1
|
Sun RW, Zhang H, Mehdi SJ, Richter GT, Bowman HH, Sifford J, Smith C, Burnett AK, Layman A, Washam CL, Byrum SD, Bennett JT, Jensen DM, Dmyterko V, Perkins JA, Shawber CJ, Wu JK, Strub GM. Upregulated MicroRNA-21 Drives the Proliferation of Lymphatic Malformation Endothelial Cells by Inhibiting PDCD4. J Invest Dermatol 2023; 143:2085-2089.e1. [PMID: 37088278 PMCID: PMC10524134 DOI: 10.1016/j.jid.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 03/20/2023] [Accepted: 04/09/2023] [Indexed: 04/25/2023]
Affiliation(s)
- Ravi W Sun
- Arkansas Children's Research Institute (ACRI), Little Rock, Arkansas, USA; Department of Otolaryngology-Head and Neck Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Haihong Zhang
- Arkansas Children's Research Institute (ACRI), Little Rock, Arkansas, USA; Department of Otolaryngology-Head and Neck Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Syed J Mehdi
- Arkansas Children's Research Institute (ACRI), Little Rock, Arkansas, USA; Department of Otolaryngology-Head and Neck Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Gresham T Richter
- Arkansas Children's Research Institute (ACRI), Little Rock, Arkansas, USA; Department of Otolaryngology-Head and Neck Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Hayden H Bowman
- Arkansas Children's Research Institute (ACRI), Little Rock, Arkansas, USA
| | - Jessica Sifford
- Arkansas Children's Research Institute (ACRI), Little Rock, Arkansas, USA
| | - Chelsea Smith
- Arkansas Children's Research Institute (ACRI), Little Rock, Arkansas, USA
| | | | - Alexander Layman
- Arkansas Children's Research Institute (ACRI), Little Rock, Arkansas, USA
| | - Charity L Washam
- Arkansas Children's Research Institute (ACRI), Little Rock, Arkansas, USA
| | - Stephanie D Byrum
- Arkansas Children's Research Institute (ACRI), Little Rock, Arkansas, USA
| | - James T Bennett
- Center for Developmental Biology and Regenerative Medicine, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Dana M Jensen
- Center for Developmental Biology and Regenerative Medicine, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Victoria Dmyterko
- Center for Developmental Biology and Regenerative Medicine, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Jonathan A Perkins
- Division of Pediatric Otolaryngology-Seattle Children's Hospital, Seattle, Washington, USA
| | - Carrie J Shawber
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York, USA; Department of Surgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - June K Wu
- Department of Surgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Graham M Strub
- Arkansas Children's Research Institute (ACRI), Little Rock, Arkansas, USA; Department of Otolaryngology-Head and Neck Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
| |
Collapse
|
2
|
Patel NA, Bonilla-Velez J, Rosenberg TL, Siegel D, Shivaram G, Chun RH, Waner M, O TM, Chen I, Moon R, Richter GT, Perkins JA. American society of pediatric otolaryngology vascular anomalies task force review of tongue venous malformations: Techniques, pearls, and pitfalls. Int J Pediatr Otorhinolaryngol 2023; 167:111497. [PMID: 36893584 DOI: 10.1016/j.ijporl.2023.111497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/20/2023] [Accepted: 02/25/2023] [Indexed: 03/11/2023]
Abstract
Management of tongue venous malformations can be challenging in the pediatric population due to their heterogeneity in presentation, extent of involvement and functional compromise. It is important to recognize the value of various treatment options in order to guide management of each patient in an individualized fashion. Here we describe a series of patients with tongue venous malformations that are managed using diverse modalities to illustrate the relative benefits and risks of each technique. The challenges of venous malformation treatment can be mitigated by tailoring the approach to each individual patient and malformation. This case series also emphasizes the need and importance of working in the setting of a multidisciplinary vascular anomalies team.
Collapse
Affiliation(s)
- Neha A Patel
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Otolaryngology-Head and Neck Surgery, Hempstead, NY, USA; Cohen Children's Medical Center, Division of Pediatric Otolaryngology, New Hyde Park, NY, USA.
| | - Juliana Bonilla-Velez
- Seattle Children's Hospital, Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle, WA, USA; University of Washington, Department of Otolaryngology-Head and Neck Surgery, Seattle, WA, USA; Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA, 98101, USA
| | - Tara L Rosenberg
- Baylor College of Medicine, Department of Otolaryngology-Head and Neck Surgery, Houston, TX, USA
| | - David Siegel
- Cohen Children's Medical Center, Division of Radiology, New Hyde Park, NY, USA
| | - Giri Shivaram
- Division of Interventional Radiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Robert H Chun
- Medical College of Wisconsin, Department of Otolaryngology-Head and Neck Surgery, Milwaukee, WI, USA
| | - Milton Waner
- Vascular Birthmark Institute of New York, Department of Otolaryngology, Lenox Hill and Manhattan Eye, Ear, and Throat Hospitals, New York, NY, USA
| | - Teresa M O
- Vascular Birthmark Institute of New York, Department of Otolaryngology, Lenox Hill and Manhattan Eye, Ear, and Throat Hospitals, New York, NY, USA
| | - Itay Chen
- Vascular Birthmark Institute of New York, Department of Otolaryngology, Lenox Hill and Manhattan Eye, Ear, and Throat Hospitals, New York, NY, USA
| | - Rony Moon
- Vascular Birthmark Institute of New York, Department of Otolaryngology, Lenox Hill and Manhattan Eye, Ear, and Throat Hospitals, New York, NY, USA
| | - Gresham T Richter
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Jonathan A Perkins
- Seattle Children's Hospital, Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle, WA, USA; University of Washington, Department of Otolaryngology-Head and Neck Surgery, Seattle, WA, USA; Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA, 98101, USA
| |
Collapse
|
3
|
Wei T, Richter GT, Zhang H, Sun RW, Smith CH, Strub GM. Extracranial arteriovenous malformations demonstrate dysregulated TGF-β/BMP signaling and increased circulating TGF-β1. Sci Rep 2022; 12:16612. [PMID: 36198763 PMCID: PMC9534897 DOI: 10.1038/s41598-022-21217-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 09/23/2022] [Indexed: 12/03/2022] Open
Abstract
Extracranial arteriovenous malformations (AVMs) are characterized by anomalous arterial-to-venous connections, aberrant angiogenesis, local inflammation and hypoxia, and disorganized histological architecture; however, the precise molecular perturbations leading to this phenotype remain elusive. We hypothesized that extracranial AVM tissue would demonstrate deregulation of the TGF-β/BMP signaling pathway, which may serve as a potential target in the development of molecular-based therapies for AVMs. AVM tissue was harvested during resection from 10 patients with AVMs and compared to control tissue. Blood was collected from 14 AVM patients and 10 patients without AVMs as controls. Expression of TGF-β/BMP pathway components was analyzed using RT-PCR, western blotting, and immunohistochemistry. Circulating levels of TGF-β1 were analyzed by ELISA. Paired t tests were utilized to perform statistical analysis. The mRNA levels of TGF-β1, ALK1, Endoglin (ENG), Smad6, Smad7, and Smad8 were significantly elevated in AVM tissue when compared to controls. Protein levels of TGF-β1 and Smad3 were elevated in AVM tissue while protein levels of BMP-9, ALK1, Smad1, Smad6, and Smad8 were significantly decreased in AVMs. Immunohistochemistry demonstrated increased TGF-β1 in the perivascular cells of AVMs compared to normal controls, and circulating levels of TGF-β1 were significantly higher in AVM patients. Patients with AVMs demonstrate aberrant TGF-β/BMP expression in AVM tissue and blood compared to controls. Targeting aberrantly expressed components of the TGF-β/BMP pathway in extracranial AVMs may be a viable approach in the development of novel molecular therapies, and monitoring circulating TGF-β1 levels may be a useful indicator of treatment success.
Collapse
Affiliation(s)
- Ting Wei
- Arkansas Children's Research Institute, 13 Children's Way, Little Rock, AR, 72202, USA
| | - Gresham T Richter
- Arkansas Children's Research Institute, 13 Children's Way, Little Rock, AR, 72202, USA.,Department of Otolaryngology, University of Arkansas for Medical Sciences, 4301 W. Markham St., Little Rock, AR, 72205, USA
| | - Haihong Zhang
- Arkansas Children's Research Institute, 13 Children's Way, Little Rock, AR, 72202, USA.,Department of Otolaryngology, University of Arkansas for Medical Sciences, 4301 W. Markham St., Little Rock, AR, 72205, USA
| | - Ravi W Sun
- Arkansas Children's Research Institute, 13 Children's Way, Little Rock, AR, 72202, USA.,Department of Otolaryngology, University of Arkansas for Medical Sciences, 4301 W. Markham St., Little Rock, AR, 72205, USA
| | - Conor H Smith
- Department of Otolaryngology, University of Arkansas for Medical Sciences, 4301 W. Markham St., Little Rock, AR, 72205, USA
| | - Graham M Strub
- Arkansas Children's Research Institute, 13 Children's Way, Little Rock, AR, 72202, USA. .,Department of Otolaryngology, University of Arkansas for Medical Sciences, 4301 W. Markham St., Little Rock, AR, 72205, USA.
| |
Collapse
|
4
|
DeHart AN, Richter GT. Laser Treatment of Vascular Anomalies. Dermatol Clin 2022; 40:481-487. [DOI: 10.1016/j.det.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
5
|
Mack JM, Peterson EC, Crary SE, Moran JH, Neville K, Pierce CD, Richter GT. Pharmacokinetics of bleomycin sclerotherapy in patients with vascular malformations. Pediatr Blood Cancer 2022; 69:e29733. [PMID: 35484878 DOI: 10.1002/pbc.29733] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/25/2022] [Accepted: 03/21/2022] [Indexed: 11/10/2022]
Abstract
Bleomycin, a chemotherapy agent that inhibits synthesis of DNA, has been increasingly utilized in sclerotherapy for patients with vascular malformations. A serious long-term risk of intravenous bleomycin is dose-dependent interstitial pneumonitis. Little is known about absorption and circulating levels of bleomycin when used in sclerotherapy for patients with vascular malformations. This is an Institutional Review Board (IRB)-approved prospective study on patients receiving bleomycin sclerotherapy in the management of vascular malformations. Depending on the type of vascular malformation, bleomycin was administered either in the lumen or interstitial space of the involved lesion. A bleomycin assay measured serum bleomycin plasma concentrations versus time at seven intervals following treatment. Pharmacokinetic parameters were obtained for each participant and included peak plasma concentration (Cmax ), time to reach peak plasma concentration (Tmax ), volume of distribution (Vd ), elimination half-life (t1/2 ), the volume of plasma cleared of the drug per unit time (CL), and total systemic exposure area under the curve (AUC). Fifteen patients were enrolled (5: lymphatic, 4: venous, 6: arteriovenous malformations). Bleomycin was administered interstitially (IS) in 11 patients and intraluminal (IL) in four; median age of 13 years (range: 2-67). Pharmacokinetic analysis revealed terminal elimination half-life (t1/2λz ) of 88.51 (±23.09) and 111.61 (±37.75) minutes for the IS and IL groups, respectively. Vd was 4.86 L (±6.74) and 1.55 L (±0.54) for the IS and IL groups, respectively. AUC was 53.9 (±23.45) and 129.17 (±93.57) mg min/L for the IS and IL groups, respectively. There were no statistically significant differences in t1/2λz , Vd , or AUC parameters between groups. Bleomycin is absorbed systemically when used as a sclerosant for vascular malformations when injected either IS or IL.
Collapse
Affiliation(s)
- Joana M Mack
- Department of Pediatrics, Division of Hematology/Oncology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Eric C Peterson
- Department of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Shelley E Crary
- Department of Pediatrics, Division of Hematology/Oncology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Jeffery H Moran
- Department of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Kathleen Neville
- Department of Pediatrics, Division of Hematology/Oncology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,Arkansas Children's Hospital, Little Rock, Arkansas, USA.,Johnson and Johnson, Raritan, New Jersey, USA
| | - C D'ann Pierce
- Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Gresham T Richter
- Arkansas Children's Hospital, Little Rock, Arkansas, USA.,Department of Surgery, Division of Otolaryngology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| |
Collapse
|
6
|
Shay AD, Zaniletti I, Davis KP, Bolin E, Richter GT. Characterizing Pediatric Bilateral Vocal Fold Dysfunction: Analysis with the Pediatric Health Information System Database. Laryngoscope 2022; 133:1228-1233. [PMID: 35796305 DOI: 10.1002/lary.30274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/16/2022] [Accepted: 06/06/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVES The purpose of this study was to characterize pediatric bilateral vocal fold dysfunction and to examine the overall inpatient mortality. METHODS Retrospective cohort analysis. Data from the Pediatric Health Information System was gathered for all pediatric patients with a diagnosis of bilateral vocal fold dysfunction between January 2008 and September 2020. Univariate and multivariate analyses were performed using Cox proportional hazard models. RESULTS 2395 patients accounted for 4799 hospitalizations with bilateral vocal fold dysfunction. Inpatient mortality occurred in 2.9% of the study sample. Chiari 2 was found in 2.8% of patients. The most common associated diagnoses were related to comorbid respiratory conditions (61.1%). The median adjusted ratio of cost to charges was $76,569. Aspiration was noted in 28 patients (1.2%). Gastrostomy was performed in 607 patients (25.3%). Tracheostomy was performed in 27% of patients. The overall 90-day readmission rate was 61%. On multivariate analysis, prognostic factors associated with increased hospital survival include gastrointestinal comorbidities (hazard ratio [HR]: 0.29; 95% confidence interval [CI]: 0.18-0.49) and tracheostomy (HR: 0.21; 95% CI: 0.12-0.37). CONCLUSION This database study represents the largest cohort analysis to date characterizing bilateral vocal fold dysfunction. Favorable prognostic indicators of overall hospital survival include gastrointestinal comorbidities and the presence of tracheostomy. Tracheostomy is associated with an increase in hospital costs, comorbidities, gastrostomy tube placement, and Chiari diagnosis. LEVEL OF EVIDENCE 4 Laryngoscope, 2022.
Collapse
Affiliation(s)
- Aryan D Shay
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas, U.S.A
| | | | - Kyle P Davis
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas, U.S.A
| | - Elijah Bolin
- Department of Pediatrics, Section of Pediatric Cardiology, University of Arkansas for Medical Sciences, Arkansas Children's Research Institute, Little Rock, Arkansas, U.S.A
| | - Gresham T Richter
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas, U.S.A
| |
Collapse
|
7
|
Dorrity J, Mack J, Wong K, Richter GT. Multimodality Treatment of Vascular Anomalies of The Head And Neck. J Oral Pathol Med 2022; 51:860-871. [PMID: 35674677 DOI: 10.1111/jop.13322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 05/03/2022] [Indexed: 11/27/2022]
Abstract
Vascular anomalies affect up to 5% of children with the majority affecting the head and neck. They present at different ages as a wide variety of lesions. Careful evaluation with history, physcial examination and imaging assist in the proper diagnosis. Depending on the condition, treatment options for vascular anomalies include topical therapy, selective photothermolysis, sclerotherapy, embolization, surgical excision and targeted systemic therapy. Staged multimodal therapeutic regimens have proven to best control disease and allow for preservation of function and aesthetics. The timing, sequence and combination of therapies is best determined by a multidisciplinary vascular anomalies team. Patients and families need to be counseled on anticipated positive outcomes following a protracted course of treatment for the majority of vascular anomalies.
Collapse
Affiliation(s)
- Jeffrey Dorrity
- University of Arkansas for Medical Sciences Department of Otolaryngology-Head and Neck Surgery, 4801 W Markham, Little Rock, AR
| | - Joana Mack
- University of Arkansas for Medical Sciences Department of Otolaryngology-Head and Neck Surgery, 4801 W Markham, Little Rock, AR
| | - Kevin Wong
- University of Arkansas for Medical Sciences Department of Otolaryngology-Head and Neck Surgery, 4801 W Markham, Little Rock, AR
| | - Gresham T Richter
- University of Arkansas for Medical Sciences Department of Otolaryngology-Head and Neck Surgery, 4801 W Markham, Little Rock, AR
| |
Collapse
|
8
|
Shewmake CN, Stephenson KJ, Bonasso PC, Odiase E, Richter GT, Bhavaraju AV, Dassinger MS. Blue Rubber Bleb Nevus Syndrome: A Rare Case of Gastrointestinal Hemorrhage Necessitating Bowel Resection. Am Surg 2022:31348221084949. [PMID: 35435006 DOI: 10.1177/00031348221084949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Blue Rubber Bleb Nevus Syndrome is a congenital rarity that manifests as vascular malformations throughout the body, including the gastrointestinal tract. With fewer than 300 cases reported, the etiology and clinical course is poorly understood; however, the literature suggests TEK mutations on chromosome 9 result in unregulated angiogenesis. We present the case of a young female treated for anemia of unknown etiology who presented in hemorrhagic shock due to gastrointestinal hemorrhage necessitating small bowel resection, with cutaneous, intestinal, hepatic, and lingual vascular malformations associated with a single somatic pathologic TEK mutation. Although uncommon, this case suggests that Blue Rubber Bleb Nevus Syndrome should be considered in the differential of a patient with persistent anemia and cutaneous lesions, carrying the potential for multiple gastrointestinal vascular malformations progressing to hemorrhage necessitating operative management. Additionally, a severe phenotype can occur without a double-hit TEK mutation.
Collapse
Affiliation(s)
- Connor N Shewmake
- College of Medicine, 155638University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Krista J Stephenson
- Department of Pediatric Surgery, 14423Arkansas Children's Hospital, Little Rock, AR, USA
| | - Patrick C Bonasso
- Department of Pediatric Surgery, 14423Arkansas Children's Hospital, Little Rock, AR, USA
| | - Elaine Odiase
- Department of Pediatric Gastroenterology, 14423Arkansas Children's Hospital, Little Rock, AR, USA
| | - Gresham T Richter
- Department of Pediatric Otolaryngology, 14423Arkansas Children's Hospital, Little Rock, AR, USA
| | - Avi V Bhavaraju
- Department of Trauma and Acute Care Surgery, 14423University of Arkansas for Medical Sciences, Little Rock, AR, US
| | - Melvin S Dassinger
- Department of Pediatric Surgery, 14423Arkansas Children's Hospital, Little Rock, AR, USA
| |
Collapse
|
9
|
Davis KP, Gaffey MM, Kompelli AR, Richter GT. Cutaneous hyperpigmentation following bleomycin sclerotherapy for vascular malformations. Pediatr Dermatol 2022; 39:103-106. [PMID: 34897790 DOI: 10.1111/pde.14869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Systemic bleomycin therapy is associated with pulmonary fibrosis and cutaneous side effects. While it is believed that there is little to no systemic distribution of bleomycin when utilized to treat vascular malformations (VMs), we present a case series in which cutaneous, adhesive-related hyperpigmentation suggests that there is systemic egress of bleomycin following direct puncture sclerotherapy (DPS). This risk of hyperpigmentation after intralesional bleomycin should be discussed with patients, and steps to minimize the chances of it occurring should be implemented.
Collapse
Affiliation(s)
- Kyle P Davis
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Megan M Gaffey
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA.,Division of Pediatric Otolaryngology, Arkansas Children's Hospital, Little Rock, AR, USA.,Department of Otolaryngology-Head and Neck Surgery, Division of Pediatric Otolaryngology, NYU Langone Health, New York, NY, USA
| | - Anvesh R Kompelli
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Gresham T Richter
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA.,Division of Pediatric Otolaryngology, Arkansas Children's Hospital, Little Rock, AR, USA
| |
Collapse
|
10
|
Kubala M, Gardner JR, Criddle J, Ward A, Richter GT. Utilizing process improvement strategies to generate clinic templates and improve patient flow in pediatric otolaryngology. Int J Pediatr Otorhinolaryngol 2021; 147:110779. [PMID: 34058529 DOI: 10.1016/j.ijporl.2021.110779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 01/29/2021] [Accepted: 05/17/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To examine outcomes from process improvement strategies aimed to: 1) develop computer generated physician clinic templates using captured and historic clinical data, and, 2) introduce said new template designs while maintaining historic daily patient volumes. METHODS An Institutional Review Board approved retrospective review of time stamped data collection in a tertiary facility pediatric otolaryngology clinic. RESULTS A discrete-event simulation was built from timestamps associated with clinic interaction milestones. The data were analyzed to develop standard clinic templates with the goal to reduce patient overall visit length by 10%. A total of 12,052 clinic visits were analyzed, 8,045 before (avg. of 62.9 visits/day) and 4,007 after (avg. of 65.7 visits/day) template standardization. The change led to a 10.5% (5.5 min, p < 0.001) decrease in total clinic visit time from 52.3 ± 25.9 min to 46.8 ± 25.0 min. This data extrapolated over a year is estimated to save 1,567 clinic hours. Secondarily, it was found that patient experience was not affected as a result of this change. CONCLUSION Discrete-event simulation, using the principles of process improvement, is effective in guiding clinic operational redesign. This quality improvement project decreased the average length of clinic visit by 10% with no impact on historic high clinic volumes. Patient flow can improve in high volume pediatric otolaryngology practices by using process improvement strategies and discrete-event simulations to create standardized provider templates. Theoretically, this strategy can lead to improved patient and physician experiences along with an increase in patient visits over time.
Collapse
Affiliation(s)
- Michael Kubala
- Department of Otolaryngology, Head and Neck Surgery, University of Arkansas for Medical Sciences, 4301 W. Markham St. #543, Little Rock, AR, 72205, USA.
| | - J Reed Gardner
- Department of Otolaryngology, Head and Neck Surgery, University of Arkansas for Medical Sciences, 4301 W. Markham St. #543, Little Rock, AR, 72205, USA.
| | - Justin Criddle
- Process Improvement, Arkansas Children's Hospital, 1 Children's Way, Little Rock, AR, 72202, USA.
| | - Amber Ward
- Division of Pediatric Otolaryngology, Arkansas Children's Hospital, 1 Children's Way, Little Rock, AR, 72202, USA
| | - Gresham T Richter
- Department of Otolaryngology, Head and Neck Surgery, University of Arkansas for Medical Sciences, 4301 W. Markham St. #543, Little Rock, AR, 72205, USA; Division of Pediatric Otolaryngology, Arkansas Children's Hospital, 1 Children's Way, Little Rock, AR, 72202, USA.
| |
Collapse
|
11
|
Schonning MJ, Koh S, Sun RW, Richter GT, Edwards AK, Shawber CJ, Wu JK. Venous malformation vessels are improperly specified and hyperproliferative. PLoS One 2021; 16:e0252342. [PMID: 34043714 PMCID: PMC8158993 DOI: 10.1371/journal.pone.0252342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 05/12/2021] [Indexed: 11/26/2022] Open
Abstract
Venous malformations (VMs) are slow-flow malformations of the venous vasculature and are the most common type of vascular malformation with a prevalence of 1%. Germline and somatic mutations have been shown to contribute to VM pathogenesis, but how these mutations affect VM pathobiology is not well understood. The goal of this study was to characterize VM endothelial and mural cell expression by performing a comprehensive expression analysis of VM vasculature. VM specimens (n = 16) were stained for pan-endothelial, arterial, venous, and endothelial progenitor cell proteins; proliferation was assessed with KI67. Endothelial cells in the VM vessels were abnormally orientated and improperly specified, as seen by the misexpression of both arterial and endothelial cell progenitor proteins not observed in control vessels. Consistent with arterialization of the endothelial cells, VM vessels were often surrounded by multiple layers of disorganized mural cells. VM endothelium also had a significant increase in proliferative endothelial cells, which may contribute to the dilated channels seen in VMs. Together the expression analysis indicates that the VM endothelium is misspecified and hyperproliferative, suggesting that VMs are biologically active lesions, consistent with clinical observations of VM progression over time.
Collapse
Affiliation(s)
- Michael J. Schonning
- Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States of America
| | - Seung Koh
- Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States of America
| | - Ravi W. Sun
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Gresham T. Richter
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Andrew K. Edwards
- Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States of America
| | - Carrie J. Shawber
- Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States of America
- Department of Ob/Gyn, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States of America
| | - June K. Wu
- Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States of America
- * E-mail:
| |
Collapse
|
12
|
Kubala M, Gardner JR, Criddle J, Nolder AR, Richter GT. Process improvement strategy to implement an outpatient surgery center efficiency model in an academic inpatient setting. Int J Pediatr Otorhinolaryngol 2021; 144:110650. [PMID: 33756390 DOI: 10.1016/j.ijporl.2021.110650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 02/07/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES By utilizing process improvement methodology, we aim to: 1) create an ambulatory surgical efficiency model (SEM) confined to an inpatient setting, and 2) reduce patient wait time and improve patient flow within the operating room. METHODS A prospective cohort of all otolaryngology cases performed from May 2016 to October 2017 at a tertiary, academic, pediatric hospital. Intraoperative timestamps were collected to determine turnover times. Time to procedure was collected from clinic visit to the day of operation. RESULTS A total of 5955 patients were enrolled. 3393 cases were performed prior to the implementation of SEM and 2562 after. Of the 2562 cases, 819 were deemed appropriate for the SEM. Prior to the SEM, the average number of working days between the clinic visit and operating room (WD) was 31.1 days (95% CI 30.7-31.4). After the SEM, the WD for non-SEM cases was 30.0 days (95% CI 29.7-30.2), and the WD for SEM cases was 14.4 days (95% CI 14.2-14.6). The average turnover time was significantly less for SEM cases at 11.4 min (95% CI 10.7-12.2) vs. non-SEM cases at 24.4 min (95% CI 23.9-25.0) (p < 0.0001). CONCLUSION Process improvement methodology is effective in improving perioperative patient flow. This quality improvement project decreased the average time from diagnosis to surgical procedure, as well as decreased the average turnover time between cases. Patient flow can improve with a high-volume SEM within an inpatient hospital operating room setting. This strategy can be instrumental in improving patient care by providing increased access to the operating room.
Collapse
Affiliation(s)
- Michael Kubala
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, 4301 W. Markham St. #543, Little Rock, AR, 72205, USA.
| | - J Reed Gardner
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, 4301 W. Markham St. #543, Little Rock, AR, 72205, USA.
| | - Justin Criddle
- Process Improvement, Arkansas Children's Hospital, 1 Children's Way, Little Rock, AR, 72202, USA.
| | - Abby R Nolder
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, 4301 W. Markham St. #543, Little Rock, AR, 72205, USA; Division of Pediatric Otolaryngology, Arkansas Children's Hospital, 1 Children's Way, Little Rock, AR, 72202, USA.
| | - Gresham T Richter
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, 4301 W. Markham St. #543, Little Rock, AR, 72205, USA; Division of Pediatric Otolaryngology, Arkansas Children's Hospital, 1 Children's Way, Little Rock, AR, 72202, USA.
| |
Collapse
|
13
|
Kubala ME, Turner M, Gardner JR, Williamson A, Richter GT. Impact of Oral Steroids on Tonsillectomy Postoperative Complications and Pain. Ear Nose Throat J 2021; 102:NP206-NP211. [PMID: 33734886 DOI: 10.1177/01455613211000832] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVES To analyze the impact of steroids on postoperative tonsillectomy recovery and implement findings for improvement in postoperative management. METHODS Institutional review board approved prospective study with retrospective analysis of private practice setting tonsillectomy patients (November 2015 to January 2017). A questionnaire was provided postoperatively to patients undergoing tonsillectomy with or without adenoidectomy. The study population was separated into 2 groups: patients who received steroids (3 days of either dexamethasone or prednisolone), postoperative steroid (POS), versus patients who did not receive steroids (PONS). RESULTS The questionnaire had a return rate of 27.3% (254/931). Nine of the 254 responses were disqualified for lack of information; therefore, the total number of responses was 245. Of these, 115 were POS and 130 were PONS. The groups were similar in mean age (POS: 13.2 ± 10.4 years, PONS: 14.7 ± 12.1 years, P = .32) and sex (POS: Male 40.0%, PONS: Male 40.0%, P = .97). There was an overall decrease of pain and nausea/vomiting (N/V) in the steroid group (P = .0007). There was reduction in pain (P < .05) from postoperative day (POD) 2, 3, 4, and 6 in the POS group. Otherwise, there was no significant reduction in pain from POD 7 to 14, day-by-day rate of N/V, bleeding, or rate of emergency department (ED) or clinic visit (P > .05). CONCLUSION Postoperative steroid reduced overall pain and N/V, as well as daily pain on POD 2, 3, 4, and 6. Pain from POD 7 to 14, rate of ED or clinic visit, or daily N/V and bleeding rate were not significantly different between cohorts.
Collapse
Affiliation(s)
- Michael E Kubala
- Department of Otolaryngology-Head and Neck Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Merit Turner
- Department of Otolaryngology-Head and Neck Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - James Reed Gardner
- Department of Otolaryngology-Head and Neck Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Adrian Williamson
- Department of Otolaryngology-Head and Neck Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA.,Arkansas Otolaryngology Centers, Little Rock, AR, USA
| | - Gresham T Richter
- Department of Otolaryngology-Head and Neck Surgery, 12215University of Arkansas for Medical Sciences, Little Rock, AR, USA.,Division of Pediatric Otolaryngology, Arkansas Children's Hospital, Little Rock, AR, USA
| |
Collapse
|
14
|
Mack JM, Pierce CD, Richter GT, Spray BJ, Nicholas R, Lewis PS, Becton D, Crary SE. Analyzing coagulation dynamics during treatment of vascular malformations with thromboelastography. Pediatr Blood Cancer 2021; 68:e28824. [PMID: 33211399 DOI: 10.1002/pbc.28824] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 09/29/2020] [Accepted: 11/03/2020] [Indexed: 11/11/2022]
Abstract
BACKGROUND/OBJECTIVES Slow-flow vascular malformations are abnormal vessels that can lead to activation and consumption of coagulation factors and thrombosis, known as localized intravascular coagulopathy (LIC). Most clinical and research evidence of vascular malformation hemostasis relies on conventional coagulation studies, which may not provide a complete picture. Thromboelastograpy (TEG) is a tool that can provide real-time assessment of a patient's coagulation dynamics, and may allow for a more individualized treatment approach. We hypothesized that patients with slow-flow vascular malformations will have changes in TEG parameters peri-procedure that will help predict blood product or medication administration. DESIGN/METHODS Institutional Review Board approved prospective study of patients with slow-flow vascular malformations undergoing a sedated, minor procedure. TEG and conventional coagulation studies were obtained preprocedure, 15 min, and when possible, at 30 min after the start of the procedure. RESULTS Twenty-five patients were enrolled. Median age was 15 years (range 3-47 years). Procedures included laser and/or sclerotherapy. There were no changes in TEG parameters from baseline to 15 min or 30 min. The following decreased from baseline to 15 min: fibrinogen 313 to 287 mg/dL (P = .001), D-dimer 1.3 to 1.1 mg/L (P = .02), hemoglobin 12.8 to 11.8 g/dL (P = .001), and platelet count 272 000 to 256 000 (P = .006). No patient had a bleeding/thrombotic complication during or within 1 week postprocedure. CONCLUSION We saw no change in TEG parameters or bleeding or clotting complications despite significant numerical changes in conventional coagulation profiles, suggesting that conventional studies may not be as useful in determining risks of bleeding or thrombotic complications peri-procedure for minor procedures.
Collapse
Affiliation(s)
- Joana M Mack
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, University of Arkansas for Medical Sciences, Little Rock, Arkansas.,Arkansas Children's Hospital, Little Rock, Arkansas
| | | | - Gresham T Richter
- Arkansas Children's Hospital, Little Rock, Arkansas.,Department of Surgery, Division of Otolaryngology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Beverly J Spray
- Arkansas Children's Research Institute, Little Rock, Arkansas
| | - Richard Nicholas
- Arkansas Children's Hospital, Little Rock, Arkansas.,Department of Surgery, Division of Orthopedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - P Spencer Lewis
- Arkansas Children's Hospital, Little Rock, Arkansas.,Department of Radiology, Division of Interventional Radiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - David Becton
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, University of Arkansas for Medical Sciences, Little Rock, Arkansas.,Arkansas Children's Hospital, Little Rock, Arkansas
| | - Shelley E Crary
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, University of Arkansas for Medical Sciences, Little Rock, Arkansas.,Arkansas Children's Hospital, Little Rock, Arkansas
| |
Collapse
|
15
|
Vickers DM, Reddy A, Akmyradov C, Brown KM, Boyanton BL, Wright HD, Taylor JA, Childress SH, Hartzell LD, Johnson AB, Key JM, Nolder AR, Richter GT, Wineland AM, Strub GM. Detection of Respiratory Pathogens Does Not Predict Risks After Outpatient Adenotonsillectomy. Laryngoscope 2020; 131:E2074-E2079. [PMID: 33150974 PMCID: PMC8246986 DOI: 10.1002/lary.29236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/18/2020] [Accepted: 10/22/2020] [Indexed: 11/24/2022]
Abstract
Objectives/Hypothesis To determine whether the presence of detectable upper respiratory infections (URIs) at the time of adenoidectomy/adenotonsillectomy is associated with increased morbidity, complications, and unexpected admissions. Study Design Prospective double‐blinded cohort. Methods In this prospective cohort study, nasopharyngeal swabs were obtained intraoperatively from 164 pediatric patients undergoing outpatient adenoidectomy/tonsillectomy with or without pressure equalization tubes (PETs) and were analyzed with PCR for the presence of 22 known URIs, including SARS‐CoV‐2. Surgeons and families were blinded to the results. At the conclusion of the study, rates of detectable infection were determined and intraoperative and postoperative events (unexpected admissions, length of PACU stay, rates of laryngospasm/bronchospasm, oxygen desaturation, bradycardia, and postoperative presentation to an emergency department) were compared between infected and uninfected patients. Results Of the 164 patients (50% male, 50% female, ages 8 mo‐18 y), 136 patients (82.9%) tested positive for one or more URI at the time of surgery. Forty one patients (25.0%) tested positive for three or more URIs concurrently, and 11 (6.7%) tested positive for five or more URIs concurrently. There were no significant differences in admission rates, length of PACU stay, rates of laryngospasm/bronchospasm, oxygen desaturation, bradycardia, or postoperative presentation to an emergency department between positive and negative patients. No patients tested positive for SARS‐CoV‐2. Conclusions A recent positive URI test does not confer any additional intraoperative or postoperative risk in the setting of outpatient adenoidectomy/tonsillectomy in healthy patients. There is no utility in preoperative URI testing, and delaying surgery due to a recent positive URI test is not warranted in this population. Level of Evidence 3 Laryngoscope, 131:E2074–E2079, 2021
Collapse
Affiliation(s)
- Donald M. Vickers
- Otolaryngology‐Head and Neck Surgery, College of MedicineUniversity of Arkansas for Medical SciencesLittle RockArkansasU.S.A.
| | - Arundathi Reddy
- Pediatric Otolaryngology, Anesthesiology, Pathology and Laboratory MedicineArkansas Children's HospitalLittle RockArkansasU.S.A.
| | - Chary Akmyradov
- Center for Pediatric Translational Research BiostatisticsArkansas Children's Research InstituteLittle RockArkansasU.S.A.
| | - Kesley M. Brown
- Otolaryngology‐Head and Neck Surgery, College of MedicineUniversity of Arkansas for Medical SciencesLittle RockArkansasU.S.A.
| | - Bobby L. Boyanton
- Otolaryngology‐Head and Neck Surgery, College of MedicineUniversity of Arkansas for Medical SciencesLittle RockArkansasU.S.A.
- Pediatric Otolaryngology, Anesthesiology, Pathology and Laboratory MedicineArkansas Children's HospitalLittle RockArkansasU.S.A.
| | - Heather D. Wright
- Pediatric Otolaryngology, Anesthesiology, Pathology and Laboratory MedicineArkansas Children's HospitalLittle RockArkansasU.S.A.
| | - Jay A. Taylor
- Pediatric Otolaryngology, Anesthesiology, Pathology and Laboratory MedicineArkansas Children's HospitalLittle RockArkansasU.S.A.
| | - Sherry H. Childress
- Pediatric Otolaryngology, Anesthesiology, Pathology and Laboratory MedicineArkansas Children's HospitalLittle RockArkansasU.S.A.
| | - Larry D. Hartzell
- Otolaryngology‐Head and Neck Surgery, College of MedicineUniversity of Arkansas for Medical SciencesLittle RockArkansasU.S.A.
- Pediatric Otolaryngology, Anesthesiology, Pathology and Laboratory MedicineArkansas Children's HospitalLittle RockArkansasU.S.A.
| | - Adam B. Johnson
- Otolaryngology‐Head and Neck Surgery, College of MedicineUniversity of Arkansas for Medical SciencesLittle RockArkansasU.S.A.
- Pediatric Otolaryngology, Anesthesiology, Pathology and Laboratory MedicineArkansas Children's HospitalLittle RockArkansasU.S.A.
| | - James M. Key
- Otolaryngology‐Head and Neck Surgery, College of MedicineUniversity of Arkansas for Medical SciencesLittle RockArkansasU.S.A.
- Pediatric Otolaryngology, Anesthesiology, Pathology and Laboratory MedicineArkansas Children's HospitalLittle RockArkansasU.S.A.
| | - Abby R. Nolder
- Otolaryngology‐Head and Neck Surgery, College of MedicineUniversity of Arkansas for Medical SciencesLittle RockArkansasU.S.A.
- Pediatric Otolaryngology, Anesthesiology, Pathology and Laboratory MedicineArkansas Children's HospitalLittle RockArkansasU.S.A.
| | - Gresham T. Richter
- Otolaryngology‐Head and Neck Surgery, College of MedicineUniversity of Arkansas for Medical SciencesLittle RockArkansasU.S.A.
- Pediatric Otolaryngology, Anesthesiology, Pathology and Laboratory MedicineArkansas Children's HospitalLittle RockArkansasU.S.A.
| | - Andre’ M. Wineland
- Otolaryngology‐Head and Neck Surgery, College of MedicineUniversity of Arkansas for Medical SciencesLittle RockArkansasU.S.A.
- Pediatric Otolaryngology, Anesthesiology, Pathology and Laboratory MedicineArkansas Children's HospitalLittle RockArkansasU.S.A.
| | - Graham M. Strub
- Otolaryngology‐Head and Neck Surgery, College of MedicineUniversity of Arkansas for Medical SciencesLittle RockArkansasU.S.A.
- Pediatric Otolaryngology, Anesthesiology, Pathology and Laboratory MedicineArkansas Children's HospitalLittle RockArkansasU.S.A.
- Center for Pediatric Translational Research BiostatisticsArkansas Children's Research InstituteLittle RockArkansasU.S.A.
| |
Collapse
|
16
|
Faucett EA, Wolter NE, Balakrishnan K, Ishman SL, Mehta D, Parikh S, Nguyen LHP, Preciado D, Rutter MJ, Prager JD, Green GE, Pransky SM, Elluru R, Husein M, Roy S, Johnson KE, Friedberg J, Johnson RF, Bauman NM, Myer CM, Deutsch ES, Gantwerker EA, Willging JP, Hart CK, Chun RH, Lam DJ, Ida JB, Manoukian JJ, White DR, Sidell DR, Wootten CT, Inglis AF, Derkay CS, Zalzal G, Molter DW, Ludemann JP, Choi S, Schraff S, Myer CM, Cotton RT, Vijayasekaran S, Zdanski CJ, El-Hakim H, Shah UK, Soma MA, Smith ME, Thompson DM, Javia LR, Zur KB, Sobol SE, Hartnick CJ, Rahbar R, Vaccani JP, Hartley B, Daniel SJ, Jacobs IN, Richter GT, de Alarcon A, Bromwich MA, Propst EJ. Competency-Based Assessment Tool for Pediatric Esophagoscopy: International Modified Delphi Consensus. Laryngoscope 2020; 131:1168-1174. [PMID: 33034397 DOI: 10.1002/lary.29126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/19/2020] [Accepted: 09/10/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS Create a competency-based assessment tool for pediatric esophagoscopy with foreign body removal. STUDY DESIGN Blinded modified Delphi consensus process. SETTING Tertiary care center. METHODS A list of 25 potential items was sent via the Research Electronic Data Capture database to 66 expert surgeons who perform pediatric esophagoscopy. In the first round, items were rated as "keep" or "remove" and comments were incorporated. In the second round, experts rated the importance of each item on a seven-point Likert scale. Consensus was determined with a goal of 7 to 25 final items. RESULTS The response rate was 38/64 (59.4%) in the first round and returned questionnaires were 100% complete. Experts wanted to "keep" all items and 172 comments were incorporated. Twenty-four task-specific and 7 previously-validated global rating items were distributed in the second round, and the response rate was 53/64 (82.8%) with questionnaires returned 97.5% complete. Of the task-specific items, 9 reached consensus, 7 were near consensus, and 8 did not achieve consensus. For global rating items that were previously validated, 6 reached consensus and 1 was near consensus. CONCLUSIONS It is possible to reach consensus about the important steps involved in rigid esophagoscopy with foreign body removal using a modified Delphi consensus technique. These items can now be considered when evaluating trainees during this procedure. This tool may allow trainees to focus on important steps of the procedure and help training programs standardize how trainees are evaluated. LEVEL OF EVIDENCE 5. Laryngoscope, 131:1168-1174, 2021.
Collapse
Affiliation(s)
- Erynne A Faucett
- Division of Otolaryngology, Head and Neck Surgery, Phoenix Children's Hospital, Department of Child Health, University of Arizona, Tucson, Arizona, U.S.A.,College of Medicine, Department of Otolaryngology, Mayo College of Medicine and Science, Phoenix, Arizona, U.S.A
| | - Nikolaus E Wolter
- Department of Otolaryngology - Head and Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Karthik Balakrishnan
- Department of Otolaryngology, Head and Neck Surgery, Stanford University, Lucile Salter Packard Children's Hospital, Palo Alto, California, U.S.A
| | - Stacey L Ishman
- Department of Otolaryngology - Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center Cincinnati, Cincinnati, Ohio, U.S.A
| | - Deepak Mehta
- Department of Pediatric Otolaryngology, Texas Children's Hospital, Houston, Texas, U.S.A
| | - Sanjay Parikh
- Division of Otolaryngology - Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Lily H P Nguyen
- Department of Otolaryngology - Head and Neck Surgery, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Diego Preciado
- Department of Otolaryngology, Children's National Health System, Division of Otolaryngology, George Washington University Washington, Washington, District of Columbia, U.S.A
| | - Michael J Rutter
- Department of Otolaryngology - Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center Cincinnati, Cincinnati, Ohio, U.S.A
| | - Jeremy D Prager
- Department of Pediatric Otolaryngology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, U.S.A
| | - Glenn E Green
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Mott Children's Hospital, Ann Arbor, Michigan, U.S.A
| | - Seth M Pransky
- Division of Pediatric Otolaryngology, Rady Children's Hospital San Diego, San Diego, California, U.S.A
| | - Ravi Elluru
- Division of Otolaryngology, Dayton Children's Hospital, Dayton, Ohio, U.S.A
| | - Murad Husein
- Department of Otolaryngology - Head and Neck Surgery, Victoria Hospital, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Soham Roy
- Department of Otorhinolaryngology, University of Texas at Houston McGovern Medical School, Houston, Texas, U.S.A
| | - Kaalan E Johnson
- Division of Otolaryngology - Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Jacob Friedberg
- Department of Otolaryngology - Head and Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Romaine F Johnson
- Department of Otolaryngology - Head and Neck Surgery, Division of Pediatric Otolaryngology University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Nancy M Bauman
- Department of Otolaryngology, Children's National Health System, Division of Otolaryngology, George Washington University Washington, Washington, District of Columbia, U.S.A
| | - Charles M Myer
- Department of Otolaryngology - Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center Cincinnati, Cincinnati, Ohio, U.S.A
| | - Ellen S Deutsch
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A.,Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Eric A Gantwerker
- Department of Otolaryngology - Head and Neck Surgery, Loyola University Medical Center, Maywood, Illinois, U.S.A
| | - J Paul Willging
- Department of Otolaryngology - Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center Cincinnati, Cincinnati, Ohio, U.S.A
| | - Catherine K Hart
- Department of Otolaryngology - Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center Cincinnati, Cincinnati, Ohio, U.S.A
| | - Robert H Chun
- Department of Otolaryngology, Children's Hospital of Wisconsin-Milwaukee Campus, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Derek J Lam
- Department of Otolaryngology - Head and Neck Surgery, Oregon Health and Science University, Pediatric Otolaryngology, Doernbecher Children's Hospital, Portland, Oregon, U.S.A
| | - Jonathan B Ida
- Division of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - John J Manoukian
- Department of Otolaryngology - Head and Neck Surgery, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - David R White
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Douglas R Sidell
- Department of Otolaryngology, Head and Neck Surgery, Stanford University, Lucile Salter Packard Children's Hospital, Palo Alto, California, U.S.A
| | - Christopher T Wootten
- Division of Otolaryngology, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee, U.S.A
| | - Andrew F Inglis
- Division of Otolaryngology - Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Craig S Derkay
- Department of Otolaryngology - Head and Neck Surgery Children's Hospital of the King's Daughters, Eastern Virginia Medical School, Norfolk, Virginia, U.S.A
| | - George Zalzal
- Department of Otolaryngology, Children's National Health System, Division of Otolaryngology, George Washington University Washington, Washington, District of Columbia, U.S.A
| | - David W Molter
- Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, U.S.A
| | - Jeffrey P Ludemann
- Pediatric Otolaryngology, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sukgi Choi
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Scott Schraff
- Arizona Otolaryngology Consultants, Phoenix, Arizona, U.S.A
| | - Charles M Myer
- Department of Otolaryngology - Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center Cincinnati, Cincinnati, Ohio, U.S.A
| | - Robin T Cotton
- Department of Otolaryngology - Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center Cincinnati, Cincinnati, Ohio, U.S.A
| | - Shyan Vijayasekaran
- Department of Otolaryngology, Head and Neck Surgery, Perth Children's Hospital, University of Western Australia, Perth, Western Australia, Australia
| | - Carlton J Zdanski
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Hamdy El-Hakim
- Division of Pediatric Surgery and Otolaryngology - Head and Neck Surgery, Departments of Surgery and Pediatrics, The Stollery Children's Hospital, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Udayan K Shah
- Division of Pediatric Otolaryngology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware, U.S.A
| | - Marlene A Soma
- Department of Paediatric Otolaryngology, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Marshall E Smith
- Division of Otolaryngology - Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah, U.S.A
| | - Dana M Thompson
- Division of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Luv Ram Javia
- Division of Otolaryngology, The Children's Hospital of Philadelphia, Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Karen B Zur
- Division of Otolaryngology, The Children's Hospital of Philadelphia, Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Steven E Sobol
- Division of Otolaryngology, The Children's Hospital of Philadelphia, Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Christopher J Hartnick
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School Boston, Boston, Massachusetts, U.S.A
| | - Reza Rahbar
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Jean-Philippe Vaccani
- Division of Otolaryngology, Department of Surgery, CHEO, University of Ottawa, Ottawa, Ontario, Canada
| | - Benjamin Hartley
- Department of Otolaryngology, Great Ormond Street Hospital, London, United Kingdom
| | - Sam J Daniel
- Department of Otolaryngology - Head and Neck Surgery, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Ian N Jacobs
- Division of Otolaryngology, The Children's Hospital of Philadelphia, Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Gresham T Richter
- Division of Pediatric Otolaryngology, Arkansas Children's Hospital, Little Rock, Arkansas, U.S.A
| | - Alessandro de Alarcon
- Department of Otolaryngology - Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center Cincinnati, Cincinnati, Ohio, U.S.A
| | - Matthew A Bromwich
- Division of Otolaryngology, Department of Surgery, CHEO, University of Ottawa, Ottawa, Ontario, Canada
| | - Evan J Propst
- Department of Otolaryngology - Head and Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto, Canada
| |
Collapse
|
17
|
Abstract
Arteriovenous malformations (AVMs) are vascular lesions that are thought to arise from congenital errors during development of vessels resulting in abnormal connections between arteries and veins. Though most AVMs develop in the brain or spinal cord, they can occur anywhere in the body. These extracranial or peripheral AVMs have a predilection for the head, neck, and limbs. Since these malformations infiltrate normal soft tissue, management requires selective treatment with preservation of normal surrounding architecture. Therefore, they are best addressed through a staged multimodal and multidisciplinary approach, using a combination of different laser, interstitial, intravascular and surgical techniques to specifically target anomalous vessels. The goal of treatment is overall disease improvement and symptom control with interventions that do not result in outcomes worse than the disease itself. Recently, the discovery of somatic and germline mutations in peripheral AVMs have contributed to a better understanding of the pathophysiology, resulting in promising new pharmacologic treatments. Recent evidence suggests that adjuvant medical therapy can enhance and sustain interventional and/or surgical outcomes. Herein we describe how a new understanding of the etiology and physiology of extracranial AVM provides guidance to current treatment approaches.
Collapse
Affiliation(s)
- Mary Roz Timbang
- University of Arkansas for Medical Sciences, Arkansas Children's Hospital, 1 Children's Way, Slot 836, Little Rock, AR 72202, United States
| | - Gresham T Richter
- University of Arkansas for Medical Sciences, Arkansas Children's Hospital, 1 Children's Way, Slot 836, Little Rock, AR 72202, United States.
| |
Collapse
|
18
|
Spradley TP, Johnson AB, Wright HD, Kincannon JM, Richter GT. Gentle ND:YAG Laser Therapy in the Treatment of Cutaneous Venous Malformations. Facial Plast Surg Aesthet Med 2020; 23:289-293. [PMID: 32856950 DOI: 10.1089/fpsam.2020.0268] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Venous malformations (VMs) are congenital vascular malformations that grow progressively and never resolve on their own. Cutaneous VMs are difficult to treat due to risk of injury and deformation. The purpose of this study was to examine the safety and efficacy of a modified neodymium-doped yttrium aluminum garnet laser (Gentle YAG) in the management of cutaneous VMs. Methods: Retrospective chart review of patients undergoing Gentle YAG therapy for cutaneous VMs and a blind prospective evaluation of photographs, performed by 10 reviewers, before and after treatment for growth, stability, improvement, or resolution of VMs. Results: Forty-five patients (18 males and 27 females) who underwent Gentle YAG therapy for a cutaneous VM were identified. Based on photographic review, Gentle YAG therapy elicited improvement in the appearance of VMs in 72% of the patients, χ2 (1, N = 45) = 25.94, p < 0.0001, with reviewers noting complete resolution in 8.2%, significant improvement in 34.5%, some improvement in 29.3%, and no growth or improvement in 20.9% of patients. Growth of the VM was noted in 7.3% of patients. Three (6.7%) patients reported complications from the treatment, which included infection, bleeding, blister, and color change. Four patients (8.9%) reported pretreatment pain, which resolved in three (75.0%) after treatment. Conclusions: Gentle YAG therapy can provide safe and effective treatment for cutaneous VMs and should be considered in the multimodal management of VMs.
Collapse
Affiliation(s)
- Thomas Ples Spradley
- Department of Otolaryngology and Head and Neck Surgery, University of Arkansas for Medical Sciences, Arkansas Children's Research Hospital and Research Institute, Little Rock, Arkansas, USA
| | - Adam B Johnson
- Department of Otolaryngology and Head and Neck Surgery, University of Arkansas for Medical Sciences, Arkansas Children's Research Hospital and Research Institute, Little Rock, Arkansas, USA
| | - Heather D Wright
- Department of Otolaryngology and Head and Neck Surgery, University of Arkansas for Medical Sciences, Arkansas Children's Research Hospital and Research Institute, Little Rock, Arkansas, USA
| | - Jay M Kincannon
- Department of Otolaryngology and Head and Neck Surgery, University of Arkansas for Medical Sciences, Arkansas Children's Research Hospital and Research Institute, Little Rock, Arkansas, USA
| | - Gresham T Richter
- Department of Otolaryngology and Head and Neck Surgery, University of Arkansas for Medical Sciences, Arkansas Children's Research Hospital and Research Institute, Little Rock, Arkansas, USA
| |
Collapse
|
19
|
Bonilla-Velez J, Moore BP, Cleves MA, Buckmiller L, Richter GT. Surgical resection of macrocystic lymphatic malformations of the head and neck: Short and long-term outcomes. Int J Pediatr Otorhinolaryngol 2020; 134:110013. [PMID: 32247220 DOI: 10.1016/j.ijporl.2020.110013] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 03/16/2020] [Accepted: 03/17/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Controversy exists on management of lymphatic malformations, with schools of thought advocating for observation, surgery or sclerotherapy. This study sought to examine outcomes after surgical resection of pediatric cervicofacial macrocystic lymphatic malformations (MLM). METHODS Case series with planned data collection on pediatric patients with cervicofacial MLM who underwent surgical resection at a tertiary referral center for vascular anomalies from January 1995 to June 2016. For consistency in patient population analysis, patients who had pre-surgical sclerotherapy or had mixed or microcystic disease were excluded. The main outcome was complete response rate (CR) and long-term recurrence-free survival (RFS). RESULTS Sixty-three patients who underwent excision of MLM were included, 52.4% were female, 77.8% Caucasian. The majority had de Serres stage I-III (96.8%) affecting the neck (71.4%). Patients were discharged the same day (28.6%), or had a 1 day median length-of-stay (interquartile range (IQR) = 2). Surgical complications included seroma/hematoma (9.5%), transient nerve weakness (facial nerve, sympathetic chain, or phrenic nerve, 6.3%), and infection (1.6%). On long-term follow-up (median: 12 months, IQR 1-43 months), a single surgery achieved CR in 90.5% of patients. RFS was achieved in 86% of patients in our observation period of up to 15 years. Most patients requiring a second intervention failed within 6-months of initial procedure (4/5 patients, 90%); associated factors included bilaterality, advanced staging, and partial response at first-follow-up (p = 0.0051, 0.0051, and <0.0001, respectively). CONCLUSIONS Surgery is safe and effective as first line treatment for selected MLM. For stage I-III MLM CR and long-term RFS can be achieved with a single surgery. A direct and randomized comparison of treatment modalities is needed.
Collapse
Affiliation(s)
- Juliana Bonilla-Velez
- Division of Pediatric Otolaryngology and Center for the Investigation of Congenital Aberrancies of Vascular Development, Arkansas Children's Hospital, 1 Children's Way, Little Rock, AR, USA; Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, 4301 W Markham St #543, Little Rock, AR, USA.
| | - Brendan P Moore
- College of Medicine, University of Arkansas for Medical Sciences, 4301 W Markham St #550, Little Rock, AR, USA
| | - Mario A Cleves
- Department of Pediatrics and Biostatistics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Lisa Buckmiller
- Baylor College of Medicine. 1 Baylor Plaza, Houston, TX, USA; Children's Hospital of San Antonio, 333 N Santa Rosa St, San Antonio, TX, USA
| | - Gresham T Richter
- Division of Pediatric Otolaryngology and Center for the Investigation of Congenital Aberrancies of Vascular Development, Arkansas Children's Hospital, 1 Children's Way, Little Rock, AR, USA; Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, 4301 W Markham St #543, Little Rock, AR, USA
| |
Collapse
|
20
|
Qiao C, Richter GT, Pan W, Jin Y, Lin X. Extracranial arteriovenous malformations: from bedside to bench. Mutagenesis 2020; 34:299-306. [PMID: 31613971 DOI: 10.1093/mutage/gez028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 09/14/2019] [Indexed: 01/08/2023] Open
Abstract
Arteriovenous malformation (AVM) is defined as a fast-flow vascular anomaly that shunts blood from arteries directly to veins. This short circuit of blood flow contributes to progressive expansion of draining veins, resulting in ischaemia, tissue deformation and in some severe cases, congestive heart failure. Various medical interventions have been employed to treat AVM, however, management of which remains a huge challenge because of its high recurrence rate and lethal complications. Thus, understanding the underlying mechanisms of AVM development and progression will help direct discovery and a potential cure. Here, we summarize current findings in the field of extracranial AVMs with the aim to provide insight into their aetiology and molecular influences, in the hope to pave the way for future treatment.
Collapse
Affiliation(s)
- Congzhen Qiao
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Gresham T Richter
- Center for Investigation of Congenital Anomalies of Vascular Development, Arkansas Vascular Biology Program, Arkansas Children's Hospital, Little Rock, AR, USA.,Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA.,Division of Pediatric Otolaryngology, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Weijun Pan
- Key Laboratory of Stem Cell Biology, CAS Center for Excellence in Molecular Cell Science, Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, Shanghai, China
| | - Yunbo Jin
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoxi Lin
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| |
Collapse
|
21
|
Gomez-Acevedo H, Dai Y, Strub G, Shawber C, Wu JK, Richter GT. Identification of putative biomarkers for Infantile Hemangiomas and Propranolol treatment via data integration. Sci Rep 2020; 10:3261. [PMID: 32094357 PMCID: PMC7039967 DOI: 10.1038/s41598-020-60025-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 12/20/2019] [Indexed: 12/29/2022] Open
Abstract
Infantile hemangiomas (IHs) are the most common benign tumors in early childhood. They show a distinctive mechanism of tumor growth in which a rapid proliferative phase is followed by a regression phase (involution). Propranolol is an approved treatment for IHs, but its mechanism of action remains unclear. We integrated and harmonized microRNA and mRNA transcriptome data from newly generated microarray data on IHs with publicly available data on toxicological transcriptomics from propranolol exposure, and with microRNA data from IHs and propranolol exposure. We identified subsets of putative biomarkers for proliferation and involution as well as a small set of putative biomarkers for propranolol's mechanism of action for IHs, namely EPAS1, LASP1, SLC25A23, MYO1B, and ALDH1A1. Based on our integrative data approach and confirmatory experiments, we concluded that hypoxia in IHs is regulated by EPAS1 (HIF-2α) instead of HIF-1α, and also that propranolol-induced apoptosis in endothelial cells may occur via mitochondrial stress.
Collapse
Affiliation(s)
- Horacio Gomez-Acevedo
- Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
| | - Yuemeng Dai
- Mesquite Rehabilitation Institute, Mesquite, Texas, USA
| | - Graham Strub
- Department of Otolaryngology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Carrie Shawber
- Department of Surgery, New York-Presbyterian/Morgan Stanley Children's Hospital, Columbia University, New York, New York, USA
| | - June K Wu
- Department of Reproductive Sciences in Obstetrics & Gynecology and Surgery, Columbia University, New York, New York, USA
| | - Gresham T Richter
- Department of Otolaryngology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Arkansas Children's Hospital, Little Rock, Arkansas, USA
| |
Collapse
|
22
|
Chan KH, Dinwiddie JK, Ahuja GS, Bennett EC, Brigger MT, Chi DH, Choo DI, Cunningham MJ, Elluru RG, Giannoni CM, Goudy SL, Koempel JA, MacArthur CJ, Malone B, Messner AH, Mitchell RB, Park AH, Richter GT, Rosbe KW, Shah UK, Sie KCY, Smith RJ, Sulman CG, Thompson JW, Thorne MC, Wei JL, Wetmore RF, White DR, Zalzal GH, Schoem SR. Advanced practice providers and children's hospital-based pediatric otolarynology practices. Int J Pediatr Otorhinolaryngol 2020; 129:109770. [PMID: 31733596 DOI: 10.1016/j.ijporl.2019.109770] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 11/04/2019] [Accepted: 11/04/2019] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Advanced practice providers (APPs), including nurse practitioners and physician assistants, have been deployed in children's hospital-based academic pediatric otolaryngology practices for many years. However, this relationship in terms of prevalence, roles, financial consequences and satisfaction has not been examined. The objective of this study is to explore how APPs impact healthcare delivery in this setting. METHODS Pediatric otolaryngology chiefs of all academic children's hospitals in the US were electronically surveyed about the ways APPs intersected clinically and financially in their respective practice. RESULTS A total of 29 of 36 children's hospital-based pediatric otolaryngology practices completed the survey, of which 26 practices (90%) utilized APP. There were large variances within the APP practice cohort in faculty size (mean/median/range = 9.4/8.5/3-29); annual patient visits (mean/median = 18,373/17,600); number of practice site (mean/median/range = 4.3/4/2-9) and number of outpatient APP (mean/median/range = 6.3/5/1-30). No factors (faculty size, annual visits and number of practice sites) differentiated between the APP and non-APP practices. Among APP practices, significant correlation (p<.00001) was observed between size of APP cohort to faculty size and annual visits. 69% of the practices did not differentiate job functions of nurse practitioners and physician assistants. 85% of the practices utilized APPs in all practice sites and 19% utilized APPs in the operating room. 77% of APPs billed independently and 46% had on-site supervision. The most prevalent APP salary bracket based on 0-5, 6-10 and > 11 years of tenure were $76-100K (65%), $100-150K (77%) and $100-150K (86%), respectively. In 46% of the practices, APPs were able to generate enough revenue to cover more than 75% of their salary and 23% of practices generated a profit. 81% of the chiefs ranked the effectiveness of APPs as high (4 and 5) on a 5-point Likert scale. DISCUSSION The majority of academic pediatric otolaryngology practices employed APPs. Despite the diversity seen in practice complexity, APP functionality and financial impact, most found the APP model to be beneficial in improving patient care, patient access and faculty productivity.
Collapse
Affiliation(s)
- Kenny H Chan
- Children's Hospital Colorado, Aurora, CO, USA; Department of Otolaryngology - Head and Neck Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Jordyn K Dinwiddie
- Children's Hospital Colorado, Aurora, CO, USA; Department of Otolaryngology - Head and Neck Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Gurpreet S Ahuja
- CHOC Children's Hospital, Orange, CA, USA; Department of Otolaryngology - Head and Neck Surgery, University of California Irvine, Orange, CA, USA
| | - Erica C Bennett
- Division of Otolaryngology - Head and Neck Surgery, University of New Mexico, Albuquerque, NM, USA
| | - Matthew T Brigger
- Rady Children's Hospital, San Diego, CA, USA; Department of Otolaryngology - Head and Neck Surgery, Naval Medical Center San Diego, San Diego, CA, USA
| | - David H Chi
- Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA; Department of Otolaryngology - Head and Neck Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Daniel I Choo
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Department of Otolaryngology - Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Michael J Cunningham
- Boston Children's Hospital, Boston, MA, USA; Department of Otolaryngology - Head and Neck Surgery, Harvard Medical School, Boston, MA, USA
| | - Ravindhra G Elluru
- Department of Otolaryngology, Dayton Children's Hospital, Dayton, OH, USA
| | - Carla M Giannoni
- Texas Children's Hospital, Houston, TX, USA; Department of Otolaryngology - Head and Neck Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Steven L Goudy
- Children's Healthcare of Atlanta, Atlanta, GA, USA; Department of Otolaryngology - Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Jeffrey A Koempel
- Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Otolaryngology - Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Carol J MacArthur
- Department of Otolaryngology - Head and Neck Surgery, Oregon Health and Science University, Portland, OR, USA
| | | | - Anna H Messner
- Lucille Packard Children's Hospital, Palo Alto, CA, USA; Department of Otolaryngology - Head and Neck Surgery, Stanford University, Palo Alto, CA, USA
| | - Ron B Mitchell
- Children's Health, Dallas, TX, USA; Department of Otolaryngology - Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Albert H Park
- Primary Children's Hospital, Salt Lake City, UT, USA; Division of Otolaryngology - Head and Neck Surgery, University of Utah, Salt Lake City, UT, USA
| | - Gresham T Richter
- Arkansa Children's Hospital, Little Rock, AR, USA; Department of Otolaryngology - Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Kristina W Rosbe
- Benioff Children's Hospital, San Francisco, CA, USA; Department of Otolaryngology - Head and Neck Surgery, University of California, San Francisco, CA, USA
| | - Udayan K Shah
- Nemours/Alfred I. DuPont Hospital for Children, Wilmington, DE, USA; Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Kathy C Y Sie
- Seattle Children's, Seattle, WA, USA; Department of Otolaryngology - Head and Neck Surgery, University of Washington, Seattle, WA, USA
| | - Richard J Smith
- Molecular Otolaryngology and Renal Research Laboratories, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Cecille G Sulman
- Children's Hospital of Wisconsin, Milwaukee, WI, USA; Department of Otolaryngology and Communication Sciences, Division of Pediatric Otolaryngology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jerome W Thompson
- LeBonheur Children's Hospital, Memphis, TN, USA; Department of Otolaryngology - Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Marc C Thorne
- C.S. Mott Children's Hospital, Ann Arbor, MI, USA; Department of Otolaryngology - Head and Neck Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Julie L Wei
- Nemours Children's Hospital, Orlando, FL, USA; Department of Otolaryngology - Head and Neck Surgery, University of Central Florida College of Medicine, Orlando, FL, USA
| | - Ralph F Wetmore
- Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Otolaryngology - Head and Neck Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - David R White
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - George H Zalzal
- Children's National Health System, Washington, DC, USA; Department of Otolaryngology - Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Scott R Schoem
- Connecticut Children's Medical Center, Hartford, CT, USA; Department of Otolaryngology - Head and Neck Surgery, University of Connecticut School of Medicine, Farmington, CT, USA
| |
Collapse
|
23
|
Propst EJ, Wolter NE, Ishman SL, Balakrishnan K, Deonarain AR, Mehta D, Zalzal G, Pransky SM, Roy S, Myer CM, Torre M, Johnson RF, Ludemann JP, Derkay CS, Chun RH, Hong P, Molter DW, Prager JD, Nguyen LHP, Rutter MJ, Myer CM, Zur KB, Sidell DR, Johnson LB, Cotton RT, Hart CK, Willging JP, Zdanski CJ, Manoukian JJ, Lam DJ, Bauman NM, Gantwerker EA, Husein M, Inglis AF, Green GE, Javia LR, Schraff S, Soma MA, Deutsch ES, Sobol SE, Ida JB, Choi S, Uwiera TC, Shah UK, White DR, Wootten CT, El-Hakim H, Bromwich MA, Richter GT, Vijayasekaran S, Smith ME, Vaccani JP, Hartnick CJ, Faucett EA. Competency-Based Assessment Tool for Pediatric Tracheotomy: International Modified Delphi Consensus. Laryngoscope 2019; 130:2700-2707. [PMID: 31821571 DOI: 10.1002/lary.28461] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 11/08/2019] [Accepted: 11/21/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS Create a competency-based assessment tool for pediatric tracheotomy. STUDY DESIGN Blinded, modified, Delphi consensus process. METHODS Using the REDCap database, a list of 31 potential items was circulated to 65 expert surgeons who perform pediatric tracheotomy. In the first round, items were rated as "keep" or "remove," and comments were incorporated. In the second round, experts were asked to rate the importance of each item on a seven-point Likert scale. Consensus criteria were determined a priori with a goal of 7 to 25 final items. RESULTS The first round achieved a response rate of 39/65 (60.0%), and returned questionnaires were 99.5% complete. All items were rated as "keep," and 137 comments were incorporated. In the second round, 30 task-specific and seven previously validated global rating items were distributed, and the response rate was 44/65 (67.7%), with returned questionnaires being 99.3% complete. Of the Task-Specific Items, 13 reached consensus, 10 were near consensus, and 7 did not achieve consensus. For the 7 previously validated global rating items, 5 reached consensus and two were near consensus. CONCLUSIONS It is feasible to reach consensus on the important steps involved in pediatric tracheotomy using a modified Delphi consensus process. These items can now be considered to create a competency-based assessment tool for pediatric tracheotomy. Such a tool will hopefully allow trainees to focus on the important aspects of this procedure and help teaching programs standardize how they evaluate trainees during this procedure. LEVEL OF EVIDENCE 5 Laryngoscope, 130:2700-2707, 2020.
Collapse
Affiliation(s)
- Evan J Propst
- Department of Otolaryngology-Head and Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Nikolaus E Wolter
- Department of Otolaryngology-Head and Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Stacey L Ishman
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Division of Pediatric Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Karthik Balakrishnan
- Department of Otolaryngology and Mayo Children's Center, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, U.S.A
| | - Ashley R Deonarain
- Department of Otolaryngology-Head and Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Deepak Mehta
- Department of Pediatric Otolaryngology, Texas Children's Hospital, Houston, Texas, U.S.A
| | - George Zalzal
- Department of Otolaryngology, Children's National Health System, Division of Otolaryngology, George Washington University Washington, DC, U.S.A
| | - Seth M Pransky
- Division of Pediatric Otolaryngology, Rady Children's Hospital San Diego, San Diego, California, U.S.A
| | - Soham Roy
- Department of Otorhinolaryngology, University of Texas at Houston McGovern Medical School, Houston, Texas, U.S.A
| | - Charles M Myer
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Division of Pediatric Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Michele Torre
- Airway Unit, Scientific Institute for Research and Healthcare, Giannina Gaslini Institute, Genoa, Italy
| | - Romaine F Johnson
- Department of Otolaryngology-Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Jeffrey P Ludemann
- Pediatric Otolaryngology, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Craig S Derkay
- Department of Otolaryngology-Head and Neck Surgery, Children's Hospital of the King's Daughters, Eastern Virginia Medical School, Norfolk, Virginia, U.S.A
| | - Robert H Chun
- Department of Otolaryngology, Children's Hospital of Wisconsin-Milwaukee Campus, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Paul Hong
- Division of Otolaryngology, Dalhousie University, Izaak Walton Killam Health Centre, Halifax, Nova Scotia, Canada
| | - David W Molter
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Jeremy D Prager
- Department of Pediatric Otolaryngology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, U.S.A
| | - Lily H P Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Michael J Rutter
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Division of Pediatric Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Charles M Myer
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Division of Pediatric Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Karen B Zur
- Department of Otolaryngology-Head and Neck Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
| | - Douglas R Sidell
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Lucile Salter Packard Children's Hospital, Palo Alto, California, U.S.A
| | - Liane B Johnson
- Division of Otolaryngology, Dalhousie University, Izaak Walton Killam Health Centre, Halifax, Nova Scotia, Canada
| | - Robin T Cotton
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Division of Pediatric Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Catherine K Hart
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Division of Pediatric Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - J Paul Willging
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Division of Pediatric Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Carlton J Zdanski
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - John J Manoukian
- Department of Otolaryngology-Head and Neck Surgery, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Derek J Lam
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Pediatric Otolaryngology, Doernbecher Children's Hospital, Portland, Oregon, U.S.A
| | - Nancy M Bauman
- Department of Otolaryngology, Children's National Health System, Division of Otolaryngology, George Washington University Washington, DC, U.S.A
| | - Eric A Gantwerker
- Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Maywood, Illinois, U.S.A
| | - Murad Husein
- Department of Otolaryngology-Head and Neck Surgery, Victoria Hospital, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Andrew F Inglis
- Division of Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Glenn E Green
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Mott Children's Hospital, Ann Arbor, Michigan, U.S.A
| | - Luv Ram Javia
- Department of Otolaryngology-Head and Neck Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
| | - Scott Schraff
- Arizona Otolaryngology Consultants, Phoenix, Arizona, U.S.A
| | - Marlene A Soma
- Department of Pediatric Otolaryngology, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Ellen S Deutsch
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Steven E Sobol
- Department of Otolaryngology-Head and Neck Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
| | - Jonathan B Ida
- Division of Pediatric Otolaryngology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Sukgi Choi
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Trina C Uwiera
- Divisions of Pediatric Surgery and Otolaryngology-Head and Neck Surgery, Departments of Surgery and Pediatrics, The Stollery Children's Hospital, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Udayan K Shah
- Division of Pediatric Otolaryngology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware, U.S.A
| | - David R White
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Christopher T Wootten
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Hamdy El-Hakim
- Divisions of Pediatric Surgery and Otolaryngology-Head and Neck Surgery, Departments of Surgery and Pediatrics, The Stollery Children's Hospital, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Matthew A Bromwich
- Division of Otolaryngology, Department of Surgery, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Gresham T Richter
- Division of Pediatric Otolaryngology, Arkansas Children's Hospital, Little Rock, Arkansas, U.S.A
| | - Shyan Vijayasekaran
- Department of Otolaryngology-Head and Neck Surgery, Perth Children's Hospital, University of Western Australia, Nedlands, Western Australia, Australia
| | - Marshall E Smith
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah, U.S.A
| | - Jean-Philippe Vaccani
- Division of Otolaryngology, Department of Surgery, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Christopher J Hartnick
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Erynne A Faucett
- Department of Pediatric Otolaryngology, Phoenix Children's Hospital, Phoenix, Arizona, U.S.A
| |
Collapse
|
24
|
|
25
|
Fuell W, Bradley L, Richter GT, Kazemi N, Albert G, McCarthy R, Ocal E. Management of an odontoid synchondrosis fracture causing chronic translational anterior atlanto-axial subluxation in a child with autism: case report. J Neurosurg Pediatr 2019; 25:1-4. [PMID: 31675721 DOI: 10.3171/2019.8.peds18517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 08/28/2019] [Indexed: 11/06/2022]
Abstract
The authors report an unusual case of an odontoid synchondrosis fracture causing chronic translational anterior atlanto-axial subluxation and present a discussion of the unique management of this case. Traumatic translational anterior atlanto-axial subluxation is a rare manifestation within pediatrics. Patients with preexisting abnormalities in ligamentous or bony structures may present with unusual symptomatology, which could result in delay of treatment. A 6-year-old male patient with autism who presented with acute respiratory arrest was noted to have an odontoid synchondrosis fracture and severe anterior translational atlanto-axial subluxation. Initial attempts at reduction with halo traction were tried for first-line treatment. However, because of concern regarding possible inadvertent worsening of the impingement, the presence of comorbid macrocephaly, and possible instability with only C1-2 fusion, a posterior C1 laminectomy was performed. Further release of the C1-2 complex and odontoid peg from extensive fibrous tissue allowed for complete reduction. Acute injuries of the C1-2 complex may not present as expected, and the presence of pain is not a reliable symptom. Halo traction is an appropriate initial treatment, but some patients may require surgical realignment and stabilization.
Collapse
Affiliation(s)
- William Fuell
- 1Division of Neurosurgery, Arkansas Children's Hospital
| | - Lucas Bradley
- 1Division of Neurosurgery, Arkansas Children's Hospital
- Departments of3Neurosurgery and
| | - Gresham T Richter
- 2Department of Otolaryngology-Head and Neck Surgery, Arkansas Children's Hospital and University of Arkansas for Medical Sciences; and
| | | | - Gregory Albert
- 1Division of Neurosurgery, Arkansas Children's Hospital
- Departments of3Neurosurgery and
| | - Richard McCarthy
- 4Neurological Surgery-Spine Division, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Eylem Ocal
- 1Division of Neurosurgery, Arkansas Children's Hospital
- Departments of3Neurosurgery and
| |
Collapse
|
26
|
Mack JM, Verkamp B, Richter GT, Nicholas R, Stewart K, Crary SE. Effect of sirolimus on coagulopathy of slow-flow vascular malformations. Pediatr Blood Cancer 2019; 66:e27896. [PMID: 31250546 DOI: 10.1002/pbc.27896] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 05/25/2019] [Accepted: 06/10/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND/OBJECTIVES Stagnant blood flow present in slow-flow vascular malformations can lead to localized intravascular coagulopathy (LIC), measured by elevated D-dimer levels, low fibrinogen, and/or thrombocytopenia. LIC can lead to localized thrombosis and/or bleeding, resulting in pain, swelling, and functional limitations. Patients with complex vascular malformations treated with sirolimus show clinical improvement in these symptoms. We hypothesized that the clinical benefits of sirolimus may correlate with improvements in coexisting LIC. DESIGN/METHODS A retrospective chart review was performed, including D-dimer, fibrinogen, and platelet count, in patients with slow-flow vascular malformations treated with sirolimus. Laboratory values were assessed at three time points (presirolimus, 1-3 months postsirolimus, and last clinic visit). Clinical response, as defined by decreased pain and swelling, was extracted from the record. RESULTS Thirty-five patients at our vascular anomalies center had been prescribed sirolimus between 2014 and 2017. Fifteen patients (12 combined slow-flow vascular malformations and three pure venous malformations) remained after excluding patients that did not have adequate records or a venous component to their vascular malformation. Patients who did not adhere to the treatment were also excluded. All 15 had elevated D-dimer levels prior to treatment and there was a statistically significant decrease in D-dimer levels following treatment with sirolimus. Symptomatic improvement of pain and swelling was reported after 3 months of starting sirolimus in 13/15 patients. CONCLUSION This study suggests that sirolimus improves coagulopathy in slow-flow vascular malformations, as evidenced by reduced D-dimer levels. Improvement in LIC symptoms also correlates with sirolimus-corrected coagulopathy.
Collapse
Affiliation(s)
- Joana M Mack
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas.,Division of Pediatric Hematology-Oncology, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Bethany Verkamp
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, Arkansas.,School of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Gresham T Richter
- Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Richard Nicholas
- Division of Pediatric Orthopedic Surgery, Department of Orthopedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Kelly Stewart
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Shelley E Crary
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas.,Division of Pediatric Hematology-Oncology, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, Arkansas
| |
Collapse
|
27
|
Wei T, Shalin S, Draper E, Miller E, Zhang H, Sun R, Lee M, Albert G, Richter GT. Abnormal elastin and collagen deposition is present in extracranial arteriovenous malformations: A comparison to intracranial disease. Histol Histopathol 2019; 34:1355-1363. [PMID: 31119718 DOI: 10.14670/hh-18-129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Vascular malformations are characterized by anomalous vascular channels with fragile walls and a propensity to bleed. Arteriovenous malformations (AVMs) in particular have disorganized vascular spaces with intervening fibrosis. Characterization of the structural abnormalities of these vessels has not been comprehensively evaluated. We hypothesize that AVMs are likely to demonstrate altered elastic and collagen fiber organization and distribution, reflecting their fragility, vascular instability, and abnormal development. METHODS Fifteen AVMs were histologically evaluated by H&E, elastin and trichrome staining. To identify potential differences between extracranial and intracranial AVMs, 5 AVMs were harvested from the brain (n=5) and 10 from extracranial sites involving the skin and deep soft tissue (n=10). RESULTS The elastin staining demonstrated reduplication, fragmentation and disruption of internal elastic lamina as well as irregular thickness, and inconsistent vascular density of all AVM specimens. Trichrome staining revealed thickening of the intimal layers of AVM arteries and demonstrated an irregular thickness of venous walls within the malformation and some areas of medial degeneration. Intracranial AVMs are characterized by more intramural inflammation with predominant neutrophil and lymphocyte infiltration. In contrast, extracranial AVMs display more extravascular inflammation with mast cell and neutrophil infiltration. Microvascular proliferations intervening between larger blood vessels were also noted in both types of AVMs, but more obvious in extracranial AVMs. CONCLUSION These observed histologic anomalies of AVMs demonstrate disorganized deposition of elastin and collagen that point to the clinically observed vascular instability and fragility of these lesions.
Collapse
Affiliation(s)
- Ting Wei
- Center for Investigation of Congenital Anomalies of Vascular Development, Department of Otolaryngology, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - Sara Shalin
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | - Emily Miller
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Haihong Zhang
- Center for Investigation of Congenital Anomalies of Vascular Development, Department of Otolaryngology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Ravi Sun
- Center for Investigation of Congenital Anomalies of Vascular Development, Department of Otolaryngology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Madison Lee
- Center for Investigation of Congenital Anomalies of Vascular Development, Department of Otolaryngology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Gregory Albert
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Gresham T Richter
- Center for Investigation of Congenital Anomalies of Vascular Development, Department of Otolaryngology, University of Arkansas for Medical Sciences, Little Rock, AR, USA.,Division of Pediatric Otolaryngology, Arkansas Children's Hospital, Little Rock, AR, USA
| |
Collapse
|
28
|
Gomez-Acevedo H, Dornhoffer JR, Stone A, Dai Y, Richter GT. Gene Expression Differences in Pediatric Lymphatic Malformations: Size Really Matters. Lymphat Res Biol 2019; 16:347-352. [PMID: 30130159 DOI: 10.1089/lrb.2017.0064] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Lymphatic malformations (LMs) are congenital vascular anomalies characterized by dilated and cystic lymphatic channels. They are subdivided into macrocystic and microcystic lesions based upon the predominant size of the cysts involved. However, significant differences in clinical characteristics, treatment outcomes, and prognosis between macrocytic and microcytic disease suggest variation in underlying biologic and genetic influences. Indirect differential expression analysis revealed that 426 genes are significantly different (p < 0.01) in a small sample of LM subtypes. Functional analyses on the differentially expressed gene sets showed that microcystic LM gene expression favors a prooncogenic profile with upregulation of MYC target genes and cell cycle proteins, whereas macrocystic expression demonstrates hypoxic events that lead to angiogenesis and cell proliferation. Therefore, microcystic and macrocystic LMs, although histologically and physiologically similar, may occur under the influence of vastly different biological pathways and mechanisms of action.
Collapse
Affiliation(s)
- Horacio Gomez-Acevedo
- 1 Department of Biomedical Informatics, University of Arkansas for Medical Sciences , Little Rock, Arkansas
| | - James R Dornhoffer
- 2 Department of Otolaryngology Head and Neck Surgery, The Medical University of South Carolina , Charleston, South Carolina
| | - Annjanette Stone
- 3 Department of Pathology, University of Arkansas for Medical Sciences , Little Rock, Arkansas.,4 Central Arkansas Veterans Healthcare System , Little Rock, Arkansas
| | - Yuemeng Dai
- 5 Mesquite Rehabilitation Institute , Mesquite, Texas
| | - Gresham T Richter
- 6 Department Otolaryngology, University of Arkansas for Medical Sciences , Little Rock, Arkansas.,7 Arkansas Children's Hospital , Little Rock, Arkansas
| |
Collapse
|
29
|
Abstract
Classified by their most prominent vessel type, congenital vascular tumors and malformations are frequently evident neonatally. Although many are identified in the first month of life, management is often delayed due to their slow expansion. Urgent interventions may be necessary in fast-growing, obstructive, destructive, or bleeding anomalies. Treatment is based on the impact on vital structures, impending aesthetic outcome, or functional risks. Frequent and fast-growing hemangiomas and lymphatic malformations are the most commonly treated neonatally. This article reviews lesions that might require early intervention, including hemangiomas, lymphatic and venous malformations, and the rare kaposiform hemangioendothelioma.
Collapse
Affiliation(s)
- Adam B Johnson
- Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, 1 Children's Way Slot 836, Little Rock, AR 72201, USA.
| | - Gresham T Richter
- Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, 1 Children's Way, Slot 836, Little Rock, AR 72201, USA
| |
Collapse
|
30
|
Hou F, Dai Y, Fan CY, Suen JY, Richter GT. Estrogen is involved in hemangioma regression associated with mast cells. Orphanet J Rare Dis 2018; 13:181. [PMID: 30340617 PMCID: PMC6195721 DOI: 10.1186/s13023-018-0928-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 10/05/2018] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Estrogen plays a role in infantile hemangioma (IH) development, but the underlying mechanism remains unclear. This study aimed to assess estrogen and estrogen receptor (ER) localization and expression levels in IH. In addition, the unexpected relationship between mast cells (MCs) and estrogen in human IH was discussed. METHODS IH (n = 29), vascular malformation (VMs, n = 33) and normal skin (n = 15) specimens were assessed. IH was classified into proliferative (n = 9; age, 3.56 ± 1.01 months), early involuting (n = 10; age, 8.90 ± 2.69 months) and late involuting (n = 10; age, 20.10 ± 4.93 months) groups. Estradiol (E2), ER-a, ER-β, and tryptase (MC marker) levels were determined immunohistochemically and/or by double immunofluorescence staining. Quantification and localization of tryptase, ER-a, and E2 were assessed for each specimen. RESULTS ER-a, E2, and tryptase were expressed in the cytoplasm and nucleus of MCs in IH. The IH specimens showed significantly more tryptase, ER-a, and E2 positive MCs (30.6 ± 12.7, 9.7 ± 5.6, and 19.8 ± 8.7 cells/high-power field [HPF], respectively) compared with VM specimens (9.0 ± 9.8, 1.5 ± 2.4, and 2.5 ± 4.1 cells/HPF, respectively) and normal skin (6.1 ± 8.5, 0.5 ± 1.2, and 1.9 ± 3.4 cells/HPF, respectively). Proliferating IH displayed fewer E2 positive MCs (14.0 6.3 cells/HPF) compared with early (22.3 ± 10.2 cells/HPF, P = 0.023) and late (22.4 ± 6.8 cells/HPF, P = 0.006) involuting specimens. In addition, proliferating IH showed fewer tryptase positive MCs (24.7 ± 10.8 cells/HPF) compared with early involuting specimens (35.7 ± 15.3 cells/HPF, P = 0.043). All IH specimens were ER-a positive and ER-β negative. CONCLUSIONS E2 and ER-a are expressed on MCs and not on IH endothelial cells. Furthermore, activated MCs may be involved in IH regression.
Collapse
Affiliation(s)
- Fang Hou
- Department of Pediatric Surgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, 610072 China
- School of medicine, University of Electronic Science and Technology of China, Chengdu, 610072 China
- Center for the Investigation of Congenital Aberrancies of Vascular Development, Little Rock, AR USA
| | - Yuemeng Dai
- Center for the Investigation of Congenital Aberrancies of Vascular Development, Little Rock, AR USA
| | - Chun-Yang Fan
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - James Y. Suen
- Department of Otolaryngology, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Gresham T. Richter
- Center for the Investigation of Congenital Aberrancies of Vascular Development, Little Rock, AR USA
- Division of Pediatric Otolaryngology, Arkansas Children’s Hospital, 1 Children’s Way, Little Rock, AR 72202 USA
| |
Collapse
|
31
|
Sun RW, Tuchin VV, Zharov VP, Galanzha EI, Richter GT. Current status, pitfalls and future directions in the diagnosis and therapy of lymphatic malformation. J Biophotonics 2018; 11:e201700124. [PMID: 28851128 DOI: 10.1002/jbio.201700124] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 07/31/2017] [Accepted: 08/25/2017] [Indexed: 06/07/2023]
Abstract
Lymphatic malformations are complex congenital vascular lesions composed of dilated, abnormal lymphatic channels of varying size that can result in significant esthetic and physical impairment due to relentless growth. Lymphatic malformations comprised of micro-lymphatic channels (microcystic) integrate and infiltrate normal soft tissue, leading to a locally invasive mass. Ultrasonography and magnetic resonance imaging assist in the diagnosis but are unable to detect microvasculature present in microcystic lymphatic malformations. In this review, we examine existing tools and elaborate on alternative diagnostic methods in assessing lymphatic malformations. In particular, photoacoustics, low-toxicity nanoparticles and optical clearing can overcome existing challenges in the examination of lymphatic channels in vivo. In combination with photothermal scanning and flow cytometry, Photoacoustic techniques may provide a versatile tool for lymphatic-related clinical applications, potentially leading to a single diagnostic and therapeutic platform to overcome limitations in current imaging techniques and permit targeted theranostics of microcystic lymphatic malformations.
Collapse
Affiliation(s)
- Ravi W Sun
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
- Arkansas Children's Hospital, Little Rock, Arkansas
| | - Valery V Tuchin
- Research-Educational Institute of Optics and Biophotonics, Saratov National Research State University, Saratov, Russia
- Institute of Precision Mechanics and Control, Russian Academy of Sciences, Saratov, Russia
- Laboratory of Femtomedicine, ITMO University, St. Petersburg, Russia
| | - Vladimir P Zharov
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
- Arkansas Nanomedicine Center, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Ekaterina I Galanzha
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
- Arkansas Nanomedicine Center, University of Arkansas for Medical Sciences, Little Rock, Arkansas
- Laboratory of Lymphatic Research, Diagnosis and Therapy (LLDT), University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Gresham T Richter
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
- Arkansas Children's Hospital, Little Rock, Arkansas
| |
Collapse
|
32
|
Wooderchak-Donahue WL, Johnson P, McDonald J, Blei F, Berenstein A, Sorscher M, Mayer J, Scheuerle AE, Lewis T, Grimmer JF, Richter GT, Steeves MA, Lin AE, Stevenson DA, Bayrak-Toydemir P. Expanding the clinical and molecular findings in RASA1 capillary malformation-arteriovenous malformation. Eur J Hum Genet 2018; 26:1521-1536. [PMID: 29891884 DOI: 10.1038/s41431-018-0196-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 05/15/2018] [Accepted: 05/22/2018] [Indexed: 11/09/2022] Open
Abstract
RASA1-related disorders are vascular malformation syndromes characterized by hereditary capillary malformations (CM) with or without arteriovenous malformations (AVM), arteriovenous fistulas (AVF), or Parkes Weber syndrome. The number of cases reported is relatively small; and while the main clinical features are CMs and AVMs/AVFs, the broader phenotypic spectrum caused by variants in the RASA1 gene is still being defined. Here, we report the clinical and molecular findings in 69 unrelated cases with a RASA1 variant identified at ARUP Laboratories. Sanger sequencing and multiplex ligation-dependent probe amplification were primarily used to evaluate RASA1. Several atypical cases were evaluated using next-generation sequencing (NGS) and array-comparative genomic hybridization (aCGH). Sixty individuals had a deleterious RASA1 variant of which 29 were novel. Nine individuals had a variant of uncertain significance. Five large RASA1 deletions were detected, giving an overall deletion/duplication rate of 8.3% (5/60) among positive cases. Most (75.4%) individuals with a RASA1 variant had CMs, and 44.9% had an AVM/AVF. Clinical findings in several cases expand the RASA1 phenotype. Our data suggest that screening for large RASA1 deletions and duplications in this disorder is important and suggest that NGS multi-gene panel testing is beneficial for the molecular diagnosis of cases with complex vascular phenotypes.
Collapse
Affiliation(s)
- Whitney L Wooderchak-Donahue
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT, USA.,Department of Pathology, University of Utah, Salt Lake City, UT, USA
| | - Peter Johnson
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT, USA
| | - Jamie McDonald
- Department of Pathology, University of Utah, Salt Lake City, UT, USA.,HHT Center, Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - Francine Blei
- Vascular Anomalies Program of Lenox Hill Hospital, Northwell Health, Hofstra School of Medicine, New York City, NY, USA
| | - Alejandro Berenstein
- Pediatric Endovascular Surgery Ichan School of Medicine, Mt. Sinai Health System, New York City, NY, USA
| | - Michelle Sorscher
- Pediatric Endovascular Surgery Ichan School of Medicine, Mt. Sinai Health System, New York City, NY, USA
| | - Jennifer Mayer
- Department of Pediatric Hematology and Oncology, All Children's Hospital Johns Hopkins Medicine, St. Petersburg, FL, USA
| | - Angela E Scheuerle
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tracey Lewis
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT, USA
| | - J Fredrik Grimmer
- Division of Otolaryngology, Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Gresham T Richter
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Marcie A Steeves
- Medical Genetics, Mass General Hospital for Children, Boston, MA, USA
| | - Angela E Lin
- Medical Genetics, Mass General Hospital for Children, Boston, MA, USA
| | - David A Stevenson
- Division of Medical Genetics, Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Pinar Bayrak-Toydemir
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT, USA. .,Department of Pathology, University of Utah, Salt Lake City, UT, USA.
| |
Collapse
|
33
|
Mack JM, Richter GT, Becton D, Salem O, Hill SEM, Crary SE. Short-term side effects and patient-reported outcomes of bleomycin sclerotherapy in vascular malformations. Pediatr Blood Cancer 2018; 65:e27008. [PMID: 29431255 DOI: 10.1002/pbc.27008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 12/27/2017] [Accepted: 01/18/2018] [Indexed: 11/08/2022]
Abstract
BACKGROUND Vascular malformations (VM) are congenital lesions that can be debilitating and cause significant aesthetic and functional limitations. The chemotherapeutic agent bleomycin has been utilized as a sclerosant, directly injected percutaneously into the VM. Unfortunately, little is known about the benefits and short-term side effects of bleomycin with intralesional injections. PROCEDURE An IRB approved, retrospective chart review was performed on patients with VM who had been treated with intralesional bleomycin. Data included type of VM, number of treatments, total bleomycin dose per m², and adverse effects. A questionnaire was administered to available patients to assess subjective outcomes and side effects. RESULTS Forty-six patients were treated with 141 procedures of bleomycin sclerotherapy for VM. Patient ages ranged from 1 to 20 years (median age 10 years). The median cumulative bleomycin dose was 16.3 units/m²/person (range of 1.7-97.0 units/m²/person). Sixty-three percent of patients were reached for a questionnaire to assess short-term side effects. Ninety percent of patients surveyed were satisfied to very satisfied with the results from the procedure. About 24% of patients experienced transient nausea, vomiting and/or local hyperpigmentation. CONCLUSION Bleomycin sclerotherapy can be an effective treatment of VM with repeat exposure with minor risk of short-term side effects, however, long-term risks are of great concern. Further studies are required to assess systemic absorption and long-term risks.
Collapse
Affiliation(s)
- Joana M Mack
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Gresham T Richter
- Department of Otolaryngology-Head and Neck Surgery, Division of Pediatric Otolaryngology, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - David Becton
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Omar Salem
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Sarah E M Hill
- College of Natural Sciences, University of Texas at Austin, Austin, Texas
| | - Shelley E Crary
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| |
Collapse
|
34
|
Mack JM, Richter GT, Crary SE. Effectiveness and Safety of Treatment with Direct Oral Anticoagulant Rivaroxaban in Patients with Slow-Flow Vascular Malformations: A Case Series. Lymphat Res Biol 2018; 16:278-281. [PMID: 29583078 DOI: 10.1089/lrb.2017.0029] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Slow-flow vascular malformations (VM) can be associated with localized intravascular coagulopathy (LIC) that is characterized by elevated D-Dimer levels and low fibrinogen and platelets. This can lead to bleeding and clotting tendencies, which can give rise to functional limitations such as pain and swelling and even progress to disseminated intravascular coagulopathy. METHODS AND RESULTS We conducted a chart review of four patients with evidence of LIC who were started on rivaroxaban. We found an improvement of D-Dimer and/or fibrinogen levels in all four patients. They also had an improvement of pain and functionality. CONCLUSIONS We report on four patients in whom anticoagulation with a direct oral anticoagulant, rivaroxaban, was effective in controlling signs and symptoms of consumptive coagulopathy with no evidence of bleeding from the use of rivaroxaban.
Collapse
Affiliation(s)
- Joana M Mack
- 1 Division of Pediatric Hematology-Oncology, Department of Pediatrics, University of Arkansas for Medical Sciences , Little Rock, Arkansas.,2 Arkansas Children's Hospital , Little Rock, Arkansas
| | - Gresham T Richter
- 2 Arkansas Children's Hospital , Little Rock, Arkansas.,3 Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences , Little Rock, Arkansas
| | - Shelley E Crary
- 1 Division of Pediatric Hematology-Oncology, Department of Pediatrics, University of Arkansas for Medical Sciences , Little Rock, Arkansas.,2 Arkansas Children's Hospital , Little Rock, Arkansas
| |
Collapse
|
35
|
Bizzell JG, Richter GT, Bower CM, Woods GL, Nolder AR. Routine pathologic examination of tonsillectomy specimens: A 10-year experience at a tertiary care children's hospital. Int J Pediatr Otorhinolaryngol 2017; 102:86-89. [PMID: 29106883 DOI: 10.1016/j.ijporl.2017.09.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 09/11/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To review histopathologic diagnoses from tonsillectomy specimens and determine whether routine pathologic exam is necessary. METHODS Pathology reports of patients undergoing tonsillectomy from 2005 to 2014 at our pediatric tertiary care hospital were reviewed. Histopathologic diagnoses were recorded with special attention to identification of malignancy. RESULTS A total of 8807 paired tonsil specimens were sent to pathology over a 10-year course. Gross analysis was performed on all. Microscopic histopathologic analysis was performed on 612 (6.95%) specimens with all but one demonstrating strictly reactive lymphoid hyperplasia. The single specimen (0.16%) demonstrated follicular hyperplasia with focal necrotizing granulomatous lymphadenitis without organisms identified on special staining. The surgeon requested pathologic diagnosis to rule out lymphoma in 4 of 8087 (0.05%) of the specimens. No malignancies were identified. The approximate charges for gross examination of a paired tonsillectomy specimen and microscopic examination were $136.10 and $294.54, respectively. Over the 10 year period of the study, total charges were estimated at $1,115,340 (gross) and $180,258 (microscopic). DISCUSSION Microscopic analysis of tonsil specimens is unlikely to identify abnormal pathology that changes patient management. This study suggests that neither gross nor microscopic pathologic examination of tonsillectomy specimens is necessary on a routine basis. Histologic analysis of tonsils should be requested only on a case by case basis when clinical suspicion for malignancy is high. Avoiding routine pathologic exam of tonsils may be cost effective and medically safe.
Collapse
Affiliation(s)
- Jamie Glancy Bizzell
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, 4301 West Markham, Slot 543, Little Rock, AR 72205, USA.
| | - Gresham T Richter
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, 4301 West Markham, Slot 543, Little Rock, AR 72205, USA; Arkansas Children's Hospital, Division of Pediatric Otolaryngology, 1 Children's Way, Slot 836, Little Rock, AR 72202, USA.
| | - Charles M Bower
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, 4301 West Markham, Slot 543, Little Rock, AR 72205, USA; Arkansas Children's Hospital, Division of Pediatric Otolaryngology, 1 Children's Way, Slot 836, Little Rock, AR 72202, USA.
| | - Gail L Woods
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, 4301 West Markham, Slot 543, Little Rock, AR 72205, USA; Arkansas Children's Hospital, Division of Pediatric Otolaryngology, 1 Children's Way, Slot 836, Little Rock, AR 72202, USA.
| | - Abby R Nolder
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, 4301 West Markham, Slot 543, Little Rock, AR 72205, USA; Arkansas Children's Hospital, Division of Pediatric Otolaryngology, 1 Children's Way, Slot 836, Little Rock, AR 72202, USA.
| |
Collapse
|
36
|
Durvasula VSPB, Shalin SC, Tulunay-Ugur OE, Suen JY, Richter GT. Effects of supramaximal balloon dilatation pressures on adult cricoid and tracheal cartilage: A cadaveric study. Laryngoscope 2017; 128:1304-1309. [PMID: 28988443 DOI: 10.1002/lary.26872] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS Cricoid fracture is a serious concern for balloon dilatation in airway stenosis. Furthermore, there are no studies examining tracheal rupture in balloon dilatation of stenotic segments. The aim of this study was to evaluate the effect of supramaximal pressures of balloons on the cricoid and tracheal rings. STUDY DESIGN Prospective cadaveric study. METHODS Seven cadaveric laryngotracheal complexes of normal adults with intact cricothyroid membranes were acquired. Noncompliant vascular angioplasty balloons (BARD-VIDA) were used for dilatation. The subglottis and trachea were subjected to supramaximal dilatation pressures graduated to nominal burst pressure (NBP) and, if necessary, rated burst pressure (RBP). Larger-diameter balloons, starting from 18 mm size to 24 mm, were used. Dilatations were maintained for 3 minutes. RESULTS The cricoid ring was disrupted by larger-diameter balloons (22 mm and 24 mm) even at lower pressures (less than NBP) in six cases. Tracheal cartilages were very distensible, and external examination after supramaximal dilatation (24 mm close to RBP) revealed no obvious cartilage fractures or trachealis tears. Histopathological examination revealed sloughing of mucosa in the areas corresponding to balloon placement, but no microfractures or disruption of the perichondrium of tracheal ring cartilages. CONCLUSIONS These results indicate that the cricoid is vulnerable to injury from larger balloons even at lower dilatation pressures. The tracheal cartilages and the membranous wall of the trachea remained resilient to supramaximal dilatation and larger balloons. LEVEL OF EVIDENCE NA. Laryngoscope, 128:1304-1309, 2018.
Collapse
Affiliation(s)
- Venkata S P B Durvasula
- Department of Otolaryngology and Head and Neck Surgery, University of Arkansas Medical Sciences, Little Rock, Arkansas, U.S.A
| | - Sara C Shalin
- Department of Pathology, University of Arkansas Medical Sciences, Little Rock, Arkansas, U.S.A
| | - Ozlem E Tulunay-Ugur
- Department of Otolaryngology and Head and Neck Surgery, University of Arkansas Medical Sciences, Little Rock, Arkansas, U.S.A
| | - James Y Suen
- Department of Otolaryngology and Head and Neck Surgery, University of Arkansas Medical Sciences, Little Rock, Arkansas, U.S.A
| | - Gresham T Richter
- Department of Otolaryngology and Head and Neck Surgery, University of Arkansas Medical Sciences, Little Rock, Arkansas, U.S.A
| |
Collapse
|
37
|
Sun RW, Bonilla-Velez J, Pesek RD, Johnson AB, Cleves MA, Richter GT. Eosinophilic esophagitis in children under the age of 5 years: Clinical characteristics. Laryngoscope 2017; 128:798-805. [DOI: 10.1002/lary.26838] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 06/20/2017] [Accepted: 07/12/2017] [Indexed: 01/04/2023]
Affiliation(s)
- Ravi W. Sun
- Department of Otolaryngology-Head and Neck Surgery; University of Arkansas for Medical Sciences, Little Rock; Arkansas
- Arkansas Children's Hospital; Little Rock Arkansas U.S.A
| | - Juliana Bonilla-Velez
- Department of Otolaryngology-Head and Neck Surgery; University of Arkansas for Medical Sciences, Little Rock; Arkansas
- Arkansas Children's Hospital; Little Rock Arkansas U.S.A
| | - Robert D. Pesek
- Department of Pediatrics; Division of Allergy and Immunology, University of Arkansas for Medical Sciences, Little Rock; Arkansas
- Arkansas Children's Hospital; Little Rock Arkansas U.S.A
| | | | - Mario A. Cleves
- Department of Pediatrics; Division of Biostatistics, University of Arkansas for Medical Sciences, Little Rock; Arkansas
- Arkansas Children's Hospital; Little Rock Arkansas U.S.A
| | - Gresham T. Richter
- Department of Otolaryngology-Head and Neck Surgery; University of Arkansas for Medical Sciences, Little Rock; Arkansas
- Arkansas Children's Hospital; Little Rock Arkansas U.S.A
| |
Collapse
|
38
|
Phillips JD, Zhang H, Wei T, Richter GT. Expression of β-Adrenergic Receptor Subtypes in Proliferative, Involuted, and Propranolol-Responsive Infantile Hemangiomas. JAMA FACIAL PLAST SU 2017; 19:102-107. [PMID: 27737446 DOI: 10.1001/jamafacial.2016.1188] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Importance Propranolol hydrochloride has become the primary medical treatment for problematic infantile hemangioma; however, the expression of propranolol's target receptors during growth, involution, and treatment of hemangioma remains unclear. Objective To measure and compare the expression of β1-, β2-, and β3-adrenergic receptors (ADBR1, ADBR2, and ADBR3, respectively) in proliferative (n = 10), involuted (n = 11), and propranolol-responsive (n = 12) hemangioma tissue. Design, Setting, and Participants Infantile hemangioma specimens were harvested for molecular investigation. Messenger RNA (mRNA) expression of the ADBR1, ADBR2, and ADBR3 genes was detected by real-time polymerase chain reaction. Protein level expression was measured by Western blot and standardized with densitometry. A total of 33 specimens were collected from patients in a tertiary pediatric hospital who underwent excision of problematic hemangiomas. This study was conducted from January 18, 2011, to September 24, 2013, and data analysis was performed from February 25, 2015, to June 25, 2016. Results Of the 33 patients included, 21 were female (64%). The mean (SD) patient age at the time of excision was 7 (2.5) months for the proliferative group lesions, 23.5 (10) months for the involuted group, and 16 (10) months for the propranolol group. The mean level of ADBR1 mRNA expression was significantly higher in proliferative hemangioma than in propranolol-responsive hemangioma (1.05 [0.56] vs 0.52 [0.36]; P = .01; 95% CI, 0.12-0.94). There was no difference in ADBR2 expression among the groups. Protein expression of ADBR3 was significantly higher in involuted (0.64 [0.12] vs 0.26 [0.04]; P < .01; 95% CI, 0.26-0.49) and propranolol-responsive hemangioma (0.66 [0.31] vs 0.26 [0.04]; P = .01; 95% CI, 0.16-0.68) compared with proliferative hemangioma. Conclusions and Relevance These data demonstrate the variable expression of ADBR subtypes among infantile hemangiomas during growth, involution, and response to treatment. These findings may have clinical implications regarding the use of selective vs nonselective β-blockade. Level of Evidence 2.
Collapse
Affiliation(s)
- James D Phillips
- Division of Pediatric Otolaryngology and Center for the Investigation of Congenital Aberrancies of Vascular Development, Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for the Medical Sciences, Little Rock2Department of Otolaryngology Head and Neck Surgery, Arkansas Children's Hospital, Little Rock
| | - Haihong Zhang
- Division of Pediatric Otolaryngology and Center for the Investigation of Congenital Aberrancies of Vascular Development, Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for the Medical Sciences, Little Rock2Department of Otolaryngology Head and Neck Surgery, Arkansas Children's Hospital, Little Rock
| | - Ting Wei
- Division of Pediatric Otolaryngology and Center for the Investigation of Congenital Aberrancies of Vascular Development, Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for the Medical Sciences, Little Rock2Department of Otolaryngology Head and Neck Surgery, Arkansas Children's Hospital, Little Rock
| | - Gresham T Richter
- Division of Pediatric Otolaryngology and Center for the Investigation of Congenital Aberrancies of Vascular Development, Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for the Medical Sciences, Little Rock2Department of Otolaryngology Head and Neck Surgery, Arkansas Children's Hospital, Little Rock
| |
Collapse
|
39
|
Kubala ME, Cox MD, Nelson KL, Richter GT, Dornhoffer JL. Influence of Behavior on Complications of Osseointegrated Bone Conduction Devices in Children. Otol Neurotol 2017; 38:535-539. [PMID: 28079679 DOI: 10.1097/mao.0000000000001334] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Compare incidences of complications following implantation of osseointegrated bone conduction devices (OBCD) between children with and without behavioral disorders. STUDY DESIGN Case series with chart review. SETTING Tertiary referral center otology and neurotology practice. PATIENTS Pediatric patients who underwent implantation of OBCD between May 2009 and July 2014 at Arkansas Children's Hospital. INTERVENTIONS Implantation with Cochlear BAHA 200 series, Cochlear BAHA BI300, or Oticon OBCD. MAIN OUTCOME MEASURES Osseointegration failure (OIF) with resulting loss of flange-fixture and/or skin and soft tissue reactions. RESULTS The total rate of complications was 66.2%, with the majority being minor complications (39.4%). There was no difference in the total rate of complication (p = 0.461), minor complications (p = 0.443), major complications (p = 0.777), and minor and major complications (p = 0.762) between the control group and children with behavioral disorders. CONCLUSION Behavior was not observed to influence the incidence of OIF or skin/soft tissue reactions after implantation of OBCD in pediatric patients.
Collapse
Affiliation(s)
- Michael E Kubala
- *Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences †Arkansas Children's Hospital, Little Rock, Arkansas
| | | | | | | | | |
Collapse
|
40
|
Richter GT, Smith JE, Spencer HJ, Fan CY, Vural E. Histological Comparison of Implanted Cadaveric and Porcine Dermal Matrix Grafts. Otolaryngol Head Neck Surg 2016; 137:239-42. [PMID: 17666248 DOI: 10.1016/j.otohns.2007.04.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2007] [Revised: 03/13/2007] [Accepted: 04/23/2007] [Indexed: 11/16/2022]
Abstract
OBJECTIVES: Histological comparison of human-based (AlloDerm) and porcine-based (ENDURAGen) dermal matrices regarding tissue incorporation and neovascularization as potential soft tissue augmentation materials.STUDY DESIGN: In vivo, rat model.METHODS: Subcutaneous implantation of 1-mm thick, 1 cm X 1 cm pieces of AlloDerm, ENDURAGen, and meshed ENDURAGen was performed in 24 Sprague Dawley rats. Implant materials were harvested at 4 (n = 12) and 8 weeks (n = 12). Histological quantification of soft tissue ingrowth and microvascular density was performed following hematoxylin-eosin staining and CD34 immunohistochemistry, respectively.RESULTS: AlloDerm showed significantly greater soft tissue in-growth and microvascular density compared with both ENDURAGen and meshed ENDURAGen at 4 and 8 weeks ( P < 0.001).CONCLUSIONS: Although these results may differ in human host tissues, AlloDerm seems to be a more suitable dermal matrix implant than ENDURAGen for cases in which tissue incorporation and neovascularization are sought for the optimal outcome based on this animal model.
Collapse
|
41
|
Smith CH, Maxson RT, Richter GT. Trans-cervical tracheal resection and repair of acquired tracheoesophageal fistula secondary to button battery ingestion. Journal of Pediatric Surgery Case Reports 2016. [DOI: 10.1016/j.epsc.2016.03.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
|
42
|
Elluru RG, Friess MR, Richter GT, Grimmer JF, Darrow DH, Shin JJ, Perkins JA. Multicenter Evaluation of the Effectiveness of Systemic Propranolol in the Treatment of Airway Hemangiomas. Otolaryngol Head Neck Surg 2015; 153:452-60. [DOI: 10.1177/0194599815591809] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Accepted: 05/27/2015] [Indexed: 12/28/2022]
Abstract
Objective To evaluate the effectiveness of systemic propranolol in airway infantile hemangioma (AIH) treatment. Design Case series with chart review. Participants Patients with AIH treated with propranolol between 2009 and 2012 with at least a 1-year follow-up. Outcomes Presenting age, treating institution, syndrome presence, presenting AIH stage, endoscopy status, propranolol initiation location/dose/duration, time to stridor resolution, adjunctive medical and surgical therapy, and treatment-associated complications. Results Twenty-seven patients met inclusion criteria. Average age of diagnosis was 2.3 months (range, 1-5 months). The AIHs were stage 1 in 7 of 27 (26%), stage 2 in 12 of 27 (44%), and stage 3 in 8 of 27 (30%). Propranolol initiation was inpatient in 25 of 27 (93%) and outpatient in 2 of 27 (7%). Propranolol dose was maintained at 2 mg/kg/d in all patients for a minimum of 7 months (range, 7-34 months; median, 15 months). Stridor was eliminated within 24 hours or less of propranolol initiation in 23 of 27 (85%). At diagnosis, staging and propranolol initiation in 11 of 27 (41%) were managed with propranolol alone; the remaining 16 of 27 (59%) also had a steroid injection. The use of adjuvant therapy at the time of propranolol initiation and the size of the AIH were not statistically correlated. Twelve patients had additional treatments after the initiation of propranolol due to recurrence of respiratory symptoms, 1 of 27 (4%) of whom was considered a nonresponder. No complications related to propranolol use were noted. Conclusions This multisite study of AIH treatment with propranolol demonstrates similar effectiveness to surgical treatment modalities. Propranolol therapy for AIH had no complications, had potentially lower resource utilization, and should be considered a first-line AIH treatment.
Collapse
Affiliation(s)
- Ravindhra G. Elluru
- Divsion of Pediatric Otolaryngology, Dayton Children’s Hospital, Dayton, Ohio, USA
| | - Melanie R. Friess
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Gresham T. Richter
- Divsion of Pediatric Otolaryngology, Arkansas Children’s Hospital, Little Rock, Arkansas, USA
| | - J. Fred Grimmer
- Divison of Pediatric Otolaryngology, University of Utah Medical Center, Salt Lake City, Utah, USA
| | - David H. Darrow
- Divison of Pediatric Otolaryngology, Children’s Hospital of The King’s Daughter, Norfolk, Virginia, USA
| | - Jennifer J. Shin
- Divison of Pediatric Otolaryngology, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Jonathan A. Perkins
- Division of Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, Washington, USA
| |
Collapse
|
43
|
Balakrishnan K, Bauman N, Chun RH, Darrow DH, Grimmer JF, Perkins JA, Richter GT, Shin JJ, Shivaram GM, Sidell DR, Elluru RG. Standardized Outcome and Reporting Measures in Pediatric Head and Neck Lymphatic Malformations. Otolaryngol Head Neck Surg 2015; 152:948-53. [DOI: 10.1177/0194599815577602] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 02/24/2015] [Indexed: 11/16/2022]
Abstract
Objective To develop general and site-specific treatment effect and outcome measures to standardize the reporting of head and neck lymphatic malformation (HNLM) treatments. Study Design Consensus statement/expert opinion. Setting Multiple tertiary academic institutions. Subjects and Methods The modified Delphi method is an iterative process of collecting expert opinions, refining opinions through discussion and feedback, statistically aggregating opinions, and using these aggregates to generate consensus opinion in the absence of other data. The modified Delphi method was used by a multi-institutional group of otolaryngology and interventional radiology experts in the field of vascular anomalies to formulate a list of recommended reporting outcomes for the study and treatment of head and neck lymphatic malformations. Results Through 3 rounds of iteration, 10 expert panelists refined 98 proposed outcome measures and 9 outcome categories to a final consensus set of 50 recommended outcome measures in 3 global categories (general, demographics, and treatment complications) and 5 site-specific categories (orbit, oral cavity, pharynx, larynx, and neck). Conclusions We propose the first consensus set of standardized reporting measures for clinical and treatment outcomes in studies of HNLMs. Consistent outcome measures across future studies will facilitate comparison of treatment options and allow systematic review. We hope that these guidelines facilitate the design and reporting of subsequent HNLM studies.
Collapse
Affiliation(s)
| | - Nancy Bauman
- Children’s National Medical Center, Washington, DC, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
44
|
Lee DR, Richter GT. Nasopharyngeal venous malformation: A rare condition managed with Nd:
YAG
laser. Laryngoscope 2015; 125:2405-7. [DOI: 10.1002/lary.25193] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 01/08/2015] [Accepted: 01/13/2015] [Indexed: 11/08/2022]
Affiliation(s)
- David R. Lee
- College of MedicineUniversity of Arkansas for Medical SciencesLittle Rock Arkansas
| | - Gresham T. Richter
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Arkansas for Medical SciencesLittle Rock Arkansas
- Vascular Malformations Center of ExcellenceArkansas Children's HospitalLittle Rock Arkansas U.S.A
| |
Collapse
|
45
|
|
46
|
|
47
|
Moak TN, Miller E, Wei T, Klug TD, Suen JY, Richter GT. Matrix Metalloproteinases and VEGF: Potential Roles in Formation of High-Flow Vascular Anomalies. Otolaryngol Head Neck Surg 2014. [DOI: 10.1177/0194599814541627a238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: Arteriovenous malformations (AVMs) are congenital vascular malformations that result from a defect in vascular morphogenesis. These lesions are slow-growing, infiltrative, and destructive resulting in significant morbidity associated with cardiac overload and increased susceptibility to massive bleeding. Recent evidence suggests a role of matrix metalloproteinases (MMPs), a family of enzymes functioning in tissue remodeling via degradation of extracellular matrix proteins and cleaving of surface molecules, in the pathogenesis of AVM development and rupture. This study sought to explore the role of MMPs, particularly MMP-9, in AVM formation and progression. Methods: Serum samples from patients with AVM, hemangioma, and pyogenic granuloma were collected and isolated at various stages of development. Relative quantities of MMP-2, MMP-9, and VEGF in each group were calculated and analyzed using sandwich-capture enzyme-linked immunosorbent assay. Results: MMP-2 concentrations were found to be decreased in AVM serum samples when compared with serum samples from the pyogenic granuloma controls (27.9 ± 5.97 vs 32.84 ± 2.20, P = 6.3 × 10–9); MMP-9 concentrations were found to be increased in AVM serum samples when compared with hemangioma serum samples (1698.81 ± 410.86 vs 1105.02 ± 239.43, P < .02); and VEGF concentrations were found to be decreased in AVM serum samples when compared with hemangioma serum samples (52.27 ± 63.02 vs 174.0 ± 9.84, P < .05). Conclusions: The results of this study provide support for a role of MMP-9 in AVM progression and recurrence. Specifically, an increase in MMP-9 appears to be associated with AVM formation and may play an important role in its pathogenesis.
Collapse
|
48
|
Rosenberg TL, Klug TD, Tullos AB, Richter GT. Primary Surgical Excision of Venous Malformations of the Head and Neck: Subsequent Management and Outcomes. Otolaryngol Head Neck Surg 2014. [DOI: 10.1177/0194599814541627a109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives: (1) Discuss primary surgical excision of head and neck venous malformations (VMs) and possible need for subsequent therapy. (2) Describe outcomes of primary surgical excision of VMs of the head and neck. Methods: We conducted a retrospective chart review of 45 patients (23 females and 22 males) treated with primary surgical excision of head and neck VMs who presented between 2001 and 2012 to a tertiary pediatric academic institution with a multi-disciplinary vascular anomalies center. Results: Mean age at presentation was 10.2 years, with a higher average age for female patients (11.7 years) than male patients (8.6 years). The most common anatomical subsites were the face/cheek (22.2%), neck (17.8%), and lower lip (11.1%). A majority of patients (73.3%) experienced significant improvement after the initial excision, though 42.2% of patients ultimately required subsequent treatments (either repeat excision, laser therapy, or sclerotherapy) to obtain overall disease control. The majority of patients (57.8%) required only the initial surgical excision for adequate treatment. Few patients experienced postoperative complications. The most common patient complaint was transient postoperative edema. The main outcome measures included need for subsequent treatments after excision, overall improvement (significantly decreased size or resolution of VM and decreased pain) postoperatively, and postoperative complication rate/patient complaints. Conclusions: Venous malformations of the head and neck are uncommon. However, when appropriately selected for surgical excision, most do not require subsequent treatment for disease control. We present a series of 45 patients who were treated with primary surgical excision, 57.8% of whom required no further treatment.
Collapse
|
49
|
Bower CM, Richter GT. Common ENT disorders in pediatrics. Otolaryngol Clin North Am 2014; 47:xi-xii. [PMID: 25132185 DOI: 10.1016/j.otc.2014.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Charles M Bower
- Department of Pediatric Otolaryngology, Arkansas Children's Hospital, 1 Children's Way, Slot #836, Little Rock, AR 72202, USA.
| | - Gresham T Richter
- Department of Pediatric Otolaryngology, Arkansas Children's Hospital, 1 Children's Way, Slot #836, Little Rock, AR 72202, USA.
| |
Collapse
|
50
|
Abstract
Arteriovenous malformations (AVMs) are fast-flow vascular malformations composed of a complex vessel network directly connecting feeding arteries to draining veins. The intervening normal capillary network is absent. Proper diagnosis and treatment of AVMs is challenging and in need of an interdisciplinary team of experienced physicians. Careful analysis of the clinical features and evaluation of therapeutic options represent the basis for successful management of AVMs. This article will focus on the clinical and radiological findings and in particular on interdisciplinary management strategies of AVMs including minimally invasive endovascular and surgical treatment.
Collapse
Affiliation(s)
- Wibke Uller
- Vascular Anomalies Center, Boston Children´s Hospital and Harvard Medical School, Boston, Massachusetts; Division of Vascular and Interventional Radiology, Boston Children´s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ahmad I Alomari
- Vascular Anomalies Center, Boston Children´s Hospital and Harvard Medical School, Boston, Massachusetts; Division of Vascular and Interventional Radiology, Boston Children´s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Gresham T Richter
- Vascular Anomalies Center of Excellence, Department of Otolaryngology-Head and Neck Surgery, Arkansas Children׳s Hospital, University of Arkansas for Medical Sciences, 4301 W Markham, Slot 546, Little Rock, Arkansas 72202.
| |
Collapse
|