Current State of Neck Dissection in the United States

The status of the cervical lymph nodes is the most important prognosticator in head and neck squamous cell carcinoma. The neck dissection is both a therapeutic and staging procedure and has evolved to include various types with standardized level designations (I–VI) for lymph node groups: the radical neck dissection, modified radical neck dissection, the selective neck dissection, and the extended neck dissection. The gross and histologic examination of a neck dissection should provide the critical information (size of metastasis, number of lymph nodes involved) for staging purposes. Additionally, extracapsular spread of lymph node metastasis must be reported because of its significance as an adverse prognosticator. Current dilemmas in nodal disease are the detection of micrometastases, isolated tumor cells, and molecular positivity. The significance of these categories of disease is still unclear, though they may explain a subset of the estimated 10% of the regional recurrences in the neck despite pathologic node negativity by traditional methods of evaluation. Sentinel lymph node biopsy has been recently applied to head and neck squamous cell carcinoma to enhance the management of the clinicoradiographically node negative patients. While still investigational, sentinel lymph node biopsy shows promise in selecting patients who require a neck dissection. Rapid highly automated real-time RT-PCR based platforms will allow for incorporation of molecular findings into the intraoperative evaluation of a sentinel lymph node.     

A Prospective Randomized Trial of Steroid-Free Maintenance Regimens in Kidney Transplant Recipients—An Interim Analysis

We compared three maintenance immunosuppressive regimens in a rapid discontinuation of prednisone protocol. From March 1, 2001, through December 31, 2003, 239 first and second kidney transplant recipients (166 LD; 73 DD) were randomized. All recipients were treated with Thymoglobulin; all received steroids intraoperatively and for 5 days postoperatively. Randomization was to cyclosporine-mycophenolate mofetil (n = 85); high-level tacrolimus (TAC) (8-12 ng/mL)-low-level sirolimus (SRL) (3-7 ng/mL) (n = 72); or low-level TAC (3-7 ng/mL)-high-level SRL (8-12 ng/mL) (n = 82). We found no difference at 24 months between groups in patient, graft, death-censored graft, or acute rejection-free graft survival, or in kidney function. Wound complications were more common in SRL-treated recipients (p = 0.02); we found no other differences between groups in complication rates. Our data suggest that excellent patient and graft survival and low rejection rates can be obtained using a variety of maintenance protocols without prednisone.     

Serum osteocalcin and bone mineral metabolism following successful renal transplantation

Serum osteocalcin (bone gla protein, BGP), a vitamin K-dependent non-collagenous bone protein and its relationship to other markers of bone and mineral metabolism were studied cross-sectionally in varying numbers of patients before and over 240 days following renal transplantation. Marked elevation of serum creatinine (11.9 +/- 0.76 mg/dl), osteocalcin (216.9 +/- 7 ng/ml), parathyroid hormone (PTH, mid-molecule fragment) (24.5 +/- 3.6 ng/ml), alkaline phosphatase (255.2 +/- 54.7 IU/l) and phosphorus (5.6 +/- 0.3 mg/dl) were noted preoperatively. Serum calcium levels remained normal throughout the study period while phosphate levels normalized within one week after transplantation. PTH levels progressively decreased postoperatively over the study period but were still elevated well above normal. Serum osteocalcin decreased to near normal values at 60-90 days after surgery. Both PTH and alkaline phosphatase correlated significantly with osteocalcin preoperatively and postoperatively. The relatively depressed values of osteocalcin in the face of still elevated PTH levels post-transplantation was attributed to the effect of immunosuppressive corticosteroid therapy. The significant correlation between PTH and osteocalcin suggests that osteocalcin may be as or more sensitive a measurement of bone turnover than alkaline phosphatase pre- and post-transplantation.     

Vitrectomy with Silicone Oil Tamponade in Rhegmatogenous Retinal Detachment following Acute Retinal Necrosis: Clinical Outcomes and Prognostic Factors

Purpose: The purpose of the study is to report the prognostic factors and outcomes of vitrectomy (PPV) with silicone oil tamponade in rhegmatogenous retinal detachment (RRD) secondary to acute retinal necrosis (ARN).

Methods: This retrospective, non-randomized, interventional comparative study included 38 eyes of 38 patients. All cases underwent PPV with silicone oil tamponade. The main outcome measure was improvement of final visual acuity relative to the presenting visual acuity and factors affecting the same Group A included eyes with favorable vision of 20/400 or better and Group B included the others.

Results: Group A included 16 eyes (42.10%), group B included 22 eyes (57.89%). In Group A 2 eyes out of 16 (12.5%) and in Group B 12 eyes out of 22 (54.54%) had RRD at presentation (p = 0.02, 95% CI for the difference 7.88–65.78%). The time interval between first presentation and development of RRD in Group A was 30.94 ± 38.8 days (median 30 days) whereas that in Group B was 10.81 ± 11.73 days (median 8 days) (p = 0.02). The odds of visual improvement post-vitrectomy when RRD occurred later was 8.4 (p = 0.01, 95% CI 1.53–46.1). The usage of systemic steroids (odds 5.2, p = 0.03, 95% CI 1.14–23.54) and oral valacyclovir (odds 4.33, p = 0.04, 95% CI 1.05–17.84) were associated with odds favoring a good visual outcome. Recurrent RRD was noted in 3/16 eyes (18.75%) in Group A and 13/22 eyes (59.09%) in Group B (p = 0.03).

Conclusion: Delayed occurrence of RRD after ARN is a good prognostic factor. Usage of systemic steroids and oral valacylocvir are associated with a favorable visual outcome when started before the onset of RRD.     

Prediction of clinical outcomes in Crohn’s disease by using confocal laser endomicroscopy: results from a prospective multicenter study

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