Recent Publications by CFE Educators

Management of splenic pseudoaneurysms in hemodynamically stable patients has shifted toward nonoperative management, including watchful waiting and endovascular embolization. Standard of treatment does not include percutaneous embolization for splenic pseudoaneurysm repair. In this case report, we document a successful percutaneous embolization of a post traumatic splenic pseudoaneurysm with thrombin. Percutaneous embolization of splenic pseudoaneurysms can be considered a viable technique in patients who fail endovascular embolization or have lesions inaccessible to endovascular repair.

OBJECTIVES

To prospectively examine durability of long-term outcomes in sialendoscopy-assisted salivary duct surgery (SASDS) in chronic obstructive sialadenitis without sialolithiasis (COSWS).

METHODS

A prospective cohort study of adult patients with COSWS who completed Chronic Obstructive Sialadenitis Symptoms (COSS) Questionnaire prior to and at 3 months and 1 year following SASDS. COSS scores scaled to 0 to 100 were analyzed by statistically significant improvements and previously published ranges corresponding to complete, partial, and nonresolution of symptoms.

RESULTS

Twenty-nine patients with COSWS affecting 41 glands had statistically significant improvements in COSS scores at 3 months following SASDS. These improvements usually were sustained at 1 year, supporting durability of treatment effect over time. A majority of cases (30 of 41, 73%) achieved at least a partial resolution of sialadenitis symptoms (COSS score ≤ 25) at 1-year follow-up. Symptom improvement after SASDS was noted in 14 of 18 (78%) glands with radioiodine-induced sialadenitis (RAI-IS). The highest proportion of persistent or recurrent disease at 1-year post-SASDS was found in autoimmune sialadenitis (2 of 4, 50%) and glands with proximal or multifocal stenoses (6 of 12, 50%). At 1 year, distal duct stenoses achieved a significantly higher proportion of partial or complete symptom resolution (18 of 21, 86%) than cases with proximal or multifocal stenoses (6 of 12, 50%; P = 0.044).

CONCLUSIONS

SASDS is effective in reducing symptoms in duct stenosis and RAI-IS, usually with durable treatment benefits at long-term follow-up. Distal stenoses appear to be more amenable to sialendoscopic treatment, achieving greater symptom reduction than proximal/multifocal stenoses. Additional larger multi-center studies are needed to further characterize risk factors for COSWS refractory to SASDS.

LEVEL OF EVIDENCE

2 Laryngoscope, 129:890-896, 2019.

OBJECTIVES

For chronic obstructive sialadenitis, there is a paucity of long-term prospective evidence of disease-specific symptom outcomes after sialendoscopy-assisted salivary duct surgery (SASDS). We prospectively assessed patients with sialolithiasis before and at 3 months and 1 year after SASDS using the Chronic Obstructive Sialadenitis Symptoms (COSS) questionnaire.

METHODS

A prospective cohort study of adult patients with sialolithiasis who underwent SASDS and completed the COSS questionnaire over a 1-year follow-up period. The COSS questionnaire consists of 20 disease-specific symptom questions. COSS score outcomes were classified by complete, partial, and nonresolution, as well as by clinically significant improvement.

RESULTS

Ninety-six patients underwent SASDS in 110 glands, of which 69 glands (63%) had findings of sialolithiasis. The following median COSS scores were reported for sialolithiasis glands: preoperative, 27.5 (interquartile range [IQR]: 12.5-44); 3 months, 1 (IQR: 0-5); and 1 year, 1 (IQR: 0-5.5). Patients with sialolithiasis reported statistically significant improvements in COSS scores from preoperative to 3 months post-SASDS (P > 0.05). A vast majority of patients maintained this improvement from 3 months to 1 year, indicating durability. Complete resolution of symptoms was attained in 95% and 85% of glands at 3 months and 1 year, respectively. Open/hybrid compared to endoscopic-only sialolithiasis extraction achieved similar 3-month and 1-year COSS outcomes. Potential risk factors for symptom persistence after SASDS included nonreachable parenchymal sialoliths and concurrent inflammatory disease and/or stenosis.

CONCLUSION

SASDS for sialolithiasis extraction is associated with durable, long-term benefit regardless of endoscopic or open technique or sialolith location, suggesting that subsequent ductal stenosis from iatrogenic or sialolithiasis-related inflammation fibrosis is unlikely.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:396-402, 2019.

BACKGROUND

Remote assessment of neurological disability in people with multiple sclerosis (MS) could improve access to clinical care and efficiency of clinical research.

OBJECTIVE

To develop and validate a telemedicine-based MS disability examination that does not require an in-home examiner.

METHODS

Adults with MS were recruited after a standardized in-person Expanded Disability Status Scale (EDSS) evaluation, and within 1 week underwent a blinded televideo-enabled EDSS examination with a different clinician. EDSS and tele-EDSS scores were compared.

RESULTS

Overall, 41 adults participated (mean (standard deviation (SD)) age: 47.0 years (11.6); median EDSS: 2 (range: 0-7)); 37 required no in-home assistance for the tele-EDSS evaluation (e.g. help positioning camera). Mean difference between EDSS and tele-EDSS was 0.34 (95% confidence interval (CI): 0.07-0.61). For 88% of evaluations, tele-EDSS and EDSS scores were within 1 point (similar to reported in-person inter-rater differences). Unweighted kappa for agreement within 0.5 point was 0.72. Correlation for individual functional systems (FS) ranged from modest (vision: 0.37) to high (bowel/bladder: 0.79). Overall correlation between EDSS and tele-EDSS was 0.89 (  0.0001); and 0.98 ( 0.0001) at EDSS range: 4-7.

CONCLUSION

In this proof of principle study, disability evaluation in mild to moderate MS is feasible using telemedicine without an aide at the patient's location.

OBJECTIVES

Moxifloxacin is not approved by the US Food and Drug Administration for pediatric use. Although its use might be indicated under certain conditions, data regarding its safety and tolerability in pediatric patients are limited. The primary objective of this study was to evaluate the safety of systemic moxifloxacin therapy in children.

METHODS

We conducted a retrospective observational study of patients aged 18 years who received oral or intravenous moxifloxacin at our institution between January 2011 and July 2016. Patient demographics, clinical characteristics, indication for moxifloxacin use, and adverse events (AEs) were extracted via chart review. The attribution of AEs to moxifloxacin use was adjudicated in consultation with a pediatric infectious disease (ID) pharmacist.

RESULTS

We identified 221 patients who received 300 courses of moxifloxacin. The average age at moxifloxacin initiation was 10.4 years. One or more AEs occurred during 195 (65%) of the courses. Of the 463 distinct AEs, 46 (9.9%) were attributed to moxifloxacin. AEs attributed to moxifloxacin included corrected QT interval (QTc) prolongation (18 [6%] courses), transaminase level elevation (7 [2.3%] courses), and increased bilirubin level (3 [1%] courses). AEs led to moxifloxacin discontinuation in 18 (6%) courses. ID consultation was associated with QTc (P .001) and transaminase (P = .002) monitoring.

CONCLUSIONS

AEs that occur during pediatric moxifloxacin therapy are relatively common but rarely serious enough to require premature discontinuation. The drug might be used safely in most children with monitoring, including evaluation for QTc prolongation, and guidance from ID specialists.

Advances in the surgical management of the axilla in patients treated with neoadjuvant chemotherapy, especially those with node positive disease at diagnosis, have led to changes in practice and more judicious use of axillary lymph node dissection that may minimize morbidity from surgery. However, there is still significant confusion about how to optimally manage the axilla, resulting in variation among practices. From the viewpoint of drug development, assessment of response to neoadjuvant chemotherapy remains paramount and appropriate assessment of residual disease-the primary endpoint of many drug therapy trials in the neoadjuvant setting-is critical. Therefore decreasing the variability, especially in a multicenter clinical trial setting, and establishing a minimum standard to ensure consistency in clinical trial data, without mandating axillary lymph node dissection, for all patients is necessary. The key elements which include proper staging and identification of nodal involvement at diagnosis, and appropriately targeted management of the axilla at the time of surgical resection are presented. The following protocols have been adopted as standard procedure by the I-SPY2 trial for management of axilla in patients with node positive disease, and present a framework for prospective clinical trials and practice.

BACKGROUND

Growth in the prevalence of severe pediatric obesity and tertiary care pediatric weight management programs supports the application of chronic disease management models to the care of children with severe obesity. One such model, the medical neighborhood, aims to optimize care coordination between primary and tertiary care by applying principles of the Patient-Centered Medical Home to all providers.

METHODS

An exploration of the literature was performed describing effective programs, approaches, and coordinated care models applied to pediatric weight management and other chronic conditions.

RESULTS

Though there was a paucity of literature discovered with applications specific to pediatric weight management, relevant disease management and care coordination approaches were found. Proposed applications to the care of children with severe obesity can be made.

CONCLUSION

The application of the medical neighborhood framework, with its inclusion of healthcare and community partners, may optimize the management of children with severe obesity.

In a case-control study, aspirin use was associated with a lower risk of a common prostate cancer molecular subtype, the gene fusion. We sought to validate this finding in a prospective cohort. In the Health Professionals Follow-up Study, 49,395 men reported on aspirin use on biennial questionnaires and were followed for prostate cancer incidence over 23 years. status was assessed by IHC for presence of ERG on archival tumor specimens for 912 patients with prostate cancer, of whom 48% were ERG-positive. In multivariable models, we found no association between regular use of aspirin and risk of -positive prostate cancer (HR, 1.02; 95% confidence interval, 0.85-1.23), nor any association with duration or frequency of aspirin use. In restricting to cases with either high Gleason grade or advanced stage disease, there remained no association with aspirin use. Data from this prospective study with repeated assessments of aspirin use do not support the hypothesis that aspirin use is associated with a lower risk of -positive prostate cancer. Aspirin use is unlikely to lower the risk of this common molecular subtype of prostate cancer. However, there is emerging data supporting the role of other lifestyle and genetic factors underlying the development of the fusion. .