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S M Graham

Publications and source records attributed to S M Graham.

At least 55 records · Page 3Linked to original sources
PubMed1999

Combined-approach orbital decompression for thyroid-related orbitopathy.

Surgical treatment of thyroid-related orbitopathy can be accomplished by transorbital or endoscopic techniques. Transorbital surgery has advantages in the orbital floor and lateral wall, and endoscopic decompression is best suited to the medial orbital wall. We describe a retrospective review of 16 orbits (10 patients) treated with surgery, combining endoscopic decompression of the medial wall and a transorbital approach to the floor and lateral wall. Follow-up averaged 20.8 months. Vision and field defects improved dramatically in compressive optic neuropathy cases. Hertel measurements improved, on average, 4.9 mm. Two patients with severe preoperative diplopia required strabismus surgery after decompression. Combined-approach decompression is a safe and efficacious operation with conceptual advantages over current surgical techniques.

Adolescent↗
PubMed1999

Mortality after the first year of life among human immunodeficiency virus type 1-infected and uninfected children.

BACKGROUND: HIV-infected and uninfected children who survived their first year of life were prospectively followed in Malawi to assess levels of mortality and related risk factors during the second and third years of life. METHODS: Children with known HIV status from an earlier perinatal intervention trial were enrolled. These children [HIV-infected (Group A); HIV-uninfected but born to HIV-seropositive mothers (Group B); and children born to HIV-seronegative mothers (Group C)] were followed every 3 months until age 36 months. Mortality data were collected at each visit. Immunologic data (CD4+ percent) were collected at or immediately after enrollment. RESULTS: Overall 702 children were enrolled and 83 children died during follow-up. The mortality rate per 1000 person years of observation was 339.3 among Group A children, 46.3 among Group B children and 35.7 among Group C children. Among HIV-infected children the cumulative proportion surviving to age 24 months was 70% and those surviving to age 36 months was 55%. By age 32 months none of the severely immunosuppressed (CD4% < 15%) children had survived. The mortality differentials between HIV-infected and uninfected children persisted after adjusting for several risk factors. The major causes of death among infected children (n = 52) were wasting and respiratory conditions. CONCLUSIONS: Although all HIV-infected children had received childhood immunizations, mortality was high. Management of these children should include aggressive antimicrobial treatment, and evaluation of prophylactic regimens should be considered.

Adult↗
PubMed1999

New techniques for surgical decompression of thyroid-related orbitopathy.

Certain cases of thyroid-related orbitopathy may require surgical decompression of the orbit. The purpose of this paper is to highlight new techniques of orbital decompression in thyroid-related orbitopathy. We present two illustrative cases selected from our recent surgical experience. The techniques of combined-approach decompression, transcaruncular approach to the medial orbital wall, drilling reduction of the greater wing of sphenoid and lateral wall lag-screw fixation after lateralization by greenstick fracture are presented. The relative utility of each technique is examined. These techniques expand the surgical repertoire for this condition and allow individualization of treatment for a specific patient's needs.

Adult↗
PubMed1998

Risk factors for malignancy in adult tonsils.

BACKGROUND: Tonsillectomy in adults (age 18 years and older) is performed for a variety of conditions. The palatine tonsils may harbor carcinoma or lymphoma, and this potentially unanticipated finding may follow routine tonsillectomy in the adult. The ability to preoperatively identify adult tonsillectomy patients at increased risk for tonsillar malignancy could sensitize the clinician to this possibility and the potential need for expedited rather than routine tonsillectomy scheduling. METHODS: A retrospective review of 476 consecutive adult patients who underwent tonsillectomy during the last 10 years at the University of Iowa Hospitals and Clinics was undertaken. Proposed risk factors for tonsillar malignancy included a prior history of head and neck cancer, tonsillar asymmetry, palpable firmness or visible lesion in the tonsil, neck mass, unexplained weight loss, and unexplained constitutional symptoms. These risk factors were correlated with the pathologic diagnosis in the reviewed cases. RESULTS: Of these 476 patients, 25 had malignant tonsil pathology. No patient without risk factors was found to have malignancy on pathologic evaluation of the tonsils. Of the 25 patients with malignant tonsillar pathology, 23 had two or more risk factors, and 2 patients had one risk factor. Tonsillar asymmetry, found in 20 of the 25 cases, was the risk factor most frequently associated with malignant pathology. CONCLUSIONS: These results indicate that the presence of certain preoperatively identifiable risk factors are associated with the pathologic finding of malignancy in adult tonsillectomy specimens. Based on these criteria, a model which is predictive of the presence of tonsil malignancy may be constructed.

Adult↗
PubMed1998

Patterns of metastases to the upper jugular lymph nodes (the "submuscular recess").

BACKGROUND: Cervical lymphadenectomy to remove metastatic disease in level II encompasses lymph nodes associated with the upper third of the internal jugular vein and the adjacent spinal accessory nerve (SAN). Conservative neck dissection (ND) preserves these structures but requires manipulation of the SAN to remove tissue located in the posterosuperior aspect of level II. Limiting the dissection to the nodal group anterior to the SAN may reduce operating time and limit injury to it without compromising the removal of lymph nodes at risk for involvement with cancer. METHODS: Seventy-one patients with squamous cell carcinoma of the head and neck treated with cervical lymphadenectomy at two separate institutions were prospectively evaluated. One hundred two neck dissection specimens were histologically analyzed for number of lymph nodes present and number involved with cancer. At the time of surgery, level II was separated into the supraspinal accessory nerve component (IIa) and the component anterior to the SAN (IIb). Nodal involvement in level II was analyzed according to characteristics of the cancer at the primary site as well as nodal involvement of other levels. RESULTS: Neck dissections were most commonly done for cancer of the oral cavity (n = 33), followed in frequency by the larynx (n = 17), oropharynx (n = 7), skin of face (n = 4), unknown primary (n = 4), and other sites (n = 6). Eighty NDs were selective and 22 were either radical or modified radical NDs. Pathologic staging of the neck specimen was most commonly N0 (n = 61), followed in frequency by N1 (n= 17), N2 (n= 11), and N3 (n= 11). Data were unclear for two specimens. Level IIb contained an average of 6.9 nodes and the IIa component contained an average of 4.2 nodes. Level II contained metastatic disease in 31 of 39 node positive specimens (79%). Level IIa was involved with cancer in four cases, all of which were preoperatively staged N2 or greater. CONCLUSIONS: The additional time required and morbidity associated with dissection of the supraspinal accessory nerve component of level II may not be necessary when performing elective ND. More research with larger numbers of patients, long-term follow-up, and meticulous tissue analysis is needed to permit conclusions as to where to draw the line in determining extent of cervical lymphadenectomy.

Adult↗
PubMed1998

Tumor reduction in vivo after adenoviral mediated gene transfer of the herpes simplex virus thymidine kinase gene and ganciclovir treatment in human head and neck squamous cell carcinoma.

Gene transfer offers the possibility of novel therapies for head and neck squamous cell carcinoma (HNSCC). To this end, we demonstrate that a replication deficient adenovirus vector (Ad.RSVlacZ) can efficiently transduce foreign genes into human HNSCC cell lines in vitro, and that adenoviral mediated transfer of herpes simplex virus thymidine kinase (Ad.RSVtk) followed by exposure to ganciclovir results in tumor cell killing in vitro and in vivo. Exposure to Ad.RSVlacZ resulted in lacZ expression at multiplicities of infection (MOIs) of 10 and 100 for the cell lines HEp-2 and FaDu, respectively. This increased to 97% (HEp-2) and 49% (FaDu) at an MOI of 10,000. For HEp-2, maximum expression occurred during the first 48 hours after exposure (52% at 24 hours, 48% at 48 hours; MOI 500), then declined by 40% per day. This rapid decline may be caused by dilution of the gene through cell proliferation, because normalizing for the increase in total protein shows that the total number of cells expressing lacZ is stable from days 1 to 4. FaDu and HEp-2 were then transduced by AD.RSVtk and exposed to 20 microM ganciclovir for 24 hours. Significant tumor cell killing, as measured by a colony forming assay, occurred at an MOI of 2 for HEp-2 and 20 for FaDu. At an MOI of 200, 100% of HEp-2 and 97% of FaDu cells were killed. Next, subcutaneous tumor nodules derived from FaDu and HEp-2 were established in the flanks of SCID mice. Direct intratumoral injection of Ad.RSVtk followed by 7 days of ganciclovir therapy resulted in an adenovirus dose dependent reduction of tumor growth, and an actual size reduction of established tumor nodules at the highest does (10(10) plaque forming units). In conclusion, an adenovirus vector can efficiently transduce HNSCC cell lines in vitro. Maximum marker gene expression occurred during the first 48 hours after transduction. Transduction by Ad.RSVtk followed by exposure to ganciclovir resulted in tumor cell killing in vitro and in vivo.

Adenoviridae↗
PubMed1998

Incidence of deep venous thrombosis and pulmonary embolism in otolaryngology-head and neck surgery.

OBJECTIVE: Postoperative deep venous thrombosis and pulmonary embolus are major causes of morbidity and mortality in patients undergoing surgical procedures. In contrast to other surgical fields, the incidence of these life-threatening conditions has not been studied in our specialty. The purposes of this study were to elucidate the incidence of deep venous thrombosis and pulmonary embolus in patients after otolaryngologic operations and to identify specific risk factors that may contribute to the development of these conditions. METHODS: A retrospective analysis was done of 12,805 total operations on adults done by the Department of Otolaryngology at our institution from January 1987 to December 1994 to determine the number of patients in whom postoperative deep venous thrombosis and pulmonary embolus developed. Patients in whom a postoperative thromboembolic event developed after an otolaryngologic surgical procedure were identified by the medical records department with use of an abstracting database. This search cross-referenced disease-specific codes for otolaryngologic procedures with the codes for deep venous thrombosis and pulmonary embolus to identify the 34 patients in this report. Results (rounded to the nearest decimal point) were then categorized according to the different subspecialties within otolaryngology, and appropriate statistical analysis tests were performed on the resulting data. RESULTS: Thirty-four patients with postoperative deep vein thrombosis were identified during the study period, for an overall incidence of 0.3%. Of these 34 patients, 24 also had a pulmonary embolus for an overall incidence of 0.2%. The incidence of deep venous thrombosis (and pulmonary embolus) in the subspecialties was as follows: head and neck surgery, 0.6% (0.4%); otology/neurotology, 0.3% (0.2%); head and neck trauma and plastic surgery, 0.1% (0.1%); and general otolaryngology, 0.1% (0.04%). Only the patient's age and the presence or absence of pneumatic compression devices were identified as independent risk factors for the development of a thromboembolic event. CONCLUSIONS: Postoperative pulmonary embolus is a rare occurrence in the field of otolaryngology-head and neck surgery. When it does occur, it causes significant morbidity and increases the cost of care for that patient. We discuss our approach to categorizing patients into low-, intermediate-, and high-risk groups, as well as prophylaxis against pulmonary embolus.

Adult↗
PubMed1998

Cost-identification analysis in oral cavity cancer management.

The objectives of this study were to investigate potential relationships between pretreatment patient-mix characteristics, treatment modalities, and costs generated during the pretreatment work-up, treatment, and 1-year follow-up periods for patients with oral cavity cancer (OCC). Another objective was to identify potential areas for cost reduction and improved resource allocation in the management of OCC patients. Using a retrospective cohort of 73 patients with OCC, pretreatment patient-mix characteristics and treatment modalities were evaluated in relation to university-based charges incurred during the pretreatment evaluation, treatment, and 1-year follow-up periods. Simple regression and stepwise multiple regression analyses were used to develop predictive models for cost based on independent variables, including age, AJCC TNM clinical stage, smoking history, American Society of Anesthesiologists (ASA) class, comorbidity as defined by the Kaplan-Feinstein grade and treatment modality. The dependent measurements included all physician, office, and hospital charges incurred at the University of Iowa Hospitals and Clinics during the pretreatment evaluation, treatment, and follow-up periods, as well as the total pretreatment through 1-year follow-up management costs. Independent variables that were identified as being significantly associated with treatment costs included T classification, N classification, TNM stage, unimodality versus multimodality treatment, and the Kaplan-Feinstein comorbidity grade. Age, smoking status, and ASA class were not significantly associated with costs. The majority of the OCC management costs were incurred during the treatment period. The most substantial decreases in management costs for OCC will be realized through measures that allow identification and treatment of disease at an early stage, in which single-modality treatment may effectively be used. Resource allocation for OCC should support the investigation of measures through which the diagnosis and treatment of OCC at the earliest possible stage is facilitated. The presence of comorbid illness is a significant component in the determination of management costs for OCC and should be included in analyses of resource allocation for OCC. The singular diagnosis of OCC encompasses a wide range of patient illness severity, and diagnosis-related reimbursement schemes for OCC treatment should optimally differentiate between early and advanced stage disease.

Aged↗
PubMed1998

Operative management of papillary cystic neoplasms of the pancreas.

BACKGROUND: Papillary cystic neoplasm (PCN) is a rare malignant tumor of the pancreas that typically occurs in young females and has an excellent prognosis. STUDY DESIGN: We report a retrospective review of 12 patients treated during a 16-year period. Pre-, intra-, and postoperative data were evaluated in all patients to determine optimal management with specific reference to surgical strategy. RESULTS: All 12 tumors occurred in young women (mean age 22 years, range 14-36 years). Six patients presented with an epigastric mass, and three with severe abdominal pain. The correct diagnosis was made preoperatively in only five patients. Incorrect diagnoses included hepatoma, pancreatic pseudocyst, and hydatid cyst. The PCNs had a mean diameter of 12.5 cm (range 8-20 cm), and occurred in the head (four), neck (three), body (three), and tail (two) of the pancreas. All were resected. Operations performed were pylorus-preserving pancreaticoduodenectomy (three), central pancreatectomy with pancreaticogastrostomy (three), distal pancreatectomy (three), and local resection (three). In one patient two liver metastases were resected in addition to the pancreatic primary. One patient presented with tumor rupture and a major bleed into the lesser sac and died of multiple organ failure after resection. Postoperative complications included a stricture at the hepaticojejunostomy after pancreaticoduodenectomy, which resolved after temporary stenting, and a pancreatic duct fistula after local tumor resection, which required a distal pancreatectomy. Eleven patients are well at followup (mean 6.6 years; range 6 months to 15 years). CONCLUSIONS: PCN should be considered in the differential diagnosis of large pancreatic masses, especially in young females. Conservative resection, where technically feasible, is safe and effective and represents the therapy of choice.

Adult↗
PubMed1998

Intra-operative ultrasound-guided drainage of parotid abscess.

Parotitis complicated by parotid abscess remains a potentially life-threatening problem. Conventional surgical treatment involves incising the parotid parenchyma in the direction of the facial nerve until the abscess is located and evacuated. Intra-operative ultrasound greatly assists in localizing the abscess and in ensuring its complete drainage. Expeditious and exact localization of the abscess reduces operative time. Equally importantly, ultrasound-assisted drainage reduces surgical dissection and the potential for facial nerve damage.

Abscess↗