Improving Resource Utilization and Outcomes Using a Minimally Invasive Pilonidal Protocol.

PURPOSE: The purpose of this study was to evaluate the resource utilization and outcome of a minimally invasive pilonidal protocol (MIPP) versus surgical excision (SE) in adolescents with pilonidal disease. METHODS: Improved hygiene, laser epilation (LE), and sinusectomy were implemented as a minimally invasive pilonidal protocol (MIPP) in March 2016. Following IRB approval, 34 consecutive MIPP patients with moderate and severe disease were compared with a random sample of 17 SE patients treated prior to MIPP implementation. Number of visits, laser epilation (LE) treatments, care duration, operations, operating room (OR) time, charges, and condition at last visit were analyzed. Charges were standardized for 2018. RESULTS: No differences were found in age or body mass index between groups. SE patients underwent an average 1.6 excisions/patient (cumulative 2598 OR minutes) and no LE. MIPP patients underwent an average 1.4 sinusectomies and 3.5 LEs/patient. Six sinusectomies (0.17/patient) were performed in OR (cumulative 258 OR minutes). No differences in number of visits or care duration were found between groups. At last follow-up, 82% of MIPP and 18% of SE patients were healed or asymptomatic (p < 0.01). Average charges were $29,098 for SE versus $8440 for MIPP (p < 0.01). CONCLUSION: A minimally invasive pilonidal protocol reduces charges and improves outcome compared with surgical excision in adolescents. LEVEL OF EVIDENCE: III. TYPE OF STUDY: Retrospective comparative study.

Pit-picking resolves pilonidal disease in adolescents.

PURPOSE: The purpose of the study was to evaluate the outcome of pit-picking on adolescents with pilonidal disease. METHODS: Patients presenting to a Pilonidal Clinic were managed by evacuation of any un-drained collections, soaking, and as needed, hair removal. Once active inflammation resolved, they underwent pit-picking under local anesthesia. Those with >3 pits underwent sequential pit-pickings 2 months apart. Hirsute patients also underwent laser hair epilation. Pilonidal disease was stratified by severity. Patient symptoms were collected prospectively and reviewed. RESULTS: Fifty-eight patients underwent at least one pit-picking from February 2016 to September 2017. There were 40 (69%) males with a mean age of 17.7 years (range 13-24). Thirty-seven hirsute patients (64%) underwent a series of laser epilation treatments. Patients required from 0 to 3 days of non-narcotic analgesia, and all returned promptly to pre-procedure activities. Seven patients (12%) were lost to follow-up. Of the 51 patients with follow-up data, 47 (92%) were symptom-free an average of 5.0 months (range 1-20) post-procedure. Four patients (8%) had persistent intermittent drainage. CONCLUSION: Pit-picking is a simple office procedure that may resolve pilonidal disease in many adolescents. A longer follow-up interval is needed to determine the long-term recurrence rate. TYPE OF STUDY: Case Series. LEVEL OF EVIDENCE: Level IV.

Coronary artery fistula and atrial septal defect: a case report and brief review of the literature.

We present a case of a 25-year-old male with a large secondum atrial septal defect (ASD) associated with a coronary artery fistula (CAF) between the right coronary artery and the right atrium. The ASD was diagnosed preoperatively by transesophageal echocardio-graphy (TEE). The fistula was found at surgery. The ASD and fistula were closed successfully without any complication. The case highlights the common presenting features of the two conditions as well as the low sensitivity of pre-operative TEE in diagnosing CAF in the setting of an ASD.

Occurrence of valvar heart disease in acute rheumatic fever without evident carditis: colour-flow Doppler identification.

OBJECTIVE: To determine the frequency of occurrence of mitral and aortic valvar regurgitation in rheumatic children in whom there was no evidence of carditis acutely or at an earlier attack. DESIGN: Colour flow Doppler imaging was used in a non-randomised study of sequentially admitted children who met the criteria for acute rheumatic fever without clinically evident carditis and patients in whom the disease was quiescent after a previous attack of rheumatic fever. Two separate control groups were used for comparison of the echocardiographic findings, and a group of patients with confirmed rheumatic carditis was included for comparison of acute phase and antistreptococcal reactants. SETTING: A general hospital with the only paediatric inpatient department in Qatar. PATIENTS: From November 1988 to October 1990, 11 children were studied during the acute rheumatic period. In seven additional children the disease was quiescent when they were studied 18 to 36 months after a documented episode of acute rheumatic fever in which there was no evidence of carditis. The control patients were all studied during the same period. MAIN OUTCOME MEASURE: Detection of mitral and aortic regurgitation in patients without clinical evidence of rheumatic carditis in the acute or quiescent stages of the disease. RESULTS: Mitral or mitral and aortic regurgitation was found in 10 of the 11 children studied in the acute rheumatic period. None had a murmur or other evidence of carditis. In all the cases studied the valvar insufficiency was mild. Four of the children studied late in the quiescent period had either aortic or mitral insufficiency by colour flow Doppler evaluation; two children who had previously had valvar insufficiency no longer showed this, and one child without positive findings in the acute phase remained without insufficiency. None of the non-rheumatic control subjects showed mitral or aortic regurgitation. CONCLUSIONS: Colour flow Doppler imaging is a useful method of identifying subclinical mitral and aortic valvar disease at all stages of rheumatic fever when carditis cannot be otherwise detected and is a valuable addition to current diagnostic criteria.

Umbilical catheter masquerading at echocardiography as a left atrial mass.

The case of a newborn who had an umbilical catheter inserted in the intensive care unit is discussed. This catheter was meant to be inserted into the umbilical artery, but was instead inadvertently inserted into the umbilical vein. It crossed a patent foramen ovale into the left atrium. This fact was not known at the time of echocardiographic evaluation. At echocardiography, abnormal echoes within the left atrium were seen. Findings were typical for a catheter within the heart, and the umbilical catheter was subsequently withdrawn. There is a potential for mistaking the echocardiographic findings for a left atrial abnormality and echocardiographers should be alert to this possibility.

The murmur of double-chambered right ventricle: phonocardiographic evaluation.

Thirteen patients undergoing complete evaluation for double-chambered right ventricle were subjected to phonocardiographic evaluation. Each of these individuals revealed a holosystolic ejection-type murmur which exhibited a similarity of appearance unaltered by the degree of physiologic derangement or associated cardiac abnormalities. This finding is considered to be caused by the obstructive elements in double-chambered right ventricle and appears to be a characteristic finding for this condition.

Contrast echocardiography in the evaluation of interatrial septal defect.

One hundred twenty-four adult patients consecutively referred for suspected interatrial septal defect (IASD) were studied with contrast echocardiography. In 58 the study eliminated altogether the diagnosis of any significant cardiac defect. Fifteen patients had other forms of cardiac abnormalities with no shunting of blood, and 51 patients had echocontrast study positive for interatrial shunting; 48 of these were subsequently proven by cardiac catheterization to have IASD. Echocontrast provided a highly sensitive and specific means of both diagnosing IASD and eliminating this diagnosis.

Persistence of third aortic arch with fourth aortic arch agenesis.

This report describes a case in which a persistent third aortic arch connection partly palliated interruption of the aortic arch. The malformation occurred without other cardiovascular abnormality in a newborn infant in whom the principal diagnostic clinical finding was the absence of all peripheral pulses except for those of the right brachial and carotid arteries. Echocardiographic and angiocardiographic examination showed a continuation of the left internal carotid artery to the descending aorta by way of an arching communication.