Bradley, Elizabeth H.

Purpose: To review cases of lateral brow dermoid cysts and gain insight into the utility of preoperative imaging, incidence of intraorbital extension, and recurrence rate. Methods: This is a retrospective study of all patients who underwent excision of lateral brow dermoid cysts at the authors' academic center over a 37-year period. Results: A total of 136 patients were included. The median age at presentation was 5.6 months [interquartile range (IQR) 3–16.5], and the median age at removal was 1.5 years (IQR 0.9–3.4). Preoperative imaging was performed in 44 patients. Intraorbital communication was predicted in 4 patients who underwent imaging and confirmed in 6 patients (4.4%) intraoperatively. Superficial dermoids were the most common depth (n=79, 58.1%), followed by periosteal (n=37, 27.2%) and intraosseous (n=14, 10.3%). Two patients (1.4%) presented with postoperative hematoma that required surgical evacuation. Recurrence was seen in 2 patients (1.4%). Among those who completed a follow-up, the median follow-up time was 1 month (IQR 0.44–5.8 months). Conclusion: The authors' study revealed that the majority of lateral brow dermoid cysts are either superficial or involve the periosteum, with orbital involvement being rare. None of our patients demonstrated intracranial communication. Imaging did not seem to add clinical value in patients for whom there was no clinical suspicion for the involvement of the deeper tissues, so careful consideration of ordering preoperative imaging would help decrease health care costs and avoid radiation exposure, which is particularly concerning for pediatric patients. The recurrence rate of lateral brow dermoid cyst seems to be low but studies with longer follow-ups are needed.

Background: Whether patients with STEMI with longer times from symptom onset to hospital presentation are less likely to be treated with any reperfusion therapy or treated with less urgency resulting in longer door-to-balloon and door-to-needle times is not known. The relationship between delay in hospital presentation and the quality of reperfusion therapy for patients with STEMI has not been examined Methods: We constructed 3 cohorts of STEMI patients to analyze use of any reperfusion (n=440,398), door-to-balloon time (n=67,207), and door-to-drug time (n=183,441) as a function of delay in hospital presentation. We constructed multivariable generalized linear models for each outcome to estimate the associations between delay in hospital presentation adjusted for all patient and hospital characteristics. Results: In adjusted analysis, longer times from symptom onset to hospital presentation was associated with lower use of any reperfusion therapy (p<0.0001 for trend). For early presenters with times of ≤1 hour, >1 to 2 hours, and >2 to 3 hours, 77%, 77%, and 73% of patients received any reperfusion therapy, respectively, and late presenters with times >9 to 10 hours, >10 to 11 hours, and >11 to 12 hours were treated with any reperfusion therapy in 53%, 50%, and 46%, respectively. Delay in hospital presentation was associated with longer drug-to-balloon and door-to-drug times (p<0.0001 for trend). For time intervals of ≤ 1 hour, >1 to 2 hours, >2 to 3 hours, >9 to 10 hours, >10 to 11 hours, and >11 to 12 hours, patients with STEMI were treated with door-to-balloon times of 99, 101, 106, 123, 125, and 123 minutes respectively. For delay time intervals of ≤ 1 hour, >1 to 2 hours, >2 to 3 hours, >9 to 10 hours, >10 to 11 hours, and >11 to 12 hours, patients were treated with door-to-drug times of 32, 34, 36, 46, 44, and 46 minutes, respectively. Conclusions: Longer time from symptom onset to hospital presentation has important implications for subsequent treatment and was associated with lower use of any reperfusion therapy and longer door-to-balloon and door-to-drug times. Longer delay in hospital presentation is associated with worse system performance for reperfusion therapy quality and represents an opportunity to improve quality of care for STEMI patients.