Severity of injury and service utilization following traumatic brain injury: the first 3 months

OBJECTIVE: To describe the medical and rehabilitation service use of model systems by brain injured participants 1 to 3 months postdischarge from inpatient rehabilitation. DESIGN: Prospective follow-up study. SETTING: Georgia Model Brain Injury System (GAMBIS). PARTICIPANTS: Seventy-three GAMBIS subjects consenting to participate in the utilization substudy. MAIN OUTCOME MEASURES: Receipt of services and intensity of service use. ANALYSIS: Chi-square analysis of receipt of services by severity of injury. RESULTS: The likelihood of service use did not vary with severity of injury. Data suggest that intensity of service use was a function of injury severity. CONCLUSIONS: Subjects with mild and moderate injuries were as likely to use a range of medical and rehabilitation services during the 3-month postdischarge period as those with severe injuries. Traditional rehabilitation services, such as physical therapy, were far more likely to be used, than nontraditional services, such as psychological counseling, in spite of the high level of cognitive and social disability associated with traumatic brain injury.     

Successful treatment of earlobe keloids in the pediatric population

Background

Keloid scars present a difficult treatment challenge. Recently, intralesional steroid injection has become a common treatment modality [Akoz et al. Aesthetic Plast Surg. 2002;6:184-188; Studdiford et al. JABFM. 2008;21:149-152]. Although this has become a proven treatment technique, there is no standard injection protocol to which treating physicians commonly adhere. We hypothesize that timing of steroid injection may improve outcomes using this treatment technique in combination with lesion excision.

Methods

Fifteen patients with 16 earlobe keloids were treated using a standard steroid injection protocol with Kenalog (Bristol-Myers Squibb, New York, NY), in combination with lesion excision. Strict follow-up was enforced, with repeat injections as needed at any sign of abnormal scar formation postoperatively.

Results

Of 16 lesions, 15 (94%) were treated successfully with no sign of lesion recurrence at 6 months of follow-up. A single lesion was lost to follow-up and presented 18 months postoperatively with recurrence. This lesion was subsequently retreated successfully.

Conclusions

Kenalog injection in combination with excision is a well-tolerated and effective treatment of earlobe keloids in the pediatric population. We feel that timing of injection and adherence to a strict follow-up regimen is crucial to success.     

Gadolinium neutron capture in glioblastoma multiforme cells

Purpose: A proof of principle for cell killing by Gadolinium (Gd) neutron capture in Magnevist® preloaded Glioblastoma multiforme (GBM) cells is provided.

Materials and methods: U87cells were pre-loaded with 5 mg/ml Magnevist® (Gd containing compound) and irradiated using an enhanced neutron beam developed at NIU Institute for Neutron Therapy at Fermilab. These experiments were possible because of an enhanced fast neutron therapy assembly designed to use the fast neutron beam at Fermilab to deliver a neutron beam containing a greater fraction of thermal neutrons and because of the development of improved calculations for dose for the enhanced neutron beam. Clonogenic response was determined.

Results: U87 cell survival after γ irradiation, fast neutron irradiation and irradiation with the enhanced neutron beam in the presence or absence of Magnevist® were determined.

Conclusions: U87 cells were the least sensitive to γ radiation, and increasingly sensitive to fast neutron irradiation, irradiation with the enhanced neutron beam and finally a significant enhancement in cell killing was observed for U87 cells preloaded with Magnevist®. The sensitivity of U87 cells pre-loaded with Magnevist® and then irradiated with the enhanced neutron beam can at least in part be attributed to the Auger electrons emitted by the neutron capture event.     

Shortterm and longterm visual and astigmatic results of an opposing 10-0 nylon double running suture technique for penetrating keratoplasty

BACKGROUND: In ophthalmic surgery, corneal transplantation (penetrating keratoplasty) may be employed when the clarity of the cornea has been significantly compromised by conditions such as scarring, edema, and variable corneal thickness. Irregularities in corneal curvature can occur postoperatively. This astigmatism is of concern, because it can impair visual acuity despite an otherwise good surgical result. Different suturing techniques have been developed to minimize astigmatism. The purpose of this study was to evaluate an opposing 10-0 nylon double running suture technique for penetrating keratoplasty. STUDY DESIGN: A retrospective study was undertaken of 91 records of patients who underwent penetrating keratoplasty performed by one surgeon (RNG). This represents 54.8% of 166 consecutive cases. Every eye with an opposing double running suture and a 1- to 3-month postsuture removal followup was selected and evaluated for best corrected visual acuity and astigmatism, excluding eyes that developed graft failure or corneal ulcer or that had lack of adequate followup. The cases were divided into five groups by preoperative diagnosis: pseudophakic bullous keratopathy (n = 43), aphakic bullous keratopathy (n = 5), keratoconus (n = 17), Fuchs dystrophy (n = 12), and miscellaneous (n = 14). The mean standard followup period was 13.7 months after penetrating keratoplasty. Thirty percent of the eyes had an extensive followup, with a mean of 33 months after penetrating keratoplasty. RESULTS: Eighty-two percent of the patients had a significant improvement of their visual acuity postoperatively, defined by a five-line improvement of best corrected visual acuity or a best corrected visual acuity of 20/40 or better. The mean astigmatic keratometric reading was 3.98 diopters, with a manifest refraction cylinder of 3.42 diopters at the 1- to 3-month postsuture removal visit. This study also shows that there is no statistically significant change in keratometric astigmatism or manifest refraction cylinder from the 1- to 3-month postsuture removal measurements to the more extensive followup of 18 to 66 months after penetrating keratoplasty (p > 0.10). CONCLUSIONS: This suture technique allows for excellent longterm stability of the wound with visual and astigmatic results that are comparable to those of previous studies. The use of the opposing double running suture is a viable alternative to some of the other widely used techniques and may be considered more stable and secure.     

Preoperative FLAC/Granulocyte-Colony-Stimulating Factor Chemotherapy for Stage II Breast Cancer: A Prospective Randomized Trial

Background: Preoperative chemotherapy for stage II breast cancer may reduce locoregional tumors and provides initial treatment for systemic micrometastases. We conducted a prospective, randomized trial to evaluate the ability of intensive preoperative chemotherapy to enhance the outcome of this approach.Methods: Patients with clinical stage II breast cancer (T2N0, T1N1, and T2N1) were prospectively randomized to receive either preoperative or postoperative chemotherapy with five 21-day cycles of fluorouracil, leucovorin calcium, doxorubicin, and cyclophosphamide (FLAC)/granulocyte-colony-stimulating factor. Local therapy consisted of modified radical mastectomy or segmentectomy/axillary dissection/breast radiotherapy, according to patient preference.Results: Fifty-three women were randomized (26 preoperative chemotherapy and 27 postoperative chemotherapy). The objective clinical response rate of the primary tumor to preoperative chemotherapy was 80%, and the pathologic complete response rate was 20%. Preoperative chemotherapy reduced the overall incidence and number of axillary lymph node metastases. There was no difference in the use of breast-conserving local therapy between the two treatment arms. There were 20 local/regional or distant recurrences (9 preoperative and 11 postoperative). There was no difference in the overall or disease-free survival between the preoperative and postoperative chemotherapy arms.Conclusions: Preoperative FLAC/granulocyte-colony-stimulating factor chemotherapy was effective against local/regional tumors in stage II breast cancer but was otherwise comparable to postoperative chemotherapy.     

Atrophic and a Mixed Pattern of Acne Scars Improved With a 1320-nm Nd:YAG Laser

BACKGROUND: Acne scar correction remains a challenge to the dermatologic surgeon. With nonablative laser resurfacing, this correction is imputed to dermal collagen remodeling and acne scar reorganization. Although atrophic acne scars tend to respond to laser treatment, the deeper ice pick and boxcar scars tend to be laser resistant. OBJECTIVE: To investigate the treatment of atrophic and a mixed pattern of facial acne scars, we evaluated a 1320-nm Nd:YAG laser. Twelve subjects with atrophic facial acne scars (N=6) or a combination of atrophic and pitted, sclerotic, or boxcar scars (N=6) received three laser treatments. Physician and patient acne scar ratings were performed at baseline and at 6 months after the last treatment. Acne scars were rated with a 10-point severity scale. RESULTS: Mean acne scar improvement was 1.5 points on physician assessments (P=0.002) and 2.2 points on patient assessments (P=0.01). Acne scars were rated more severely by patients than by the physician at all intervals. There were no noted complications at 6 months. CONCLUSION: The 1320-nm Nd:YAG laser is a safe and effective nonablative modality for the improvement of atrophic and a mixed pattern of facial acne scars.     

The Clinical Conundrum of Corticotropin-independent Autonomous Cortisol Secretion in Patients with Bilateral Adrenal Masses

Background Management of patients with bilateral adrenal masses and corticotropin (ACTH)-independent Cushing syndrome (CS) or subclinical CS is problematic. We report our experience with adrenal venous sampling (AVS) in the evaluation of 10 patients with bilateral masses who had ACTH-independent CS or subclinical CS. Patients and Methods Ten patients (9 women, 1 man, mean age 56.4 years) with bilateral adrenal masses and ACTH-independent CS (n = 3) or subclinical CS (n = 7) underwent AVS. Autonomous cortisol secretion was documented in all cases with suppressed serum ACTH concentrations and lack of cortisol suppression with dexamethasone administration. Adrenal venous sampling was performed on the second day of dexamethasone administration. Cortisol and epinephrine levels were measured from each adrenal vein (AV) and from a peripheral vein (PV). Results Mean (± SD) maximal diameter of the adrenal masses on computed tomography was 3.3 ± 1.3 cm (range: 1.2–6.0 cm). Successful catheterization was confirmed with AV:PV epinephrine gradients. A cortisol AV:PV gradient >6.5 was consistent with a cortisol-secreting adenoma in 11 adrenal glands; 5 patients had clinically important bilateral autonomous cortisol hypersecretion, 3 had bilateral cortisol-secreting adenomas, and 2 had ACTH-independent macronodular adrenal hyperplasia. Adrenal venous sampling-guided adrenalectomy was completed in all 10 patients—2 patients had total bilateral adrenalectomy and 2 others had subtotal bilateral adrenalectomy. During a mean follow-up of 36.1 months (range: 0.7–123 months), CS or clinically important cortisol secretory autonomy did not recur. Conclusions Adrenal venous sampling contributed to the localization of autonomous hypercortisolism in the setting of ACTH-independent CS or subclinical CS in patients with bilateral adrenal masses. Presented at the Annual Meeting of the International Association of Endocrine Surgeons, Montreal, Canada, August 26–29, 2007. J. A. Carney is an Emeritus Member of the Department of Laboratory Medicine and Pathology.