Periocular non-tuberculous mycobacterial infection after autologous fat transfer with micro-needling and fractional radiofrequency skin resurfacing.

A 59-year-old woman with prior bilateral lower eyelid autologous fat transfer, subdermal micro-needling and fractional radiofrequency skin resurfacing presented with delayed left-sided preseptal cellulitis with small multinodular abscesses unresponsive to oral outpatient antibiotic regimens and inpatient intravenous antibiotics. Wound culture revealed Mycobacterium chelonae infection treated successfully with a 4-month regimen of clarithromycin and tedizolid without recurrence. This case highlights (1) the need for vigilance and a broad differential in delayed post-operative wound infections including non-tuberculous mycobacterial infections, (2) resolution of infection without recurrence on clarithromycin and novel tedizolid oral antibiotic therapy, and (3) that caution should be exercised when performing combination autologous fat transfers with subdermal micro-needling procedures as the breakdown in skin integrity may potentiate infection.

Outcomes of Sympathetic Blocks in the Management of Complex Regional Pain Syndrome: A Retrospective Cohort Study.

BACKGROUND: Sympathetic dysfunction may be present in complex regional pain syndrome, and sympathetic blocks are routinely performed in practice. To investigate the therapeutic and predictive values of sympathetic blocks, the authors test the hypotheses that sympathetic blocks provide analgesic effects that may be associated with the temperature differences between the two extremities before and after the blocks and that the effects of sympathetic blocks may predict the success (defined as achieving more than 50% pain reduction) of spinal cord stimulation trials. METHODS: The authors performed a retrospective study of 318 patients who underwent sympathetic blocks in a major academic center (2009 to 2016) to assess the association between pain reduction and preprocedure temperature difference between the involved and contralateral limbs. The primary outcome was pain improvement by more than 50%, and the secondary outcome was duration of more than 50% pain reduction per patient report. The authors assessed the association between pain reduction and the success rate of spinal cord stimulation trials. RESULTS: Among the 318 patients, 255 were diagnosed with complex regional pain syndrome and others with various sympathetically related disorders. Successful pain reduction (more than 50%) was observed in 155 patients with complex regional pain syndrome (155 of 255, 61%). The majority of patients (132 of 155, 85%) experienced more than 50% pain relief for 1 to 4 weeks or longer. The degree and duration of pain relief were not associated with preprocedure temperature parameters with estimated odds ratio of 1.03 (97.5% CI, 0.95-1.11) or 1.01 (97.5% CI, 0.96-1.06) for one degree decrease (P = 0.459 or 0.809). There was no difference in the success rate of spinal cord stimulation trials between patients with or without more than 50% pain relief after sympathetic blocks (35 of 40, 88% vs. 26 of 29, 90%, P > 0.990). CONCLUSIONS: The authors conclude that sympathetic blocks may be therapeutic in patients with complex regional pain syndrome regardless of preprocedure limb temperatures. The effects of sympathetic blocks do not predict the success of spinal cord stimulation.

Continuous Positive Airway Pressure Thresholds for Nasolacrimal Air Regurgitation in a Cadaveric Model.

PURPOSE: To elucidate the mechanisms underlying nasolacrimal air regurgitation (AR) in the setting of continuous positive airway pressure therapy. METHODS: Twelve nasolacrimal systems of 6 fresh female human cadavers were evaluated individually for AR using continuous positive airway pressure therapy before any nasolacrimal procedure. Cadavers were then randomly assigned to undergo nasolacrimal duct probing or endoscopic dacryocystorhinostomy and then each hemisystem was again evaluated for AR. The pressure where AR was first observed (discovery pressure) or maximum possible pressure in systems without AR was recorded. In systems that demonstrated AR, the pressure was then gradually decreased to the lowest pressure where regurgitation persisted. This pressure was recorded as the secondary threshold pressure. RESULTS: None of the 12 unoperated nasolacrimal systems or the 6 systems that underwent nasolacrimal duct probing demonstrated AR through the maximum continuous positive airway pressure therapy (30 cm H2O). After endoscopic dacryocystorhinostomy, all 6 nasolacrimal systems demonstrated AR. The mean discovery pressure was 16.0 cm H2O (range, 14.0-18.0 cm H2O) and mean secondary threshold pressure was 7.25 cm H2O (range, 6.5-8.0 cm H2O). CONCLUSIONS: Air regurgitation during continuous positive airway pressure therapy in the setting of prior endoscopic dacryocystorhinostomy can be replicated in a cadaver model. The secondary threshold pressures required for AR in this model were similar to AR pressures reported clinically. Prior to dacryocystorhinostomy, patients using continuous positive airway pressure therapy should be counseled on AR, and physicians should consider this phenomenon when evaluating ophthalmic complaints in postoperative patients on positive airway pressure therapy.

Evidence-based knee injections for the management of arthritis.

OBJECTIVE: Arthritis of the knee affects 46 million Americans. We aimed to determine the level of evidence of intraarticular knee injections in the management of arthritic knee pain. METHODS: We systematically searched PUBMED/MEDLINE and the Cochrane databases for articles published on knee injections and evaluated their level of evidence and recommendations according to established criteria. RESULTS: The evidence supports the use of intraarticular corticosteroid injections for rheumatoid arthritis (1A+ Level), osteoarthritis (1A+ Level), and juvenile idiopathic arthritis (2C+ Level). Pain relief and functional improvement are significant for months up to 1 year after the injection. Triamcinolone hexacetonide offers an advantage over triamcinolone acetonide and should be the intraarticular steroid of choice (2B+ Level). Intraarticular injection of hyaluronate may provide longer pain relief than steroid injection in osteoarthritis (2B+ Level). It can also be effective for rheumatoid arthritis knee pain (1A+ Level). However, it is only recommended for patients with significant surgical risk factors and for patients with mild radiographic disease in whom conservative treatment has failed (2B± Level). Botulinum toxin type A injection is effective in reducing arthritic knee pain (2B+ Level), and so is tropisetron (2B+ Level) and tanezumab (2B+ Level). The new agents, such as rAAV2-TNFR:Fc, SB-210396/CE 9.1, and various radioisotopes have provided various degrees of success, but their long-term safety and efficacy remains to be determined. CONCLUSIONS: We conclude that strong evidence supports the use of intraarticular knee injection as a valuable intervention in the continuum of management of arthritis between conservative treatment and knee surgeries.

Teprotumumab in advanced reactivated thyroid eye disease.

Purpose: To report the case of a patient with reactivated, refractory thyroid eye disease (TED) treated with teprotumumab. Observations: A 51-year-old female with a 16-year history of thyroid eye disease previously treated with orbital decompression and multiple eyelid surgeries presented in a recurrent flare of the disease. The disease recurrence was refractory to intravenous steroid therapy and only partially responsive to oral steroid therapy, and the patient developed dysthyroid optic neuropathy in the right eye with decreased visual acuity and color vision. Clinical activity score was 8/10 and proptosis measurements were 27 mm OD and 26 mm OS. The patient underwent treatment with eight infusions of teprotumumab coinciding with a low taper of oral prednisone and experienced resolution of dysthyroid optic neuropathy, decrease of clinical activity score to 1, and dramatic improvement in proptosis (17 mm OD, 17 mm OS) and extraocular muscle size on imaging. Thirty weeks after completion of teprotumumab and 2 weeks after the second dose of the COVID vaccine, she experienced another flare and subsequently underwent bilateral orbital decompressions. Conclusion: This case report suggests teprotumumab may be used in patients with reactivation of longstanding thyroid eye disease. Reduction of extraocular muscle size and improvement in proptosis suggest teprotumumab may be disease-modifying even in advanced cases.

Retinal Complications after Yttrium-Aluminum-Garnet Laser Vitreolysis for Vitreous Floaters.

This is an observational case series of two patients who developed direct retinal damage following neodymium-doped yttrium-aluminum-garnet (YAG) laser treatment for symptomatic vitreous floaters. The first patient developed a vitreous hemorrhage and subsequent branch retinal vein occlusion from laser damage to a major retinal venule. The second patient developed a temporal scotoma from a full-thickness retinal break in the posterior pole requiring laser retinopexy. Direct YAG laser damage to the posterior pole can cause permanent visual deficits. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:610-613.].

Heparin-mediated antibiotic delivery from an electrochemically-aligned collagen sheet.

BACKGROUND: Implantable medical devices and hardware are prolific in medicine, but hardware associated infections remain a major issue. OBJECTIVE: To develop and evaluate a novel, biologic antimicrobial coating for medical implants. METHODS: Electrochemically compacted collagen sheets with and without crosslinked heparin were synthesized per a protocol developed by our group. Sheets were incubated in antibiotic solution (gentamicin or moxifloxacin) overnight, and in vitro activity was assessed with five-day diffusion assays against Pseudomonas aeruginosa. Antibiotic release over time from gentamicin-infused sheets was determined using in vitro elution and high performance liquid chromatography (HPLC). RESULTS: Collagen-heparin-antibiotic sheets demonstrated larger growth inhibition zones against P. aeruginosa compared to collagen-antibiotic alone sheets. This activity persisted for five days and was not impacted by rinsing sheets prior to evaluation. Rinsed collagen-antibiotic sheets did not produce any inhibition zones. Elution of gentamicin from collagen-heparin-gentamicin sheets was gradual and remained above the minimal inhibitory concentration for gentamicin-sensitive organisms for 29 days. Conversely, collagen-gentamicin sheets eluted their antibiotic load within 24 hours. Overall, heparin-associated sheets demonstrated larger inhibition zones against P. aeruginosa and prolonged elution profile via HPLC. CONCLUSION: We developed a novel, local antibiotic delivery system that could be used to coat medical implants/hardware in the future and reduce post-operative infections.

Laryngotracheal reconstruction with a prefabricated fasciocutaneous free flap for recurrent papillary thyroid carcinoma.

BACKGROUND: Prefabricated composite free flaps have been described as a technique for reconstruction of laryngotracheal defects. METHODS: We present a 74-year-old woman with recurrent papillary thyroid carcinoma (PTC) who was initially treated with thyroidectomy, tracheal resection, and subsequent vocal cord medialization. The patient's recurrent disease was treated with partial laryngectomy and reconstruction using a prefabricated composite free flap. A 2-stage procedure was performed using conchal cartilage to create a prefabricated radial forearm free flap. RESULTS: The patient's airway was successfully reconstructed with preservation of speech and swallow function. CONCLUSION: This case provides further evidence supporting the use of prefabricated free flaps in airway reconstruction and the ability to obtain successful outcomes in a patient with multiple prior surgeries in the operative field and requiring adjuvant external beam radiation therapy. © 2016 Wiley Periodicals, Inc. Head Neck 38: E2512-E2514, 2016.