Biomedical subjects

J L Freeman

Publications and source records attributed to J L Freeman.

153 records · Page 9Linked to original sources

PubMedDate not supplied

Validity of test occlusion studies prior to internal carotid artery sacrifice.

Twenty-nine patients with lesions of the neck, skull base, and cavernous sinus had test balloon occlusions of the internal carotid artery (ICA) to determine the feasibility of sacrifice of the artery. Only one patient (3.4%) showed evidence of cerebrovascular compromise. Sixteen patients who tolerated test occlusions went on to ICA sacrifice. Ten patients had permanent balloon occlusion (PBO) of the ICA for cavernous aneurysms or to "trap" carotid-cavernous fistulae (CCF). Complications occurred in three patients (30%) with permanent morbidity in one patient (10%). One patient with CCF had PBO of the proximal ICA only, resulting in an unstable neurologic state and ultimately in death. Two patients had resection of skull base tumors 2 and 6 days after PBO of the ICA. Both suffered strokes and one died. Three patients had surgical sacrifice of the ICA without PBO. Two of these patients suffered cerebral ischemia without permanent sequelae. We conclude that test occlusion of the ICA with clinical monitoring will miss a significant number of patients with inadequate cerebrovascular reserve. Sensitivity is improved by controlled reduction of systemic blood pressure during the test occlusion. Resection of a skull base tumor soon after PBO of the ICA should be done in a delayed fashion or preceded by extracranial-intracranial arterial bypass. Patients who have had the artery sacrificed should be monitored in an intensive care setting for 48 hours to avoid hypotension, which could cause cerebrovascular ischemia.

Adult↗

PubMedDate not supplied

Intracranial extension of a nasal dermoid sinus cyst in a 56-year-old man.

BACKGROUND: Nasal dermoid sinus cysts are rare congenital lesions that result from aberrant embryonal development. Cases of nasal dermoids associated with intracranial extension have been reported in the past, but have almost always occurred in children. METHODS: One case of a nasal dermoid cyst with intracranial involvement in a 56-year-old man is reported herein. RESULTS: A 56-year-old man presented with a draining sinus in the right medial canthal area and a nasal pit. Imaging studies suggested a nasal dermoid cyst with intracranial extension. He subsequently underwent a craniofacial removal of the lesion with a satisfactory postoperative course. CONCLUSION: That nasal dermoid cysts can remain dormant until the age of 56 suggests that the incidence of this lesion with intracranial extension may be higher than previously reported. A one-stage combined otolaryngologic/neurosurgical procedure is advocated for those lesions that are extra- and intracranial.

Craniotomy↗

PubMedDate not supplied

Role of Epstein-Barr virus in fine-needle aspirates of metastatic neck nodes in the diagnosis of nasopharyngeal carcinoma.

BACKGROUND: The patient with nasopharyngeal carcinoma (NPC) frequently is initially seen with regional node dissemination. Preliminary investigations suggest that the presence of Epstein-Barr virus (EBV) genomes in neck metastases from an occult primary may be diagnostic and predictive of NPC. The goal of this study was to test this proposition. METHODS: The polymerase chain reaction (PCR) was used to detect the presence of EBV DNA in fine-needle aspirate (FNA) samples obtained from malignant neck nodes. Control samples were obtained from other locations in the head and neck. PATIENTS: The patients in this study were evaluated at the Toronto Princess Margaret Hospital, a province-wide tertiary-care cancer treatment center. Of the 23 patients evaluated with malignant neck masses, 6 had NPC, 5 patients had metastatic squamous cell carcinoma of an unknown primary, and 12 patients served as controls with other known head and neck carcinomas. One of the patients initially diagnosed as an unknown primary later demonstrated NPC. FNA specimens were also obtained from 24 normal parotid, submandibular, or thyroid glands for comparison. RESULTS: In the samples with sufficient DNA for analysis, EBV was detected in 5 of 5 neck nodes from patients with known NPC. EBV was also detected in the neck node of a patient who went on to develop NPC and in a cervical node from 1 of 2 patients in whom the primary tumor remained unknown. None of the evaluable control neck nodes of FNA controls from other sites demonstrated EBV. CONCLUSIONS: These results demonstrate the utility of NPC-diagnostic EBV gene amplification in FNA samples of neck metastases and suggest that the presence of the EBV genome in FNA samples of neck nodes is predictive of the presence of NPC.

Adolescent↗

PubMedDate not supplied

Parathyroid gland transplantation after total thyroidectomy with pharyngolaryngoesophagectomy.

Surgical treatment of extensive hypopharyngeal carcinoma often includes total thyroidectomy together with resection of the primary disease. The risk of removing or damaging the parathyroid glands is considerable; this may render the patient permanently hypoparathyroid with all the problems of management. These patients must be on lifelong supplementation and at times, due to failure to take the medication, hypocalcemic crises are precipitated. To avoid this problem, we have been identifying the parathyroid glands intraoperatively and, after pathological confirmation, have transplanted them to the forearm. Three patients who underwent this procedure are presented. All are normocalcemic without supplementation and parathyroid hormone assays on serum from the transplanted forearm show significantly elevated levels.

Aged↗

PubMedDate not supplied

Measuring frailty in the hospitalized elderly: concept of functional homeostasis.

Functional homeostasis is the ability of an individual to withstand illness without loss of function. We investigate whether the level of functional homeostasis predicts adverse outcomes in the 6 months posthospital discharge in older men and women. A prospective cohort study was conducted in an acute care geriatric inpatient unit of a university hospital. Subjects included a consecutive series of patients admitted to the unit. The Functional Independence Measure (FIM) instrument was used to assess patients at four time points: preillness, hospital admission, hospital discharge, and 6 months postdischarge. Of the 122 subjects available for analysis, 64 (52%) experienced a decline in functional level from preillness to hospital discharge and were defined as having poor functional homeostasis, whereas 58 (48%) experienced no change or an increase in functional status and were defined as having good functional homeostasis. Those with poor functional homeostasis had a higher 6-month readmission rate to the hospital (59.4 v 39.7%; P=0.03) and a higher rate of any adverse outcome (78.1 v 50%; P=0.001) than those with good functional homeostasis. In logistic regressive analyses, functional homeostasis remained a significant and powerful predictor of adverse outcomes independent of actual level of function at discharge, age, gender, living status, and other factors that might influence outcomes. Change in functional status associated with an acute illness is an independent predictor of adverse outcomes and, in this study, a better predictor than actual level of function at discharge. Functional homeostasis is one approach to the quantification of the important but elusive concept of frailty in the elderly.

Activities of Daily Living↗

PubMedDate not supplied

Ultrasonography of the thyroid and parathyroid glands.

High-frequency ultrasonography is ideally suited to imaging of the thyroid and parathyroid glands by virtue of their superficial location in the neck. Ultrasonography of the thyroid is most commonly used in the evaluation of the solitary nodule. Ultrasonography of the parathyroid glands is usually performed to evaluate and localise parathyroid abnormalities in patients with hypercalcemia. The increased diagnostic acumen offered by this modality allows a realistic working diagnosis and leads to a rational management strategy.

Humans↗

PubMedDate not supplied

Hospital matrix management and DRG-based prospective payment.

If hospitals are to succeed in their efforts in cost control, they must segregate the influence of efficiency and effectiveness and integrate the medical staff into the management structure. One management model that facilitates such integration is Clinical Matrix Management. Using such a model, the distinct responsibilities in patient care can be segregated between the administration and the medical staff and appropriate accountability and responsibility allocated. Without the explicit integration of the medical staff into the organizational structure, the attempt to control patient care costs is unlikely to succeed.

Ancillary Services, Hospital↗

PubMedDate not supplied

Parotid gland and parapharyngeal space imaging--the surgical significance.

Wise head and neck surgeons, for whom parotid gland surgery constitutes a substantial portion of their case load, make full use of the radiologist and cytologist in arriving at a rational pre-operative diagnosis. They utilize the skill of these allied consultants to qualify (by histology) and quantify (by staging) diffuse and mass lesions of the parotid gland (and subjacent parapharyngeal space) in order to evolve an effective surgical, radiation or other treatment plan. They understand the basic principles of diagnostic imaging and apply them to the clinical problem at hand. They minimize diagnostic and intra-operative "surprises", reduce intra-operative and post-operative complications and generally have a more "informed" patient and patient's family. The purpose of this manuscript is to discuss a contemporary role for diagnostic imaging in neoplastic (and other) diseases of the parotid gland and subjacent parapharyngeal space. Not all lesions of the parotid gland require imaging, although a pre-operative clinical photograph, including evidence of facial nerve function, is always welcome. Other lesions may need diagnostic imaging, from simple to complex and sophisticated, depending upon the problem. Properly used, effective and selective diagnostic imaging can improve the surgeon's confidence by providing a more realistic provisional diagnosis and a better pre-operative staging process and treatment plan, thereby avoiding the surgically unexpected and facilitating prognosis.

Humans↗

PubMedDate not supplied

Decision making in thyroid and parathyroid surgery: the influence of imaging.

Surgical decision making is essentially based on experience, augmented by a management philosophy. In this manuscript we review concepts of thyroid and parathyroid surgical decision making in relation to diagnostic imaging input. These two endocrine glands have crucial anatomic associations, but very different pathologic conditions; it is the specific pathologic considerations that ultimately determine the decision-making process. For us, diagnostic imaging has enabled a more effective surgical decision-making process through thorough pre-operative planning. The strategy for parathyroid surgery is based upon the pathologic localization obtained by high resolution ultrasound. Thyroid surgical strategy is more heavily influenced by experience, and our policy is total thyroidectomy for all malignant and benign tumors with airway compression.

Adenoma↗