Management of Adult Inpatient Otolaryngologic Consultations During the COVID-19 Pandemic: A Proposed Tier-Based Triage System.

The coronavirus disease 2019 (COVID-19) pandemic has placed tremendous strain on health care systems, leading to unprecedented challenges and obstacles in the delivery of patient care. Otolaryngologists are frequently called on for inpatient consultations for an array of pathologies, ranging from chronic benign conditions to acutely life-threatening processes. Professional otolaryngologic societies across the world have proposed limiting patient care to time-sensitive and urgent matters; however, limited literature is available to describe how this transient change in philosophy may translate to clinical practice. Here we present a structured algorithm that allows for rapid triage of otolaryngologic consults during the ongoing pandemic, in efforts to minimize infectious spread and protect clinicians while preserving high-quality patient care. Considerations for managing these consults are presented, with a commentary on practical and ethical considerations.

Reinstating Elective Surgeries in MedStar Health: A Roadmap for Healthcare Organizations.

Introduction: Coronavirus disease 2019 (COVID-19) infections have strained hospital resources worldwide. As a result, many facilities have suspended elective operations and ambulatory procedures. As the incidence of new cases of COVID-19 decreases, hospitals will need policies and algorithms to facilitate safe and orderly return of normal activities. We describe the recommendations of a task force established in a multi-institutional healthcare system for resumption of elective operative and ambulatory procedures applicable to all hospitals and service lines. Methods: MedStar Health created a multidisciplinary task force to develop guidelines for resumption of elective surgeries/procedures. The primary focus areas included the establishment of a governance structure at each healthcare facility, prioritization of elective cases, preoperative severe acute respiratory syndrome coronavirus 2 testing, and an assessment of the needs and availability of staff, personal protective equipment, and other essential resources. Results: Each hospital president was tasked with establishing a local perioperative leadership team answering directly to them and granted the authority to prioritize elective surgery and ambulatory procedures. An elective surgery algorithm was established using a simplified Medically Necessary Time Sensitive score, with multiple steps requiring a "go/no-go" assessment based on local resources. In addition, mandatory preoperative COVID testing policies were developed and operationalized. Conclusions: Even when the COVID pandemic has passed, hospitals and surgical centers will require COVID screening and testing, case prioritization, and supply chain management to provide care essential to the surgical patient while protecting their safety and that of staff. Our guidelines consider these factors and are applicable to both tertiary academic medical centers and smaller community facilities.

Post-approval upper airway stimulation predictors of treatment effectiveness in the ADHERE registry.

Upper airway stimulation (UAS) has been shown to reduce severity of obstructive sleep apnoea. The aim of this study was to identify predictors of UAS therapy response in an international multicentre registry.Patients who underwent UAS implantation in the United States and Germany were enrolled in an observational registry. Data collected included patient characteristics, apnoea/hypopnoea index (AHI), Epworth sleepiness scale (ESS), objective adherence, adverse events and patient satisfaction measures. Post hoc univariate and multiple logistic regression were performed to evaluate factors associated with treatment success.Between October 2016 and January 2018, 508 participants were enrolled from 14 centres. Median AHI was reduced from 34 to 7 events·h-1, median ESS reduced from 12 to 7 from baseline to final visit at 12-month post-implant. In post hoc analyses, for each 1-year increase in age, there was a 4% increase in odds of treatment success. For each 1-unit increase in body mass index (BMI), there was 9% reduced odds of treatment success. In the multivariable model, age persisted in serving as statistically significant predictor of treatment success.In a large multicentre international registry, UAS is an effective treatment option with high patient satisfaction and low adverse events. Increasing age and reduced BMI are predictors of treatment response.

Upper Airway Stimulation for Obstructive Sleep Apnea: Results from the ADHERE Registry.

Objective Upper airway stimulation (UAS) is an alternative treatment option for patients unable to tolerate continuous positive airway pressure (CPAP) for the treatment of obstructive sleep apnea (OSA). Studies support the safety and efficacy of this therapy. The aim of this registry is to collect retrospective and prospective objective and subjective outcome measures across multiple institutions in the United States and Germany. To date, it represents the largest cohort of patients studied with this therapy. Study Design Retrospective and prospective registry study. Setting Ten tertiary care hospitals in the United States and Germany. Subjects and Methods Patients were included who had moderate to severe OSA, were intolerant to CPAP, and were undergoing UAS implantation. Baseline demographic and sleep study data were collected. Objective and subjective treatment outcomes, adverse events, and patient and physician satisfaction were reviewed. Results The registry enrolled 301 patients between October 2016 and September 2017. Mean ± SD AHI decreased from 35.6 ± 15.3 to 10.2 ± 12.9 events per hour ( P < .0001), and Epworth Sleepiness Scale scores decreased from 11.9 ± 5.5 to 7.5 ± 4.7 ( P < .0001) from baseline to the posttitration visit. Patients utilized therapy for 6.5 hours per night. There were low rates of procedure- and device-related complications. Clinical global impression scores demonstrated that the majority of physicians (94%) saw improvement in their patients' symptoms with therapy. The majority of patients (90%) were more satisfied with UAS than CPAP. Conclusions Across a multi-institutional registry, UAS therapy demonstrates significant improvement in subjective and objective OSA outcomes, good therapy adherence, and high patient satisfaction.

Ectopic parathyroid adenoma in the pyriform sinus.

BACKGROUND: Ectopic parathyroid glands may complicate the surgical approach to primary hyperparathyroidism. We describe a rare ectopic parathyroid location, the pyriform sinus. METHODS: Three patients, 2 after prior unsuccessful parathyroid exploration, were found to have ectopic parathyroid adenomas in the pyriform sinus. Two cases were identified by 4D-CT of the neck. The other was localized by a technetium 99m sestamibi single photon emission CT (SPECT). In each case, office endoscopy confirmed the lesions. The patients were treated by either transoral laser or robotic resection of the parathyroid adenoma. RESULTS: After surgery, the patients had resolution of their hyperparathyroidism. CONCLUSION: Ectopic parathyroid adenomas in the pyriform sinus are rare, but should be considered in those patients who have had a failed neck exploration and in those who undergo 4D-CT scanning or SPECT scanning.

Metastasis of laryngeal squamous cell carcinoma to bilateral thigh muscles.

Importance. Laryngeal cancer infrequently results in distant metastases, but metastasis to skeletal muscle is extremely uncommon. Observations. A 55-year-old male presenting with progressive dyspnea and hoarseness was found to have Stage IVA T4aN2cM0 laryngeal cancer and eventually underwent total laryngectomy. Before the patient could be started on adjuvant chemoradiation, the patient developed masses on both thighs. Biopsy revealed metastatic squamous cell carcinoma consistent with the primary laryngeal cancer. He was offered palliative chemotherapy; however, he developed new soft tissue masses to the left of his stoma and in the prevertebral area one week later. He also had new cervical and supraclavicular nodes and a pathological compression fracture of L3. Patient died within 4 months of diagnosis. Conclusions. Distant metastasis such as skeletal metastasis portends a poor prognosis. Further studies are required to determine the best course of treatment in these patients.

Surgeon experience and complications with Transoral Robotic Surgery (TORS).

OBJECTIVE: To investigate surgeon preferences for perioperative management of transoral robotic surgery (TORS) and explore the frequency of postoperative complications. STUDY DESIGN: Retrospective survey. SETTING: Multi-institutional. SUBJECTS AND METHODS: An electronic survey was sent to over 300 TORS-trained surgeons in the United States identified by Intuitive Surgical, Inc. Participation was voluntary and solicited by email invitations to participate 3 times over a 1-month period. RESULTS: A total of 2015 procedures were reported by 45 respondent TORS-trained surgeons: 67% academic, 33% nonacademic. A minority of TORS procedures (n = 214, 10.6%) were performed on previously irradiated patients. Neck dissections were performed concurrently (58%) or staged (42%). Fewer than 6% of TORS procedures required tracheotomy or reconstruction. Most surgeons (62%) initiated oral intake on postoperative day 0-1. Of the patients who required readmission, bleeding (n = 62, 3.1%) was the most common cause followed by dehydration (n = 26, 1.3%). Other complications of surgery included tooth injury (n = 29, 1.4%), percutaneous endoscopic gastrostomy (PEG) dependency >6 months (n = 21, 1.0%), temporary hypoglossal nerve injury (n = 18, 0.9%), and lingual nerve injury (n = 11, 0.6%). A total of 6 deaths (0.3%) were reported within 30 days of TORS. All reported deaths were due to postoperative hemorrhage. The complication rate decreased significantly with higher surgeon case volume (>50 cases). CONCLUSIONS: TORS is associated with a low major complication rate, early initiation of oral intake, and a low rate of long-term PEG dependency. Postoperative hemorrhage was the most common cause of hospital readmission and postoperative mortality.

In vivo diagnosis of plaque erosion and calcified nodule in patients with acute coronary syndrome by intravascular optical coherence tomography.

OBJECTIVES: The aim of this study was to characterize the morphological features of plaque erosion and calcified nodule in patients with acute coronary syndrome (ACS) by optical coherence tomography (OCT). BACKGROUND: Plaque erosion and calcified nodule have not been systematically investigated in vivo. METHODS: A total of 126 patients with ACS who had undergone pre-intervention OCT imaging were included. The culprit lesions were classified as plaque rupture (PR), erosion (OCT-erosion), calcified nodule (OCT-CN), or with a new set of diagnostic criteria for OCT. RESULTS: The incidences of PR, OCT-erosion, and OCT-CN were 43.7%, 31.0%, and 7.9%, respectively. Patients with OCT-erosion were the youngest, compared with those with PR and OCT-CN (53.8 ± 13.1 years vs. 60.6 ± 11.5 years, 65.1 ± 5.0 years, p = 0.005). Compared with patients with PR, presentation with non-ST-segment elevation ACS was more common in patients with OCT-erosion (61.5% vs. 29.1%, p = 0.008) and OCT-CN (100% vs. 29.1%, p < 0.001). The OCT-erosion had a lower frequency of lipid plaque (43.6% vs. 100%, p < 0.001), thicker fibrous cap (169.3 ± 99.1 µm vs. 60.4 ± 16.6 µm, p < 0.001), and smaller lipid arc (202.8 ± 73.6° vs. 275.8 ± 60.4°, p < 0.001) than PR. The diameter stenosis was least severe in OCT-erosion, followed by OCT-CN and PR (55.4 ± 14.7% vs. 66.1 ± 13.5% vs. 68.8 ± 12.9%, p < 0.001). CONCLUSIONS: Optical coherence tomography is a promising modality for identifying OCT-erosion and OCT-CN in vivo. The OCT-erosion is a frequent finding in patients with ACS, especially in those with non-ST-segment elevation ACS and younger patients. The OCT-CN is the least common etiology for ACS and is more common in older patients. (The Massachusetts General Hospital Optical Coherence Tomography Registry; NCT01110538).

Cardiovascular effects of tumour necrosis factor α antagonism in patients with acute myocardial infarction: a first in human study.

OBJECTIVE: The inflammatory cytokine, tumour necrosis factor α (TNF-α), exerts deleterious cardiovascular effects. We wished to determine the effects of TNF-α antagonism on endothelial function and platelet activation in patients with acute myocardial infarction. DESIGN AND SETTING AND PATIENTS: A double-blind, parallel group, randomised controlled trial performed in a tertiary referral cardiac centre. 26 patients presenting with acute myocardial infarction randomised to receive an intravenous infusion of etanercept (10 mg) or saline placebo. MAIN OUTCOME MEASURES: Leucocyte count, plasma cytokine concentrations, flow cytometric measures of platelet activation and peripheral vasomotor and fibrinolytic function were determined before and 24 h after study intervention. RESULTS: Consistent with effective conjugation of circulating TNF-α, plasma TNF-α concentrations increased in all patients following etanercept (254 ± 15 vs 0.12 ± 0.02 pg/ml; p < 0.0001), but not saline infusion. Etanercept treatment reduced neutrophil (7.4 ± 0.6 vs 8.8 ± 0.6 × 10(9) cells/l; p = 0.03) and plasma interleukin-6 concentrations (5.8 ± 2.0 vs 10.6 ± 4.0 pg/ml; p = 0.012) at 24 h but increased platelet-monocyte aggregation (30 ± 5 vs 20 ± 3%; p = 0.02). Vasodilatation in response to substance P, acetylcholine and sodium nitroprusside, and acute tissue plasminogen activator release were unaffected by either treatment (p > 0.1 for all). CONCLUSIONS: Following acute myocardial infarction, etanercept reduces systemic inflammation but increases platelet activation without affecting peripheral vasomotor or fibrinolytic function. We conclude that TNF-α antagonism is unlikely to be a beneficial therapeutic strategy in patients with acute myocardial infarction.

A prospective, randomized, double-blind study comparing the efficacy of topical anesthetics in nasal endoscopy.

INTRODUCTION: Transnasal endoscopy is commonly performed in an outpatient otolaryngology setting. Patients are typically administered a topical anesthetic and decongestant prior to this procedure to alleviate discomfort and improve visualization. There is no consensus on which topical anesthetic is most effective in optimizing patient experience during the procedure. OBJECTIVE: To determine whether there is a difference in the efficacy between atomized 2% tetracaine and 4% lidocaine as a topical anesthetic prior to transnasal endoscopy. STUDY DESIGN: Prospective, randomized, double-blind study. METHODS: A total of 99 patients received oxymetazoline and were randomized to receive either 2% tetracaine or 4% lidocaine prior to transnasal endoscopy. Immediately following the procedure, participants completed a survey assessing level of discomfort and other adverse symptoms pertaining to the procedure using a 10-point visual analog scale (VAS). RESULTS: There were no significant differences in VAS scores between the lidocaine and tetracaine groups. There were also no significant differences between genders in overall VAS scores and in the lidocaine and tetracaine subgroups. Older patients demonstrated significantly less discomfort or a sensation of bad taste overall. In contrast to patients receiving lidocaine, older patients receiving tetracaine experienced significantly less overall pain and discomfort, unpleasant taste, and dyspnea. CONCLUSION: In patients undergoing transnasal endoscopy, use of either 2% tetracaine or 4% lidocaine has similar effect. Tetracaine may be a better choice in older patients, however.

Staphylococcal thoracic aortitis complicated by aortic dissection.

BACKGROUND: The diagnosis of aortitis is often delayed as symptoms are largely non-specific. We report a case of Staphylococcal thoracic aortitis in a 73-year-old Chinese woman complicated by aortic dissection. METHODS: The patient presented with pyrexia of unknown origin, and a contrast enhanced computed tomography aortogram revealed a large thrombus at the anterior aspect of the ascending aorta with two large ulcerations as a result of a chronic type A aortic dissection. A hemiarch replacement with a 28 mm Gleweave Vascutek graft was performed with resuspension of aortic valve commisures. Aortic thrombus cultures were positive for coagulase negative Staphylococcus aureaus, and histology showed chronic dissection of the aorta. RESULTS: The patient was treated with intravenous cefazolin for a 6-week duration and made good progress. CONCLUSIONS: This case highlights Staphylococcal infective aortitis complicated by dissection presenting as fever of unknown origin. Timely diagnosis is essential as progression to catastrophic rupture may occur.

Staphylococcal thoracic aortitis complicated by aortic dissection / 世界急诊医学杂志（英文）

@#BACKGROUND: The diagnosis of aortitis is often delayed as symptoms are largely non-specific. We report a case of Staphylococcal thoracic aortitis in a 73-year-old Chinese woman complicated by aortic dissection. METHODS: The patient presented with pyrexia of unknown origin, and a contrast enhanced computed tomography aortogram revealed a large thrombus at the anterior aspect of the ascending aorta with two large ulcerations as a result of a chronic type A aortic dissection. A hemiarch replacement with a 28 mm Gleweave Vascutek graft was performed with resuspension of aortic valve commisures. Aortic thrombus cultures were positive for coagulase negative Staphylococcus aureaus, and histology showed chronic dissection of the aorta. RESULTS: The patient was treated with intravenous cefazolin for a 6-week duration and made good progress. CONCLUSIONS: This case highlights Staphylococcal infective aortitis complicated by dissection presenting as fever of unknown origin. Timely diagnosis is essential as progression to catastrophic rupture may occur.

Impact of timing to coronary angiography in acute coronary syndrome on contemporary clinical practice.

Recent studies appear to suggest a correlation between timing to coronary angiography and clinical outcome among patients with acute coronary syndrome (ACS). We aim to study 12-month outcomes of ACS patients who are stratified according to early (≤24 hours), intermediate (>24 to <48 hours) and delayed (≥48 hours) coronary angiography. This is a prospective observational study of patients with ACS defined as either unstable angina pectoris or non-ST elevation myocardial infarction (MI) admitted between October 2008 and July 2009. Baseline clinical characteristics of age, gender, cardiovascular risk factors (diabetes mellitus, hypertension, dyslipidemia) and TIMI score were analyzed and adjusted for outcomes. The primary outcome was combined major adverse cardiovascular events (MACE) of death or non-fatal MI, as well as target vessel revascularization (TVR) up to 12 months. This study consisted of 642 patients (75% males, mean age 60±13) with median follow-up of 7 months and median TIMI score of 4. Over half (50.2%) were categorized as high-risk (TIMI score ≥4). 281 patients (43.5%) had early angiography, 170 (26.5%) had angiography between >24 to <48 hours and 191(30%) patients had delayed angiography ≥48 hours. In high-risk patients, the primary outcome occurred in 10.9% of patients in the early group, as compared with 13.2% in intermediate group and 23.9% in delayed group (p=0.015) at six months. However, in low-risk patients (TIMI scores <4), there was no significant difference between the groups (7.1% vs. 3.4% vs. 5.9%, p=0.316) at six months. Compared to the intermediate and delayed groups, patients in the early group had lower overall MACE at 12 months (21% vs. 14% vs. 10%, p=0.006) that was largely related to a lower frequency of death at 12 months (11% vs. 7% vs. 4.6%, p=0.03). There were no differences in rates of TVR between the groups (4% vs. 7% vs. 3.5%, p=0.14). In this observational analysis, an early strategy to coronary angiography was associated with improved survival at one year while an early to intermediate strategy benefitted the subgroup of high-risk patients with significant reductions in cardiovascular events at six months.

Meta-analysis of endoscopic versus sublabial pituitary surgery.

OBJECTIVES/HYPOTHESIS: To determine whether the endoscopic or sublabial transseptal transsphenoidal approach for pituitary surgery has superior outcomes or decreased complication rates. STUDY DESIGN: Retrospective meta-analysis of literature. METHODS: A MEDLINE search was conducted identifying all relevant literature in the English language from 1998 through 2010. Studies explicitly identifying pure sublabial or completely endoscopic approaches were included. Meta-analysis comparing the two techniques was performed for multiple outcome measures utilizing a random effects approach. RESULTS: A total of 21 endoscopic studies (n = 2,335) and 17 sublabial studies (n = 2,565) met inclusion criteria. Analysis revealed significantly superior rates of gross tumor resection (79% vs. 65%, P < .0001), as well as lower rates of cerebral spinal fluid leak (5% vs. 7%, P < .01), septal perforation (0% vs. 5%), and postoperative epistaxis (1% vs. 4%, P < .0001) for the endoscopic approach compared to the sublabial approach. There was no difference between the two techniques in the incidence of meningitis, diabetes insipidus, or resolution of hormonal abnormality. Hospital stay (P = .01) was shorter for endoscopic surgery compared to sublabial surgery, and there was no significant difference in terms of length of operation. CONCLUSIONS: The sublabial transsphenoidal approach has been the gold standard for pituitary surgery for many years. However, meta-analysis of the recent literature demonstrates superior outcomes and decreased postoperative complications with the endoscopic approach, potentially justifying a shift toward endoscopic pituitary surgery.

Comparing the use of cobalt chromium stents to stainless steel stents in primary percutaneous coronary intervention for acute myocardial infarction: a prospective registry.

OBJECTIVES: To determine clinical outcome and rates of target vessel revascularization (TVR) in patients undergoing primary percutaneous coronary intervention (PCI) for STEMI who were treated with cobalt-chromium stents compared to stainless steel bare metal stents (BMS). BACKGROUND: The newer generation cobalt chromium stents were reported to achieve lower rates of TVR compared with conventional BMS. METHODS: Consecutive STEMI cases admitted within 12 h of symptom onset and undergoing primary angioplasty and bare metal stent implantation 1 January 2002 and 31 December 2008 were identified. Primary outcomes were rates of clinically-driven TVR at six months as well as occurrence of major adverse cardiovascular events (MACE) either of all-cause death, repeat myocardial infarction or TVR at six months. RESULTS: 1030 cases with 1175 lesions (84% males) and median age of 58 years underwent primary PCI for STEMI in our registry. Overall procedural success rate was 98%. Stainless steel stents were inserted in 65% of the culprit lesions (stainless steel, n = 766 versus cobalt chromium, n = 264). Primary outcomes of TVR (3.5% in the stainless steel group and 3.4% in the cobalt chromium group, P = 0.93) and MACE (8.4% in the stainless steel group and 5.3% in the cobalt chromium group, P = 0.11) after six months were no different between the two groups. However, there were more deaths at 30 days in the stainless steel group compared to the cobalt chromium group (3.5% versus 0.4%, HR 4.04 (1.03-3.88), P = 0.04). CONCLUSION: Both cobalt-chromium and stainless steel coronary stents were associated with similar and low risk of clinically-driven TVR.

Clinical review: Ectopic cervical thyroid carcinoma--review of the literature with illustrative case series.

CONTEXT: More than 99% of thyroid cancers arise eutopically within the thyroid gland. The most frequent sites of ectopic thyroid tissue are lingual, sublingual, thyroglossal, laryngotracheal, and lateral cervical. Thyroid tissue can also be found in remote structures that were associated with the thyroid anlage during development, including the esophagus, mediastinum, heart, aorta, adrenal, pancreas, gallbladder, and skin. Ectopic thyroid tissue can be subject to the same pathological processes as normal eutopic thyroid tissue such as inflammation, hyperplasia, and tumorigenesis. The aim of this review is to describe aspects of thyroid cancer arising from the ectopic thyroid tissue in the neck in regard to epidemiology, diagnosis, and treatment and to present an illustrative series of cases of ectopic thyroid cancer. DATA ACQUISITION: We have searched the PubMed database for articles including the keywords "ectopic thyroid cancer" published between January 1, 1960, and January 1, 2011. As references, we used clinical case series, case reports, review articles, and practical guidelines focused on ectopic thyroid cancer confined to the neck region. SYNTHESIS AND CONCLUSIONS: The possibility of an ectopic thyroid cancer should be considered in the differential diagnosis of a pathological mass in the neck. Treatment of ectopic cervical thyroid cancer is based predominantly on the surgical excision of the malignant lesion. Management strategies, including performance of total thyroidectomy, neck dissection, and treatment with radioiodine, should be based on individualized risk stratification.

Percutaneous coronary intervention in Asians--are there differences in clinical outcome?

BACKGROUND: Ethnic differences in clinical outcome after percutaneous coronary intervention (PCI) have been reported. Data within different Asian subpopulations is scarce. We aim to explore the differences in clinical profile and outcome between Chinese, Malay and Indian Asian patients who undergo PCI for coronary artery disease (CAD). METHODS: A prospective registry of consecutive patients undergoing PCI from January 2002 to December 2007 at a tertiary care center was analyzed. Primary endpoint was major adverse cardiovascular events (MACE) of myocardial infarction (MI), repeat revascularization and all-cause death at six months. RESULTS: 7889 patients underwent PCI; 7544 (96%) patients completed follow-up and were included in the analysis (79% males with mean age of 59 years ± 11). There were 5130 (68%) Chinese, 1056 (14%) Malays and 1001 (13.3%) Indian patients. The remaining 357 (4.7%) patients from other minority ethnic groups were excluded from the analysis. The primary end-point occurred in 684 (9.1%) patients at six months. Indians had the highest rates of six month MACE compared to Chinese and Malays (Indians 12% vs. Chinese 8.2% vs. Malays 10.7%; OR 1.55 95%CI 1.24-1.93, p < 0.001). This was contributed by increased rates of MI (Indians 1.9% vs. Chinese 0.9% vs. Malays 1.3%; OR 4.49 95%CI 1.91-10.56 p = 0.001), repeat revascularization (Indians 6.5% vs. Chinese 4.1% vs. Malays 5.1%; OR 1.64 95%CI 1.22-2.21 p = 0.0012) and death (Indians 11.4% vs. Chinese 7.6% vs. Malays 9.9%; OR 1.65 95%CI 1.23-2.20 p = 0.001) amongst Indian patients. CONCLUSION: These data indicate that ethnic variations in clinical outcome exist following PCI. In particular, Indian patients have higher six month event rates compared to Chinese and Malays. Future studies are warranted to elucidate the underlying mechanisms behind these variations.

Long-term outcomes after coronary bare-metal-stent and drug-eluting-stent implantations: a 'real-world' comparison among patients with diabetes with diffuse small vessel coronary artery disease.

BACKGROUND AND AIM: Drug-eluting stents (DESs) have been reported to be more efficacious compared with bare-metal stents (BMSs) in reducing the need for target vessel revascularization (TVR). However, the long-term benefits for patients with diabetes with small vessel disease are less certain. We aim to determine the clinical outcome of patients with diabetes with diffuse small vessel coronary artery disease who undergo percutaneous coronary intervention. METHODS: This is a single-center prospective registry of all patients with diabetes with target lesions implanted with stents that were 2.25 mm or less in diameter and approximately 20 mm in total stent length between January 2002 and October 2008. Primary outcome was combined major adverse cardiovascular events: death, nonfatal myocardial infarction and TVR up to 5 years. Outcomes were adjusted for age, sex and cardiovascular risk factors. RESULTS: There were 544 patients (63% males, mean age 62±10 years) with 1010 lesions that were followed up for a mean duration of 3±2 years. Two hundred and thirty-nine patients (439 lesions) received BMS whereas 305 (571 lesions) received DES. DES lesions were longer (mean length 23.3±6.96 vs. 17.8±5.02 mm, P<0.001) than BMS lesions. Procedural success was similar for BMS and DES patients (86.2 vs. 86.6%, P=0.90). DES patients had less TVR at 6 months [3.9 vs. 9.2%, odds ratio (OR): 4.90, 95% confidence interval (CI): 1.53-15.65, P=0.007], 1 year (1 vs. 3.8%, OR: 8.01, 95% CI: 1.25-51.10, P=0.028) and 3 years (13.8 vs. 18.0%, OR: 5.50, 95% CI: 3.74-8.13, P=0.043). By 5 years, the primary outcome was lower in DES patients (21.6 vs. 28%, OR: 1.79, 95% CI: 1.14-2.80, P=0.011). Independent predictors of TVR at 6 months were above or equal to 59 years of age (OR: 0.95, 95% CI: 0.90-1.00, P=0.032) and use of glycoprotein-IIbIIIa inhibitors (OR: 0.02, 95% CI: 0.001-0.50, P=0.018). Stent length was not a significant predictor of TVR. CONCLUSION: Our observational analysis suggests that DES seems to have short-term and mid-term advantages over BMS in reducing TVR and overall major adverse cardiovascular events. Percutaneous coronary intervention with DES may be considered as an option in these patients with limited revascularization options.

Follicular dendritic cell sarcoma of the neck: case report and review of current diagnostic and management strategies.

Follicular dendritic cell sarcoma (FDCS) is a rare malignant neoplasm that can clinically mimic a number of other tumors. FDCS can follow either an indolent or aggressive course. The prognosis tends to be worse for patients with large or high-grade tumors and/or an intra-abdominal tumor site. For optimal management, complete surgical excision is recommended. Radiation therapy and/or chemotherapy may be considered for incompletely resected tumors and for tumors with poor prognostic features, but the exact role of adjuvant therapy is unknown. We report a case of cervical FDCS in a 39-year-old black man, and we review the presentation and management of this disorder, with emphasis on the differential diagnosis.

Salivary gland malignancy and radioiodine therapy for thyroid cancer.

BACKGROUND: The risk of second primary malignancies in patients with well-differentiated thyroid cancer is of special interest because of the common use of radioactive iodine (RAI) ablation and/or treatment of these patients and the theoretical risk of subsequent nonthyroid malignancies associated with the radiation exposure. This brief report focuses specifically on the occurrence of second primary malignancies of the salivary glands. RAI residency within salivary tissues is known to have both acute and chronic consequences on salivary function, but secondary neoplasia is quite unusual. SUMMARY: We present a very rare case of a patient with papillary thyroid cancer treated with 600 mCi of RAI, who subsequently developed salivary gland cancer. CONCLUSIONS: We recommend salivary gland protection to diminish potential side effects after the exposure to radioiodine. On the basis of our experience we suggest administration of sialogogues (such as lemon juice) continuously, every 30-60 minutes for 24 hours, after RAI administration.