Dacryocystitis associated with malignant lymphoma of the lacrimal sac

BACKGROUND: Tumors of the lacrimal sac are unusual, and lymphomas of the lacrimal sac are quite rare. Four patients with a history of well-differentiated, small cell lymphoma or chronic lymphocytic leukemia presented with either acute or chronic dacryocystitis and epiphora due to lymphomatous infiltration of the lacrimal sac. METHODS: All four patients underwent dacryocystorhinostomy with lacrimal sac biopsy. All tissues underwent complete histopathologic evaluation including immunohistochemical studies for cell surface markers and, in addition, were compared with previous biopsies performed for the initial diagnosis of lymphoma. FINDINGS: All biopsies demonstrated small cell well-differentiated lymphoma on histologic and immunofluorescent examination. No patient demonstrated orbital involvement on computed tomography. One patient had previously diagnosed chronic lymphocytic leukemia and one patient demonstrated diffuse lymph node involvement on postoperative systemic evaluation. All four patients underwent additional chemotherapy. No recurrence of dacryocystitis or epiphora occurred. CONCLUSION: Four patients presented with dacryocystitis secondary to lacrimal sac lymphoma. Lymphomatous lacrimal sac infiltration is an unusual cause of dacryocystitis. Biopsy of the lacrimal sac plays a diagnostically important role in dacryocystorhinostomy even in the absence of obvious tumorous involvement of the lacrimal sac mucosa.     

Significance of arterial circulation disorders for the planning of hip prosthesis interventions

Between 1980 and 1990 a total of 17 patients who had undergone or had been selected for total hip replacement were treated in the Department of Surgery at Münster University. Angiographic studies performed because of persistent symptoms revealed circulatory disorders of the pelvic floor. Vascular surgery was necessary to eliminate symptoms in these patients. Postoperative complications in 3 patients following total hip replacement were also only eliminated by vascular surgery. In the present authors' view, failure to recognize preoperatively existing arterial circulation disorders can lead to misdiagnosis and severe postoperative complications. Every hip replacement operation should be preceded by a thorough clinical and--if doubt persists--an angiological examination. Documented arterial circulation disorders should be eliminated by vascular surgery prior to hip surgery.     

Prevention of deep-vein thrombosis after total hip arthroplasty. Comparison of warfarin and dalteparin

The effectiveness and safety of warfarin were compared with those of a low-molecular-weight heparin (dalteparin) for the prevention of deep-vein thrombosis after total hip arthroplasty in a prospective, randomized, multi-institutional trial. Patients who were older than eighteen years of age and were scheduled to have an elective primary or revision total hip arthroplasty were eligible; 580 patients were randomized, 550 had the operation and received prophylaxis, and 382 had evaluable venograms. Prophylaxis was provided either with warfarin beginning the night before the operation or with dalteparin beginning two hours before the operation and was continued until venography was performed. Bleeding was assessed on the basis of intraoperative blood loss, transfusion requirements, a decrease in hematocrit, and clinically identified bleeding complications. The prevalence of deep-vein thrombosis was found to be significantly lower in the patients who had received dalteparin than in those who had received warfarin (twenty-eight [15 per cent] of 192 patients compared with forty-nine [26 per cent] of 190 patients; p = 0.006). Deep-vein thrombosis occurred in the calf veins of twenty-one patients (11 per cent) who had received dalteparin and of forty-three patients (23 per cent) who had received warfarin; this difference was significant (p = 0.003). Proximal deep-vein thrombosis occurred in ten patients (5 per cent) who had received dalteparin and in sixteen patients (8 per cent) who had received warfarin; however, with the numbers available, no significant difference could be detected (p = 0.185). We also could not detect a significant difference with regard to the intraoperative and postoperative blood loss, the decrease in hematocrit, and the prevalence of major bleeding complications between the two groups; however, the patients who had received dalteparin had a significantly higher prevalence of bleeding complications involving the operative site (p = 0.03), and a significantly greater percentage required postoperative transfusions (p = 0.001). We concluded that preoperative prophylaxis with dalteparin is significantly more effective than that with warfarin in preventing deep-vein thrombosis after total hip arthroplasty. The greater effectiveness of dalteparin must be considered, however, in light of an increased need for postoperative transfusions and an increase in the prevalence of wound-related bleeding complications.     

Postoperative mortality after total hip arthroplasty. An analysis of deaths after two thousand seven hundred and thirty-six procedures

We retrospectively determined the prevalence and nature of mortality as many as ninety days after 2736 primary and revision total hip arthroplasties performed in 2002 patients by one surgeon at a teaching hospital between January 1969 and December 1996. All but seventy-one of the patients had received prophylaxis against venous thromboembolic disease. There were no intraoperative deaths, and no events during the operation could be linked directly to postoperative mortality. Eight deaths (mortality rate, 0.3 per cent) occurred within ninety days after the 2736 procedures. Four deaths (mortality rate, 0.15 per cent) occurred during the initial hospitalization. The cause of seven of the deaths was determined. Three patients died as a result of preexisting disease (severe hepatorenal disease, metastatic esophageal cancer, or severe cardiac disease), and one patient died from sepsis with a gram-negative organism during a thoracotomy eight days postoperatively. A bleeding complication that occurred while the patient was receiving warfarin therapy led to the death of two other patients; one of these deaths occurred in 1974 and the other, in 1982. At the time that these patients were managed, the desired prothrombin time was considered to be twice the control value. The remaining patient, who had had a clip placed on the inferior vena cava after a pulmonary embolus occurred in 1970, died secondary to acute, severe thrombosis of this vessel after a total hip arthroplasty in 1971. The patient for whom the cause of death was not determined had had an artificial aortic valve and had been receiving chronic warfarin therapy. She died suddenly eighty-nine days postoperatively; no autopsy was performed. No patient died as the direct result of a known pulmonary embolus. No deaths related to venous thromboembolic disease or its prophylaxis or treatment occurred after 1982 (1458 operations). We attribute this, in part, to reduced levels of warfarin prophylaxis and improved management with warfarin. The ninety-day postoperative mortality rate after 2736 procedures performed over nearly three decades was low (0.3 per cent). This span of time included the period before the introduction of many current improvements in perioperative care, such as routine intubation of patients under general anesthesia, continuous monitoring of the electrocardiogram intraoperatively, and blood-gas determinations. When the patients who died as a result of known, severe preexisting disease were excluded, the mortality rate was 0.18 per cent (five of 2733).     

Total wrist arthroplasty in rheumatoid arthritis. A long-term clinical review

Fourteen total wrist arthroplasties performed in 13 patients with rheumatoid arthritis between 1978 and 1982 were reviewed to evaluate long term outcome. Most patients had Stages III or IV rheumatoid arthritis at the time of surgery. Pain was the primary presenting complaint in 87%. Average followup was 6.5 years (range, 3.5-11.5 years). Pain relief was achieved in 86% of patients. Using objective data obtained from their wrist scores, 72% of the patients had a good result, 14% had a fair result, and 14% had a poor result. No patient had an excellent result. Twenty-seven percent suffered postoperative complications related to their surgical procedure. Although these results help confirm the usefulness of total wrist arthroplasty as an alternative to arthrodesis of the wrist, it is a technically demanding procedure, and should be reserved for the patient who has severely involved arthritis. Additional improvements are needed to decrease the currently high complication and failure rate.     

Treatment of infection with débridement and retention of the components following hip arthroplasty

Forty-two patients (forty-two hips) who had an infection following a hip arthroplasty were managed with open débridement, retention of the prosthetic components, and antibiotic therapy. After a mean duration of follow-up of 6.3 years (range, 0.14 to twenty-two years), only six patients (14 per cent) -- four of nineteen who had had an early postoperative infection and two of four who had had an acute hematogenous infection -- had been managed successfully. Of the remaining thirty-six patients, three (7 per cent of the entire group) were being managed with chronic suppression with oral administration of antibiotics and thirty-three (79 per cent of the entire group) had had a failure of treatment. All nineteen patients who had a late chronic infection were deemed to have had a failure of treatment. Débridement had been performed at a mean of six days (range, two to fourteen days) after the onset of symptoms in the patients who had been managed successfully and at a mean of twenty-three days (range, three to ninety-three days) in those for whom treatment had failed. Débridement with retention of the prosthesis is a potentially successful treatment for early postoperative infection or acute hematogenous infection, provided that it is performed in the first two weeks after the onset of symptoms and that the prosthesis previously had been functioning well. In our experience, this procedure has not been successful when it has been performed more than two weeks after the onset of symptoms. Retention of the prosthesis should not be attempted in patients who have a chronic infection at the site of a hip arthroplasty as this approach universally fails.     

Lymphopenic effect of carbamazepine in a patient with chronic lymphocytic leukemia

OBJECTIVE: To report a dramatic and reproducible suppressive effect of carbamazepine on circulating lymphocytes in an elderly woman with chronic lymphocytic leukemia. CASE SUMMARY: An elderly woman taking phenytoin for a stroke-associated seizure disorder had lymphocyte count of 28,800 x 10(6) cells/L. Speculating an unusual lymphadenopathic effect of the phenytoin therapy, carbamazepine therapy was substituted. After 15 weeks of carbamazepine treatment, the lymphocyte count declined to 3200 x 10(6) cells/L. Because of severe diarrhea, carbamazepine therapy was stopped and phenytoin therapy was reinstituted. At the end of 4 months of phenytoin treatment, the lymphocyte count had increased to 23,200 x 10(6) cells/L. Phenytoin therapy was discontinued and carbamazepine therapy was begun. The lymphocyte count decreased to 10,700 x 10(6) cells/L. Severe diarrhea recurred and phenytoin treatment was reinstituted. Over 12 days the lymphocyte count increased to 28,900 x 10(6) cells/L. Phenytoin therapy was stopped and valproic acid therapy was started. The lymphocyte count continued to increase during valproic acid therapy, reaching a peak of 114,300 x 10(6) cells/L. DISCUSSION: In this patient with chronic lymphocytic leukemia, carbamazepine therapy had a significant and reproducible lymphopenic effect that was readily reversible upon discontinuation of the drug. Unfortunately, this effect was associated with severe diarrhea, preventing further attempts at exploiting this potentially beneficial action. CONCLUSIONS: Carbamazepine had a reproducible suppressive effect on lymphocyte counts in an elderly patient with chronic lymphocytic leukemia. This unique observation raises the possibility that carbamazepine therapy may have a useful effect in patients with chronic lymphocytic leukemia.     

Total hip arthroplasty with porous-coated prostheses fixed without cement in patients who are sixty-five years of age or older

We reviewed the results of 212 total hip arthroplasties performed without cement in 203 unselected, consecutive patients who were sixty-five years of age or older. The outcome was known for 196 hips, thirty-seven of which had been followed until the death of the patient and 159 of which had been followed for a minimum of five years. A reoperation was done in 4 percent (seven) of the 196 hips. These reoperations included one revision because of loosening of the stem and five revisions of the cup. Three of the acetabular revisions were done because of fracture due to polyethylene wear; one, because of recurrent dislocation; and one, because of polyethylene wear and a fracture due to lysis. In the seventh reoperation, a cup and stem were exchanged because of infection. The probability that a hip prosthesis would survive twelve years without a reoperation was 0.92 (95 percent confidence interval, 0.85 to 0.99). We evaluated the clinical results for 152 patients who had not had a reoperation and had been followed for at least five years (mean, 8.5 years; range, five to fourteen years). Of these patients, thirteen (9 percent) had pain that limited activity: five (3 percent) had pain in the thigh (four patients) or groin (one patient), and eight (5 percent) had trochanteric pain and tenderness. One hundred and forty-four (95 percent) of the patients noted an improvement in overall function, and 149 (98 percent) reported satisfaction with the outcome. One hundred and thirty-five hips that were not revised were followed radiographically for at least five years (mean, 8.2 years; range, five to fourteen years). In this group, osteolysis was observed in three hips (2 percent); loosening of the cup, in three (2 percent); and loosening of the stem, in one (1 percent). Stress-shielding was seen on the two-year postoperative radiographs of forty-five (26 percent) of the 174 hips that were followed for at least that duration. The prevalence of osteolysis, loosening of a component, and reoperations was no greater in this subgroup than in the overall group. These results indicate that total hip arthroplasty without cement can be successful in older patients. This study also provides a reference for comparison with the results of total hip arthroplasty performed with cement and those of so-called hybrid total hip arthroplasty (an acetabular component fixed without cement and a femoral component fixed with cement) in patients who are sixty-five years of age or older.     

Effect of inpatient rehabilitation measures on patients with total hip endoprostheses--evaluation 15 months after operation

159 patients were examined approximately 15 months after hip arthroplasty. 116 of these patients have had at that time point a postoperative 4 week hospital stay for rehabilitation. A score that considered pain at motion and at rest, maximal walking capacity and activity of daily living was used for evaluation. The preoperative conditions did not differ between patients that had their postoperative hospital stay for rehabilitation (n = 116) and those that did not (n = 43). The results at the time of examination were regarded as excellent (group 1; score 3) in 64 (40.3%) patients, as good (group 2; score 4) in 56 (35.2%) patients and as poor (group 3; score > or = 5) in 39 (24.5%) patients. The amount of patients with a hospital stay for rehabilitation was significantly (p = 0.025) higher in the patient groups with excellent or good results in comparison with the patients with poor postoperative outcome. The most excellent results were obtained in patients who had their rehabilitation within the first two months after surgery (p = 0.008). Apart from the above mentioned score the following-additionally assessed-parameters differed significantly between the 3 groups: hip mobility; pain elicited by pressure on the operated joint; pain in the contralateral hip or knee joints; consumption of analgetics; walking time for 15 meters; degree of handicap as assessed by the patient or the occupational therapist or the physician; coping with household activities (for females only). We conclude that a poor result of hip arthroplasty may be due not only to degenerative joint disease of the lower limbs but also (or in combination) to the lack of a postoperative hospital stay for rehabilitation.     

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.     

Operative treatment of hip fractures in patients with renal failure

The conditions of a hip fracture and renal failure cause particularly high mortality. Eight patients (average age, 63 years) who had operative treatment for nine hip fractures were studied retrospectively. Three had intertrochanteric fractures fixed with sliding compression screws, and five had femoral neck fractures (bilateral in one patient): two nondisplaced femoral neck fractures were fixed with percutaneous screws, and four displaced femoral neck fractures were treated with arthroplasties in three and percutaneous screws in one. Operative treatment was done when the patient was in medically stable condition (average, 8 days). Full weightbearing was allowed on the injured limb after surgery. Early morbidity analysis showed no wound infections, thromboembolic events, or hemorrhagic complications. The first year mortality was three (38%). Late morbidity included one nonunion and one sliding screw penetration. Total mortality at 6 years was seven (88%) patients, with an average postoperative survival time of 28 months. Preoperative ambulation was preserved in five of seven (71%) patients. One the basis of this study, it appears that a team approach to operative management including nephrologist and surgeon helps to reduce short term complications and mortality and allows such patients to be mobilized and regain ambulation.     

Long-term follow-up of patients with chronic lymphocytic leukemia (CLL) receiving fludarabine regimens as initial therapy

One hundred seventy-four patients with progressive or advanced chronic lymphocytic leukemia (CLL) have received initial therapy with fludarabine as a single agent or fludarabine combined with prednisone. The overall response rate was 78% and the median survival was 63 months. No difference in response rate or survival was noted in the 71 patients receiving fludarabine as a single agent compared with the 103 patients who received prednisone in addition. The median time to progression of responders was 31 months and the overall median survival was 74 months. Patients over the age of 70 years had shorter survivals. Patients with advanced stage disease (Rai III and IV) had a somewhat shorter survival than earlier stage patients. More than half the patients who relapsed after fludarabine therapy responded to salvage treatment, usually with fludarabine-based regimens. Second remissions were more common in patients who had achieved a complete remission on their initial treatment. The CD4 and CD8 T-lymphocyte subpopulations decreased to levels in the range of 150 to 200/microL after the first 3 courses of treatment. Although recovery towards normal levels was slow, the incidence of infections was low in patients in remission (1 episode of infection for every 3.33 patient years at risk) and decreased with time off treatment. There was no association of infections or febrile episodes with the use of corticosteroids or the CD4 count at the end of treatment and a poor correlation with the increase in CD4 counts during remission. Infectious episodes were less common in patients who had a complete response compared with partial responders. Richter's transformation occurred in 9 patients and Hodgkin's disease occurred in 4 patients. Five other patients died from other second malignancies. Fludarabine appears to be an effective initial induction therapy with a reasonable safety profile for patients with CLL.     

Prevention of heterotopic bone formation after acetabular fracture fixation by single-dose radiation therapy: a preliminary report

A common complication after acetabular fracture fixation is formation of heterotopic ossification (HO) in the soft tissues about the hip. We are reporting on the use of a single, low-dose radiation therapy regimen to prevent HO in the population of postoperative acetabular fracture patients. Thirty acetabular fracture patients who were at risk for HO after surgery were reviewed with an average follow-up of 12 months. Twenty-one of these patients received radiation therapy in the postoperative period according to a single dose protocol. Nine patients did not receive any prophylactic treatment for the prevention of HO during the same period. One patient from each of these categories was lost to follow-up. Of the 20 treated and followed patients, none developed HO higher than grade 2, and nine had no HO at all. None of the treated patients had any functional deficit due to HO, and none had any complications related to radiation treatment. Of the untreated patients, all had grade 2 HO or above. Three developed grade 4 HO and have undergone reoperation for resection of HO. Study weakness include the fact that the non-treated patients were significantly different from the treated patients in several ways; including the incidence of multiple trauma, head injury, and delay to surgery. No attempt was made to randomize patients prospectively, nor to directly compare the two groups. However, we can conclude, based on comparison with reported rates of HO formation, that single, low-dose radiation therapy is a safe and effective method for prevention of HO in the postoperative acetabular fracture patient. It is as effective as previously reported multidose regimens.     

Autosomal dominant overfolding of the helices

We report the case of a patient with chronic lymphocytic leukemia (CLL) who developed fatal intravascular autoimmune hemolytic anemia (AIHA) after fludarabine treatment. He had previously received several treatments including two courses of fludarabine. The direct antiglobulin test (DAT) was negative at diagnosis but was found to be positive with anti-IgG after the first fludarabine treatment. When the patient was treated again with fludarabine nine months later, the DAT became positive with anti-IgG and anti-C3d antiglobulins after the second course of treatment. Abrupt, fatal intravascular hemolysis occurred after the third course. The occurrence of severe AIHA in CLL patients treated with fludarabine has been reported by several authors. Physicians should be aware of the risk of severe AIHA in CLL patients with a history of AIHA or positivation of the DAT during previous fludarabine administration, or in case of secondary fixation of complement to the red cell membrane occurring during fludarabine treatment.     

2-Chlorodeoxyadenosine: a newer purine analog active in the treatment of indolent lymphoid malignancies

OBJECTIVE: To review the structure, mechanism of action, pharmacologic features, and clinical trial results of the newer purine analog, 2-chlorodeoxyadenosine (2-CdA). DATA SOURCES AND STUDY SELECTION: English-language medical literature review of more than 70 articles. DATA SYNTHESIS: 2-Chlorodeoxyadenosine is unique compared with traditional antimetabolite drugs in that it is equally active against dividing and resting lymphocytes, which may be especially important in indolent lymphoid malignancies, such as chronic lymphocytic leukemia, because most cells in these disorders are in the resting phase. In patients with alkylator-refractory chronic lymphocytic leukemia who were treated with 2-CdA, 44% achieved a response (4% complete responses, 40% partial responses), and 54%, scored as nonresponders, had a sustained reduction in their peripheral lymphocytosis. Patients with untreated chronic lymphocytic leukemia had an 85% response rate (25% complete responses, 60% partial responses). Patients with previously treated low-grade lymphoma achieved an overall response rate of 43%. The most striking clinical effects of this drug have been seen in hairy cell leukemia, in which a single course of therapy induces complete remissions in 85% of partial remissions in 12%. Activity has also been shown in cutaneous T-cell lymphoma and the myeloid leukemias. CONCLUSIONS: 2-Chlorodeoxyadenosine is a newer purine analog with potent activity in the treatment of indolent lymphoproliferative diseases and illustrates the model for rational drug development.     

Surface replacement hemiarthroplasty for the treatment of osteonecrosis of the femoral head

We reviewed the results of thirty-three femoral resurfacing procedures in twenty-five patients who had stage-III or early stage-IV osteonecrosis of the femoral head according to the classification system of Ficat and Arlet. There were no perioperative complications. Thirty hip prostheses (91 percent) survived for a minimum of five years. At a mean of 10.5 years (range, four to fourteen years) postoperatively, sixteen (62 percent) of the twenty-six hips with stage-III disease had a good or excellent Harris hip score. Four of the seven hips with stage-IV disease did not have or need a total hip arthroplasty. Overall, twenty hips (61 percent) had a good or excellent result according to the scoring system of Harris, and thirteen (39 percent) had a fair or poor result and subsequently had or needed a total hip arthroplasty. The mean interval between the hemiarthroplasty and the total hip arthroplasty was sixty months (range, thirty-six to 136 months). These thirteen hips all had a successful clinical result (a Harris hip score of at least 80 points) at a mean of thirty months (range, twenty-four to seventy-two months) after the total hip arthroplasty. The results of the present study suggest that resurfacing of the femoral head can be a successful interim procedure for the management of patients who have Ficat and Arlet stage-III or early stage-IV disease with a large lesion that is not amenable to other treatment options except total hip arthroplasty.     

Surface antigens on malignant Sézary and T-CLL cells correspond to those of mature T cells

Tumor cells from eight adult patients with T-cell chronic malignancies were investigated with a series of monoclonal antibodies recognizing T-cell differentiation antigens. This series allowed definition of discrete subpopulations of mature T cells with functional specialization. All six patients with Sézary syndrome and one patient with T-chronic lymphocytic leukemia had cells with the same phenotype as normal helper/inducer T cells, whereas the other patient with T-chronic lymphocytic leukemia had cell with the same phenotype as normal cytotoxic/suppressor T cells. Some clinical manifestations observed in these patients may reflect retention of functional activities by their malignant cells.     

Cardiac pacemaker infection: surgical management with and without extracorporeal circulation

BACKGROUND: Pacemaker infections are rare, but serious complications of pacemaker therapy. The generator pocket, the pacing leads, or both may be involved. METHODS: We report on 12 patients with infected pacemaker systems. Four patients suffered from localized generator pocket infections, 6 had infected leads, and 2 patients had both. Pacemaker systems were completely removed in all patients. When the infection was limited to the generator pocket, the pacemaker system was removed at the original implantation site. Extracorporeal circulation was employed for the explantation of infected pacing leads. RESULTS: No complications occurred in patients with localized generator pocket infections. One patient with infected leads who was preoperatively already in a serious clinical condition died of septic shock in the early postoperative period; another patient died of pulmonary complications after tricuspid valve replacement 14 months after pacemaker explantation. No recurrent infections were observed. CONCLUSIONS: Explantation of the complete pacemaker system has proved a reliable method to eradicate infection. Complications have been rare, except in patients in a critically ill state who undergo cardiopulmonary bypass.     

Oral anticoagulant prophylaxis and epidural catheter removal

BACKGROUND AND OBJECTIVES: The use of regional anesthesia in patients receiving anticoagulants is controversial. The purpose of this review is to document the incidence of neurologic complications with insertion and removal of an epidural catheter in patients receiving oral anticoagulants and antiplatelet medication. METHODS: A retrospective review was made of the charts of 459 patients who underwent hip pinning or hip or knee replacement under regional anesthesia and received postoperative epidural analgesia and warfarin thromboembolism prophylaxis. The number of patients receiving preoperative antiplatelet therapy and warfarin, as well as baseline coagulation parameters, was documented. For patients who had postoperative epidural analgesia, the prothrombin time on the day of epidural catheter removal was obtained. Neurologic complications during the hospital stay were noted. RESULTS: Spinal anesthesia was administered to 47 patients and epidural anesthesia and postoperative analgesia to 412. Before surgery, antiplatelet therapy was given to 270 and warfarin to 180 patients, with some patients receiving both. The mean +/- SD preoperative prothrombin and partial thromboplastin times were 10.8 +/- 1.2 seconds (normal, 9.6-11.1 seconds) and 27.5 +/- 3.5 seconds (normal, 24.6-33.2 seconds), respectively. Blood on needle or catheter insertion was noted in 21 patients, all of whom were taking antiplatelet medication and/or warfarin. Epidural catheters remained postoperatively for a mean of 43.6 +/- 12.5 hours (range 5-118 hours). The mean prothrombin time on the day of epidural catheter removal was 14.1 +/- 3.2 seconds. Four postoperative peripheral neuropathies were detected. There was no clinical evidence of spinal hematoma in any patient. CONCLUSIONS: Epidural catheter placement and removal in patients taking oral anticoagulants appears to be safe. Careful monitoring of the patient for evidence of spinal hematoma after epidural catheter removal is recommended.     

The use of erythropoietin in the management of Jehovah's Witnesses who have revision total hip arthroplasty

Five Jehovah's Witnesses (one man and four women) were managed with revision total hip arthroplasty. The average age of the patients at the time of the index operation was 66.4 years (range, fifty-eight to seventy-eight years). All of the patients received subcutaneous injections of recombinant human erythropoietin before the operation, at an initial dose of 100 international units per kilogram of body weight three times a week. The duration of preoperative treatment was determined by the hematocrit at the time of presentation. The hematocrit was monitored weekly, beginning with the second week of treatment, and the dose was adjusted accordingly until the time of the operation. Erythropoietin therapy was discontinued if the hematocrit exceeded 0.45 at any time. The hematocrit before the erythropoietin therapy was begun, at the time of admission to the hospital (one or two days preoperatively), immediately postoperatively, and at the time that the patient was discharged were recorded for this study. All five revision total hip arthroplasties were performed successfully without a blood transfusion. No patient had any complications associated with an excessive loss of blood or a low hematocrit. The average hematocrit was 0.395 (range, 0.317 to 0.447) before the erythropoietin therapy was begun and was 0.476 (range, 0.431 to 0.509) after treatment with erythropoietin and before the operation (that is, at the time of admission to the hospital). The average duration of erythropoietin therapy was twenty-six days preoperatively and 3.6 days postoperatively. The average hematocrit was 0.368 (range, 0.272 to 0.424) immediately after the operation and was 0.308 (range, 0.294 to 0.327) at the time of discharge from the hospital. No patient had evidence of deep venous thrombosis. This study illustrates that it is possible and apparently safe to optimize the hematocrit, by use of erythropoietin, in a patient who is scheduled for an operation. This may be particularly beneficial to a patient with anemia who has failure of a total hip arthroplasty. A relatively high hematocrit (0.45 to 0.50) preoperatively provides a relative margin of safety to a procedure that frequently involves a great deal of intraoperative blood loss. The use of erythropoietin preoperatively is particularly suited to joint replacements and revisions because of their elective nature and the moderately flexible timing associated with these procedures.