Recent Publications by CFE Educators

BACKGROUND

Imperfect detection on screening tests can lead to erroneous conclusions about the natural history of thyroid nodules following radiation exposure. Our objective was to assess in a repeatedly screened I-131-exposed population the frequency with which a thyroid nodule could be retrospectively identified on ultrasonography studies preceding the one on which it was initially detected.

METHODS

A cohort of over 13,000 young people exposed to fallout from Chornobyl underwent ultrasonography screening at 2-year intervals from 1998 to 2007. The study group consisted of screening examinations on which a thyroid nodule was detected following one or more prior negative examinations. In the study group there were 48 cancers and 92 benign nodules. For each of these 140 index studies a comparison set was created containing all available prior studies plus (to test for bias) negative studies from control subjects. While viewing the index study, three independent reviewers scored the comparison studies for the presence and size of a preexisting nodule. Detection rates were compared for true priors versus controls, for cancer versus benign, and for histologic subtypes of papillary carcinoma.

RESULTS

A preexisting nodule was identified by at least one reviewer in 24.0% of the true prior versus 8.3% of the controls and by all three reviewers in 11% versus 1% (Fisher's exact test, p  0.0001). There was no significant difference in detection rates between cancers and benign nodules (22.4% vs. 24.7%, p = 0.411). There was no correlation between time from prior to index study and change in nodule size for either malignant or benign nodules (r = 0.01, NS). There were no differences in detection rates or size among papillary cancer subtypes. Reviewers could not distinguish between true priors and controls.

CONCLUSIONS

These findings, showing significant rates of undetected benign and malignant nodules and no evidence for rapid growth, suggest that conclusions drawn from screening studies about the frequency of late-developing, rapidly growing thyroid nodules following radiation exposure should be interpreted with caution.

OBJECTIVE

To evaluate the eruption path of the permanent maxillary canine during a 1-year period after secondary alveolar bone grafting and to (1) compare the canine eruption path on the cleft and noncleft side, (2) examine the number of congenially missing lateral incisors and the rate of canine impaction, and (3) examine the relationship between the eruption status of the canine and timing of alveolar bone grafting relative to age and canine root development using cone beam computed tomography (CBCT).

METHODS

Cone beam computed tomography scans for 17 nonsyndromic unilateral cleft lip and palate (UCLP), and four bilateral cleft lip and palate (BCLP) consecutive cases of alveolar bone grafting surgery were obtained after orthodontic expansion and before alveolar bone grafting and at least 1 year postsurgery on the Hitachi MercuRay CBCT machine. The DICOM files were imported into Dolphin 3D Imaging 10.5 and reoriented for consistency. The X, Y, and Z coordinates were determined for the canine cusp tip and root tip on both the cleft and noncleft sides. The direction of movement of the canine in 1 year was determined.

RESULTS

Most canines on both the cleft and noncleft sides moved incisally, facially, and mesially. Twelve percent of the canines on the cleft side appeared to require surgical exposure. Eighty percent of the canines had less than half root development at the time of bone grafting. The amount of root development did not affect the outcome in terms of eruption amount or direction.

CONCLUSIONS

Most canines on both the cleft and noncleft side moved incisally, facially, and mesially.

Duplication 9p syndrome (partial trisomy 9p) is characterized by craniofacial anomalies, mental retardation, and distal phalangeal hypoplasia. Here, we present a female patient with microcephaly and incomplete bilateral cleft lip and palate, whose initial cytogenetic analysis revealed a de novo trisomy 9p. The patient, now 21 years old, has persistent microcephaly, craniofacial and hand anomalies, history of a seizure disorder, and global mental retardation. Oligonucleotide-based array comparative genomic hybridization was performed and revealed partial trisomy 9p21.1->9pter and a deletion of 9p12.1 to 9p11.2. Our case supports the utility of array comparative genomic hybridization for the precise characterization of chromosomal anomalies and for the ascertainment of genotype-phenotype correlation in patients with partial trisomy 9p.

OBJECTIVE

To determine the optimal gestational age of delivery for women with placenta previa by accounting for both neonatal and maternal outcomes.

STUDY DESIGN

A decision-analytic model was designed comparing total maternal and neonatal quality-adjusted life years for delivery of women with previa at gestational ages from 34 to 38 weeks. At each week, we allowed for four different delivery strategies: (1) immediate delivery, without amniocentesis or steroids; (2) delivery 48 hours after steroid administration (without amniocentesis); (3) amniocentesis with delivery if fetal lung maturity (FLM) positive or retesting in one week if FLM negative; (4) amniocentesis with delivery if FLM testing is positive or administration of steroids if FLM negative.

RESULTS

Delivery at 36 weeks, 48 hours after steroids, for women with previa optimizes maternal and neonatal outcomes. In sensitivity analyses, these results were robust to a wide range of variation in input assumptions. If it is assumed that steroids offer no neonatal benefit at this gestational age, outright delivery at 36 weeks' gestation is the best strategy.

CONCLUSION

Steroid administration at 35 weeks and 5 days followed by delivery at 36 weeks for women with placenta previa optimizes maternal and neonatal outcomes.

IMPORTANCE OF THE FIELD

Erectile dysfunction (ED) is the most common male sexual dysfunction presented for treatment affecting between 10 and 20% of men. PDE type 5 inhibitors (PDE5I) now account for the largest segment of the ED market. While these drugs are highly efficacious for many men, a relatively large subset of ED patients who do not respond to PDE5I is increasingly recognized.

AREAS COVERED IN THIS REVIEW

In this review, we discuss clinical and preclinical evidence supporting various emerging compounds that regulate penile erection both centrally (clavulanic acid, dopamine and melanocortin receptor agonists) and peripherally (novel PDE5I, soluble and particulate guanylil cyclase activators, rho-kinase inhibitors and maxi-K channel openers).

WHAT THE READER WILL GAIN

The reader will gain a broad understanding of erectile (patho-)physiology and gain insights in the mechanisms of action, efficacy and adverse events of various compounds under development for the treatment of ED.

TAKE HOME MESSAGE

We expect emerging drugs to allow treatment protocols tailored to the specific needs of each individual patient, taking into consideration the efficacy of erectile performance enhancement and the potential for adverse events. This tailored approach may include combination of various emerging drugs to enhance efficacy in difficult-to-treat patients.

OBJECTIVE

Ossified Peyronie's plaques may require surgical excision because of the palpable problems and penile curvature that result. As tunical excision can result in impotence and decrease penile sensation, we describe a novel method of tunical preserving excision of such lesions.

PATIENTS AND METHODS

We evaluated 12 men with dorsal penile curvature between 10° and 90°. Penile plaque size ranged from 1 to 5 cm. 80% had painful erections. An artificial erection was induced with intracavernous injection of papaverine to assess penile deformity. Via a circumcising or ventral incision, plication sutures were placed to correct penile curvature. A lateral longitudinal corporotomy was made and the calcified/ossified portion was dissected free from the tunica albuginea/plaque of the corpora cavernosa. Watertight tunical closure was then performed.

RESULTS

Postoperatively, 80% of men reported erections always adequate for intercourse and normal sensation with a mean follow-up of 7 months (range 2.1-14.5 months). All patients required simultaneous penile plication to ensure a straight phallus. Pathologic evaluation of plaque specimens all showed bone fragments.

CONCLUSION

Tunica-sparing excision of the ossified/calcified portion of Peyronie's plaques shows a durable benefit for large, ossified lesions and maintains potency and penile sensation.

BACKGROUND

Reversible posterior leukoencephalopathy syndrome (RPLS) is a clinico-radiologic diagnosis associated with numerous medical conditions including hypertension, immunosuppressant medications, and eclampsia. It is characterized by headache, altered mental status, seizures, visual disturbance, and neuroimaging consistent with posterior-predominant vasogenic edema. The objective of this study was to characterize the clinical spectrum and outcomes in a large series of RPLS patients, and to compare the presentation of patients taking calcineurin inhibitors (CNIs) to that of other RPLS patients.

METHODS

We reviewed records of patients seen by the neurology and transplant services over an 18-year period. Comorbid conditions, medications, blood pressure, laboratory testing, clinical outcomes, and radiographic findings were collected.

RESULTS

84 episodes of RPLS were identified in 79 patients. Etiologies included CNIs (43%), hypertension (29%), renal disease (12%), preeclampsia/eclampsia (7%), and chemotherapy (5%). Patients on CNIs had lower blood pressures (p=0.002) and a lower prevalence of headache (p=0.02) compared to RPLS patients with other etiologies. Clinical recovery occurred in 65% of episodes, and radiographic resolution occurred in 67%.

CONCLUSIONS

Patients with CNI-induced RPLS have lower blood pressure than other RPLS patients, but otherwise present similarly. RPLS typically occurs within days to weeks of CNI initiation in patients without elevated medication levels. Clinical and radiographic recovery occurred in the majority of patients in this series, but one-third suffered residual neurologic deficits or death. These findings highlight the importance of prompt recognition and treatment of RPLS triggers to prevent permanent sequelae.