Magnetic resonance imaging-directed stereotactic endoscopic third ventriculostomy

Third Ventriculostomy has been proposed as the procedure of choice for many patients with acquired obstructive hydrocephalus. Various techniques have been used to perform this procedure. This report describes the use of magnetic resonance images to guide the performance of a stereotactic third ventriculostomy with a rigid endoscope, allowing continuous direct visualization. This procedure has been performed on three patients, yielding clinical improvement without the need for extracranial shunting. Magnetic resonance imaging allows accurate identification of the important anatomical landmarks (i.e., foramen of Monro and interpeduncular cistern), with axial, coronal, and sagittal images, and is readily used in conjunction with the Cosman-Roberts-Wells stereotactic apparatus.     

An audit of pancreatic pseudocyst management and the role of endoscopic pancreatography

BACKGROUND: A rational algorithm for the management of symptomatic pancreatic pseudocysts is necessary with the increasing availability of radiological, surgical and endoscopic methods of treatment. METHODS: A retrospective audit of the management and outcome of all patients who presented with symptomatic pancreatic pseudocysts to the Auckland Hospital over a 9-year period (1988-96) was made. RESULTS: There were 44 patients (28 men, 16 women; median age 50; range 18-81) in this series. Initial management was not based on pseudocyst size, duration, location, wall thickness, the patients' symptoms and comorbidity, or the aetiology of pancreatitis. Of the 27 patients who had initial conservative management, 15 pseudocysts (56%) completely resolved. Of the 17 patients who were initially or subsequently treated with percutaneous catheter drainage (PCD), 10 pseudocysts (59%) completely resolved without additional treatment. Of the 13 patients initially or subsequently treated by surgery, all but one completely resolved after the first procedure. Two patients were successfully treated with endoscopic pancreatic stent placement. Complications arose in eight patients treated with PCD (47%) and four patients treated with surgery (31%). There was no mortality. The decision for active treatment was not preceded by delineation of the pancreatic duct by ERCP (endoscopic retrograde cholangiopancreatography) in 60% of patients. CONCLUSIONS: More than one-third of all patients with symptomatic pancreatic pseudocysts can be managed conservatively. Surgery yields excellent results but PCD has a high failure rate in patients with an underlying pancreatic duct stricture. A rational management algorithm is presented, based on pre-intervention ERCP, which should improve patient selection and outcome.     

Central diabetes insipidus: a complication of ventriculoperitoneal shunt malfunction during pregnancy

During pregnancy ventriculoperitoneal shunts have reported complication rates of 30% to 60%. In this case a functionally occluded shunt resulted in prolonged increased intracranial pressure, pituitary stalk damage, and permanent central diabetes insipidus. This complication of ventriculoperitoneal shunt occlusion during pregnancy has not been previously reported.     

Biliary complications of Fasciola hepatica: the role of endoscopic retrograde cholangiography in management

The parasite Fasciola hepatica resides in the biliary tree but rarely causes significant clinical sequelae. In this report, we review our experience with four patients in whom F. hepatica infection resulted in biliary complications, especially severe biliary colic and jaundice. The diagnosis was achieved with endoscopic retrograde cholangiography which demonstrated the worms in the extrahepatic bile ducts. Endoscopic sphincterotomy was performed uneventfully in all patients allowing balloon extraction of the parasites and resolution of their symptoms.     

The management of the cirrhotic patient after transjugular intrahepatic portosystemic shunt

Transjugular intrahepatic portosystemic shunts (TIPS) achieve portal decompression in a manner analogous to side-to-side surgical portacaval shunts but avoid the risks of general anesthesia and major surgery. These considerations have popularized this procedure for the treatment of refractory variceal hemorrhage. However, its increasing use has also led to the recognition of both expected as well as unexpected complications associated with TIPS. Also, the natural history of cirrhosis and portal hypertension after TIPS has now been well described. Such data allow optimizing management strategies for individual patients after TIPS placement. The use of TIPS for active variceal bleeding and the clinical factors influencing subsequent management are discussed in this article.     

The role of laparoscopy in the management of impalpable testes

Both diagnostic and operative laparoscopy were used in the management of 68 impalpable testes. Twenty-three were either vanishing or atrophied, and were associated with a precarious blood supply. Two were found in the groin, 12 in the inguinal canal, and 32 at variable distances from the internal ring; of these, 2 were in a patient with persistent müllerian duct syndrome. Two atrophied abdominal testes were removed laparoscopically, 3 patients underwent a two-stage Fowler-Stephens procedure, and 28 underwent one-stage, laparoscopically assisted orchidopexy. An algorithm for surgical management of the impalpable testis based on laparoscopic findings is proposed.     

The role of physiatry in the management of neuromuscular disease

Patients with neuromuscular disease (NMD) are complex and pose a myriad of clinical problems. Management is best carried out by a team consisting of physicians, physical, occupational, and speech therapists, social workers, vocational counselors, and psychologists, among others. Physiatrists are well-suited to this type of multi-disciplinary care and can play a significant role in the care of these patients.     

The role of chemotherapy in the management of nasopharyngeal carcinoma

BACKGROUND: Nasopharyngeal carcinoma (NPC) is a radiosensitive tumor for which there is a high local control rate after radical radiotherapy (RT). However, for patients with locoregionally advanced disease, the rate of distant metastasis is high and the 5-year overall survival rate is poor. METHODS: A review of retrospective and prospective clinical studies was performed to assess the role of chemotherapy in three settings: metastatic disease; neoadjuvant and/or adjuvant; and concurrent chemotherapy with radiotherapy. RESULTS: Cisplatin-based combination chemotherapy results in a high response rate in patients with metastatic NPC, and a subgroup may achieve long term disease free survival. The use of neoadjuvant and adjuvant chemotherapy to treat locoregionally advanced disease has resulted in consistently high response rates, but no randomized trial to date has demonstrated an improvement in overall survival. A recent Head and Neck Intergroup study randomized patients in the United States to receive concurrent chemotherapy (cisplatin) and radiotherapy or radiotherapy only. Although this approach demonstrated significant benefit in overall survival favoring the use of concurrent chemotherapy and radiotherapy, its applicability in geographic areas of high NPC incidence remains to be proven. CONCLUSIONS: NPC is a chemosensitive tumor, and patients with metastatic disease have a high response rate. Further prospective studies will define the standard approach to treating locoregionally advanced NPC, which is likely to incorporate into the primary treatment some form of systemic chemotherapy.     

The role of radiotherapy in the management of cancer--an overview

Cervical lymph nodes biopsies from 31 HIV positive patients (with or without AIDS) were studied by histologic methods and immunohistochemistry (StreptABC staining of paraffin sections) to identify cellular and extracellular matrix components. The results were the following: (1) the biopsies were included in the stages of follicular hyperplasia without fragmentation FH-FF (4 cases); follicular hyperplasia with follicular fragmentation FH + FF (16 cases); follicular involution FI (6 cases) and diffuse pattern DP (5 cases); (2) the most important alteration was the germinal centers disruption due to follicle lysis, which began in the light zone; (3) there was coincidence between intrafollicular hemorrhages and segmental hyaline mycroangiopathy; (4) during the progression of the disease occurred; (a) an increase in the number of mast cells, CD68+ and Mac 387+ macrophages; (b) a diffuse augment of collagen III, elastic fibers, laminin, fibronectin and proteoglycans; (c) maintenance of Factor VIII-related antigens in the vascular endothelial cells, with decrease in the expression of Ulex-Europeus I lectin. Follicular hyperplasia (FH - FF or FH + FF) was the most common histologic pattern recognized in the lymph nodes of patients without AIDS and follicular involution and difuse pattern were seen in those who had AIDS. The results indicate that the lymph node biopsies may provide important information about the evolutive stage of the disease and its prognosis.     

The role of esophagectomy in the management of esophageal perforations

BACKGROUND: Despite the many advancements made in thoracic surgery, the management of patients with esophageal perforation remains problematic and controversial. METHODS: Between 1985 and 1995, 27 esophagectomies were performed for perforation of the thoracic esophagus. A retrospective review of the records of these patients was carried out, and a scoring scale developed by Elebute and Stoner to grade the severity of sepsis was applied. RESULTS: Among the 27 patients undergoing esophagectomy for a perforation, the interval between rupture and esophagectomy was less than 24 hours in only 11 patients (40.7%). Postoperative surgical complications occurred in 4 patients (14.8%) and nonsurgical complications, in 7 (25.9%). The hospital mortality rate was 3.7% (1/27). In 14 patients, primary reconstruction was performed in the bed of the excised esophagus. There were no anastomotic leaks in this subgroup. This suggests that an anastomosis between viable, well-vascularized tissues is more important for successful healing than avoidance of some degree of contamination of the adjacent mediastinum. On follow-up, which averages 41 months, 73% of patients (16/22) have neither symptoms nor complaints. CONCLUSIONS: Esophageal resection definitively eliminates the source of intrathoracic sepsis, the perforation, and the affected esophagus. Reconstruction carried out in one stage does not increase operative morbidity. Esophageal resection and reconstruction is a valid approach even in cases of spontaneous perforation in which the diagnosis is markedly delayed.     

The role of orchiectomy in the management of postpubertal cryptorchidism

PURPOSE: Owing to the risk of future malignancy, many postpubertal male subjects presenting with unilateral cryptorchidism undergo orchiectomy rather than orchiopexy. We examined the incidence of spermatogenesis and carcinogenesis in whole orchiectomy specimens removed from postpubertal cryptorchid male subjects. We review the concept that orchiectomy is justifiable in these patients. MATERIALS AND METHODS: A total of 52 patients with postpubertal cryptorchidism (unilateral in 48, bilateral in 4) were retrospectively analyzed from 1984. Patient age ranged from 15 to 66 years (mean 26). Six patients presented with primary infertility (unilateral in 3, bilateral in 3). The undescended testicles were palpable in 32 cases (62%). All patients underwent unilateral orchiectomy and whole specimens were examined histologically. RESULTS: Histology showed normal spermatogenesis in only 1 orchiectomy specimen, while 15 had maturation arrest, 6 testicular agenesis and 30 seminiferous tubular atrophy and/or Sertoli-cell-only syndrome with no spermatogenesis. The location of the undescended testis was the superficial inguinal pouch in 32 cases, inguinal canal in 6 and inside the deep ring in 8. Absent spermatogenesis was significantly associated with a high level of maldescent and with increasing age. Two patients (4%) had carcinoma in situ of the testicle. Torsion of an undescended testicle occurred in 1 patient (2%). CONCLUSIONS: This analysis of cryptorchid testes in postpubertal male subjects confirms that the majority cannot contribute to fertility, have significant malignant potential and may undergo torsion. Therefore, orchiectomy remains the treatment of choice for the majority of postpubertal male subjects presenting with unilateral cryptorchidism.     

Surgical management of third nerve palsy

AIMS: A surgical technique has been developed in order to obtain ocular alignment in the primary position in patients with third nerve palsy. METHODS: A method for surgically correcting the vertical deviation and the pseudoptosis is described in three patients with longstanding third nerve palsy. By decreasing the ability of the non-involved eye to elevate, a fixation duress was created which eliminated the secondary deviation that characteristically occurs in such patients when the involved eye fixates. As a result of this technique, both eyes in all patients on attempted fixation were under similar duress, therefore requiring equal amounts of stimulation to move into the primary position. When the fixation duress was sufficient, elimination of the hypotropia and ptosis was achieved. Additionally, in order to correct the exotropia, generous recession and resection procedures in the involved eye and recession of the lateral rectus in the noninvolved eye were performed. RESULTS: Between 8 and 10 prism dioptres of esotropia were achieved and maintained in two patients. One patient had 20 prism dioptres of exotropia. Two patients had no residual ptosis and one required an additional anterior levator resection to achieve a satisfactory result. CONCLUSION: Patients with a third nerve palsy and a pseudoptosis may be candidates for this approach.     

The role of endoscopic therapy in chronic pancreatitis-induced common bile duct strictures

During endoscopic retrograde cholangiography, common bile duct strictures are encountered in up to 30% of patients with chronic pancreatitis. The indications for treatment of these strictures are discussed. A surgical biliodigestive anastomosis has always been the traditional treatment modality. Not all patients need treatment, however, and endoscopic biliary drainage is the treatment of choice for certain subgroups of patients.     

The role of urine sugar in diabetic management

The concentration of reducing sugar in the urine is commonly used in the management of diabetes in children. Supplemental doses of regular insulin are administered in response to the concentration of urine sugar according to a protocol termed the "sliding scale." This practice assumes that the concentration of sugar in urine is a good indicator of the plasma glucose concentration. This assumption was tested by comparing urine sugar concentrations in first and second voided urines with the plasma glucose concentrations in 220 children with diabetes. The correlation was good (r = .92) for both the first and second voided urine specimens. Thus, urine sugar concentrations in general define the level of plasma glucose. The large standard deviation of the plasma glucose at each concentration of urine sugar, however, limits the usefulness of urine sugar as an accurate reflection of the coincident plasma glucose concentration. The urine sugar concentration, although useful for the general management of diabetes, provides significant risk when used to guide frequent adjustments in insulin administration. Therefore, the "sliding scale" should not be used in the treatment of children with diabetes.     

The role of surgery in the management of low back pain

Life-history characteristics of female threespine stickleback (Gasterosteus aculeatus) were examined in 12 populations, 11 freshwater and one anadromous, within the Cook Inlet region of Alaska. Because this area has been deglaciated during the last 20 000 years, the freshwater populations are recently derived, probably independently, from the local marine or anadromous stickleback. Freshwater threespine stickleback have undergone considerable morphological evolution within this region, apparently in response to environmental factors including predatory regimes and environmental productivity. Our freshwater study populations were selected to sample this range of morphological variation in order to determine whether life-history traits and morphologies have followed similar evolutionary trajectories. Freshwater populations could be categorized generally into one of three ecomorphotypes: those inhabiting relatively productive lakes having one or more piscivorous fishes present, and in which the stickleback exhibit a fully developed pelvic girdle; those inhabiting low-calcium lakes that lack piscivorous fishes, and in which the pelvic structures are incomplete; those living in streams with piscivorous fishes, in which the stickleback have fully developed pelvic girdles. The anadromous population constituted a fourth ecomorphotype that lives in marine waters, and is robustly armored. The freshwater populations showed considerable variation in all life-history traits assessed, and this variation generally corresponded to our ecomorphological classifications. Nevertheless, within each ecomorphotype there was sufficient variation to suggest that morphological and life-history traits may not always respond in the same manner in response to the same selective regime.Copyright 1998 The Linnean Society of London     

The role of intravenous amiodarone in the management of cardiac arrhythmias

PURPOSE: To review the electropharmacology, clinical applications, side effects, and hemodynamic profile of intravenous amiodarone. DATA SOURCES: The MEDLINE database was searched for English-language material, including reports of clinical trials and in vivo studies, review articles, and abstracts presented at national symposia, that was published between 1985 and 1996. Bibliographies of textbooks and articles were also examined. STUDY SELECTION: Studies that reported on the efficacy, toxicity, and hemodynamic profile of intravenous amiodarone and studies that examined the pharmacologic behavior of intravenous amiodarone in laboratory models were reviewed. DATA EXTRACTION: Study design and quality and relevant data on efficacy of suppression and treatment of arrhythmias with oral and intravenous amiodarone therapy, the reported mechanisms of antiarrhythmic effect, and hemodynamic changes seen with therapy were analyzed. DATA SYNTHESIS: Amiodarone is a unique antiarrhythmic agent that is now available in oral and intravenous forms in the United States. The use of intravenous amiodarone in the short-term treatment of life-threatening or hemodynamically unstable rhythm disturbances has generated much interest. Amiodarone has many electropharmacologic actions, some of which differ between the oral and intravenous forms. The wide clinical application of amiodarone includes treatment and prevention of supraventricular and ventricular arrhythmias and arrhythmias related to myocardial infarction. Intravenous amiodarone is effective for supraventricular and ventricular arrhythmias that are resistant to other antiarrhythmic agents. The effectiveness of intravenous amiodarone as short-term treatment also suggests that the drug has an important role in protocols of advanced cardiac life support. Intravenous amiodarone seems to have an overall favorable hemodynamic profile and does not produce many of the unwanted long-term side effects associated with oral therapy. CONCLUSION: Intravenous amiodarone shows much promise for the short-term treatment of unstable arrhythmias. Its favorable hemodynamic effects and minimal short-term side effects make it an attractive option in the management of cardiac arrhythmias.     

The role of the clinical nurse specialist in acute pain management

The role of nursing in infusional cancer chemotherapy (ICC) may vary depending on the practice setting. Nurses in free-standing centers and office practices perform many duties that nurses in other facilities may not, because of the lack of many of the supports that benefit hospitals with their multidepartmental and hierarchical structures. Nurses function collaboratively with physicians in the planning and the implementation of patient treatment. Patient-related nursing responsibilities include patient/family education, drug preparation and administration, patient assessment for treatment toxicity, recognition and management of complications related to the catheter or infusion device, and telephone triage. Other duties more removed from patient care might include inventory management, research data collection and management, quality assurance and improvement, compliance with regulatory issues, and a myriad of other responsibilities. The transition of patient care to the outpatient setting has broadened the scope of nursing to include nonpatient care responsibilities due to financial constraints brought about by health care reform, changes in reimbursement patterns, and overhead required to maintain and deliver quality patient care. As a result of nursing responsibilities, it becomes paramount that the aforementioned constructs for program support are in place and that all nurses are consistently trained and have a template to follow for patient treatment and management. Nursing ability to perform patient-related tasks should be proven by formal written and practical competencies repeated annually and as procedural changes are implemented. The paragraphs to follow suggest nursing management of patients receiving ICC using a model developed at The Cancer Center of Boston (TCC).