Intralesional Injections of a TNF-α Inhibitor to Treat Orofacial Granulomatosis.

We present the first documented case of successful treatment of orofacial granulomatosis by intralesional injections of a tumor necrosis factor α inhibitor to the lip. Our patient had rapid symptomatic improvement after 3 injections, and near resolution within 4 months of anti-tumor necrosis factor α therapy.

The evolving neurosurgical perspective on Enhanced Recovery After Surgery (ERAS): a systematic review.

INTRODUCTION: Enhanced recovery after surgery (ERAS) programs may be implemented to minimize the body's stress response to surgery and enable a safe and timely discharge. Successful implementation involves a multifaceted approach from surgeons, anesthesiologists, nurses, nutritionists, and nonclinical staff. EVIDENCE ACQUISITION: National databases (MEDLINE (PubMed), Cochrane Central, and Google Scholar databases) were searched to identify studies on the clinical implementation of ERAS protocols in neurosurgery. A systematic review was chosen to select studies and pooled data analysis was performed. EVIDENCE SYNTHESIS: Thirty-five studies reported the use of enhanced recovery after surgery (ERAS), with 13 studies on cranial surgery and 22 on spinal surgery. Overall, 27 studies reported length of stay, 10 studies reported differences in opioid use, 21 studies reported either complications, readmission rate, or long term (>30 day) follow-up, 14 studies reported patient feedback, and 10 studies reported cost reduction of ERAS implementation. Findings supported significant reduction in length of stay, opioid use, and costs associated with ERAS regimens. Complications, readmission rates, and follow-up pain scores remained similar in ERAS and control groups. CONCLUSIONS: Our review finds that ERAS regimen implementation can serve an important role in facilitating clinical quality improvement and cost-effective care in all applications related to neurosurgical care and recovery. While application of ERAS in neurological surgery may have an important role in facilitating patient beneficial and cost-effective care, the findings of this review confirm that several challenges remain in select settings and prevent widespread implementation.

When a stuffy nose won't go away: Rhabdomyosarcoma masquerading as adenoiditis.

Embryonal Rhabdomyosarcoma is a malignant mesenchymal proliferation of immature skeletal muscle and may arise in children in the orbit, middle ear, nasal cavity, paranasal sinuses, or nasopharynx. Clinical diagnosis may be difficult in a subset of patients who have no significant deformities or irregularities upon visual inspection of the oropharynx. Rhabdomyosarcoma in this setting may be mistaken for a more common underlying etiology such as an upper respiratory infection. We report a case of a 7-year-old male with embryonal variant rhabdomyosarcoma previously misdiagnosed by 3 different physicians to be adenoiditis based on clinical exam and laryngoscopy. This case highlights the capacity for rhabdomyosarcoma to mimic commonly encountered adenoiditis. It also serves as a reminder to maintain a high level of diagnostic vigilance and clinical suspicion of noninfectious etiologies when symptoms persist and are refractory to standard treatment.

Community-associated methicillin-resistant Staphylococcus aureus colonization burden in HIV-infected patients.

BACKGROUND: The epidemic of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has had a disproportionate impact on patients with human immunodeficiency virus (HIV). METHODS: We evaluated CA-MRSA colonization burden (number of colonized sites per total number sampled) among HIV-infected and HIV-negative inpatients within 72 hours of hospitalization. From March 2011 through April 2012, we obtained cultures from nasal and extranasal sites (throat, axilla, inguinal, perirectal, and chronic wound if present) and collected risk factor data. RESULTS: Of 745 patients (374 HIV-infected, 371 HIV-negative), 15.7% were colonized with CA-MRSA at any site: 20% of HIV and 11% of HIV-negative patients (relative prevalence=1.8, P=.002). HIV-infected patients had a higher prevalence of nasal, extranasal, and exclusive extranasal colonization as well as higher colonization burden. Perirectal and inguinal areas were the extranasal sites most frequently colonized, and 38.5% of colonized patients had exclusive extranasal colonization. Seventy-three percent of isolates were identified as USA300. Among HIV-infected patients, male sex, younger age, and recent incarceration were positively associated whereas Hispanic ethnicity was negatively associated with higher colonization burden. Among HIV-negative patients, temporary housing (homeless, shelter, or substance abuse center) was the only factor associated with higher colonization burden. Predictors of USA300 included HIV, younger age, illicit drug use, and male sex; all but 1 colonized individual with current or recent incarceration carried USA300. CONCLUSIONS: HIV-infected patients were more likely to have a higher CA-MRSA colonization burden and carry USA300. In certain populations, enhanced community and outpatient-based infection control strategies may be needed to prevent CA-MRSA cross-transmission and infection.