Suprachoroidal hemorrhage. Clinical features and results of secondary surgical management

PURPOSE: The purposes of this study are to identify clinical features in eyes with suprachoroidal hemorrhage which portend a poor visual prognosis and to determine visual outcome in these eyes after secondary surgical management of suprachoroidal hemorrhage. METHODS: This was a retrospective study of 106 patients with suprachoroidal hemorrhages occurring in association with trauma (35), cataract surgery (30), glaucoma surgery (17), penetrating keratoplasty (6), corneal perforation (5), secondary lens implantation (3), pars plana vitrectomy (3), and other causes (7). RESULTS: Five (10%) of 49 eyes with a suprachoroidal hemorrhage and an initial retinal detachment had a visual outcome of 20/200 or better compared with 21 (43%) of 49 eyes without a retinal detachment. The presence or absence or a retinal detachment could not be determined in eight patients and all eight of these patients had a poor visual outcome. Sixteen (20%) of 82 eyes with a 360 degrees suprachoroidal hemorrhage had a visual outcome of 20/200 or better compared with 10 (47%) of 21 for those with suprachoroidal hemorrhage limited to one or two quadrants. The extent of the hemorrhage could not be determined in three eyes. Overall, 34% (14/41) of the patients with suprachoroidal hemorrhage who had a secondary surgical procedure achieved a visual outcome of 20/200 or better. Forty-three percent (6/14) who had a suprachoroidal hemorrhage during or after cataract surgery and who were treated with secondary surgical management achieved a visual outcome of 20/200 or greater. CONCLUSION: Clinical features associated with a poorer visual outcome included initial or indeterminate retinal detachment and 360 degrees suprachoroidal hemorrhage. Limited suprachoroidal hemorrhage without initial retinal detachment usually has a good visual prognosis and does not usually require secondary surgical intervention. However, if the former complication is present, secondary surgical intervention should be considered.     

Pathological changes according to the severity of asthma

BACKGROUND: There have been many studies concerning pathological changes in bronchial mucosa from asthmatics; however, few studies has been carried out to evaluate pathological changes according to the severity of asthma. OBJECTIVE: This study was designed to evaluate the cellular components in bronchoalveolar lavage fluid (BALF) and histological abnormalities in asthmatics according to the severity of asthma. METHODS: Bronchoalveolar lavages, bronchoscopic biopsies and ultrastructural examinations were performed in 13 asthmatics and 11 (BAL) or four (biopsies) non-asthmatic controls. The proportions of epithelial cells and correlations with PC20Meth which reflects bronchial hyperresponsiveness. Light microscopic examination revealed loss of epithelium, inflammatory cell infiltrations and thickening of the basement membrane which also showed significant correlation with PC20Meth. Hypertrophy of airway smooth muscles and hyperplasia of mucous glands were prominent in asthmatics but there was no difference according to the severity of asthma. Ultrastructural examination revealed that basement membrane thickening on light microscopic examination is due to the increased subepithelial collagen deposition with normal thickness of basal lamina. CONCLUSION: These data suggest that loss of epithelial cells, infiltration of inflammatory cells, especially eosinophils, and increased deposition of subepithelial collagen play major roles in determining the severity of asthma and non-specific bronchial hyperresponsiveness.     

Management of acquired rectourinary fistulas: outcome according to cause

PURPOSE: Acquired rectourinary fistulas, an infrequent complication of pelvic conditions, remain a therapeutic problem for which neither a widely accepted classification nor long-term outcome data are available. This study was designed to provide a new etiologic classification system and examine the success of various surgical therapies. It also looked at the need for permanent fecal or urinary diversion or radical excision depending on the cause of the fistula, i.e., benign vs. malignancy-related. METHODS: A retrospective analysis was made of 41 patients treated for acquired rectourinary fistulas between 1980 and 1995. Acquired rectourinary fistulas were classified as 1) benign but caused by Crohn's disease, trauma, perirectal sepsis, or iatrogenic injury; and 2) malignancy-related fistulas secondary to neoplasm, radiation, surgery, or combined tumor and treatment effects. Surgical interventions were classified as repair, excision, fecal diversion, and urinary diversion. RESULTS: Thirty-seven males and 4 females with acquired rectourinary fistula were identified with a mean age of 62 (range, 28-90) years. Nineteen patients had fistulas involving their urethras, and 22 patients had fistulas involving the bladder. Eight patients were not treated surgically; one was not treated because of an advanced malignancy, three because of patient preference, three because of sepsis, and one because of a poor general condition. Of the remaining 33 patients, nine had benign fistulas of which two were the result of Crohn's disease, two were the result of trauma, two were from an iatrogenic response, and three were from perirectal sepsis. Twenty-four patients had malignancy-related fistulas, and five patients had neoplasm at their fistula sites. The remaining 19 patients had malignancy-related fistulas that were the result of cancer treatments. Of the 19 malignancy-related fistulas, 5 were from radiation, 9 were from surgical trauma, and 5 were from radiation and surgical trauma. Forty-nine percent of the patients had undergone attempts at fistula treatment before referral. A resolution of symptoms after initial and reoperative surgery occurred more often in patients with benign fistulas (44 and 100 percent; mean, 1.8 surgeries per patient) compared with malignancy-related fistulas (21 and 88 percent; mean, 2.1 surgeries per patient). The rates of permanent fecal, urinary, and fecal plus urinary diversion were also lower for benign fistulas (11, 0, and 33 percent) compared with malignancy-related fistulas (13, 8, and 54 percent). Permanent diversion was avoided in 56 percent of the benign fistulas but in only 25 percent of the malignancy-related fistulas. The rates of excisional and radical (ileal conduit) surgery were lower for benign fistulas than for malignancy-related fistulas (44 and 11 percent vs. 50 and 54 percent). CONCLUSION: Successful management of rectourinary fistulas typically requires aggressive reoperative therapy with permanent diversion more often required for malignancy-related fistulas. Better outcomes can be anticipated for benign fistulas.     

Costs of asthma according to the degree of severity

An increase in asthma-related morbidity and mortality has been reported recently, resulting in a substantial increase in the economic impact of this condition. Little information is available relating to the costs of asthma depending on the degree of severity of the disease. Total, direct and indirect costs generated by asthma patients who sought medical care for asthma control over a one-year period in a northern area of Spain were determined. Data were obtained from the patients themselves and severity of illness was classified into mild, moderate and severe according to the International Consensus Report on Diagnosis and Treatment of Asthma, 1992. The average total annual asthma-derived cost was estimated at US$2,879 per patient, with averages of US$1,336 in mildly asthmatic patients, US$2,407 in moderate asthma and US$6,393 in severe asthma. At all levels of severity, indirect costs were twice as high as direct costs, and at the same degree of severity, direct costs due to medication and hospitalization were higher among females than males. A minority of severe asthmatics incurred some 41% of the total costs. The cost of asthma was surprisingly high and varied substantially depending on the degree of severity of the disease. Further knowledge of the costs of asthma across various levels of severity will contribute to a better characterization of optimal intervention strategies for asthma care.     

Evaluation of occupational diseases according to their risk and severity

Article covers approaches to evaluation and forecasting of occupational risk for workers exposed to occupational hazards, formulates a concept to evaluate occupational disease according to risk and severity categories, gives an integral parameter for qualitative and quantitative analysis of group risk for one occupational disease or their combination. Trials proved acceptability of the method for group risk evaluation according to WHO concept concerning occupational diseases.     

Process and outcome quality in giant cell tumor in relation to surgical management

Giant-cell bone tumors display a locally aggressive growth pattern, frequently recur if no adjuvant treatment is given, and may potentially metastasize. By virtue of their biological behavior and typically juxta-articular localization, giant-cell bone tumors require specific surgical management. Thus, an intralesional tumor excision must be supplemented by adjuvant bone cementing, possibly combined with instillation of phenol or cryotherapy. These combined treatment modalities assure a high-quality procedure, defined as the actual way medical care is delivered, by promoting the quality of the outcome, defined as the effect of a medical procedure on the patient's state of health.     

Assessment of the severity of grave cranio-cerebral injury and its outcome according to the state of energy metabolism in the brain]

A dynamic study of the arteriovenous oxygen and lactic acid content difference, as well as a study of the CSF content of the lactic acid in patients with a severe craniocerebral trauma permitted to evaluate the severity of the pathological process and the results of its treatment. A growing production of lactic acid by the brain and its progressive accumulation in the CSF to a high level as 45-50 mg%, and a sharp dissociation between the increasing lactate level in the CSF and its growing concentration in the venous blood flowing from the brain is a prognostic sign of an unfavourable course and outcome of the disease.     

Injury severity and outcome: A meta-analysis of prospective studies on TBI outcome.

Objective: The recent movement to apply evidenced-based approaches to medical and rehabilitation care has increased the importance of approximating outcomes as early in the recovery process as possible. The relationship between injury severity and outcome following traumatic brain injury (TBI), however, has remained unclear due to the variety of predictor and criterion variables used throughout the literature. Method: A meta-analysis of eligible prospective studies that assessed the bivariate association between injury severity and outcome at 1-year postinjury was conducted. Results: Twenty-six studies met the inclusion criteria (total N = 21,050 patients). Injury severity was a significant predictor of outcome at 1-year postinjury (r = .257). Homogeneity testing by means of the Q test, Q(n), indicated that injury severity measurement, Q(68) = 1140.76, p     

Symptomatic liver cyst: special reference to surgical management

OBJECTIVE: To evaluate the outcome of a new modification of percutaneous needle suspension, using a bone anchor system for fixing the suture at the public bone, and to compare the results with those published previously. PATIENTS AND METHODS: From March 1996, 37 patients with stress urinary incontinence (> 2 years) were treated using a bone anchor system. On each side the suture was attached to the pubocervical fascia and the vaginal wall via a broad 'Z'-stitch. A urodynamic investigation performed preoperatively in all patients confirmed stress incontinence and excluded detrusor instability. The outcome was assessed by either by a clinical follow-up investigation or using a standardized questionnaire, over a mean follow-up of 11 months (range 6-18). RESULTS: In the 37 patients, the procedure was successful in 25 (68%), with 16 (43%) of the patients completely dry and nine (24%) significantly improved. Removal of the bone anchor and suture was necessary in two patients, because of unilateral bacterial infection in one and a bilateral soft tissue granuloma in the other. One bone anchor became dislocated in a third patient. In two cases where the treatment failed, new detrusor instability was documented urodynamically. Minor complications were prolonged wound pain in 10 (26%) and transient urinary retention or residual urine in 12 patients (32%). CONCLUSION: The poor success rate in the study corresponds with the long-term results of conventional or modified needle suspension procedures and does not reinforce the optimistic results of bone anchoring published recently. Because of the poorer long-term results from percutaneous needle suspension than from other techniques of open retropubic bladder neck suspension, it remains questionable whether percutaneous needle suspension should be considered a first-line procedure for the treatment of female stress urinary incontinence.     

Current management of pelvic fractures: a combined surgical-angiographic approach to hemorrhage

Pelvic retroperitoneal hemorrhage after pelvic fracture accounts for the high mortality and morbidity associated with this injury, a concept confirmed by analysis of 357 patients with pelvic fractures at the University of Kentucky Medical Center. The overall mortality of 9.8% was almost exclusively limited to patients with unstable fractures or crush injuries. The reliability of diagnostic peritoneal lavage in excluding associated intraperitoneal injury and the recognized utility of angiographic methods in identifying the site of bleeding constitute a major advance in management. Prompt angiographic definition of injury to major arterial trunks can lead to early operative intervention for direct vascular control. Bleeding from branches of the hypogastric artery can be managed effectively by clot embolization technic, avoiding operation. Venous bleeding is best treated by tamponade in most cases.     

Intracranial hemorrhage: diagnosis and emergency management

Intracranial hemorrhages are an important cause of acute neurologic disease presenting in the emergency setting. To optimize outcome, it is important that the physician quickly recognize intracranial hemorrhages. To minimize mortality and neurologic morbidity, it is often necessary to initiate urgent therapy in the emergency rooms and to obtain neurosurgical consultation in order to pursue early surgical therapy. This article discusses the recognition and early treatment of the various types of intracranial hemorrhages.     

Myringoplasty in children: factors influencing surgical outcome

Experiments were designed to evaluate whether guanosine 3',5'-cyclic monophosphate (cGMP)-mediated mechanisms contribute to vasodilation via propofol in rat mesenteric resistance arteries. Ring segments were suspended in the myograph system for isometric tension recording, and responses to propofol were tested in the presence and absence of methylene blue (MB), an inhibitor of guanylate cyclase. At concentrations > or = 1 microM, propofol caused concentration-dependent relaxation of vessel rings precontracted with U46619 (a thromboxane analog). The effect was not affected by N-monomethyl-L-arginine (L-NMMA; 50 microM). MB (5 microM) reversed propofol-induced vasodilation by 30% (p < 0.001). In contrast, MB has no effect on nifedipine-inhibited vasocontraction. The propofol-induced relaxation was further tested in rings incubated in Ca2+-free solution. U46619-induced contractions were significantly reduced by propofol (40 microM) but not by nifedipine (1 microM). Propofol reduced to a similar degree the contractions obtained to exogenously added calcium chloride in the absence and the presence of MB. Furthermore, propofol (10-100 microM) increased cGMP content in cultured bovine vascular smooth-muscle cells. Soluble guanylate cyclase inhibitors, such as MB and LY83583, attenuated this effect. This investigation suggests that propofol-induced relaxations in small arteries, in addition to inhibition of calcium influx, are mediated by increases of cGMP in the smooth muscle cells.     

Recurrent intracranial hemorrhage due to postpartum cerebral angiopathy: implications for management

BACKGROUND: Postpartum cerebral angiopathy as a cause of hemorrhagic stroke in young women is not well recognized. It is unknown whether this disorder represents a true inflammatory vasculitis or transient vasoconstriction related to the hormonal events of pregnancy and the postpartum period. CASE DESCRIPTION: A 39-year-old woman presented with postpartum intracranial hemorrhage and, 32 months later, with subarachnoid hemorrhage, following normal pregnancies. Cerebral angiography obtained after each stroke demonstrated diffuse irregularity of branches of the middle cerebral arteries consistent with a diffuse vasospastic process or classic vasculitis. Neurological deficits resolved and results of a transcranial Doppler study normalized after a short course of high-dose corticosteroids following the second stroke. CONCLUSIONS: Postpartum cerebral angiopathy should be considered in the differential diagnosis of recurrent intracranial hemorrhagic stroke in young women. Recognition of this condition may preclude treatment with potentially toxic therapies for vasculitis and will have important implications for counseling women on subsequent pregnancies.     

The impact of initial surgical management on outcome in young patients with differentiated thyroid cancer

BACKGROUND/PURPOSE: It is generally believed that differentiated thyroid cancer (DTC) in young patients has an excellent prognosis. This calls into question the need for more extensive surgical ablation of the thyroid gland with attendant risks of surgical complications. The purpose of this report was to investigate both the incidence of surgical morbidity and the impact of surgery on locoregional recurrence of disease. METHODS: The authors reviewed the clinical course of patients under 22 years of age treated for DTC within Department of Defense hospitals since 1950. Data were available for determination of surgical morbidity in 126 and for outcome in 105. RESULTS: The incidence of postoperative hypocalcemia was 17% and of recurrent laryngeal nerve injury 3%. Factors predictive of morbidity were (1) more extensive thyroid surgery (P = .023), and (2) the presence of gross tumor invasion (P = .022). The incidence of neck recurrence was analyzed among a cohort of 90 patients. A total of 19 (21%) patients had a local recurrence. The median time to recurrence was 24 months. The factor predictive of recurrence was the presence of gross invasion (P = .0001). A strong trend toward locoregional recurrence was found among patients with metastatic disease to more than five cervical nodes (P < .08). The primary operations on the thyroid and regional nodes were not significant predictors of neck recurrence. Among these 19 patients there have been no deaths, but 25% had persistent disease at a mean follow-up of 12.6 years. CONCLUSIONS: The incidence of surgical morbidity does increase with more extensive surgery. Outcome is predicted primarily by the initial extent of disease.     

Ureteropelvic junction obstruction: relation of etiology and age at surgical repair to clinical outcome

Ureteropelvic junction (UPJ) obstruction is a congenital anomaly either caused by intrinsic narrowing of the upper ureter or by extrinsic pressure on the ureter caused by aberrant vessels or fibrous bands. We reviewed 121 cases of pyeloplasties performed in our department for UPJ obstruction. The cases were grouped by age and by the underlying pathology. Postoperative urographic evaluation showed that dismembered pyeloplasty was successful in 98.4% of the patients, with no significant difference between age groups. Persistence or recurrence of preoperative symptoms occurred in some patients (16.6%). Extrinsic obstruction of the ureter was associated with better postoperative clinical results and less recurrence of symptoms.     

Pituitary tumors: surgical and medical management

The pituitary gland has been termed the 'master gland' because of the myriad of hormones that emanate from it that are vital for normal homeostasis as well as growth and development. Primary tumors of this region are frequent and account for up to 10% of intracranial tumors. Pituitary tumors are monoclonal in origin, and may arise from any of the different cell types of the pituitary gland. Hence, these tumors may be manifest by their hormonal secretions. This may lead to profound and striking physiological changes attributable, for example, to prolactin, growth hormone, or ACTH excess. The central location of the pituitary gland also leads to characteristic compressive symptoms. This review will explore the clinical presentations of growth hormone, ACTH, and prolactin secreting tumors as well as the non-secreting pituitary tumors. Advances in neuroimaging and neuropharmacology have resulted in changes in our treatment of these tumors. Treatment modalities including surgical, medical, and radiation therapy will be addressed. The treatment of choice is dictated by the type of tumor and the nature of the excessive hormonal expression. Outcomes and efficacy of treatment are discussed.     

Risk of complication in perforated duodenal ulcer operations according to the surgical technique employed

We prospectively analyzed a homogeneous group of 65 patients with perforated duodenal ulcer whose medical condition (no perioperative shock, no associated disease, underwent laparotomy within 12 hours after perforation, and an APACHE II score below 11) would have little effect on the outcome of surgery to study the influence of the surgical procedure (suture closure, vagotomy, or gastrectomy) on the morbidity and mortality rate. Thirty-three patients (51%) underwent vagotomy, 25 (38%) simple suture closure, and seven (11%) gastrectomy. Five patients (8%) suffered postoperative complications, two (3%) required further operation, and one (1.5%) died of pulmonary sepsis. Statistical analyses revealed that "vagotomy" presented significantly better results than did "simple suture" and "gastrectomy" that had similar results. The type of surgery, however, was not a significant risk factor in predicting complications in this sample. This study points out the need to stratify the perforated duodenal ulcer patients for accurate investigations. It also shows that definitive operations (gastrectomy or vagotomy) do not increase surgical risk in this group of patients, and, considering the poorer results with simple suture closure compared to vagotomy, the latter is an attractive option because it also treats the underlying ulcer disease.     

Substance-dependent, conduct-disordered adolescent males: severity of diagnosis predicts 2-year outcome

Most delinquent youths have conduct disorder (CD), often with comorbid substance use disorder (SUD), attention-deficit/hyperactivity disorder (ADHD) and depression. Some youths' conduct problems later abate, while those of others persist into adult antisocial personality disorder. Earlier CD onset and ADHD reportedly predict persisting antisocial problems, but predictors of persisting SUD are poorly understood. Males aged 13-19 years (n = 89), most referred by criminal justice and social service agencies, received residential treatment for comorbid CD and SUD. They had diagnostic assessments for SUD at intake and for CD, ADHD, and depression (as well as drug-use assessments) at intake and 6, 12 and 24 months later. At intake nearly all had DSM-III-R substance dependence (usually on alcohol and marijuana) and CD with considerable violence and criminality. The 2-year follow-ups revealed improvements in criminality, CD, depression and ADHD, but substance use remained largely unchanged. Various aspects of conduct, crime and substance outcomes at 2 years were predicted by intake measures of intensity of substance involvement, and by CD severity and onset age, but not by severity of either ADHD or depression, nor by treatment duration. Earlier CD onset, more severe CD and more drug dependence predicted worse outcomes, supporting the validity of these diagnoses in adolescents.