Primary Gouty Tophi Involving the Eyelid.

A 51-year-old male with no known history of gout was referred by his optometrist for bilateral lower eyelid cysts near the puncta. The lesions were not painful but were cosmetically concerning and excision was desired. Utilizing local anesthesia, the lesions were excised and sent to pathology for review. Pathology noted lesions to be "gouty tophus." Given that our patient had no history of gout, this is the first case report of gouty tophus on the eyelid being the initial manifestation of gout.

Predicting Complications in Breast Reconstruction: Development and Prospective Validation of a Machine Learning Model.

IMPORTANCE: Necrosis of the nipple-areolar complex (NAC) is the Achilles heel of nipple-sparing mastectomy (NSM), and it can be difficult to assess which patients are at risk of this complication (Ann Surg Oncol 2014;21(1):100-106). OBJECTIVE: To develop and validate a model that accurately predicts NAC necrosis in a prospective cohort. DESIGN: Data were collected from a retrospectively reviewed cohort of patients who underwent NSM and immediate breast reconstruction between January 2015 and July 2019 at our institution, a high -volume, tertiary academic center. Preoperative clinical characteristics, operative variables, and postoperative complications were collected and linked to NAC outcomes. These results were utilized to train a random-forest classification model to predict necrosis. Our model was then validated in a prospective cohort of patients undergoing NSM with immediate breast reconstruction between June 2020 and June 2021. RESULTS: Model predictions of NAC necrosis in the prospective cohort achieved an accuracy of 97% (95% confidence interval [CI], 0.89-0.99; P = 0.009). This was consistent with the accuracy of predictions in the retrospective cohort (0.97; 95% CI, 0.95-0.99). A high degree of specificity (0.98; 95% CI, 0.90-1.0) and negative predictive value (0.98; 95% CI, 0.90-1.0) were also achieved prospectively. Implant weight was the most predictive of increased risk, with weights greater than 400 g most strongly associated with NAC ischemia. CONCLUSIONS AND RELEVANCE: Our machine learning model prospectively predicted cases of NAC necrosis with a high degree of accuracy. An important predictor was implant weight, a modifiable risk factor that could be adjusted to mitigate the risk of NAC necrosis and associated postoperative complications.

Care Coordination and Multispecialty Teams in the Care of Colorectal Cancer Patients.

OBJECTIVES: To estimate the association between provider and team experience and adherence to guidelines, survival, and utilization among colorectal cancer patients in North Carolina. SUBJECTS: The analysis cohort included 7295 patients diagnosed with incident stage II/III colorectal cancer between 2004 and 2013 who received surgery. METHODS: Primary outcomes included adherence to guidelines: consultation with a medical oncologist (stage III), receipt of adjuvant chemotherapy (stage III), and receipt of surveillance colonoscopy posttreatment. Secondary outcomes included 5-year overall survival, number of surveillance radiology studies, any unplanned hospitalization, and any emergency department visit. The primary predictors were measures of provider volume and patient sharing across surgeons and medical oncologists. Regression analyses adjusted for patient and provider characteristics. RESULTS: Patients whose surgeons shared >40% of their colorectal cancer patients in the previous year with a medical oncologist were (1) more likely to have had a consultation with a medical oncologist [marginal effect (ME)=13.3 percentage points, P-value<0.001], (2) less likely to receive a surveillance colonoscopy within 12 months (ME=3.5 percentage points, P-value=0.049), and (3) received more radiology studies (ME=0.254 studies, P-value=0.029). Patients whose surgeon and medical oncologist shared >20% of their colorectal cancer patients with each other in the previous year had a higher likelihood of receiving adjuvant chemotherapy (ME=11.5 percentage points, P-value<0.001) and surveillance colonoscopy within 12 months (ME=6.7 percentage points, P-value=0.030) and within 18 months (ME=6.2 percentage points, P-value=0.054). CONCLUSIONS: Our study shows that team experience is associated with patients' quality of care, survival, and utilization.

USE OF COMPUTED TOMOGRAPHY FOR INVESTIGATION OF RHINITIS AND SINUSITIS IN A GREATER RHEA (RHEA AMERICANA).

Sinusitis is a common finding in avian species; however, it presents unique treatment challenges in ratites. A 6-yr-old male greater rhea ( Rhea americana ) presented acutely with right infraorbital sinus swelling and chemosis. Oral antibiotics were prescribed based on bacterial culture results with incomplete resolution of clinical signs. A computed tomography scan of the skull demonstrated a mixed-density soft tissue mass with extensive destruction of the right nasal bone, hard palate, maxilla, and frontal bone. The affected tissue was surgically resected and histopathology was consistent with inspissated necrotic tissue. Aerobic culture of the mass grew a multidrug-resistant Escherichia coli and was treated with amikacin. Ten months postsurgery, no further clinical signs were observed. Advanced diagnostic imaging with computed tomography and surgical therapy facilitated complete resolution of this resistant bacterial sinusitis in a species that is not typically amenable to frequent handling and restraint.