First-line Treatment Modality Research Articles

Outcomes in 11 patients with dermatofibrosarcoma protuberans treated with Mohs micrographic surgery

Dermatofibrosarcoma protuberans (DFSP) is an uncommon intermediate-grade fibrohistiocytic sarcoma. It occurs most often in adults aged 20-50 years and is associated with local invasion and a high recurrence rate. Uncontrolled local disease or metastases may result in death. Treatment has involved wide excision, Mohs micrographic surgery (MMS) and other approaches. The purpose of the current study was to review our experience with MMS in the treatment of patients with DFSP over the past six years. We carried out a retrospective chart review for all patients treated with MMS at the Hospital Italiano de Buenos Aires during a six-year period to October 2009. Patient data included age and sex, site, and prior surgical treatment (if any) of the tumor and details of the Mohs procedure. Eleven patients were treated for DFSP. Four (36.4%) patients had been previously treated with a standard wide excision. Three (27.3%) of the 11 tumors were located on the back, four (36.4%) on the upper extremity, one (9.1%) on the lower extremity, and three (27.3%) on the trunk. Mean lesion size at presentation was 5.16 cm(2), and mean defect size was 12.65 cm(2), yielding a difference of 7.49 cm(2) and a ratio (defect size/lesion size) of 2.45. No tumors recurred after MMS. The recurrence potential of DFSP is directly related to the extent of resection. Mohs micrographic surgery with continuous histological margin control allows for maximum tissue preservation and low recurrence rates and is rapidly emerging as a first-line treatment modality for this condition.

Comparing oil based ointment versus standard practice for the treatment of moderate burns in Greece: a trial based cost effectiveness evaluation

BackgroundThe local treatment of burn wounds has long been a subject of debate. The objective of this study was to compare the cost and the effectiveness of Moist Exposed Burn Ointment -MEBO versus a combination of povidone iodine plus bepanthenol cream for partial thickness burns.MethodsThe study was carried out in the Burn Center of a state hospital in Athens, Greece. 211 patients needing conservative therapy were prospectively selected according to the depth of the burn wound. The treatment was allocated according to the Stratified Randomization Design. The outcomes measured were mean cost of in-hospital stay, rate of complications, time of 50% wound healing, pain scores, in hospital stay diminution. We have adopted a societal perspective.ResultsIn the total groups MEBO presented lower cost, (although not significantly different: p = 0.10) and better effectiveness. The data suggest that MEBO is the dominant therapy for superficial partial burn wound with significantly lower costs and significantly higher effectiveness due to a lesser time of recovery and consequently lower time of hospitalization and follow-up. MEBO presented similar percentages of complications with the comparator, lower pain levels and smaller time of no healthy appearance of the burn limits for superficial partial thickness burns.ConclusionsThe data suggested that topical application of MEBO may be considered for further investigation as a potential first-line treatment modality for superficial partial thickness burns.Trial registrationThe trial has been registered on the International Standard Randomised Controlled Trial Number Register (ISRCTN) and given the registration number ISRCTN74058791.

Tongue position controller as an alternative treatment for obstructive sleep apnea

Obstructive sleep apnea (OSA) is a common, but underdiagnosed, public health problem that predisposes the patient to higher cardiovascular morbidity and mortality. Nasal continuous positive airway pressure (nCPAP) has been established as a standard treatment for OSA for nearly three decades, whereas oral appliances (i.e., mandibular repositioning splint and tongue retaining device) have been prescribed for patients with mild to moderate OSA and/or who have failed to respond to nCPAP [1–3]. A tongue retaining device is particularly recommended in patients who are contraindicated for mandibular repositioning splints due to an insufficient number of teeth, severe periodontal disease, temporomandibular joint problems, and so on [1]. To improve the patency of the pharyngeal airway, this device holds the tongue at a protruded position by negative pressure that is generated within the anterior socket, thus possibly displacing the tongue base ventrally. Dort and Brant [4] succeeded in reducing the respiratory disturbance index (from a baseline of 15.5±17.6 to 8.9±7.6 at follow-up) with a tongue retaining device that had an improved anterior socket for tongue suction. There have also been a few reports on the efficacy of, compliance with, and indications for a tongue stabilizing device [5–7], which is considered to be a type of tongue retaining device. In a pilot study, Kingshott et al. [5] first documented that a tongue stabilizing device reduced the severity of snoring and microarousals. Deane et al. [6] later demonstrated that a tongue stabilizing device was as efficacious as a mandibular repositioning splint in terms of reducing the apnea– hypopnea index (AHI), but noted that a lower compliance was observed with the tongue stabilizing device when both appliances were offered. After the Fukushima Daiichi Nuclear Power Plant accident that occurred right after the East Japan earthquake, Tsuiki et al. [7] proposed that a tongue stabilizing device could be a first-line treatment modality for snorers with suspected OSA at temporary refuges because of its simplicity. Although these reports describe certain favorable results with tongue retaining devices, strong evidence indicating the effectiveness of the device is still limited. Clinically, incomplete tongue suction often fails to hold the tongue, leading to unsatisfactory outcomes. Moreover, the tongue retaining device does not involve alternative methods when the suction pressure is incomplete. This may result in an overall lower effectiveness of tongue retaining devices [2] in comparison with mandibular repositioning splints. S. Tsuiki :K. Maeda :M. Kobayashi : T. Sasai :Y. Takahashi : Y. Inoue Neuropsychiatric Research Institute, Tokyo, Japan

Ménétrier’s Disease of the Stomach: A Clinical Challenge

Ménétrier's disease is a rare hyperproliferative protein-losing gastropathy of the gastric foveolar epithelium. Most common symptoms include epigastric pain with fullness and vomiting, and generalized peripheral edema with hypoalbuminemia. Radiologically, the wall of the gastric body and fundus is diffusely thickened, often with antral sparing. Giant rugal edematous folds are seen on gastroscopy, and histology of biopsy material shows diffuse foveolar hyperplasia with cystic dilatation of the glandular portion of the gastric mucosa in the absence of significant inflammatory infiltrate. The recent discovery of transforming growth factor α overexpression opens the way of epidermal growth factor receptor blockade with cetuximab as first-line treatment modality in severe cases of Ménétrier's disease.

Ultrasensitive Detection of Drug-Resistant Pandemic 2009 (H1N1) Influenza A Virus by Rare-Variant-Sensitive High-Resolution Melting-Curve Analysis

Oseltamivir (Tamiflu), an oral neuraminidase inhibitor, has been widely used to treat pandemic 2009 (H1N1) influenza A. Although a majority of 2009 (H1N1) influenza A virus remains oseltamivir susceptible, the threat of resistance due to the His275Tyr mutation is highlighted by the limitations of alternative therapies and the potential for rapid, global fixation of this mutation in the circulating influenza A virus population. In order to better understand the emergence of resistance, we developed a rare-variant-sensitive high-resolution melting-curve analysis method (RVS-HRM) that is able to detect the His275Tyr oseltamivir resistance mutation to 0.5% in a background of susceptible virus. We applied RVS-HRM to clinical specimens from patients who developed oseltamivir resistance and demonstrated the ultrasensitive detection of influenza A virus N1 neuraminidase quasispecies. Interestingly, we were unable to detect the oseltamivir resistance mutation in pretreatment samples, suggesting that resistant virus does not reach even this very low detection threshold until exposed to selective drug pressure. Thus, patients naive to oseltamivir are most likely to be susceptible when this drug is used as a first-line treatment modality.

Antioxidants in the treatment of hypertension

Hypertension is a major health problem worldwide. Individuals with hypertension are at an increased risk for stroke, heart disease, and kidney failure. Although the etiology of essential hypertension has a genetic component, lifestyle factors such as diet play an important role. Insulin resistance and glucose intolerance are common features of hypertension in humans and in animal models. Altered glucose metabolism leads to an increased production of the reactive aldehyde, methylglyoxal. Methylglyoxal binds sulfhydryl and amino groups of proteins forming conjugates/advanced glycation end products (AGEs). This alters protein structure and function and can affect vascular calcium channels, enzymes, and tissue proteins leading to increased oxidative stress. These alterations impair endothelial function leading to an increase in intracellular free calcium, peripheral vascular resistance, and hypertension. Supplementation with antioxidants, including vitamin C, E, or B6, thiols such as lipoic acid and cysteine, and the quinone enzyme Q10, have been shown to lower blood pressure in animal models and humans with essential hypertension. The Dietary Approaches to Stop Hypertension (DASH) studies demonstrated that a well-balanced diet, rich in these nutrients, was effective in lowering blood pressure. These antioxidants may achieve their antihypertensive effects by reducing aldehyde conjugate/AGE formation and oxidative stress, by improving insulin resistance and endothelial function, or by normalizing calcium channels and peripheral vascular resistance. In essential hypertension, deficiencies of antioxidants may exist or a higher than normal amount may be required to correct metabolic abnormalities. Dietary supplementation with antioxidants may be a beneficial, inexpensive, first-line alternate treatment modality for hypertension.

The significance of serum interleukin-10 on the outcome of unresectable hepatocellular carcinoma (HCC).

205 Background: Serum interleukin-10 (IL-10) is associated with active hepatitis in patients (pts) with hepatitis B viral (HBV) infection. In HBV-related HCC, elevation of serum IL-10 is frequently observed but its significance on the outcome of HCC is unclear. Methods: A prospective cohort of newly diagnosed and inoperable HCC was recruited from a multidisciplinary clinic from Prince of Wales Hospital from 2006 to 2008. The baseline demographics, tumor characteristics/stage, laboratory parameters, virologic factors (HBV DNA, antiviral therapy) and first-line treatment modality were documented at the time of diagnosis. Serum IL-10 was measured by enzyme-linked immunosorbent essay. Univariate and multivariate analyses were conducted. Overall survival (OS) was the primary endpoint. Results: Total 180 new cases of inoperable HCC were evaluated. The median follow-up time was 15.5 months. Median age was 60.5 years. Most (159 pts; 88.3%) were males. 81.1% of them were positive for HBsAg. Total 120 (66.7%) had radiologic evidence of cirrhosis. 20 (11.1%), 85 (47.2%) and 75 (41.7%) received locoablative, trans- arterial/systemic therapy and supportive care respectively. The mean level of serum IL-10 was 18.1pg/ml (range: 2.8-11.7). 114 (63.3%) had log IL-10 higher than 1.0 pg/ml. Pts with log IL-10 >1.0 pg/ml had significantly worse OS than those with log IL-10≤ 1.0 pg/ml (14.8 vs. 4.5 months; HR 2.39; p<.0001). Multivariate analysis found log IL-10 (HR=2.57; p=0.005), CLIP score, TNM stage, treatment modality and the use of anti-viral therapy for HBV infection be the independent prognostic factors. Exploratory analyses showed that pts with Log IL-10>1.0pg/ml had higher ALT and HBV DNA, lower albumin, higher chance of ascites, worse Child-Pugh stage and worse tumor stage (Table). Conclusions: Serum IL-10 is an independent prognostic factor for inoperable HCC. Pts with high IL-10 level have poorer liver reserves and worse tumor staging. [Table: see text] No significant financial relationships to disclose.

Metformin: Its emerging role in oncology

Metformin is considered, in conjunction with lifestyle modification, as a first-line treatment modality for type 2 diabetes mellitus (DM). Recently, several clinical studies have reported reduced incidence of neoplastic diseases in DM type 2 patients treated with metformin, as compared to diet or other antidiabetic agents. Moreover, in vitro studies have disclosed significant antiproliferative and proapoptotic effects of metformin on different types of cancer. Metformin acts by activating AMP-activated protein kinase (AMPK), a key player in the regulation of energy homeostasis. Moreover, by activating AMPK, metformin inhibits the mammalian target of rapamycin complex 1 (mTORC1) resulting in decreased cancer cell proliferation. Concomitantly, metformin induces activation of LKB1 (serine/threonine kinase 11), a tumor suppressor gene, which is required for the phosphorylation and activation of AMPK. These new encouraging experimental data supporting the anti-cancer effects of metformin urgently require further clinical studies in order to establish its use as a synergistic therapy targeting the AMPK/mTOR signaling pathway.

Percutaneous Cholecystostomy as a First-Line Therapy in Chronic Hemodialysis Patients with Acute Cholecystitis with Midterm Follow-up

The purpose of this article was to share midterm results of percutaneous cholecystostomy (PC) as a first-line therapy in chronic hemodialysis patients with acute cholecystitis. Fourteen chronic hemodialysis patients with acute cholecystitis underwent PC between March 2007 and May 2009 at our institute. On preoperative assessment, the patients were classified into the ASA score by the anesthesiology team. All patients were class IV because of severe underlying comorbidities. The patients were referred to interventional radiology unit for PC by consensus of the multidisciplinary team. The PC was technically successful in all the patients without minor or major complications related to the procedure. Clinical symptoms in three patients who presented with sepsis and multiorgan failure did not resolve after PC, and these patients died following urgent surgery, including open cholecystectomy and common bile duct exploration. A new cholecystitis attack was detected in one patient in the acalculous group at the sixth month of the follow-up period. The mean catheterization time was 31.7 (range, 28-41) days. The mean follow-up time was 13.3 (range 4-21) months. The PC may come into consideration as a first-line treatment modality in the management of acute cholecystitis in poor surgical candidate chronic hemodialysis patients. This is the first report focusing on the midterm results of PC as a first-line therapy in hemodialysis patients with acute cholecystitis who could be operated on.

Reduction in Astigmatism Using Propranolol as First-Line Therapy for Periocular Capillary Hemangioma

To examine the shift in astigmatic error following the use of oral propranolol as first-line treatment for periocular capillary hemangioma. Retrospective observational study. study population: Three healthy infants (1 male) clinically diagnosed with periocular capillary hemangioma. Cycloplegic refraction measurements were obtained at presentation. After a comprehensive clinical evaluation, oral propranolol therapy was starting with a loading dose and titrated up to 2 mg/kg/day under monitoring of heart rate, blood pressure, and blood glucose alterations. Clinical follow-up and repeating cycloplegic refraction measurements were undertaken at the 1-week and 1- and 3-month follow-up visits. Oral propranolol therapy for infants diagnosed with periocular capillary hemangioma. Astigmatic refractive errors before and after propranolol treatment. The infants' mean age at the initiation of propranolol therapy was 6.3 months (range: 3.0-8.0 months). A rapid therapeutic effect was noticed in all cases, including a major change in lesion size and color. No complications were recorded during or following treatment. The mean astigmatic error decreased from 2.83 diopters before propranolol treatment to 1.33 diopters after 1 month of treatment. The drug was well tolerated by all 3 patients and no side effects were noted. Infants can benefit from a rapid, meaningful reduction in periocular capillary hemangioma-induced astigmatism following oral propranolol treatment. Propranolol seems to be an effective and safe drug, which can be used as a steroid-sparing first-line treatment modality in this patient population.

Major complications during negative pressure wound therapy in poststernotomy mediastinitis after cardiac surgery

Negative pressure wound therapy is the first-line treatment modality for poststernotomy mediastinitis in many heart centers. The aim of this study was to analyze major complications and possible preventive methods during negative pressure wound therapy in patients with deep sternal wound infections. We retrospectively analyzed 69 consecutive patients treated with negative pressure wound therapy for poststernotomy mediastinitis between June 2006 and September 2009. Five (7.2%) patients sustained major complications during negative pressure wound therapy. Bleeding from coronary artery venous bypass grafts was observed in 4 patients and fulminant bleeding from an infected homograft of the ascending aorta was observed in 1 patient during routine dressing changes of the negative pressure wound therapy system. Bleeding is the major complication during negative pressure wound therapy for poststernotomy mediastinitis. Covering the heart with several layers of paraffin gauze is a necessary protective maneuver but cannot completely prevent major complications during negative pressure wound therapy. All operative procedures, including dressing changes, should be performed in the operating room under optimal hygienic and monitoring conditions to increase the salvage rate and to guarantee optimal surgical and anesthesiologic conditions in case of negative pressure wound therapy-related complications.

Augmentation Strategies following the Microfracture Technique for Repair of Focal Chondral Defects

The operative management of focal chondral lesions continues to be problematic for the treating orthopedic surgeon secondary to the limited regenerative capacity of articular cartilage. Although many treatment options are currently available, none fulfills the criteria for an ideal repair solution, including a hyaline repair tissue that completely fills the defect and integrates well with the surrounding normal cartilage. The microfracture technique is an often-utilized, first-line treatment modality for chondral lesions within the knee, resulting in the formation of a fibrocartilaginous repair tissue with inferior biochemical and biomechanical properties compared to normal hyaline cartilage. Although symptomatic improvement has been shown in the short term, concerns about the durability and longevity of the fibrocartilaginous repair have been raised. In response, a number of strategies and techniques for augmentation of the first-generation microfracture procedure have been introduced in an effort to improve repair tissue characteristics and reduce long-term deterioration. Recent experimental approaches utilize modern tissue-engineering technologies including local supplementation of chondrogenic growth factors, hyaluronic acid, or cytokine modulation. Other second-generation microfracture-based techniques use different types of scaffold-guided in situ chondroinduction. The current article presents a comprehensive overview of both the experimental and early clinical results of these developing microfracture augmentation techniques.

Risk factors for recurrence of small hepatocellular carcinoma after long-term follow-up of percutaneous radiofrequency ablation

Radiofrequency ablation (RFA) as a local therapy for liver cancer is widely used. The study is to evaluate the therapeutic efficacy of RFA on hepatocellular carcinoma (HCC) and identify the risk factors for recurrence. Clinical records of 124 patients with 135 small HCC with percutaneous RFA as a first-line treatment modality were evaluated in Liver Cancer Institute, Zhongshan Hospital from October 2001 to December 2006. With a median follow-up period of 46 months after RFA therapy, the 1-, 2-, 3-, 4-, and 5-year cumulative survival rates and disease-free survival rates were 91, 70, 61, 48 and 40% and 64, 44, 31, 24 and 24%, respectively. The total recurrence and metastasis rates were 50 and 6.5%, respectively. Independent risk factors for recurrence after RFA included tumor with diameter more than 3 cm, located near the intrahepatic blood vessels, subcapsular locations and PT prolonged more than 3 s. Severe complications occurred in 2 cases (1.6%), including biliary tract hemorrhage and subphrenic effusion. RFA appears to be a safe and effective treatment for HCC. It will benefit the efficacy of RFA therapy if those risk factors are considered during the clinical practice.

Treatment of Erectile Dysfunction in the Older Diabetic Patient

A degree of erectile dysfunction affects more than 30% of men over the age of 50 years and is thought to be approximately three times more prevalent in diabetic compared with nondiabetic individuals. The etiology and pathophysiology of erectile dysfunction in this subpopulation is multifactorial and a good understanding of the contributing issues is required in order to provide holistic and effective management to the patients. Phosphodiesterase 5 inhibitors are currently the first-line treatment modality, but these are ineffective in approximately a third of patients and more so in diabetics. Other treatments available include androgen replacement, vacuum-erection devices, intracavernosal injections of drugs such as vasoactive intestinal peptide, phentolamine and prostaglandin E1 (also available as intraurethral and topical preparations), as well as surgical prostheses. Future therapeutic options that are promising include drugs that combine nitric oxide donation and phosphodiesterase 5 inhibitory activity, RhoA kinase antagonists and gene therapy.

Clinical Effect of a Topical Herbal Ointment on Pain in Temporomandibular Disorders: A Randomized Placebo-Controlled Trial

The aim of this study was to compare the effectiveness of using Ping On ointment and using petroleum jelly in the treatment of temporomandibular joint (TMJ) and masticatory muscle pain, in order to establish the true efficacy of Ping On ointment. In this randomized, double-blinded, placebo-controlled trial, 55 subjects with TMJ and/or masticatory pain (Group I patients according to the Research Diagnostic Criteria for Temporomandibular Disorder (RDC/TMD) received Ping On ointment for 4 weeks, or placebo for 4 weeks. Subjects were evaluated with standard measures of efficacy: pain intensity measured by visual analogue scale and maximal comfortable mandibular opening, at baseline and again after 4 weeks of treatment. Ping On ointment significantly reduced the symptoms of painful TMJs and/or masticatory muscles. Maximal comfortable mandibular opening also improved in the Ping On ointment group compared with the placebo, but was not clinically significant. This preliminary study suggests that topical application of Ping On ointment may be considered for further investigation as a potential first-line treatment modality, before prescribing analgesics, for the management of TMDs. It is topically applied, safe, reversible, and effective in managing TMDs and masticatory muscle pain.

Physiopathologie et prise en charge de la maladie de La Peyronie

Peyronie's disease (PD) is due to a fibrotic plaque forms in the tunica albuginea layer of the penis. It is responsible of penile pain, angulation, and erectile dysfunction. Even though the aetiology remains unknown, the knowledge of the pathophysiology has evolved in recent years. Recent studies indicate that PD has prevalence of 3 to 9% in adult men. During the initial acute phase (6 to 18 months), the condition may progress, stabilize or regress in 20%. Therefore, a conservative treatment approach has been advocated. An initial discussion about evaluation, information, and reassurance is necessary in most cases. The most commonly employed oral therapies include tocopherol (vitamin E), and para-aminobenzoate (Potaba), which have failed to demonstrate efficiency. Intralesional injection therapies with interferon alpha-2B, verapamil are frequently used as a first-line treatment modality, and can provide an improvement in decreasing penile pain and penile curvature. Current literature has shown that extracorporeal shock wave lithotripsy was only active on the pain. Regarding penile curvature, there are discrepancies in the published series. The surgical approach is restricted to men unresponsive to nonoperative therapies (i.e., 10% of patients). In such cases, plication, grafting or even penile prosthesis implantation are conceivable management options.

Comparison of Treatment Efficacy between Shock Wave Lithotripsy and Ureteroscopic Stone Removal for Lower Ureteral Stones

Purpose: We compared the efficacy and patient satisfaction between shock wave lithotripsy (SWL) and ureteroscopic removal of stone (URS) for the treatment of lower ureteral stones. Materials and Methods: We reviewed 223 patients who were treated for lower ureteral stones from August 2006 to January 2009. SWL and URS were performed in 47 and 176 patients, respectively. After treatment, the patients' subjective inconvenience/pain and their satisfaction with the treatment process were estimated by questionnaire. We analyzed success rates, complication rates, inconvenience/pain scores, and satisfaction scores for each group of patients. Results: The overall success rates of SWL and URS were 82.9% and 97.7%, respectively (p=0.001). The complication rates of SWL and URS were 8.5% and 10.8%, respectively (p=0.162). The satisfaction scores of SWL and URS were 7.4 and 9.2, respectively (p=0.001). Whereas 87.5% of the URS group preferred the same treatment in case of a recurrence of ureteral stones, only 68% of the SWL group preferred the same treatment in the future (p=0.002). Conclusions: URS was more successful and satisfactory to the patients with lower ureteral stones. Although both SWL and URS were highly effective for treatment of distal ureteral stones, we believe that URS is the first-line treatment modality for lower ureteral stones. (Korean J Urol 2009;50: 884-891) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

Upper gastrointestinal Dieulafoy's lesions and endoscopic treatment: First report from a Mexican centre

The aim was to evaluate the initial success, rebleeding rate, need for emergent surgery, and mortality rates of patients with Dieulafoy's lesion (DL) and endoscopic treatment (ET). Patients with DL from a tertiary center were included. We included 20 patients with follow-up of 90 (60-550) days. The lesser curvature was the most common localization. Initial success, rebleeding, and emergent surgery requirement were observed in 90%, 10%, and 15%, respectively. No objective variables were related with response to ET. In conclusion, ET is secure and useful in patients with DL and it must be considered as the first-line treatment modality.

Prospective randomized trial comparing EUS and EGD for transmural drainage of pancreatic pseudocysts (with videos)

Although prior studies evaluated the role of EUS and EGD for drainage of pancreatic pseudocysts, there are no randomized trials that compared the technical outcomes between both modalities. To compare the rate of technical success between EUS and EGD for transmural drainage of pancreatic pseudocysts. A prospective randomized trial. A tertiary-referral center. Those with a history of pancreatitis and symptomatic pancreatic pseudocysts that measured greater than 4 cm in size who were referred for endoscopic transmural drainage. Patients with pancreatic abscess or necrosis were excluded. Technical success was defined as the ability to access and drain a pseudocyst by placement of transmural stents. Complications were assessed at 24 hours and at day 30. Treatment success was defined as the complete resolution or decrease in size of the pseudocyst to <or=2 cm on CT in association with clinical resolution of symptoms at 6 weeks of follow-up. Thirty patients were randomized to undergo pseudocyst drainage by EUS (n = 15) or EGD (n = 15) over a 6-month period. Of the 15 patients randomized to EUS, drainage was not undertaken in one, because an alternative diagnosis of biliary cystadenoma was established at EUS and was excluded (after randomization) from analysis. The mean age of the patients was 47 years; 62% were men (18/29). Except for their sex, there was no difference in patient or clinical characteristics between the 2 cohorts. Although all the patients (n = 14) randomized to an EUS underwent successful drainage (100%), the procedure was technically successful in only 5 of 15 patients (33%) randomized to an EGD (P < .001). All 10 patients who failed drainage by EGD underwent successful drainage of the pseudocyst on a crossover to EUS. There was no significant difference in the rates of treatment success between EUS and EGD after stenting, either by intention-to-treat (ITT) analysis (100% vs 87%; P = .48) or as-treated analysis (95.8% vs 80%; P = .32). Major procedure-related bleeding was encountered in 2 patients in whom drainage by EGD was attempted; one resulted in death and the other necessitated a blood transfusion. No significant difference was observed between EUS and EGD with regard to complications either by ITT (0% vs 13%; P = .48) or as-treated analyses (4% vs 20%; P = .32). Technical success was significantly greater for EUS than EGD, even after adjusting for luminal compression and sex (adjusted exact odds ratio 39.4; P = .001). Short duration of follow-up. When available, EUS should be considered as the first-line treatment modality for endoscopic drainage of pancreatic pseudocysts given its high technical success rate.

The Role of the Nasopharyngeal Airway for Obstructive Sleep Apnea in Syndromic Craniosynostosis

Syndromic craniosynostosis is known to be associated with obstructive sleep apnea (OSA), which can often present in infancy. Although multifactorial, a predominant contributing factor is midface hypoplasia. Nasal continuous positive airway pressure has proven to be an effective treatment modality but may be poorly tolerated in certain cases. This study looks at the effectiveness of bypassing midface obstruction with a nasopharyngeal airway (NPA). Twenty-seven children with syndromic craniosynostosis with confirmed moderate to severe OSA were initially treated with an NPA. The mean age of NPA insertion was 12.3 months (range, 0.5-48 mo). Seventeen had severe OSA, and 10 had moderate OSA preinsertion. Post-NPA insertion, 26 of 27 children (96%) demonstrated an improvement in sleep severity scores, resulting in 3 with moderate OSA and 24 with mild OSA. There was a significant improvement in mean oxygen saturation, mean number of saturation dips greater than 4% per hour, percentage time spent less than 90% SpO2, and number of pulse rate rises per hour. There were no significant differences in mean pulse rate. The NPA was well tolerated by this patient group, with 24 of 26 children retaining it for at least 6 weeks. We believe that an NPA is therefore an effective first-line treatment modality in the management of OSA in children with syndromic craniosynostosis. It is well tolerated by the patient and may obviate the need for continuous positive airway pressure or tracheostomy.