Topical Tranexamic Acid Does Not Reduce The Incidence Of Hematoma In Reduction Mammoplasty: A Double-Blinded, Randomized Placebo-Controlled Trial.

BACKGROUND: Breast reduction mammoplasty (BRM) is among the most common procedures in plastic surgery, with a 1-7% postoperative hematoma incidence reported. Tranexamic acid (TXA) has been shown to reduce perioperative bleeding and need for transfusion when administered intravenously or topically, but remains underutilized in plastic surgery. This study aims to investigate whether topical administration of topical TXA reduces postoperative hematoma following BRM. METHODS: A double-blinded, randomized controlled trial of 98 patients (196 breasts) undergoing bilateral primary reduction mammoplasty at a single academic institution was performed. Patients were used as internal matched controls, with one breast randomized to receive 1000mg of topical TXA before closure, and the other receiving saline. All members of the surgical team and patient were blinded as to which breast received the study drug. Postoperative complications, including hematoma, within 30 days of surgery, drain outputs, and duration of drain use, were compared between treatment and placebo breasts. RESULTS: The overall hematoma rate was 1.5%. There was no significant association between application of TXA and development of a hematoma (p=0.56) or other complications. The hematoma rate of patients enrolled in the trial was similar to the overall rate of hematoma during the study time period (1.5% versus 2.4%, p=0.511). In a multivariate model, TXA was not significantly associated with differences in drain output after controlling for resection weight, age, and duration of drain use (p=0.799). No adverse effects or thromboembolic events from TXA were observed. CONCLUSION: Topical application of TXA does not decrease the incidence of hematoma following reduction mammoplasty.

Topical Nitroglycerin Ointment Reduces Mastectomy Flap Necrosis in Immediate Autologous Breast Reconstruction.

BACKGROUND: Mastectomy flap necrosis (MFN) is a common complication of immediate breast reconstruction that greatly affects patient satisfaction and cosmetic outcomes. Topical nitroglycerin ointment, with its low cost and negligible side effects, has been shown to significantly decrease the incidence of MFN in immediate implant-based breast reconstruction, but its utility has not been studied in immediate autologous reconstruction. METHODS: With institutional review board approval, a prospective cohort study was performed of all consecutive patients undergoing immediate free-flap breast reconstruction by a single reconstructive surgeon at a single institution between February of 2017 and September of 2021. Patients were divided into two cohorts: those who received 30 mg of topical nitroglycerin ointment to each breast at the conclusion of the operation (September of 2019 to September of 2021) and those who did not (February of 2017 to August of 2019). All patients underwent intraoperative SPY angiography, and mastectomy skin flaps were débrided intraoperatively based on imaging. Independent demographic variables were analyzed, and dependent outcome variables included mastectomy skin flap necrosis, headache, and hypotension requiring removal of ointment. RESULTS: A total of 35 patients (49 breasts) were included in the nitroglycerin cohort and 34 patients (49 breasts) were included in the control group. There was no significant difference in patient demographics, medical comorbidities, or mastectomy weight between cohorts. The rate of MFN decreased from 51% in the control group to 26.5% in the group that received nitroglycerin ointment ( P = 0.013). There were no documented adverse events associated with nitroglycerin use. CONCLUSION: Topical nitroglycerin ointment significantly decreases the rate of MFN in patients undergoing immediate autologous breast reconstruction without significant adverse effects. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Effect of intraoperative blood pressure on incidence of hematoma in breast reduction mammoplasty.

BACKGROUND: Postoperative hematomas are among the most frequent complications following breast reduction mammoplasty (BRM). Intraoperative hypotension has been implicated in the development of postoperative hematomas following breast reduction. In this study, we performed a retrospective, propensity-matched analysis of patients undergoing primary breast reduction to determine the relationship between intraoperative blood pressure and the development of a postoperative hematoma. METHODS: A retrospective review of all patients that underwent BRM at a single institution from 2017 to 2019 (n = 563) was conducted. Patients who developed a postoperative hematoma were propensity matched to two controls based on body mass index (BMI) and age. The mean systolic blood pressure (SBP) and average mean arterial pressure (MAP) were recorded for each third of the operation. Data were analyzed using conditional logistic regression. RESULTS: Thirty-two patients that developed postoperative hematomas were propensity matched to 64 controls. There was no difference in baseline SBP, diastolic blood pressures, or prevalence of hypertension between groups. There was no significant difference in average SBP or MAP between groups. The average MAP during the first third of the procedure was found to be lower in patients who developed a hematoma (69 vs. 72 mmHg), which approached significance at p = 0.08. Closed suction drains were used in 53% of the hematoma group and 78% of the control group (p = 0.02). CONCLUSION: There does not appear to be an association between intraoperative blood pressure and the incidence of hematoma when comparing patients who developed hematomas after BRM to propensity-matched controls.

Postoperative pain and opioid use after breast reduction with or without preoperative nerve block.

BACKGROUND: Physician-prescribed opioids have been implicated as key contributing factors in the current opioid epidemic in the United States. Breast reduction mammoplasty is one of the most commonly performed procedures in plastic surgery and patients are often prescribed large amounts of postoperative opioids. Here we investigate the effects of erector spinae nerve blocks on postoperative pain, opioid consumption, and quality of life after breast reduction. METHODS: Following the institutional review board (IRB) approval, a prospective cohort study of some patients undergoing breast reduction mammoplasty at Montefiore Medical Center between June and September 2019 was undertaken. The patients were stratified into two cohorts for further analysis: those who received preoperative erector spinae nerve block and those who did not. Primary outcomes measures analyzed included Likert pain scores, patient-reported outcome measures, and opioid consumption for the first five postoperative days. RESULTS: Forty-seven patients were enrolled in the analysis. Thirteen patients (28%) received nerve blocks, 34 (72%) did not. On average, the patients were prescribed 114.3 (±34.6) morphine equivalents postoperatively and they consumed 45% (±35.3) by the end of the first five days post-surgery. There were no significant differences between cohorts in morphine equivalents prescribed or consumed, postoperative pain scores, or patient-reported outcome measures. CONCLUSIONS: Following breast reduction mammoplasty, patients on average consumed < 50% of prescribed opioids, suggesting over-prescription of postoperative opioids for breast reduction recovery. Preoperative nerve block did not improve pain scores or decrease opioid consumption for the first five days after surgery.

The Expanding Role of Geometric Morphometrics in Craniofacial Surgery.

INTRODUCTION: Geometric morphometrics (GM) is an advanced landmark-based quantitative method used to study biological shape and form. Historically, GM has been limited to non-biomedical fields such as comparative biology; however, this technique confers advantages over traditional cephalometric methods, warranting a review of current applications of GM to human craniofacial disorders. METHODS: The RISmed package was used to extract metadata associated with PubMed publications referencing GM analysis techniques in craniofacial and reconstructive surgery. PubMed search terms included "geometric AND morphometric AND craniofacial;" and "geometric AND morphometric AND reconstructive surgery." Duplicate search results were eliminated. RESULTS: Search yielded 139 studies between 2005 and 2020, of which 27 met inclusion criteria. Human craniofacial studies constituted 2% of all queried GM studies. Among these, cleft lip and palate were the most commonly studied craniofacial conditions (7 studies, 26%), followed by sagittal craniosynostosis (4 studies, 15%). Seventeen studies (63%) used GM to assess skeletal structures, seven studies (26%) examined both skeletal and soft tissues, and three studies (11%) analyzed soft tissues only. Eleven studies (40.1%) employed a GM approach to evaluate postoperative changes in craniofacial morphology. Two studies (7%) systematically compared GM analysis with conventional shape measurements. CONCLUSION: The ability to study shape while controlling for variability in structure size and imaging technique make GM a promising tool for understanding growth patterns in complex craniofacial diseases. Furthermore, GM overcomes many limitations of traditional cephalometric techniques, and hence may claim an expanded role in the study of human craniofacial disorders in clinical and research settings.

Do larger reductions yield larger returns? patient-reported outcomes as a function of specimen weight in bilateral reduction mammoplasty.

BACKGROUND: Patients undergoing breast reduction mammoplasty for symptomatic macromastia have a significantly improved quality of life postoperatively. However, there are no data that examine the effect of reduction mammoplasty on quality of life as a function of the weight of tissue removed. Because the process by which insurance providers consider patients' candidacy for this breast reduction mammoplasty is most often based on the proposed weight of tissue to be removed, this gap in our understanding is particularly glaring. We therefore designed a prospective trial with the intent of investigating the correlation between breast reduction specimen weight and postoperative pain and quality of life. METHODS: After obtaining institutional review board (IRB) approval, patients presenting for breast reduction mammoplasty at a single academic medical center between January 2016 and September 2019 were prospectively enrolled in the study. Study participants completed the Numerical Pain Rating Scale (NPRS), the short-form McGill Pain Questionnaire (SF-MPQ), and the BREAST-Q at set time points (preoperatively, 1 week/1 month/3 months/6 months postoperatively). Patients were divided into three cohorts based on breast reduction specimen weights: small (<500 g reduction), intermediate (500-1000 g reduction), and large (>1000 g reduction). The surveys were then analyzed while controlling for demographic factors and complications. RESULTS: A total of 85 women were enrolled in the study and completed pre- and postoperative surveys (small reduction n = 21 (25%), intermediate n = 45 (53%), and large n = 19 (22%)). Regardless of reduction specimen weight, patients reported decreased overall pain and increased satisfaction with their breasts, as well as improved psychosocial, sexual, and physical well-being at each postoperative visit. Preoperative SF-MPQ pain scores were significantly lower in the small specimen weight group compared with either the intermediate or the large group (p = 0.001). Postoperatively, both the intermediate and large groups reported significant improvement in pain at each time point. The small specimen weight group did not report significant pain improvement until 3 months postoperatively. CONCLUSIONS: Patients undergoing breast reduction mammoplasty experience decreased pain and improved quality of life regardless of reduction specimen weight. Improvement in these parameters manifests as early as 1 week postoperatively and maintained at 3 months postoperatively. These data suggest that many patients who are denied coverage for reduction mammoplasty on the basis of low projected reduction specimen weight would derive significant benefit from the procedure.

Pituitary adenoma consistency: Direct correlation of ultrahigh field 7T MRI with histopathological analysis.

PURPOSE: Tumor consistency is a critical factor in surgical planning that influences ease of resection and risk of operative morbidity. The ability of MRI to predict tumor consistency tumor consistency has been shown to increase with higher field strength. The present study examined the utility of 7 T (7 T) MRI in predicting the tumor consistency of pituitary adenomas. METHOD: Fifteen patients with pituitary adenomas were preoperatively scanned at 7 T MRI. Regions of interest were drawn around lesions for voxel-based signal intensity (SI) analysis. The percentage of tumor voxels with intensity higher than local gray matter was calculated on T2-weighted imaging. A single neurosurgeon rated tumor firmness for all patients. Histopathological analysis was performed. Radiological tumor features were correlated with intraoperative tumor consistency measurements and histopathology. RESULTS: Tumors rated as 'soft' intraoperatively were hyperintense to local gray matter on T2-weighted imaging. 'Firm' tumors were hypointense to local gray matter. There was no significant difference in SI ratio between soft and firm tumors (p = 0.098). Soft tumors had a significantly higher percentage of tumor voxels greater than local gray matter compared to firm tumors (p = 0.035, Cohen's D-effect size = 1.208). Soft tumors had higher vascularity than firm tumors, p = 0.015. CONCLUSIONS: The signal and contrast advantage conferred by 7 T MRI may provide valuable preoperative information regarding pituitary tumor consistency and physiology. The use of granular, voxel-based analysis maximizes the potential afforded by the high resolution of 7 T imaging, and may be a valuable method of predicting consistency of pituitary adenoma.

Retroperitoneal Approach for Ilioinguinal, Iliohypogastric, and Genitofemoral Neurectomies in the Treatment of Refractory Groin Pain After Inguinal Hernia Repair.

Inguinal hernia repair is one of the most commonly performed surgical procedures. Postoperative neuropathic groin pain is a potentially disabling complication and can be due to a neuroma of the ilioinguinal, iliohypogastric, and/or genitofemoral nerves. In this article, we present our operative technique-a retroperitoneal approach to the ipsilateral ilioinguinal, iliohypogastric, and genitofemoral nerves with neurectomy and proximal transposition of these nerves-for management of neuropathic pain. A retrospective review was performed of 12 of the patients who underwent this surgery at our institution. Three of 12 patients underwent a selective neurectomy, whereas 9 of 12 underwent a triple neurectomy; 3 of the 9 patients who underwent triple neurectomy also had a retroperitoneal peripheral nerve stimulator placed at the time of neurectomy. Pain visual analog scores (VASs) demonstrated significant improvement after neurectomy (preoperative pain VAS of 85 ± 11 vs postoperative pain VAS of 47 ± 32, P = 0.0027). Eight of 12 patients experienced partial or complete pain relief, whereas 4 of 12 patients had no pain relief. There were no major complications, and the minor complication rate was low for all patients and primarily related to peripheral nerve stimulator placement. This retroperitoneal approach to triple neurectomy for treatment of refractory groin pain in postoperative inguinal hernia repair patients is safe and effective for an otherwise devastating problem.

Neuroanatomical Determinants of Secondary Trigeminal Neuralgia: Application of 7T Ultra-High-Field Multimodal Magnetic Resonance Imaging.

BACKGROUND: Seven-Tesla (7T) magnetic resonance imaging (MRI) has demonstrated value for evaluating a variety of intracranial diseases. However, its utility in trigeminal neuralgia has received limited attention. The authors of the present study applied ultra-high field multimodal MRI to two representative patients with secondary trigeminal neuralgia due to epidermoid tumors to illustrate the possible clinical and surgical advantages of 7T compared with standard clinical strength imaging. Techniques included co-registration of multiple 7T sequences to optimize the detection of potential concurrent neurovascular and neoplasm-derived compression. METHODS: 7T MRI studies were performed using a whole body scanner. Two- and three-dimensional renderings of potential neurovascular conflict were created by co-registering time-of-flight angiography and T2-weighted turbo spin echo images in MATLAB and GE software. Detailed comparisons of the various field strength images were provided by a collaborating neuroradiologist (B.D.). RESULTS: 7T MRI clearly illustrated minute tumor-adjacent vasculature. In contrast, conventional, low-field imaging did not consistently provide adequate details to distinguish cerebrospinal fluid pulsatility from vessels. The tumor margins, although distinct from the trigeminal nerve fibers at 7T, blended with those of the surrounding structures at 3T. Two- and three-dimensional co-registration of time-of-flight angiography with T2-weighted MRI suggested that delicate, intervening vasculature may have contributed to these illustrative patients' symptomatology. CONCLUSIONS: 7T provided superior visualization of vital landmarks and subtle nerve and vessel features. Co-registration of various advanced 7T modalities may help to resolve complex disease etiologies. Future studies should explore the extent to which this dual etiology might persist across tumor types and utilize diffusion-based techniques to quantify what microstructural differences might exist between patients with trigeminal neuralgia from varying etiologies.

Postoperative Pain Management Following Craniosynostosis Repair: Current Practices and Future Directions.

BACKGROUND: Postoperative analgesia following craniosynostosis repair is a clinical challenge for plastic and reconstructive surgeons. There is a paucity of published data on the postoperative pain associated with craniosynostosis repair procedures and the prescribed analgesia varies with different unit protocols. The authors sought to summarize the current knowledge of the postoperative analgesia following craniosynostosis repair by reviewing the literature for existing regimens, clinical outcomes, and recommendations. METHODS: Two independent investigators conducted a literature search of the Pubmed, Cochrane, and Google Scholar databases for relevant clinical studies. Studies were abstracted for procedure type, postoperative pain management protocol, pain scores, side effects, complications, and clinical recommendations. RESULTS: Ten studies describing the use of analgesic agents in open craniosynostosis surgery from 2000 to 2018 were fully reviewed, comprising a total of 431 patients undergoing surgical procedures using a combination regimen of narcotic and nonnarcotic agents (n = 315) and nonnarcotic agents alone (n = 116). CONCLUSION: Multimodal analgesia is the primary regimen used following open craniosynostosis repair procedures. Opioids are a critical component in pain management regimens, relieving patient discomfort. However, due to the deleterious effects that come with their prolonged use, intravenous acetaminophen is currently used as an alternative in many centers. The preferred mode of pain medication administration in the pediatric population is increasingly via the intravenous route which ensures that a full dose of pain medication is given. The authors suggest the use of dexmedetomidine, both an adjunct to intravenous acetaminophen and as a substitute for morphine due to its superior safety and efficacy profile.

Quantitative assessment of secondary white matter injury in the visual pathway by pituitary adenomas: a multimodal study at 7-Tesla MRI.

OBJECTIVE: The objective of this study was to investigate microstructural damage caused by pituitary macroadenomas by performing probabilistic tractography of the optic tracts and radiations using 7-T diffusion-weighted MRI (DWI). These imaging findings were correlated with neuro-ophthalmological results to assess the utility of ultra-high-field MRI for objective evaluation of damage to the anterior and posterior visual pathways. METHODS: Probabilistic tractography employing 7-T DWI was used to reconstruct the optic tracts and radiations in 18 patients with adenomas and in 16 healthy volunteers. Optic chiasm compression was found in 66.7% of the patients and visual defects in 61.1%. Diffusion indices were calculated along the projections and correlated with tumor volumes and results from neuro-ophthalmological examinations. Primary visual cortical thicknesses were also assessed. RESULTS: Fractional anisotropy was reduced by 21.9% in the optic tracts (p < 0.001) and 17.7% in the optic radiations (p < 0.001) in patients with adenomas. Patients showed an 8.5% increase in mean diffusivity of optic radiations compared with healthy controls (p < 0.001). Primary visual cortical thickness was reduced in adenoma patients. Diffusion indices of the visual pathway showed significant correlations with neuro-ophthalmological examination findings. CONCLUSIONS: Imaging-based quantification of secondary neuronal damage from adenomas strongly correlated with neuro-ophthalmological findings. Diffusion characteristics enabled by ultra-high-field DWI may allow preoperative characterization of visual pathway damage in patients with chiasmatic compression and may inform prognosis for vision recoverability.

Utility of preoperative meningioma consistency measurement with magnetic resonance elastography (MRE): a review.

Meningioma consistency is a critical factor that influences preoperative planning for surgical resection. Recent studies have investigated the utility of preoperative magnetic resonance elastography (MRE) in predicting meningioma consistency. However, it is unclear whether existing methods are optimal for application to clinical practice. The results and conclusions of these studies are limited by their imaging acquisition methods, such as the use of a single MRE frequency and the use of shear modulus as the final measurement variable, rather than its storage and loss modulus components. In addition, existing studies do not account for the effects of cranial anatomy, which have been shown to significantly distort the MRE signal. Given the interaction of meningiomas with these anatomic structures and the lack of supporting evidence with more accurate imaging parameters, MRE may not yet be reliable for use in clinical practice.

Solving Congestion in the Plastic Surgery Match: A Game Theory Analysis.

Plastic and reconstructive surgery is among the most competitive specialties in the residency match. Applicants seeking to maximize their chances of a successful match often submit numerous applications to the National Residency Matching Program. It is not uncommon for those applying to plastic and reconstructive surgery to apply to every program. The high application volume imparts significant time and financial burden for applicants and programs alike. Furthermore, it makes distinguishing between applicants with a genuine interest in a specific program and those who are merely hoping to improve their chances vastly more difficult. The authors sought to characterize trends in the match rate, as the number of integrated plastic and reconstructive surgery programs continues to increase. Furthermore, they reviewed the literature on game theory for possible solutions to residency application congestion. The authors propose the use of the game theory model to explain the observed results and show why an application limit is the most reasonable approach to address this issue.

Systemic Changes Affecting the Morphology of Calvarial Bone.

Plastic surgeons are frequently consulted to evaluate concerns about a patient's skull. Imaging studies often reveal abnormalities in bone morphology, from increased porosity to sclerotic changes. While focal findings imply a benign or malignant neoplasm, the etiology of more diffuse findings can be more varied, making the correct diagnosis challenging. The present review summarizes the differential diagnosis of osseous lesions of the calvarium that affect the bone and contribute to changes seen on imaging studies.

Antifibrinolytic Agents in Plastic Surgery: Current Practices and Future Directions.

BACKGROUND: Prevention of blood loss is a chief consideration in plastic and reconstructive surgery. The antifibrinolytic drugs tranexamic acid and ε-aminocaproic acid have emerged as promising agents to reduce both perioperative blood loss and transfusion requirements. However, published reports in the plastic surgery literature are lacking. The authors sought to summarize the current knowledge of the use of antifibrinolytics in plastic surgery by reviewing the existing literature for clinical outcomes and recommendations. METHODS: A systematic review of the PubMed, Cochrane, and Google Scholar databases was conducted for publications examining the use of antifibrinolytics in plastic surgery. Studies were abstracted for procedure type, antifibrinolytic dose, time and mode of administration, blood loss, transfusion requirements, and complications. RESULTS: Thirty-three studies were deemed eligible for inclusion, comprising a total of 1823 patients undergoing plastic surgical procedures with tranexamic acid (n = 1328) and/or ε-aminocaproic acid (n = 495). CONCLUSIONS: Tranexamic acid and ε-aminocaproic acid are widely used to reduce blood loss and transfusion requirements in craniofacial and orthognathic surgery, without an increased risk of adverse events. Intravenous administration is most commonly used, although topical formulations show similar efficacy with a reduced systemic distribution. Tranexamic acid has also emerged as a promising agent in aesthetic surgery and burn care, due to its favorable safety profile and role in reducing blood loss, achieving an improved surgical field, and reducing edema and ecchymosis. Further investigation of these agents in the fields of burn care, aesthetic surgery, and microsurgery is warranted to standardize protocols for clinical use.

Plastic Surgery Resident-Run Cosmetic Clinics: A Survey of Current Practices.

BACKGROUND: The recently increased minimum aesthetic surgery requirements set by the Plastic Surgery Residency Review Committee of the Accreditation Council for Graduate Medical Education highlight the importance of aesthetic surgery training for plastic surgery residents. Participation in resident aesthetic surgery clinics has become an important tool to achieve this goal. Yet, there is little literature on the current structure of these clinics. OBJECTIVES: The authors sought to evaluate current practices of aesthetic resident-run clinics in the United States. METHODS: A survey examining specific aspects of chief resident clinics was distributed to 70 plastic surgery resident program directors in the United States. Thirty-five questions sought to delineate clinic structure, procedures and services offered, financial cost to the patient, and satisfaction and educational benefit derived from the experience. RESULTS: Fifty-two questionnaires were returned, representing 74.2% of programs surveyed. Thirty-two (63%) reported having a dedicated resident aesthetic surgery clinic at their institution. The most common procedures performed were abdominoplasty (n = 20), breast augmentation (n = 19), and liposuction (n = 16). Most clinics offered neuromodulators (n = 29) and injectable fillers (n = 29). The most common billing method used was a 50% discount on surgeon fee, with the patient being responsible for the entirety of hospital and anesthesia fees. Twenty-six respondents reported feeling satisfied or very satisfied with their resident aesthetic clinic. CONCLUSIONS: The authors found aesthetic chief resident clinics to differ greatly in their structure. Yet the variety of procedures and services offered makes participation in these clinics an effective training method for the development of both aesthetic surgical technique and resident autonomy.

Can MRI predict meningioma consistency?: a correlation with tumor pathology and systematic review.

Tumor consistency is a critical factor that influences operative strategy and patient counseling. Magnetic resonance imaging (MRI) describes the concentration of water within living tissues and as such, is hypothesized to predict aspects of their biomechanical behavior. In meningiomas, MRI signal intensity has been used to predict the consistency of the tumor and its histopathological subtype, though its predictive capacity is debated in the literature. We performed a systematic review of the PubMed database since 1990 concerning MRI appearance and tumor consistency to assess whether or not MRI can be used reliably to predict tumor firmness. The inclusion criteria were case series and clinical studies that described attempts to correlate preoperative MRI findings with tumor consistency. The relationship between the pre-operative imaging characteristics, intraoperative findings, and World Health Organization (WHO) histopathological subtype is described. While T2 signal intensity and MR elastography provide a useful predictive measure of tumor consistency, other techniques have not been validated. T1-weighted imaging was not found to offer any diagnostic or predictive value. A quantitative assessment of T2 signal intensity more reliably predicts consistency than inherently variable qualitative analyses. Preoperative knowledge of tumor firmness affords the neurosurgeon substantial benefit when planning surgical techniques. Based upon our review of the literature, we currently recommend the use of T2-weighted MRI for predicting consistency, which has been shown to correlate well with analysis of tumor histological subtype. Development of standard measures of tumor consistency, standard MRI quantification metrics, and further exploration of MRI technique may improve the predictive ability of neuroimaging for meningiomas.

Mycobacterium marinum and Carpal Tunnel Syndrome: Three Case Reports.

Infection with Mycobacterium marinum is often difficult to diagnose. Infection with M. marinum in the upper extremity may involve the tendon sheaths, producing clinical manifestations such as tenosynovitis and symptoms of carpal tunnel syndrome. We report 3 cases of M. marinum infection of the hand associated with carpal tunnel syndrome during an outbreak in New York City's Chinatown. A combination of carpal tunnel release, flexor tenosynovectomy, and appropriate antibiotics yielded complete resolution of symptoms in all cases.

Metabolic In Vivo Visualization of Pituitary Adenomas: a Systematic Review of Imaging Modalities.

OBJECTIVE: Pituitary adenomas (PAs) are the most common intrasellar mass. Functional PAs constitute most of pituitary tumors and can produce symptoms related to hormonal overproduction. Timely and accurate detection is therefore of vital importance to prevent potentially irreversible sequelae. Magnetic resonance imaging is the gold standard for detecting PAs, but is limited by poor sensitivity for microadenomas and an inability to differentiate scar tissue from tumor residual or predict treatment response. Several new modalities that detect PAs have been proposed. METHODS: A systematic review of the PubMed database was performed for imaging studies of PAs since its inception. Data concerning study characteristics, clinical symptoms, imaging modalities, and diagnostic accuracy were collected. RESULTS: After applying exclusion criteria, 25 studies of imaging PAs using positron emission tomography (PET), magnetic resonance spectroscopy (MRS), and single photon emission computed tomography were reviewed. PET reliably detects PAs, particularly where magnetic resonance imaging is equivocal, although its efficacy is limited by high cost and low availability. Single photon emission computed tomography possesses good sensitivity for neuroendocrine tumors but its use with PAs is poorly documented. MRS consistently detects cellular proliferation and hormonal activity, but warrants further study at higher magnetic field strength. CONCLUSIONS: PET and MRS appear to have the strongest predictive value in detecting PAs. MRS has the advantage of low cost, but the literature is lacking in specific studies of the pituitary. Due to high recurrence rates of functional PAs and low sensitivity of existing diagnostic workups, further investigation of metabolic imaging is necessary.

Contemporary spinal oncology treatment paradigms and outcomes for metastatic tumors to the spine: A systematic review of breast, prostate, renal, and lung metastases.

Metastatic spinal disease most frequently arises from carcinomas of the breast, lung, prostate, and kidney. Management of spinal metastases (SpM) is controversial in the literature. Recent studies advocate more aggressive surgical resection than older studies which called for radiation therapy alone, challenging previously held beliefs in conservative therapy. A literature search of the PubMed database was performed for spinal oncology outcome studies published in the English language between 2006 and 2016. Data concerning study characteristics, patient demographics, tumor origin and spinal location, treatment paradigm, and median survival were collected. The search retrieved 220 articles, 24 of which were eligible to be included. There were overall 3457 patients. Nine studies of 1723 patients discussed parameters affecting median survival time with comparison of different primary cancers. All studies found that primary cancer significantly predicted survival. Median survival time was highest for primary breast and renal cancers and lowest for prostate and lung cancers, respectively. Multiple spinal metastases, a cervical location of metastasis, and pathologic fracture each had no significant influence on survival. Survival in metastatic spinal tumors is largely driven by primary tumor type, and this should influence palliative management decisions. Surgery has been shown to greatly increase quality of life in patients who can tolerate the procedure, even in those previously treated with radiotherapy. Surgery for SpM can be used as first-line therapy for preservation of function and symptom relief. Future studies of management of SpM are warranted and primary tumor diagnosis should be studied to determine contribution to survival.