Thymectomy in black children with juvenile myasthenia gravis

Fifteen black children with juvenile myasthenia gravis presented to our institution over a 10-year period at ages ranging from 18 months to 7 years, 4 males and 11 females. Twelve presented with progressive, generalised weakness and 3 had bulbar manifestations. Ocular signs were absent in 2 patients. All 15 patients were placed on pyridostigmine bromide (Mestinon) and 1 also required steroids and plasmapheresis. Medical therapy only was instituted in 5 patients, of whom 2 came to surgery, 2 died, and 1 was lost to follow-up. Thymectomy was performed in 12 children (including the 2 with failed medical therapy) via a median sternotomy with no mortality or morbidity related to the operation. The timing of surgery was less than 3 months in 75% of the children. Thymic hyperplasia was noted in 10 glands and 2 were reported as normal. Of the children in the operative group, 83% are on minimal medication or in total remission. Better results were noted in young patients with early thymectomy and diseased glands.     

Nasal septum repair-plasty with pedicled flap technique in 126 patients--an analysis

BACKGROUND: The surgical closure of a nasal septal perforation is considered to be one of the most difficult procedures in nasal surgery with a relatively poor success rate. After a new surgical concept ("bipedicled-flap technique") was developed, a follow-up study was done in order to find out whether surgical results can be improved by means of this new method. PATIENTS AND METHOD: From 1988-1995 the bipedicled-flap technique was applied in 126 patients with nasal septal perforations (82 males, 44 females). In all patients the closure of the septal perforation was performed with an endonasal bilateral bipedicled-flap plasty and reconstruction of the cartilaginous defect with an autogenous cartilage graft from either the rib, the auricle, or from remnants of the septal cartilage. Postoperative results were evaluated in all patients. The follow-up period varied from a minimum of six months to a maximum of over seven years. RESULTS: The age peak was found in the third decade of life (females) and fifth decade (males), respectively. Most frequent preoperative symptoms were difficult nasal breathing, crusting and recurrent epistaxis. 65.8% of septal perforations were of iatrogenic origin. In 32 patients, the aetlology remained unknown. Six patients used silicone obturators preoperatively without getting any relief from complaints. In nine patients, surgical repair of the septal perforation had been attempted previously at another hospital. With the bipedicled-flap technique, primary closure was achieved in 118 patients (= 93.6%); revision surgery (same technique) was successfully performed in 2 patients, increasing the final success rate to 95.2%. Complications were rare and could always be managed easily. CONCLUSIONS: At present, the bipedicled-flap technique appears to be the most successful method for surgical repair of nasal septal perforations. The underlying principles responsible for the good success rate are: (1) the bilateral closure of the mucosal defects; and (2) the additional reconstruction of the cartilaginous septal defect with an autogenous cartilage graft only.     

Silicone versus polymethylmethacrylate intraocular lenses with regard to capsular opacification

Between May 1996 and May 1997, a total of 398 patients (321 males, 77 females) were registered at our institute for trans-telephonic electro-cardiographic monitoring (TTEM). Their age ranged from one month to 95 years. Almost two-third (67%) of patients were from Delhi and one-third (33%) from other places in India and neighbouring countries. Clinical profile of these patients was post-bypass surgery, post-myocardial infarction, chest pain for evaluation, post-percutaneous transluminal coronary angioplasty, chronic stable angina, evaluation of palpitations, arrhythmias, and pace-maker follow-up. Out of 664 symptomatic transmissions, 568 (86%) were received for cardiac symptoms and 96 (14%) for non-cardiac symptoms. Seventy-nine percent patients had chest pain or palpitations at the time of transmission, whereas 21 percent had other symptoms like chest discomfort, breathlessness or dizziness. The electro-cardiograms were transmitted within one hour of the onset of chest pain in 84 percent, palpitations in 78 percent and dizziness in 75 percent. Of patients with symptomatic transmissions, 628 (95%) required either reassurance or drug-dose adjustment and outpatient department review. Only 36 (5%) patients were hospitalised as an emergency, and out of these only 19 (3%) needed acute management. In conclusion, trans-telephonic electro-cardiographic monitoring is a very convenient and an 'all-time-available' monitoring facility for establishing patient-physician contact in the shortest time. It is useful in rendering instant advice for hospitalisation in emergency situations while avoiding unnecessary visits to the hospital.     

Dislocation after bipolar hemiarthroplasty of the hip

Although bipolar hemiarthroplasty of the hip is a frequently performed procedure, little information is available about the frequency of postoperative dislocation and its treatment. For this study, 1,934 hips treated consecutively with primary bipolar hemiarthroplasty were reviewed. A postoperative dislocation developed in 29 patients (1.5%): during the first month after surgery in 24 patients and between 1 month and 5 years after surgery in five patients. Of the 29 dislocations, 25 were successfully reduced with with routine closed methods. Among these 25 hips, 13 (52%) subsequently redislocated, and 7 of these required operative treatment for the recurrent dislocation. Dislocation after primary bipolar hemiarthroplasty is infrequent, can usually be reduced by routine closed methods, but is associated with a high rate of recurrent dislocation.     

Bleeding complications after CASH

We assessed the frequency and studied the possible mechanisms of bleeding after classic abdominal Semm hysterectomy (CASH) in a retrospective, nonrandomized review of 70 women (47 premenopausal) undergoing the procedure with 1-year minimum follow-up. In several women CASH was associated with adhesiolysis, and in more than 50% with bilateral oophorectomy. Of the 47 patients who were menstruating prior to surgery, 6 (13%) reported postoperative menstruation. Two additional patients required repeat surgery, and one required transfusion. Endometrial glands were present in one excised specimen, suggesting the possibility that menstruation and hematometra may occur.     

A long-term assessment of adjuvant chemotherapy on outcome of patients with extracapsular spread of cervical metastases from squamous carcinoma of the head and neck

BACKGROUND: Extracapsular spread (ECS) of cervical lymph node metastases of squamous cell carcinoma from head and neck sites portend poor prognosis. Therefore, a program of combined surgery, postoperative irradiation therapy, and adjuvant methotrexate and 5-fluorouracil (5-FU) was initiated in 1982 for such patients. METHOD: All patients operated on between June 1982 and December 1992 by the full-time faculty of the Department of Otolaryngology at the University of Pittsburgh School of Medicine were eligible and reported in this trial. All patients had negative surgical margins of excision of the primary carcinoma, and histologic evidence of cervical metastases with ECS. Postoperative irradiation included 50-60 cGy for 5 to 6 weeks followed by methotrexate and 5-FU administered on an outpatient basis on days 1 and 8 every 21 days. All patients were followed for 30 or more months for evidence of recurrent disease. RESULT: A total of 371 patients met eligibility criteria. Of this group, 53 (14%) were treated with surgery only, 187 (50%) received surgery and postoperative irradiation, and 131 (35%) received surgery, irradiation therapy, and chemotherapy. The primary site, extent of nodal involvement, and stage of the three patient groups were similar. However, performance status (Karnofsky) was best in the patients who received chemoradiation (average 90) when compared with those who received surgery and irradiation (average 80) or surgery only (average 70). Absolute disease free survival rate (30 months) was 9.5% in patients treated with surgery only, 34% in patients treated with surgery plus irradiation, and 53% in patients treated with surgery, irradiation, and chemotherapy. When adjusted for patients who died of intercurrent disease with less than 30 months follow-up, survival rates became 17%, 40%, and 58%, respectively. These differences are highly significant (P < 0.001). CONCLUSION: Results of this study suggest that postoperative chemoradiation may improve survival in patients with ECS of cervical metastases. Compliance with the chemoradiation was suboptimal and suggests that improved strategy must be developed.     

Gender differences in the outcomes of participants in home programs compared to those in structured cardiac rehabilitation programs

This study compared gender differences in outcomes of patients who had had coronary bypass surgery and either attended structured cardiac rehabilitation programs or participated in home programs. The principal advantages related to patients' attending a structured hospital-based outpatient rehabilitation program, compared to a home program, included increased exercise adherence for males and females, increased knowledge about the condition for males, and increased stress control for females. Return to work, self-efficacy, and aspects of self-care such as adherence to a medication regimen and smoking cessation were not significantly different, regardless of type of program, for either sex. In general, females at home fared the worst regarding lifestyle changes, showing decreased exercise adherence, decreased ability to control stress, and no significant increase in knowledge about their medical condition.     

Trabeculectomy function after cataract extraction

OBJECTIVE: To examine the effect of cataract extraction (CE) after trabeculectomy on intraocular pressure (IOP) control. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: A total of 115 consecutive patients who underwent extracapsular CE (N = 58) or phacoemulsification (N = 57) with intraocular lens (IOL) placement after trabeculectomy were studied. INTERVENTION: Cataract extraction with IOL after trabeculectomy was performed. MAIN OUTCOME MEASURES: Preoperative, intraoperative, and postoperative factors were evaluated for association with loss of IOP control requiring additional medications, bleb needling, or further glaucoma surgery, using Kaplan-Meier survival analysis and Cox multivariate proportional hazards survival regression. RESULTS: After mean postoperative follow-up of 21.1 +/- 14.3 months, additional glaucoma medication or needling of the filtering bleb to maintain IOP control was required in 35 eyes (30.4%) and was significantly associated with intraoperative iris manipulation and early postoperative peak IOP greater than 25 mmHg. Additional glaucoma surgery was eventually required in 11 eyes (9.6%) and was significantly associated with age of 50 years or younger, preoperative IOP greater than 10 mmHg, and early postoperative peak IOP greater than 25 mmHg. The cumulative proportion of patients who did not require reoperation for glaucoma was 93% and 90% at 1 and 2 years, respectively. The mean IOP at last visit had increased 1.6 mmHg above the pre-CE level and did not vary significantly after the first postoperative month. The median interval from CE to the addition of glaucoma medication or bleb needling was 1.6 months (within 3 months in 20 of 33 eyes) and that from nonsurgical intervention to further glaucoma surgery was 3.6 months (before the 7th postoperative month in 6 of 11 eyes). Of 19 eyes with hypotony (IOP < or = 6 mmHg) before CE, 11 eyes remained hypotonous after CE despite an increase in the mean IOP from 4.6 to 7.5 mmHg. CONCLUSIONS: When CE is performed after trabeculectomy, age of 50 years or younger, preoperative IOP greater than 10 mmHg, intraoperative iris manipulation, and early postoperative IOP greater than 25 mmHg are associated with worsened postoperative IOP control. Most bleb failures occur soon after CE. Resolution of pre-existing hypotony after CE is unpredictable.     

Patient recovery after infrainguinal bypass grafting for limb salvage

PURPOSE: The outcome of infrainguinal bypass surgery for limb salvage has traditionally been assessed by graft patency rates, limb salvage rates, and patient survival rates. Recently, functional outcome of limb salvage surgery has been assessed by patient ambulatory status and independent living status. These assessments fail to consider the adverse long-term patient effects of delayed wound healing, episodes of recurrent ischemia, and need for repeat operations. An ideal result of infrainguinal bypass surgery for limb salvage includes an uncomplicated operation, elimination of ischemia, prompt wound healing, and rapid return to premorbid functional status without recurrence or repeat surgery. The present study was performed to determine how often this ideal result is actually achieved. METHODS: The records of 112 consecutive patients who underwent initial infrainguinal bypass surgery for limb salvage 5 to 7 years before the study were reviewed for operative complications, graft patency, limb salvage, survival, patient functional status, time to achieve wound healing, need for repeat operations, and recurrence of ischemia. RESULTS: The mean patient age was 66 years. The mean postoperative follow-up was 42 months (range, 0 to 100.1 months). After operation 99 patients (88%) lived independently at home and 103 (92%) were ambulatory. There were seven perioperative deaths (6.3%), and wound complications occurred in 27 patients (24%). By life table, the assisted primary graft patency and limb salvage rates of the index extremity 5 years after operation were 77% and 87%, respectively, and the patient survival rate was 49%. At last follow-up or death, 73% of the patients (72 of 99) who lived independently at home before the operation were still living independently at home, and 70% (72 of 103) of those who were ambulatory before the operation remained ambulatory. Wound (operative and ischemic) healing required a mean of 4.2 months (range, 0.4 to 48 months), and 25 patients (22%) had not achieved complete wound healing at the time of last follow-up or death. Repeat operations to maintain graft patency, treat wound complications, or treat recurrent or contralateral ischemia were required in 61 patients (54%; mean, 1.6 reoperations/patient), and 26 patients (23.2%) ultimately required major limb amputation of the index or contralateral extremity. Only 16 of 112 patients (14.3%) achieved the ideal surgical result of an uncomplicated operation with long-term symptom relief, maintenance of functional status, and no recurrence or repeat operations. CONCLUSIONS: Most patients who undergo infrainguinal bypass surgery for limb salvage require ongoing treatment and have persistent or recurrent symptoms until their death. A significant minority have major tissue loss despite successful initial surgery. Clinically important palliation is frequently achieved by bypass surgery, but ideal results are distinctly infrequent.     

A descriptive study of drug therapy and cost for elderly residents in a nursing home

Drug therapy for 115 patients in Health Board contracted beds in a long-stay institution for the elderly were studied. The results were analysed for frequency, type and cost of medicines. 96.5% of patients received a total of 473 routine medicines, an average of 4.1 medicines per patient, females received a higher number of medicines than males. The average cost per person per day was 67.6p for all medicines. The most frequently prescribed medicines were for therapeutic groups CNS (32.3%) CVS (17.8%) and GIS (14.2%).     

Surgical treatment of choledochal cyst in adults: results and long-term follow-up

BACKGROUND/AIMS: Results of the surgical management of 60 adults with choledochal cysts at Chang Gung Memorial Hospital Taipei are presented. PATIENTS AND METHODS: All patients were diagnosed and surgically managed during the period between March 1979 and December 1992. There were 47 females and 13 males, with ages ranging from 16 to 81 years (mean age = 31.9 years). Of the total, there were 41 Type I, one Type II, 14 Type IV, and four Type V choledochal cysts classified according to Todani's classification system. The definite surgical procedures were cyst excision and hepatico-jejunostomy in 43 cases in type I and IV diseases, one cyst excision in type II disease, two hepatectomy for type V disease, cyst enterostomy in seven cases, and T-tube choledochocystostomy in seven cases. RESULTS: The operative mortality rate was 3.3% and the complication rate related to the surgical procedure was 20%. Early postoperative complications include wound infection, leakage of anastomosis, acute pancreatitis, septic shock, left pleural effusion, and intra-abdominal abscessing. Reoperations were needed in the early postoperative days in two cases due to hepatico-jejunostomy leakage and intraabdominal abscess formation. Long-term surgical outcome, concerning recurrence of symptoms, was related to the following factors, excluding the factors of surgery: presence of bile duct lithiasis, common channel less than 22 mm, presence of preoperative pancreatitis and acute angle type pancreaticobiliary unions. Only common channel less than 22 mm is statistically significant. The percentage of recurrence of the symptoms after resectional surgery was 32.5% in the long term follow-up period. Most of the cases responded well to an antibiotics treatment. Three of the cases required a second operation or PTCD as well as dilatation to treat the recurrent cholangitis. CONCLUSION: Although the recurrence of symptoms is not uncommon and satisfactory explanation of the analysed factors is still the treatment of choice for adult patients with choledochal cysts.     

Incontinence and vesical neck strictures following radical retropubic prostatectomy

OBJECTIVES: To evaluate the incidence and severity of vesical neck strictures and urinary incontinence after radical retropubic prostatectomy (RRP) for prostate cancer. METHODS: Between August 1983 and December 1991, 481 consecutive patients underwent RRP by 1 of 2 senior surgeons. Strictures were treated by passing a urethral sound. Incontinence was measured by asking patients for a daily "pad count" of pads required to control urinary leakage. Results were compared to patient age, tumor volume, number of neurovascular bundles spared, preoperative urinary complaints, and previous transurethral resection of the prostate. RESULTS: Of 456 patients with adequate follow-up to determine stricture formation, 82.5% had no strictures, 6.8% required a single dilation, 3.7% required 2 dilations, 3.1% required 3 dilations, and 3.9% required more than 3 dilations. Risk of stricture formation was unrelated to every variable studied. Of 458 patients with adequate follow-up to determine recovery of continence, 80.1% required no pads, 8.1% required 1 to 2 pads a day, 6.6% required 3 to 5 pads a day, and 5.2% were totally incontinent 1 year or more after surgery. Incontinence was closely associated with postoperative urinary urgency. CONCLUSIONS: Strictures are a common but easily managed complication of RRP for prostate cancer. Despite substantial surgical experience, we report a somewhat higher rate of postoperative incontinence than other recently reported series. Our experience is more closely matched by published surveys of patient-reported complications after RRP.     

Pre- and postoperative radiotherapy to prevent heterotopic ossification of the hip joint

BACKGROUND: In-vivo experimental data indicate that both pre- and postoperative radiotherapy can prevent heterotopic ossification after hip surgery. This comparison was clinically tested in a randomized study. PATIENTS AND METHODS: From June 1992 to September 1993, 84 patients with high risk for the development of heterotopic ossification were randomized. The treatment concept consisted either of preoperative radiotherapy within four hours prior to surgery (arm A) or postoperative radiotherapy within 72 hours following hip surgery (arm B). Preoperative radiotherapy was given in one fraction of 7 Gy, while the postoperative radiotherapy was delivered in five fractions of each 3.5 Gy (total 17.5 Gy). All patient variables (age, sex, prior surgery) and predisposing risk factors were comparable in both treatment arms. For the radiological assessment of heterotopic ossification according to (Brooker-Score) X-rays of the pelvis or hip were evaluated which had been taken immediately pre- and postoperatively as well as at least six months following surgery and prophylactic irradiation. The functional hip status was evaluated pre- and postoperatively using the Harris-Score. Cases in which the Brooker- and/or Harris-Score worsened during the postoperative follow-up as compared to the pre- and immediate postoperative situations were considered as treatment failures. RESULTS: Of 44 patients with at least six months follow-up 41 (93%) experienced a successful prophylaxis. Two failures were observed in the preoperative and one in the postoperative group. The prophylactic efficacy was not influenced if the pre- or postoperative interval was longer than prescribed. All intra- and postoperative complications were comparable for both treatment groups. The mean interval to partial strain (50% body weight) of the operated hip was longer in the preoperative group (mean 19 +/- 27 days) as compared to the postoperative group (mean 8 +/- 13 days). With respect to full strain (100% body weight), the results were equal in both groups. The functional hip status decreased in two patients. Again the mean overall improvement in the postoperative group was larger (mean 42.7 +/- 17.1 points) as compared to the preoperative group (mean 34.3 +/- 13.7 points). CONCLUSIONS: Preoperative and postoperative radiotherapy have equal prophylactic efficacy to prevent heterotopic ossification following hip surgery. The main advantage of preoperative radiotherapy are the simple management of the patient, the reduction of possible complications associated with transport and positioning of the patient in the postoperative period as well as excellent acceptance of this treatment concept by patients, nurses and staff.     

Treatment of postoperative nausea and vomiting with single intravenous doses of dolasetron mesylate: a multicenter trial. Dolasetron Mesylate PONV Treatment Study Group

This study was conducted to determine the efficacy and safety of four intravenous (I.V.) doses of dolasetron, an investigational 5-HT3 receptor antagonist, for the treatment of postoperative nausea and/or vomiting (PONV) after outpatient surgery under general anesthesia. This multicenter, randomized, double-blind trial compared the antiemetic efficacy of 12.5, 25, 50, or 100 mg I.V. dolasetron with placebo over 24 h using complete response (no emetic episodes and no rescue medication), time to first emetic episode or rescue medication, and patient nausea and satisfaction with antiemetic therapy as rated by visual analog scale (VAS). Of 1557 patients enrolled, 620 patients were eligible for treatment. Complete response rates for all dolasetron doses--12.5 mg (35%), 25 mg (28%), 50 mg (29%), and 100 mg (29%)--were significantly more effective than placebo (11%, P < 0.05). There was a significant gender interaction for complete response (P < 0.01). Of the patients in the 25-mg and 100-mg dose groups, 12% and 13%, respectively, experienced no nausea (VAS score < 5 mm) versus 5% in the placebo group (P < 0.05). There were no clinically relevant changes in vital signs or laboratory values and no trends with dose for adverse events. Dolasetron is effective for treating PONV and has an adverse event profile similar to that of placebo. The 12.5-mg dose was as effective as larger doses for complete response. IMPLICATIONS: Nausea and vomiting are common problems for postsurgical patients. In this study of 620 patients undergoing surgery, a 12.5-mg dose of intravenous dolasetron, a new serotonin-receptor blocker, was significantly more effective than placebo in treating established postoperative nausea and vomiting. Dolasetron 12.5 mg was as safe as placebo.     

Dolicho-arteriopathies (kinking, coiling, tortuoosity) of the carotid arteries: study by color Doppler ultrasonography

BACKGROUND: This work aimed to study extracranial carotid dolichoarterial disease in outpatients using color Doppler ultrasonography. METHODS: A total of 1220 outpatients, 620 males and 600 females, aged between 25 and 89 years old, were enrolled in the study. Subjects were divided into three groups according to age: under 60, between 60 and 70, over 70. Color Doppler ultrasonography was performed on the extracranial carotid using Acuson 128 XP/5 ultrasonograph and linear 7 MHz probe. Reference was made to Weibel and Field's classification for kinking, coiling and tortuosity for the classification of dolichoarterial disease. RESULTS: Of the 1220 subjects examined, 316 (25.9%) presented dolichoarterial disease, 126 males (39.9%) and 190 females (60.1%) with a male/female ratio of 1:1.5. Of the 316 cases of dolichoarterial disease, 171 (54.1%; 14% of the patients examined) showed kinking, 36 (11.4%; 2.9% of the patients examined) showed coiling, 109 (34.5%; 8.9% of the patients examined) showed tortuosity. Females were predominantly affected by kinking (male/female ratio: 1:1.8) and coiling (male/female ratio: 1:1.8), whereas the two sexes were equally affected by tortuosity (male/female ratio: 1:1). 76 out of 387 subjects (19.6%) presented dolichoarterial disease in the under-60 group, 128 out of 441 subjects (29.3%) in the 60-70-year-old group, and 112 out of 392 subjects (28.6%) in the over-70 group. The prevalence of dolichoarterial disease remained stationary after the age of 70, as the result of different findings in the two sexes, but continued to increase in males, while it diminished in females. This trend was clearly evident for kinking and coiling, whereas the prevalence of the two sexes was comparable with regard to tortuosity, slightly higher in females under the age of 70 and slightly higher in males after the age of 70. Of the 316 cases of dolichoarterial disease diagnosed, 297 (94%) were localised at the level of the internal carotid artery, with a predominance for the left (47.8%) artery compared to the right (22.1%), 14 (4.4%) at the level of the external carotid artery and 5 (1.6%) affecting the common carotid. Dolichoarterial disease was monolateral in 239 subjects (75.6%) and bilateral in 77 (24.4%). Of the bilateral cases, only one affected the common carotid, 76 the internal carotid with much higher presence of kinking and coiling compared to tortuosity. As far as concerns the site of dolichoarterial disease, no difference was observed between the sexes. CONCLUSIONS: In conclusion, non-invasive color Doppler ultrasonography, which is easily repeatable, can provide useful data for the morphological evaluation of dolichoarterial disease. Further studies in large populations which will enable the anatomofunctional aspects obtained using color Doppler ultrasonography to be correlated with clinical symptoms and possible effects on the central nervous system are now required for an improved clinical and prognostic assessment of dolichoarterial disease.     

Radiofrequency ablation in the therapy of supraventricular and ventricular arrhythmias

We summarize our experience with RF-ablation in 70 patients with symptomatic tachycardia (38 females and 32 males, age 25-73 years). 19 patients with AV reentry tachycardia in WPW-syndrome, 28 patients with node reentry tachycardia (AVNRT), 10 patients with ventricular tachycardia, 9 patients with atrial fibrillation and 4 patients with atrial flutter were treated. The primary success rate in the whole patient group is 87% and the longterm success rate (up to 1 year) 81%. RF-ablation of tachycardia is a highly effective therapy. The patients are free of symptoms and need no further medication. In patients with AVNRT in WPW-syndrome and ventricular tachycardia (structurally normal heart), RF-ablation is the therapy of choice. 32/70 patients were treated on an outpatient basis.     

Glaucoma after macular hole surgery

OBJECTIVE: The study aimed to report incidence and to assess risk factors of postoperative glaucoma in patients with stage 3 idiopathic macular hole treated with pars plana vitrectomy, removal of posterior hyaloid membrane, and perfluoropropane gas tamponade. DESIGN: The author performed a retrospective chart review and statistical analysis of risk factors of postoperative glaucoma by using chi-square statistics, Fisher's exact test, and logistic regression. PARTICIPANTS: Forty consecutive patients with stage 3 idiopathic macular hole who were operated on between January 1994 and December 1995 were studied. INTERVENTION: A pars plana vitrectomy, removal of posterior hyaloid membrane, and 14% perfluoropropane gas tamponade were done to all patients. MAIN OUTCOME MEASURES: Preoperative and postoperative intraocular pressure measurements were performed. RESULTS: Twenty-one (52%) of 40 patients experienced transient intraocular pressure elevation to more than 30 mmHg. Nine (22%) had pressure elevation within 2 to 4 hours, 6 (15%) in 24 hours, and 6 (15%) in 1 week after surgery. Three patients, including one with a history of preoperative ocular hypertension, required extended topical antiglaucoma medication. Factors of age, race, gender, lens status, preoperative intraocular pressure (all preoperative intraocular pressure were 25 mmHg or less), and success in closure of macular hole were not to any statistically significant degree associated with postoperative pressure elevation. CONCLUSION: Glaucoma is a significant complication after stage 3 macular hole surgery even without adjunctive therapy. Usually happening within the first postoperative week, elevation of intraocular pressure in most cases is transient and can be controlled by medication. However, extended medication might become necessary in some cases.     

Comparison of routine and selective endoscopic retrograde cholangiography before laparoscopic cholecystectomy

To evaluate the role of endoscopic retrograde cholangiography (ERC) before laparoscopic cholecystectomy, we compared the frequency of concomitant common bile duct stones, their clinical outcome, and the frequency of bile duct injury between a group of 128 patients with routine preoperative ERC (group A) and 1010 patients with selective ERC (group B). Overall, 48 patients (4.2%) had duct stones, but the predictive signs were absent in six of them (12.5%). The stones were demonstrated by ERC and removed by sphincterotomy in all 11 patients in group A. Of 37 patients in group B, 22 were diagnosed by selective ERC and underwent endoscopic removal. Of four patients whose stones were found by operative cholangiography, one had immediate open surgery, another passed a stone spontaneously, and the other two underwent postoperative sphincterotomy, which failed in one. The stones were not recognized until pain recurred in the remaining 11 patients. Sphincterotomy was successful in nine patients but failed in the other two. Thus postoperative sphincterotomy failed in 3 of 13 patients (23%), necessitating open surgery. Forty-two patients overall (3.7%) had aberrant biliary tract anatomy, which did not lead to bile duct injury in any of the patients. Morbidity of routine ERC (3.1%) was lower than that of selective ERC (7.4%) (p < 0.05). It should be noted that a certain proportion of duct stones may be missed by selective ERC, necessitating laparotomy when sphincterotomy fails. The routine use of preoperative ERC may be justified at institutions where the expertise is available, at least until laparoscopic lithotomy becomes easy.     

Thrombotic thrombocytopenic purpura associated with pregnancy

The prevalence of syphilis and its cardiovascular complications were investigated in the living population more than 60 years of age. The prevalence of positive serologic test for syphilis (STS) were 16.9% (124/736) in males and 17.1% (236/1380) in females, which were not statistically different. Aortic regurgitation (AR) was significantly more frequent in those with positive STS (9.68% in males, 5.08% in females) compared with negative STS (0.98% in males, 1.75% in females) in both sexes (p less than 0.01) and it was marked in males. AR with positive STS had a significantly lower minimal blood pressure than AR with negative STS (p less than 0.05). Calcifications in the ascending aorta were noticed in 5 out of 24 syphilitic AR. Myocardial infarctions were almost equally found among those with positive STS (1.67%) and negative STS (1.65%), and 2 out of 6 syphilitic cases were complicated by AR. The measurement of the aortic width was not valuable for the diagnosis of uncomplicated syphilitic aortitis.     

Oral contraceptives enhance the risk of clinical manifestation of venous thrombosis at a young age in females homozygous for factor V Leiden

In 29 patients (17 females) homozygous Arg 506 Gln mutation (FV Leiden) was identified. 25 had been investigated because of venous thromboembolism (VTE); four asymptomatic patients were found during family studies. The first VTE had occurred significantly earlier in females (median age [m] 26 years, range 17-49) than in males (m=38 years, range 21-82) (P=0.01). 12 females (80%) had taken oral contraceptives (OC, estrogen content 0.02-0.1 mg) for 6-150 months prior to thrombosis. Further triggering conditions in females were hormone replacement (n=1) and pregnancy (n=2). In 8/10 males the first VTE had occurred spontaneously--in two after surgery. The sites of VTE were deep vein thrombosis, pulmonary embolism, caval vein thrombosis and superficial thrombophlebitis. From our data we conclude that OC medication is the most important precipitating factor for VTE in females with homozygous FV Leiden.