Combined erector spinae plane block with surgical intercostal nerve cryoablation for Nuss procedure is associated with decreased opioid use and length of stay.

BACKGROUND AND OBJECTIVES: Pain management for patients undergoing the Nuss procedure for treatment of pectus excavatum can be challenging. In an effort to improve pain management, our institution added bilateral single injection erector spinae plane (ESP) blocks to surgeon placed intercostal nerve cryoablation. We aimed to assess the efficacy of this practice change. METHODS: Retrospective clinical data from a single academic medical center were evaluated. Due to an institutional change in clinical management, we were able to perform a before and after study. Twenty patients undergoing Nuss procedure who received bilateral ultrasound-guided single-shot T6 level ESP blocks and intercostal nerve cryoablation were compared with a historical control cohort of 20 patients who underwent Nuss procedure with intercostal nerve cryoablation alone. The primary outcome variables included postoperative pain scores, total hospital opioid use, and hospital length of stay. RESULTS: Median total hospital intravenous morphine milligram equivalents was lower for the ESP group than for the control group (0.60 (IQR 0.35-0.88) vs 1.15 mg/kg (IQR 0.74-1.68), p<0.01). There was no difference in postoperative pain scores between the two groups. Mean hospital length of stay was 2.45 (SD 0.69) days for the control group and 1.95 (SD 0.69) days for the ESP group (p=0.03). No adverse events related to block placement were identified. CONCLUSIONS: In a single-center academic practice, the addition of bilateral single injection ESP blocks at T6 to surgeon performed cryoablation reduced opioid consumption without a change in subjectively reported pain scores. The results from this pilot study can provide effect size estimates to guide the design of future randomized trials.

Cell therapy for ARDS: efficacy of endobronchial versus intravenous administration and biodistribution of MAPCs in a large animal model.

Introduction: Bone marrow-derived multipotent adult progenitor cells (MAPCs) are adult allogeneic adherent stem cells currently investigated clinically for use in acute respiratory distress syndrome (ARDS). To date, there is no agreement on which is the best method for stem cells delivery in ARDS. Here, we compared the efficacy of two different methods of administration and biodistribution of MAPC for the treatment of ARDS in a sheep model. Methods: MAPC were labelled with [18F] fluoro-29-deoxy-D-glucose and delivered by endobronchial (EB) or intravenous route 1 hour after lipopolysaccharide infusion in sheep mechanically ventilated. PET/CT images were acquired to determine the biodistribution and retention of the cells at 1 and 5 hours of administration. Results: The distribution and retention of the MAPC was dependent on the method of cell administration. By EB route, PET images showed that MAPC remained at the site of administration and no changes were observed after 5 hours, whereas with intravenous route, the cells had broad biodistribution to different organs, being the lung the main organ of retention at 1 and 5 hours. MAPC demonstrated an equal effect on arterial oxygenation recovery by either route of administration. Conclusion: The EB or intravenous routes of administration of MAPC are both effective for the treatment of ARDS in an acute sheep model, and the effect of MAPC therapy is not dependent of parenchymal integration or systemic biodistribution.

Intrathyroidal parathyroid carcinoma in a pediatric patient.

Parathyroid carcinoma is unusual and its intrathyroidal variant is extremely rare. Therefore, few cases have been reported to describe a case of parathyroid carcinoma located inside the thyroid gland. The case corresponds to a 14-year-old girl who came to the office with a severe osteoarticular disease, depression, calcemia of 14.3 mg/dl and parathyroid hormone of 2,792 pg/ml. Right neck exploration was conducted and a parathyroid carcinoma was found located intrathyroidally. A right thyroid lobectomy was performed. A 20-month follow-up period revealed no recurrence of clinical or biochemical signs. In patients with severe hypercalcemia and significant elevation of parathyroid hormone, the diagnosis of parathyroid carcinoma has to be considered. It is worth highlighting the early age of presentation in this case. Treatment has allowed the effective control of the disease and its recommended long-term follow-up.

[Evaluation of fine needle aspiration cytology in the diagnosis of cancer of the parotid gland]. / Evaluación de la citología por punción-aspiración con aguja fina en el diagnóstico de cáncer de la glándula parótida.

BACKGROUND: Fine needle aspiration (FNA) is commonly used in the study of neoplastic lesions of the parotid gland, however controversy exists regarding its diagnostic accuracy. OBJECTIVE: To evaluate the performance of FNA biopsy as compared to open surgical biopsy in the diagnosis of carcinoma of the parotid gland. MATERIAL AND METHOD: Forty-six patients with parotid masses from 7 health centres in Bucaramanga, Colombia were identified and included in the study. All patients underwent FNA and open surgical biopsy, with the latter considered the diagnostic gold standard. The FNA and final surgical histopathology were interpreted as either positive or negative for malignancy by pathologists blinded to the FNA outcome. Only standard histological stains were used. The data were compared in a contingency table and analyzed statistically to determine the accuracy of FNA to predict the surgical pathology according to standard measures. RESULTS: The mean age of patients was 52 +/- 16 years old and 59 % were female. Using FNA, 18 % of the initial diagnoses were found to be erroneous at final pathology. FNA had a sensitivity of 0.54, a specificity of 0.90, a PPV of 0.70, an NPV of 0.83, an LR+ of 5.92, an LR of 0.5, and kappa of 0.48 in the identification of parotid gland carcinoma from referral population with a disease prevalence of 28.3 %. CONCLUSIONS: In line with other previous studies, FNA biopsy alone was unreliable to diagnose parotid gland carcinoma. Its low sensitivity and LR indicates its limitations as a screening test; in addition its low kappa shows a modest correlation to the eventual diagnosis. Therefore, further critical examination of techniques and interpretation of parotid FNA are recommended. The development of new methods allowing a valid and precise diagnosis of this pathology and that, like the FNA, have low cost and ease of application is recommended.

[Congenital anomalies of thymic origin in the neck]. / Anomalías congénitas de origen tímico en el cuello.

RATIONALE: A symptomatic mass in the thymus is due to anomalies in the development of the pharyngeal pouches and is also an unusual cause of consultation. These anomalies may be found anywhere along the natural path of the embryonic thymus, from the angle of the jaw to the upper mediastinum. AIM: To review the epidemiology, pathogenesis, diagnosis, and management of congenital anomalies of thymic origin in the neck. MATERIAL AND METHOD: A MEDLINE search was carried out, using the Cochrane methodology, for articles published from January 1980 to January 2007 using the terms "thymus gland," "cervical mass." Following this bibliographical search, the texts considered most relevant by the authors were selected. CONCLUSIONS: While this anomaly is relatively common, its level of presentation is very low and it should always be considered in the differential diagnosis of congenital masses in the neck. New diagnostic imaging techniques provide an early and more accurate diagnosis, thus allowing a better outcome in these patients.

Evaluación de la citología por punción-aspiración con aguja fina en el diagnóstico de cáncer de la glándula parótida / Evaluation of fine needle aspiration cytology in the diagnosis of cancer of the parotid gland

Contexto: La punción-aspiración con aguja fina (PAAF) se utiliza con frecuencia en el estudio de las lesiones neoplásicas de la glándula parótida, a pesar de que se mantiene la controversia respecto a su precisión diagnóstica. Objetivo: Evaluación del rendimiento de la PAAF en comparación con la biopsia quirúrgica abierta para el diagnóstico del carcinoma de la glándula parótida. Material y método: En el estudio participaron 47 pacientes con lesiones ocupantes de espacio en la glándula parótida y que fueron atendidos en 7 centros sanitarios de Bucaramanga, Colombia. Todos los pacientes fueron evaluados mediante PAAF y biopsia quirúrgica abierta, considerada esta última como la prueba diagnóstica de referencia. La PAAF y el estudio anatomopatológico final efectuado sobre la biopsia quirúrgica abierta fueron interpretados como positivos o negativos para lesión maligna por anatomopatólogos que desconocían el resultado obtenido en la PAAF. Sólo se utilizaron técnicas de tinción histológicas convencionales. Los datos fueron comparados mediante una tabla de contingencia y analizados estadísticamente para determinar la precisión de la PAAF en la predicción del resultado diagnóstico anatomopatológico obtenido en la biopsia quirúrgica abierta mediante muestreo y análisis transversal. Resultados: La media ± desviación estándar de edad de los pacientes fue 52 ± 16 años; el 59 % eran mujeres. El 18 % de los diagnósticos establecidos mediante la PAAF fue erróneo en comparación con el diagnóstico anatomopatológico final. La PAAF presentó una sensibilidad y una especificidad de 0,54 y 0,90, respectivamente; unos valores predictivo positivo y predictivo negativo de 0,90 y 0,70, respectivamente; unos cocientes de probabilidad positivo y negativo de 5,92 y 0,5, respectivamente, y un estadístico kappa de 0,48, respecto a la identificación del carcinoma de la glándula parótida en la población evaluada, en la que la prevalencia de la enfermedad fue del 28,3 %. Conclusiones: La PAAF, utilizada como método diagnóstico aislado, careció de fiabilidad para el diagnóstico del carcinoma de la glándula parótida, en concordancia con los resultados obtenidos en otros estudios previos. Sus bajos valores de sensibilidad y de cociente de probabilidad negativo indican sus limitaciones como prueba de detección o cribado; además, el escaso valor del estadístico kappa demuestra que esta técnica posee una correlación modesta con el diagnóstico final. Por tanto, se recomienda el análisis crítico adicional con otras técnicas de análisis adicionales que mejoren la interpretación de la PAAF sobre la glándula parótida. También se considera importante el desarrollo de nuevos métodos que permitan establecer un diagnóstico válido y preciso de este problema y que, de la misma manera que la PAAF, tengan un coste económico bajo y sean fáciles de utilizar

Background: Fine needle aspiration (FNA) is commonly used in the study of neoplastic lesions of the parotid gland, however controversy exists regarding its diagnostic accuracy. Objective: To evaluate the performance of FNA biopsy as compared to open surgical biopsy in the diagnosis of carcinoma of the parotid gland. Material and method: Forty-six patients with parotid masses from 7 health centres in Bucaramanga, Colombia were identified and included in the study. All patients underwent FNA and open surgical biopsy, with the latter considered the diagnostic gold standard. The FNA and final surgical histopathology were interpreted as either positive or negative for malignancy by pathologists blinded to the FNA outcome. Only standard histological stains were used. The data were compared in a contingency table and analyzed statistically to determine the accuracy of FNA to predict the surgical pathology according to standard measures. Results: The mean age of patients was 52 ± 16 years old and 59 % were female. Using FNA, 18 % of the initial diagnoses were found to be erroneous at final pathology. FNA had a sensitivity of 0.54, a specificity of 0.90, a PPV of 0.70, an NPV of 0.83, an LR+ of 5.92, an LR– of 0.5, and kappa of 0.48 in the identification of parotid gland carcinoma from referral population with a disease prevalence of 28.3 %. Conclusions: In line with other previous studies, FNA biopsy alone was unreliable to diagnose parotid gland carcinoma. Its low sensitivity and LR– indicates its limitations as a screening test; in addition its low kappa shows a modest correlation to the eventual diagnosis. Therefore, further critical examination of techniques and interpretation of parotid FNA are recommended. The development of new methods allowing a valid and precise diagnosis of this pathology and that, like the FNA, have low cost and ease of application is recommended

Anomalías congénitas de origen tímico en el cuello / Congenital anomalies of thymic origin in the neck

Justificación: La masa tímica sintomática en el cuello se debe a anomalías en el desarrollo de las bolsas faríngeas y es una causa inusual de consulta. Estas anomalías se pueden encontrar a lo largo de la vía embriológica de descenso del timo, desde el ángulo de la mandíbula hasta el mediastino superior. Objetivo: Realizar una revisión estructurada de la epidemiología, la patogenia, el diagnóstico y el tratamiento de las masas congénitas de origen tímico en el cuello. Material y método: Se realizó una búsqueda en MEDLINE, según la metodología Cochrane, de artículos publicados desde enero de 1980 a enero de 2007 usando los términos “thymus gland” y “cervical mass”; los autores seleccionaron de esta búsqueda los manuscritos que consideraron relevantes. Conclusiones: Aunque esta anomalía es relativamente común, su presentación clínica es poco frecuente; siempre se debe considerar en el diagnóstico diferencial de las masas congénitas en el cuello. Las nuevas técnicas de imágenes facilitan un diagnóstico precoz y más preciso, lo que permite un mejor pronóstico para estos pacientes

Rationale: A symptomatic mass in the thymus is due to anomalies in the development of the pharyngeal pouches and is also an unusual cause of consultation. These anomalies may be found anywhere along the natural path of the embryonic thymus, from the angle of the jaw to the upper mediastinum. Aim: To review the epidemiology, pathogenesis, diagnosis, and management of congenital anomalies of thymic origin in the neck. Material and method: A MEDLINE search was carried out, using the Cochrane methodology, for articles published from January 1980 to January 2007 using the terms “thymus gland,” “cervical mass.” Following this bibliographical search, the texts considered most relevant by the authors were selected. Conclusions: While this anomaly is relatively common, its level of presentation is very low and it should always be considered in the differential diagnosis of congenital masses in the neck. New diagnostic imaging techniques provide an early and more accurate diagnosis, thus allowing a better outcome in these patients