Changing practices: The addition of a novel surgical approach to gynecomastia

INTRODUCTION

Gynecomastia can be a significant impediment to quality of life for men who suffer from this affliction. Numerous surgical techniques have been described in the literature ranging from minimally invasive options such as liposuction to incision based reductions. The standard for the general surgeons at our institution has been subcutaneous mastectomy through a circumareolar incision, which often proved inadequate for patients with grade II or III gynecomastia. In November 2013 we adopted a new technique, the "double donut", that offers the post-operative appearance of a limited incision, with the additional benefits of mastopexy, skin reduction, and mastectomy through an enlarged incision which is not superficially evident at the completion of the procedure.

METHODS

We reviewed our surgical database for all cases performed for gynecomastia in the period from May 2005 to August 2016. Basic demographic information, diagnostic modality, symptoms, indication for procedure, operation performed, and final pathology were collected and analyzed.

RESULTS

There were 70 mastectomies performed on 52 subjects. All subjects were male; 14 were African American and 38 were Caucasian. The average age was 47 (23-73) years old. The majority of the patients were evaluated with mammogram and/or ultrasound. All but one patient presented with pain as the chief complaint. There were 41 mastectomies done prior to initiation of this technique and 29 were performed after. The average total volume of breast tissue excised via the previous technique was 97.4 cm³, this increased to 186.5 cm³ with the new technique. No necrosis of the NAC was seen and no wound infections resulted in complication. Cosmetic satisfaction was seen in 98% of patients.

CONCLUSION

The "double donut" technique is particularly useful for males with grades II or III gynecomastia. It provides good wound results, with acceptable patient satisfaction and cosmetic outcomes. Although initially developed for patients with higher grade gynecomastia, the improved visibility and increased patient satisfaction allowed this to become the preferred technique at our institution.

European consensus for starting and stopping enzyme replacement therapy in adult patients with Pompe disease: a 10-year experience

BACKGROUND AND PURPOSE

Pompe disease is a rare inheritable muscle disorder for which enzyme replacement therapy (ERT) has been available since 2006. Uniform criteria for starting and stopping ERT in adult patients were developed and reported here.

METHODS

Three consensus meetings were organized through the European Pompe Consortium, a network of experts from 11 European countries in the field of Pompe disease. A systematic review of the literature was undertaken to determine the effectiveness of ERT in adult patients on a range of clinical outcome measures and quality of life. A narrative synthesis is presented.

RESULTS

Consensus was reached on how the diagnosis of Pompe disease should be confirmed, when treatment should be started, reasons for stopping treatment and the use of ERT during pregnancy. This was based on expert opinion and supported by the literature. One clinical trial and 43 observational studies, covering a total of 586 individual adult patients, provided evidence of a beneficial effect of ERT at group level. At individual patient level, the response to treatment varied, but factors associated with a patient's response to ERT were not described in many studies. Eleven observational studies focused on more severely affected patients, suggesting that ERT can also be beneficial in these patients. There are no studies on the effects of ERT in pre-symptomatic patients.

CONCLUSIONS

This is the first European consensus recommendation for starting and stopping ERT in adult patients with Pompe disease, based on the extensive experience of experts from different countries.

Severe Hypertension and Bradycardia Secondary to Midodrine Overdose

The objective of this case is to describe the pharmacokinetics and toxicity of midodrine in overdose. A 20 year old female ingested up to 350 mg midodrine while recovering in hospital from another overdose. She developed vomiting and severe hypertension (blood pressure [BP], 210/100 mmHg). Remarkable findings included a heart rate with a range of 43-60 beats/min, spontaneous respirations (20 breaths/min), and oxygen saturations of >95 % on FiO2 25 %, and a GS of 8. She was admitted to intensive care and had a normal non-contrast CT brain. She was treated with a glyceryl trinitrate patch (5 mg) and observed for 36 h with subsequent BP reduction to 124/81 mmHg and improved in conscious state. Midodrine and desglymidodrine concentrations were measured with liquid chromatography tandem mass spectrometry and were detected with 2-h post-ingestion at concentrations of 158.4 and 169.7 ng/mL, respectively. The parent drug concentrations rapidly decreased with an elimination of half-life of 1.6 h, and the metabolite initially increased and then decreased. The peak in blood pressure appeared to coincide with peak metabolite concentrations. Midodrine in overdose can potentially cause severe hypertension and reflex bradycardia but given its short half-life treatment with vasodilator agents and supportive care is sufficient.

Epidemiological Aspects of Referral to TIA Clinics in Glasgow

A retrospective cohort study was carried out of new referrals to transient ischaemic attack (TIA) clinics in Glasgow. The aims of the study were to describe the profile of referrals and to assess the odds ratios for TIA, minor stroke or amaurosis fugax of both cardiovascular risk factors and clinical features.

In total, data were collected for 813 new referrals in a period of six months. Thirteen point eight percent of referrals were from other Health Boards. The overall referral rate among residents of Greater Glasgow NHS Board was 165.6 per 100,000 per year. About 20% of referrals were made by clinicians in secondary care. The specialties from which referrals were most commonly made were accident and emergency, general medicine, ophthalmology and geriatric assessment. The most common risk factors in patients referred were hypertension (52.9%), smoking (31.7%), ischaemic heart disease (22.7%) and former smokers (22.4%). The most common clinical features were hemiparesis (13.3%), weakness of an upper limb (8.7%), vertigo (7.9%) and dysphasia (7.3%). In 48.7% of cases, a non-cerebrovascular diagnosis was made.

Separate multivariate models were established for risk factors and clinical features. In the model for risk factors, five factors were significant for risk of TIA, stroke or amaurosis fugax. These were hyperlipidaemia, age over 64 years, hypertension, smoking and ex-smoking. In the model for clinical features, five factors were also significant. These were visual field defect, speech defact, facial weakness and hemiparesis.

Care that Matters: Quality Measurement and Health Care

Barry Saver and colleagues caution against the use of process and performance metrics as health care quality measures in the United States.

Physician Communication Training and Parental Vaccine Hesitancy: A Randomized Trial

BACKGROUND AND OBJECTIVES

Physicians have a major influence on parental vaccine decisions. We tested a physician-targeted communication intervention designed to (1) reduce vaccine hesitancy in mothers of infants seen by trained physicians and (2) increase physician confidence in communicating about vaccines.

METHODS

We conducted a community-based, clinic-level, 2-arm cluster randomized trial in Washington State. Intervention clinics received physician-targeted communications training. We enrolled mothers of healthy newborns from these clinics at the hospital of birth. Mothers and physicians were surveyed at baseline and 6 months. The primary outcome was maternal vaccine hesitancy measured by Parental Attitudes on Childhood Vaccines score; secondary outcome was physician self-efficacy in communicating with parents by using 3 vaccine communication domains.

RESULTS

We enrolled 56 clinics and 347 mothers. We conducted intervention trainings at 30 clinics, reaching 67% of eligible physicians; 26 clinics were randomized to the control group. Maternal vaccine hesitancy at baseline and follow-up changed from 9.8% to 7.5% in the intervention group and 12.6% to 8.0% in the control group. At baseline, groups were similar on all variables except maternal race and ethnicity. The intervention had no detectable effect on maternal vaccine hesitancy (adjusted odds ratio 1.22, 95% confidence interval 0.47-2.68). At follow-up, physician self-efficacy in communicating with parents was not significantly different between intervention and control groups.

CONCLUSIONS

This physician-targeted communication intervention did not reduce maternal vaccine hesitancy or improve physician self-efficacy. Research is needed to identify physician communication strategies effective at reducing parental vaccine hesitancy in the primary care setting.