Immunohistological Evaluation of Von Willebrand Factor in the Left Atrial Endocardium and Atrial Thrombi from Cats with Cardiomyopathy.

Aortic thromboembolism (ATE) occurs in cats with cardiomyopathy and often results in euthanasia due to poor prognosis. However, the underlying predisposing mechanisms leading to left atrial (LA) thrombus formation are not fully characterised. von Willebrand Factor (vWF) is a marker of endothelium and shows increased expression following endothelial injury. In people with poor LA function and LA remodelling, vWF has been implicated in the development of LA thrombosis. In this study we have shown (1) the expression of endocardial vWF protein detected using immunohistofluorescence was elevated in cats with cardiomyopathy, LA enlargement (LAE) and clinical signs compared to cats with subclinical cardiomyopathy and control cats; (2) vWF was present at the periphery of microthrombi and macrothrombi within the LA where they come into contact with the LA endocardium and (3) vWF was integral to the structure of the macrothrombi retrieved from the atria. These results provide evidence for damage of the endocardial endothelium in the remodelled LA and support a role for endocardial vWF as a pro-thrombotic substrate potentially contributing to the development of ATE in cats with underlying cardiomyopathy and LAE. Results from this naturally occurring feline model may inform research into human thrombogenesis.

Coding for Otolaryngology Office Procedures.

This review article provides a summary of current correct coding for in-office surgical procedures. The relevant Current Procedural Terminology codes are covered and tips and guidance provided for their correct use. Also, where applicable, facility versus nonfacility reimbursement policy and the associated implications for physicians practicing in hospital-based clinics are discussed.

A Rare Case of Painful Goiter Secondary to Pediatric Hashimoto's Thyroiditis Requiring Thyroidectomy for Pain Control.

Hashimoto's thyroiditis (HT) usually presents as painless thyroid swelling. Painful pediatric HT is a rare condition with limited literature on pain management. We report a 15-year-old female who presented with 4 weeks history of fatigue, malaise and progressive, painful midline thyroid swelling. There was no difficulty in swallowing, no fever or recent upper respiratory infection symptoms. Exam was remarkable for diffusely enlarged, very tender, and non-nodular thyroid. Thyroid function tests, C-reactive protein, and complete blood count were normal. Ultrasound revealed diffusely enlarged non-nodular, non-cystic gland with mild increased vascularity. Diagnosis of HT was confirmed by biopsy and thyroid antibodies. Over a 6 week period, pain management with ibuprofen, levothyroxine, corticosteroid, gabapentin and amitriptyline was unsuccessful. Ultimately, total thyroidectomy resulted in complete resolution of thyroid pain. We can conclude that thyroidectomy may be considered for the rare case of painful HT in children.

The Value of Mentorship.

The recent Young Physicians needs assessment survey identified mentorship as the single greatest need for this demographic, which includes physicians under 40 years of age or in their first 8 years of practice after completion of training. Much has been written in textbooks and other journals about mentorship, and as young physicians are certainly not alone in this need, mentorship has become a key focus of future Academy endeavors. Serving as Chair of the Young Physicians Section over the past year has afforded me the opportunity to interact with a variety of dynamic and engaging leaders in our Academy, and herein I provide a synopsis of what these experiences have taught me as well as provide some of the most important pearls that I have picked up along the way.

Descemet's membrane detachment in horses; case series and literature review.

The aim of this article was to describe Descemet's membrane detachment (DMD) following phacoemulsification in five equine eyes and to review the human literature on this topic. In the last decade, there has been increased reporting of DMD in the human literature, in particular following cataract surgery. The natural history of DMD remains unknown and although various medical and surgical treatments have been advocated there is no recognized 'gold standard' treatment for DMD. This case series reports the diagnosis of DMD in four horses (5 eyes) in association with phacoemulsification surgery. The diagnosis of DMD in these patients was made intra-operatively, postoperatively or on subsequent histopathological examination. The surgical reports, photographic or video recordings, and ultrasound data were evaluated and possible factors associated with the pathophysiology of DMD are discussed. This is the first description of DMD in the veterinary literature, and the authors believe that DMD might hitherto have been overlooked in veterinary ophthalmology due to a lack of awareness of the condition. The possible causes, clinical signs, and treatment of DMD as described in the human literature are also reviewed.

The Management of Spontaneous Otogenic CSF Leaks: A Presentation of Cases and Review of Literature.

Objective The types of otogenic cerebrospinal fluid (CSF) fistulae were previously classified into defects through, adjacent to, or distal to the otic capsule. This article presents cases of the three different types of spontaneous CSF fistulae and reviews pertinent literature. We examine the management of the different types of otogenic CSF leaks with modern audiovestibular testing, imaging, and surgical techniques. Design Case series and review of the literature. Setting Academic tertiary neurotologic referral practice. Participants Four patients identified through a retrospective search. Main outcome measures Resolution of CSF leak and absence of meningitis. Results Surgical intervention was performed on the four cases described in this series; none had a return of CSF otorrhea in the postoperative period or meningitis. Conclusions Otogenic CSF fistulae may lead to life-threatening infection and in congenital forms are typically not diagnosed unless meningitis has occurred. Rapid and proper recognition, work-up, and treatment of such leaks decrease the risk of permanent neurologic sequelae as well as recurrent meningitis.

Pediatric peritonsillar abscess: Quinsy ie versus interval tonsillectomy.

PERITONSILLAR ABSCESS: Quinsy versus interval tonsillectomy. OBJECTIVES STUDY DESIGN: Case series with chart review. METHODS: We reviewed the records of children treated for peritonsillar abscess between 2007 and 2011 at an academic tertiary pediatric hospital. We identified patients by searching the hospital database for all children treated for the ICD-9 code 475 (peritonsillar abscess). Data points extracted included length of stay, intraoperative blood loss, operative time, and incidence of complications. Statistical analysis was performed to identify significant differences between treatment categories. Children who never received a tonsillectomy (CPT codes 42820/42821/42825/42826) were excluded. RESULTS: 34 children received tonsillectomy for peritonsillar abscess from 2007 to 2011. Of these: 23 received a Quinsy tonsillectomy, and 11 received antibiotics with or without incision and drainage, followed by tonsillectomy a minimum of 2 weeks later. Total hospital days in treatment course was 2.2 days for Quinsy tonsillectomy group and 2.3 days for the interval tonsillectomy group. Estimated blood loss was less than 20 ml for both groups. Operative time was 38 min for Quinsy tonsillectomy and 39 min for interval tonsillectomy. There were no post-tonsillectomy hemorrhages. One patient in the interval tonsillectomy group required readmission for dehydration. CONCLUSION: There were no significant differences in total hospital days, blood loss, operative time, or post-operative complications between Quinsy tonsillectomy and interval tonsillectomy in the treatment of pediatric peritonsillar abscess.

Airway management following pediatric cardiothoracic surgery.

OBJECTIVES: (1) Review airway management in pediatric patients undergoing cardiothoracic surgery (CTS); (2) determine the incidence of airway-related complications of CTS in this population. DESIGN: Case series with chart review. Setting Tertiary care children's hospital. Patients Children undergoing CTS over a 4-year period. METHODS: Patients who underwent CTS at a single, tertiary care, children's hospital between June 1, 2007, and May 31, 2011, were retrospectively reviewed; those <18 years who had open CTS were included. Statistical analysis examined relationships of intubation duration, complications, and need for tracheotomy while comparing patient characteristics, comorbidities, and types of surgery. RESULTS: Eight hundred seventy-five primary surgeries in 745 patients met inclusion criteria. Mean postoperative intubation duration was 7.2 days and median 3 days. On univariate analysis, significantly longer postoperative intubation requirements were found in patients younger in age, with congenital comorbidities or prematurity, with preoperative ventilation requirements, and those with early postoperative complications. Multivariate analysis found younger age, presence of congenital comorbidities, preoperative intubation requirements, and early postoperative complications each lengthen ventilation requirements. Four patients developed vocal cord paralysis and 5 developed phrenic nerve palsy. Nineteen patients required tracheotomy. CONCLUSIONS: In this large cohort, CTS in the pediatric population is associated with few long-term or permanent airway-related complications. Patients who are younger in age and those with congenital comorbidities, preoperative ventilation requirements, or early postoperative complications required longer periods of postoperative intubation.

Successful discontinuation of propranolol for infantile hemangiomas of the head and neck at 12 months of age.

BACKGROUND: Although propranolol can be an effective primary medical therapy for infantile hemangiomas of the head and neck, the duration of treatment and time to discontinue propranolol is unclear. OBJECTIVE: The objective of this study is to determine the duration of treatment and age at which propranolol may be successfully discontinued in children with infantile hemangiomas of the head and neck. METHODS: A review of all patients presenting to a pediatric vascular anomalies clinic from January 2008 to December 2011 was performed. Those with head and neck infantile hemangiomas who completed propranolol therapy were included. Each patient's records were reviewed for demographics, clinical response to propranolol, age at discontinuation of propranolol, and adverse events. RESULTS: Forty-five patients were included for review (mean age at presentation, 3.5 months) with all demonstrating positive responses. The mean age at discontinuation of propranolol was 11.8 months of age (range, 8-15 months) with a mean treatment duration of 6.5 months (range, 3-11 months). No recurrences were noted over a mean follow-up period of 19.9 months (range, 10-28 months). CONCLUSION: Discontinuation of propranolol at approximately 12 months of age was found to be appropriate in our study population.

Impact of incision and drainage of infected thyroglossal duct cyst on recurrence after Sistrunk procedure.

OBJECTIVE: To determine whether incision and drainage of infected thyroglossal duct cysts (TGDCs) is associated with increased risk of recurrence after Sistrunk procedure when compared with antibiotic treatment alone. DESIGN: Retrospective case review. SETTING: Tertiary referral practice. PATIENTS: Patients treated for thyroglossal duct remnants in a tertiary care pediatric center from January 1, 2002, through December 31, 2008. Study subjects were identified using the diagnosis code for TGDC or the procedure code for excision of thyroglossal duct cyst or sinus. MAIN OUTCOME MEASURES: The presence of infection, treatment of infected TGDCs, and relationship between infection, treatment of infection, and recurrence. RESULTS: We identified 120 patients from 2002 through 2008 who met the search criteria. The mean age at the time of presentation was 5.1 years; at the time of surgery, 5.4 years. More than half the patients (58.2%) were male, and the most common presentation was an asymptomatic midline neck mass. Forty-nine of our patients (40.8%) had a history of infection and 6 of these (12%) required incision and drainage. The overall recurrence rate was 10.8%. Ten of the patients with preoperative infection (20%) had a recurrence compared with 3 of the 71 patients (4%) without preoperative infection (P = .002). Of all patients with recurrences, only 1 had undergone incision and drainage. CONCLUSIONS: This case series suggests that preoperative infection is associated with an increased recurrence rate. Incision and drainage of an infected TGDC may not increase the risk of postoperative recurrence. The results of this case series may assist in preoperative counseling and management of infected TGDC prior to definitive surgery.

Survey of Ménière's disease in a subspecialty referral practice.

OBJECTIVES: To define the prevalence of definite Ménière's disease (MD) among patients presenting with characteristic symptoms and examine the utility of published diagnostic guidelines. STUDY DESIGN AND SETTING: Retrospective review in an academic referral practice. RESULTS: The prevalence of definite MD in these 295 individuals was 64%. The next-largest group (23%) consisted of patients with only cochlear symptoms. Those initially classified as probable are usually reclassified as definite with extended follow-up. Of those with definite MD, the mean duration of disease at last follow-up was 7.6 years, 56% were female, 19% had bilateral disease, and 34% required surgical management for vertigo. CONCLUSIONS: The 1995 AAO-HNS guidelines are useful for classification of MD according to certainty of diagnosis and severity of disease, though some modifications could be considered. SIGNIFICANCE: Application of consistent diagnostic criteria is essential for epidemiological, genetic, or outcomes studies of Ménière's disease.

Serological prevalence of canine respiratory coronavirus in southern Italy and epidemiological relationship with canine enteric coronavirus.

Canine respiratory coronavirus (CRCoV) has been detected in dogs suffering from respiratory disease and is thought to be involved in canine infectious respiratory disease (CIRD) complex. Canine enteric coronavirus (CECoV) is a widespread pathogen of dogs, responsible for mild to severe diarrhea in pups. The purpose of this study was to establish the seroprevalence of CRCoV in Italy and its relationship to CECoV type II seroprevalence. The age and year of sample collection from seropositive dogs was also assessed. Of adult domestic dogs, 23.3% had antibodies to CRCoV, compared with 86.1% with antibodies to CECoV. Amongst a population of kenneled pups, 4.0% had antibodies to CRCoV, and 97.0% had antibodies to CECoV.

Clinical predictors for hearing loss in children with bacterial meningitis.

OBJECTIVES: To identify clinical risk factors that predict a higher incidence of hearing loss in children with bacterial meningitis, to determine the overall incidence of hearing loss in a large group of children proven by culture findings to have bacterial meningitis, and to compare clinical characteristics among patients with Streptococcus pneumoniae meningitis and Neisseria meningitidis meningitis. DESIGN: Retrospective review SETTING: Tertiary pediatric hospital. PATIENTS: A total of 171 children identified with bacterial meningitis who met inclusion criteria over a consecutive 10-year period. MAIN OUTCOME MEASURE: Presence of sensorineural hearing loss. RESULTS: Of 134 patients who underwent audiologic testing during their initial hospitalization, 41 (30.6%) were found to have at least a unilateral mild sensorineural hearing loss. The incidence of hearing loss was greater in patients with S pneumoniae meningitis than in patients with N meningitidis meningitis (35.9% and 23.9%, respectively). Length of hospitalization, development of seizures, elevated cerebrospinal fluid protein, and decreased cerebrospinal fluid glucose were significant predictors for hearing loss in children with bacterial meningitis. These factors were not found to be as strong a predictor for hearing loss in patients with N meningitidis meningitis. Stability of hearing was demonstrated with limited follow-up audiometry. CONCLUSIONS: Sensorineural hearing loss is a common sequela in children with bacterial meningitis. Identification of hearing loss in children with bacterial meningitis and early rehabilitation will lessen the long-term educational and social difficulties these children may experience.