequences, myocarditis should be considered in patients with AS syndrome presenting with heart failure.

Feasibility of early discharge after implantable cardioverter-defibrillator procedures.

INTRODUCTION: Registry data demonstrate considerably low complication rates after implantable cardioverter-defibrillator (ICD) procedures for primary prevention of sudden death. Yet standard of care includes postimplant overnight in-hospital observation that may levy substantial unnecessary financial burden on health care systems. In appropriate patients, discharge soon after implant could translate into significant cost savings, if such practice does not result in complications. We applied a simple clinical algorithm to assess feasibility of discharge on the same day of ICD implantation in patients at low risk for procedural complications. METHODS: We prospectively randomized primary prevention ICD candidates at low risk for complications (not pacing-dependent or requiring bridging heparin anticoagulation) to next-day discharge with overnight in-hospital observation, or same-day discharge with remote monitoring for 24 hours after ICD implant. Implants were performed via cephalic vein access, and randomization occurred after 4-hours clinical observation and device interrogation. All patients were followed for a minimum of 6 weeks to assess acute procedural complications. RESULTS: 71 patients comprised the study cohort (mean age 62, 79% male) after 3 were excluded. The most common indication for ICD implant was ischemic cardiomyopathy with ejection fraction ≤35%. Device data obtained through 24-hour remote monitoring was comparable to 4-hour postimplant parameters in same-day discharge patients. No acute complications occurred in same-day discharge patients; 1 next-day discharge patient developed pneumothorax. CONCLUSION: ICD implantation with same-day discharge is reasonable in patients at low risk for complications. Remote monitoring can be useful in indicating lead-parameter stability during the immediate postoperative period.

Laughter-induced left bundle branch block.

We present the case of a patient with ischemic heart disease and intermittent left bundle branch block, reproducibly induced by laughter. Following treatment of ischemia with successful deployment of a drug-eluting stent, no further episodes of inducible LBBB were seen. Transient ischemia, exacerbated by elevated intrathoracic pressure during laughter, may have contributed to onset of this phenomenon.

Initiation of statin therapy: are there age limits?

Cardiovascular disease (CVD) is the leading cause of death, with a higher prevalence in older adults who form an increasing proportion of the population of the United States. Statin treatment reduces cardiovascular morbidity and mortality in middle-aged adults. However, few studies have included older individuals, particularly ages 80 years or older. We review recent publications regarding primary and secondary prevention of CVD with statin therapy in older adults. Risk scores and their limitations in this population are discussed. The association of adverse effects with intensive doses of statin and their interactions with other drugs may be more problematic in older adults. Statin therapy appears cost-effective for individuals with higher CVD risk but this is dependent on the assumptions used. Evidence remains limited regarding the overall benefit of starting statin therapy in adults ages 80 years and older; thus, clinical judgment remains necessary in making this decision.

Aortic dissection and pericardial tamponade causing compression of the pulmonary arteries in a patient with prior cardiac surgery.

A patient with prior aortic valve surgery presented with aortic dissection and pericardial tamponade, with subsequent compression of the pulmonary arteries. While both expanding pericardial effusions and aortic dissections have been reported to cause compression of other adjacent structures, compression of the pulmonary artery vasculature in a patient with prior cardiac surgery has never been described. In this case report, we highlight this situation, which may have occurred because of alterations in the pericardial and mediastinal spaces.

Predictors of long-term major adverse cardiac events and clinical restenosis following elective percutaneous coronary stenting.

Limited data exist regarding the predictors of long-term clinical outcomes following elective percutaneous coronary intervention (PCI) in the current era of stenting. The authors investigated the predictors of major adverse cardiac events (MACE) and clinical restenosis in 740 consecutive patients who underwent successful elective PCI with bare metal stents (BMSs) or drug-eluting stents (DESs). At 30-month follow-up, compared with BMS recipients, DES recipients had a significantly lower rate of MACE, which was mainly driven by a decreased repeat target vessel PCI. The rate of 30-month clinical restenosis was significantly lower in DES recipients. The authors conclude that baseline clinical, angiographic, and procedural characteristics determine long-term MACE and clinical restenosis after elective PCI, with DES being the independent predictor for both.

Predictors of periprocedural creatine kinase-myocardial band elevation complicating elective percutaneous coronary intervention.

Limited data are available regarding the predictors of periprocedural creatine kinase-MB (CK-MB) isoenzyme increase after elective percutaneous coronary intervention (PCI) in the stenting era. We explored the predictors of periprocedural CK-MB increase in 882 consecutive patients with normal preprocedural CK-MB who underwent 919 angiographically successful elective PCIs with (n = 814) or without (n = 105) stenting. Patients were categorized into 3 groups based on their peak CK-MB levels after PCI: (1) normal CK-MB (n = 761), (2) minor CK-MB increase (CK-MB 1 to 3 times normal, n = 112), and (3) major CK-MB increase (CK-MB >3 times normal, n = 46). By logistic regression analysis, independent predictors for minor CK-MB increase included thrombus (odds ratio [OR] 5.09, p = 0.001), platelet IIb/IIIa antagonist use (OR 0.53, p <0.01), number of lesions treated (per additional lesion, OR 1.54, p <0.01), maximum balloon size (per millimeter increase, OR 1.57, p <0.05), American College of Cardiology/American Heart Association type C lesion (OR 1.68, p <0.05), sustained chest pain during procedure (OR 1.94, p <0.05), dissection (OR 2.05, p <0.05), and transient side branch occlusion (OR 4.54, p <0.05). Independent predictors for major CK-MB increase were chest pain at end of procedure (OR 9.66, p <0.001), type C lesion (OR 2.42, p <0.05), Canadian Cardiovascular Society angina class III to IV (OR 3.32, p <0.05), thrombus (OR 5.09, p = 0.001), and abrupt closure (OR 5.30, p <0.05). In conclusion, baseline clinical and angiographic characteristics and procedural complications were associated with minor and major CK-MB increases. Patients with chest pain at the end of the procedure were at the highest risk for major CK-MB increase.