Phacoemulsification of cataract in patients receiving Coumadin therapy: ocular and hematologic risk assessment

PURPOSE: To assess the risks of intra- and postoperative bleeding tendency associated with uncomplicated cataract surgery by phacoemulsification in patients receiving Coumadin treatment. DESIGN: Prospective, nonrandomized, interventional, consecutive case series. METHODS: Sixty-three consecutive patients underwent cataract extraction with lens implantation in 75 eyes. All patients were receiving Coumadin therapy at the time of surgery, and nine patients (14.3%) were also taking antiaggregants. The operations were performed by phacoemulsification technique under topical anesthesia. All patients underwent a hemostatic work-up before intervention. Structured questionnaires were completed by the surgeon immediately after the operation. In 18 (24%) eyes, the surgery was videotaped, and the tapes were reviewed subsequently for any bleedings by an independent observer. RESULTS: Twelve patients (19%) underwent surgery in both eyes, not simultaneously. The mean prothrombin time international normalized ratio (INR) was 2.03 at the time of the surgery. No significant intraoperative bleeding occurred. Four (6.3%) patients had minor postoperative ocular bleeding. A microscopic hyphema and a dot retinal hemorrhage were each seen in one eye on the first postoperative day, and small iris hemorrhages were identified in two additional eyes at the one-week visit. All bleedings disappeared within one week without affecting the visual acuity. The mean INR of the four patients with minor bleedings was 2.1. CONCLUSIONS: Cataract surgery by phacoemulsification in uncomplicated eyes can be performed safely in patients receiving Coumadin treatment. However, a large clinical trial is required to assess the safety of continuous Coumadin treatment associated with phacoemulsification in eyes with complicated cataract.     

Glottal function index: a predictor of glottal disorders in children

OBJECTIVES: Hyperkinetic laryngeal behaviors may be used to achieve glottal closure in the presence of vocal cord disorders. In adults, the Glottal Function Index (GFI) is a validated self-administered survey used to evaluate glottal insufficiency. In children, the relationships between glottal closure and vocal cord lesions have not been examined. We undertook to evaluate the efficacy of the GFI in detecting disorders of the vocal cords in children. METHODS: We evaluated 100 consecutive children who underwent flexible fiberoptic laryngoscopy. A 4-item GFI questionnaire was administered to the parents of each study subject on study entry. The videotapes of the examinations were evaluated and scored by 3 investigators in a blinded manner. The GFI scores were compared in subjects with and without vocal cord findings. RESULTS: The final analysis included 100 children 2 to 16 years of age. The-mean age of the study group was 7.3 years (+/-3.9 years). Of the 100 patients, 54 had vocal cord disorders. The most common was vocal cord nodules, in most cases combined with bowing of the vocal cords; the two variables were highly correlated (p < .01). We performed a receiver operating characteristics test between the presence of vocal cord disorders and the GFI score. We found that the "optimal" score, on which the sensitivity and specificity curves cross, was 3. Of the 54 patients who had vocal cord disorders, the index identified 38 patients (70%), whereas the patients' complaints identified only 30 patients (55.6%). This difference was statistically significant (p < .05). CONCLUSIONS: The GFI is a reliable 4-item symptom index with excellent correlation to the presence of vocal cord lesions in children.     

Surgery for thyroid cancer

A technique of thyroidectomy that facilitates resection of the thyroid, preserves the parathyroid glands with their blood supply, and preserves the recurrent and the superior laryngeal nerves is described. This technique provides a simple and versatile means of complete extracapsular thyroidectomy for lesions of the thyroid gland and minimizes postoperative complications.     

Pretreatment surgical lymph node staging predicts results of trimodality therapy in esophageal cancer

Objective: Prediction of responders to induction therapy in esophageal cancer (EC) patients is important. In this study, we evaluated the role of thoracoscopic/laparoscopic (Ts/Ls) staging in prediction of treatment response and survival in EC patients with trimodality treatment. Methods: Retrospective study of EC patients who had undergone Ts/Ls staging and received trimodality treatment at the University of Maryland Medical Center and the Baltimore Veterans Administration Hospitals from July, 1991 to December, 1999. Preoperative therapy consisted of concurrent chemotherapy (5-FU+cisplatinum) and radiotherapy. Results: Forty-four EC patients who underwent pretreatment Ts/Ls staging during the study period were able to complete concurrent chemoradiotherapy followed by surgical resection. There were 36 men and 8 women aged 40 to 77 (median age 62). Twenty-seven (61.4%) patients were found to have lymph node metastasis by surgical staging. Fourteen patients (31.8%) had a pathologic complete response. Patients with positive lymph nodes had a lower response rate than those with negative lymph nodes (14.8% vs. 58.8%, P=0.006). Other clinicopathologic features including gender, weight loss, clinical TNM stage, surgical T stage, and histology did not correlate with treatment response. Univariate analysis showed that weight loss and treatment response were important prognostic factors for disease-free survival (P=0.01 and P=0.02, respectively). Histology, surgical N stage and surgical TNM stage appeared to be associated with prognosis (P=0.067–0.097). Multivariate analysis revealed that only surgical N status and weight loss were significant prognostic factors (P=0.05, and P=0.006, respectively). Conclusions: Surgical Ts/Ls staging provides accurate evaluation of tumor spread in EC patients. Pretreatment N status was the single most important predictor of response to induction treatment as well as a reliable prognosticator of survival.     

A novel approach for prevention of lethal GVHD by selective elimination of alloreactive donor lymphocytes prior to stem cell transplantation

OBJECTIVE: Experiments were designed to investigate a new concept aiming for induction of graft-vs-malignancy (GVM) effect prior to stem cell transplantation (SCT). Mismatched lymphocytes given pre-SCT will be followed by a selective elimination of alloreactive donor lymphocytes, thus avoiding lethal graft-vs-host disease (GVHD). METHODS: Recipient mice treated with sublethal total-body irradiation (TBI) received a single injection of allogeneic splenocytes, either na?ve or rIL-2 activated (ADL), for induction of GVHD. To prevent lethal GVHD, cyclophosphamide (Cy) (200 mg/kg) or TBI (9 Gy) were given 4 days after cell inoculation. One day later, treated mice were rescued with syngeneic bone marrow cells. RESULTS: Both Cy and TBI significantly (p < 0.001) prevented GVHD in all recipients inoculated with either na?ve cells or ADL and all recipients survived more than 250 days. Control mice not rescued with CY or TBI died of GVHD within 20 to 25 days. A significant proportion of recipients inoculated with 4T1 tumor cells, treated with ADL followed by TBI 9 Gy, survived more than 250 days disease-free in comparison with 22 days in untreated control mice (p <0.001). CONCLUSIONS: Attempting to induce short, yet effective, GVM effects before rather than after SCT, thus avoiding lethal GVHD, may represent an innovative approach for more effective yet safer use of SCT for tumor immunotherapy.     

Splenic nerve is required for cholinergic antiinflammatory pathway control of TNF in endotoxemia

The autonomic nervous system maintains homeostasis through its sympathetic and parasympathetic divisions. During infection, cells of the immune system release cytokines and other mediators that cause fever, hypotension, and tissue injury. Although the effect of cytokines on the nervous system has been known for decades, only recently has it become evident that the autonomic nervous system, in turn, regulates cytokine production through neural pathways. We have previously shown that efferent vagus nerve signals regulate cytokine production through the nicotinic acetylcholine receptor subunit α7, a mechanism termed “the cholinergic antiinflammatory pathway.” Here, we show that vagus nerve stimulation during endotoxemia specifically attenuates TNF production by spleen macrophages in the red pulp and the marginal zone. Administration of nicotine, a pharmacological agonist of α7, attenuated TNF immunoreactivity in these specific macrophage subpopulations. Synaptophysin-positive nerve endings were observed in close apposition to red pulp macrophages, but they do not express choline acetyltransferase or vesicular acetylcholine transporter. Surgical ablation of the splenic nerve and catecholamine depletion by reserpine indicate that these nerves are catecholaminergic and are required for functional inhibition of TNF production by vagus nerve stimulation. Thus, the cholinergic antiinflammatory pathway regulates TNF production in discrete macrophage populations via two serially connected neurons: one preganglionic, originating in the dorsal motor nucleus of the vagus nerve, and the second postganglionic, originating in the celiac-superior mesenteric plexus, and projecting in the splenic nerve.